The body and tail of the pancreas are mobilized by dissecting the inferior and superior border of the pancreas (dashed black lines with arrows) (Fig. 9.2).

A vessel loop can be placed to encircle the gland and help with mobilization (Fig. 9.3).

The splenic vessels are identified. Some series describe an attempt to save the spleen. In that case, the splenic artery and vein are ligated and divided (Fig. 9.4). The viability of the spleen is observed during the duration of the procedure; splenectomy is then performed if the remaining vasculature does not support it.

Our preference is to mobilize the tail of the pancreas en bloc with the spleen and perform splenectomy in all cases, thus eliminating postoperative complications related to the spleen, such as infarction or abscess. With this technique, the spleen can be used as “a handle” in mobilizing the distal pancreas (Figs. 9.5 and 9.6), thus decreasing the likelihood of trauma from handling and manipulating the gland.

The spleen can be excised at this point and the pancreas reflected further medially to identify the splenic artery and splenic vein at their origins (Fig. 9.7).

With the pancreas reflected medially, the splenic artery will be encountered close to its origin at the celiac axis. Dense lymphatic tissue usually surrounds it. The splenic artery is dissected out and encircled with a vessel loop (Fig. 9.8).

The splenic vein is then dissected out at its junction with the portal vein (Fig. 9.9). The inferior mesenteric vein (IMV) (blue arrow) is saved in continuity with the splenic vein if possible, to preserve all outflow from the intestine. The splenic vein just distal to the IMV (yellow arrow) is looped for later division. The dissection of the splenic vein is continued until the portal vein and superior mesenteric vein are identified. The body of the pancreas is dissected off these structures.

The retractor ring is repositioned to the right, so that a Kocher maneuver can be performed. The duodenum and the head of the pancreas are fully and widely mobilized.

A cholecystectomy is performed at this point, if the gallbladder is still present. Hilar dissection is then commenced just superior to the upper border of the duodenum. The portal structures are outlined. The common bile duct (blue arrow) is identified, encircled, and divided as distally as possible (Fig. 9.10).

The portal vein and gastroduodenal artery are identified along the superior border of the pancreas. Our preference is to try to preserve the gastroduodenal artery, if possible, as it passes posterior to the duodenum and ultimately gives branches to the distal stomach and pylorus region. Identification of the portal vein superior to the pancreas allows one to easily develop the plane posterior to the neck of the pancreas, thus freeing the posterior aspect of the gland completely from the anterior aspect of the entire length of the portal vein (Fig. 9.11).

The proximal duodenum is then divided 2 cm distal to the pylorus using a GIA stapler (yellow arrow), and the distal duodenum is divided just distal to the uncinate process of the pancreas (blue arrow) (Fig. 9.12).

The gastroduodenal artery (GDA) (blue arrow) is followed from the common hepatic artery (yellow arrow) as it tracks posterior on the pancreas (Fig. 9.13). The duodenal branches are preserved, and the pancreatic branches are divided using a thermal sealing device. We try to preserve the GDA and its branches to the distal stomach and duodenum if possible; a pyloric preserving procedure is performed, and this maintains maximal blood supply to the region.