After gaining access to the peritoneal cavity, the hepatic flexure of the colon is mobilized and reflected inferiorly to expose the head of the pancreas and the duodenum. A complete Kocher maneuver is performed, elevating the head of the pancreas out of the retroperitoneum (Fig. 18.2). To maximize exposure of the pancreas, it is often necessary to divide the right gastroepiploic vein as it enters the superior mesenteric vein. Dividing this vessel connects the dissection of the head with the body and tail allowing for complete exposure of the anterior surface of the pancreas.

Once the pancreas is completely exposed, the peritoneum on the inferior border of the pancreas is sharply incised (Fig. 18.3), and the pancreas is lifted out of the retroperitoneum. Caution should be taken to avoid any injury to the splenic vein, inferior mesenteric vein, or superior mesenteric vein.

The pancreas can now be palpated bimanually to identify any tumors. Intraoperative ultrasound imaging of the pancreas can be performed (Fig. 18.4) to localize nonvisible lesions and to further assess the relationship of the tumor to the main pancreatic duct. If concern exists that enucleation will result in injury to the main pancreatic duct, a formal pancreatic resection should be considered.

To proceed with enucleation of a deep lesion, the pancreatic parenchyma overlying the tumor should be carefully opened, with small vessels being ligated with fine sutures or cauterized (Fig. 18.5). Most lesions that are amenable to enucleation are on or close to the surface of the pancreas. A combination of sharp and blunt dissection is used to shell the tumor out of the pancreatic parenchyma. Small vessels are controlled with a combination of fine sutures, clips, or an energy device. Dissection is begun at the edges of the lesion and continues with care being taken to stay close to but not entering the tumor.

Once the tumor is excised, the bed of the tumor should be carefully examined for any evidence of a major pancreatic duct injury. A closed suction drain should be left near the resection bed.