This document describes the steps of a surgical procedure involving the duodenum, pancreas, stomach, and other abdominal organs. Key steps include: 1) Kocherization to mobilize the duodenum and expose surrounding structures. 2) Bursectomy and dissection of surrounding tissues to further expose vessels. 3) Division of vessels including the right gastric and gastroduodenal arteries. 4) Transection of the duodenum and dissection of the pancreas and surrounding lymph nodes. 5) Distal pancreatectomy and esophagojejunostomy to reconstruct the digestive tract.

1. Kocherization 1 Assistant’s hands holding the duodenum Inf. vena cava Transv. colon 2 nd part of the duodenum Head

2. Kocherization 2

3. Kocherization 3 Inf. vena cava Transv. colon Aorta Lt. renal V. Rt. kidney

4. Bursectomy Omentum Duodenum Ant. sheet of transv. mesocolon Post. sheet of transv. mesocolon

5. Completion of Bursectomy Pancreatic tail

6. Exposure of the Gastro-colic Trunk Middle colic V. Acc. rt. colic V. Rt. gastro-epiploic V. Ant. sup. panc. duod. V. Sup. mesenteric V. Gastro-colic trunk

7. Division of the Right Gastro-epiploic Vein

8. Exposure of the Supra-pyloric Area Rt. gastric A. Sup. duodenal A. Pylorus

9. Exposure of the Right Gastric Argery Gastroduodenal A. Rt. gastric A.

10. Transection of the Duodenum

11. Dissection of the Upper Border of the Pancreas

12. Identification of the Splenic Artery Splenic A. Gastroduodenal A. No. 8a LN Common hepatic A.

13. Dissection of the No. 12a Nodes No. 12a LN Common hepatic A. Proper hepatic A. Portal V.

14. Taping of the Common Hepatic Artery

15. Lymphadenectomy along the Splenic Artery Great pancreatic A. Splenic V. Post. gastric A. Splenic A.

16. Ligation of the Splenic Artery

17. Division of the Left Gastric Artery Lt. gastric A. stump

18. Exposure of the Esophageal Hiatus Diaphragmatic crus Post. wall of the cardia Post. vagal trunk

19. Exposure of the Abdominal Esophagus

20. Transection of the Esophagus

21. Mobilization of the Pancreas 1 Pancreatic body Spleen Lt. adrenal

22. Mobilization of the Pancreas 2 Pancreatic tail Spleen Lt. kidney

23. Mobilization of the Spleen Spleen

24. Completion of Mobilization Spleen Stomach

25. Exposure of the Splenic Vein Splenic V. Splenic A. Celiac A. Lt. gastric A. stump Pancreatic tail

26. Distal Pancreatectomy

27. Completion of No. 14v Dissection Sup. mesenteric V. Acc. rt. colic V. Ant. sup. panc. duod. V. Middle colic V. Rt. gastro-epiploic V. stump Tape on the gastro-colic trunk

28. Esophago-jejunostomy 1

29. Esophago-jejunostomy 2

30. Closure of the Jejunal Stump Esophagojejunostomy

31. Jejuno-jejunostomy

32. Completion of Roux-en-Y Reconstruction Jejuno-jejunostomy

33. Closure of the Mesenteric Defect