ANZ J. Surg. 2003; 73: 856–857 SURGICAL TECHNIQUE Surgical Technique CONTROL OF VENOUS BLEEDING DURING DISSECTION NEAR THE HEAD OF THE PANCREAS JASWINDER S. SAMRA AND ROSS C. SMITH Department of Gastrointestinal Surgery, Royal North Shore Hospital, St Leonards, New South Wales, Australia Avulsion injury to portal vein tributaries can result in worrying haemorrhage during pancreatic gastric, and colonic resection. Attempts to control these avulsion injuries can result in extension of the tear into major portal vein tributaries. Pressure on the bleed- ing point tends to extend the laceration towards the portal vein, which bleeds torrentially when pressure is released for suturing. A technique is described to control the bleeding from these portal vein tributaries. This technique relies on adequate visualization and control of the torn ends of the portal vein tributaries thus enabling the surgeon to precisely suture the disrupted vessel without any collateral damage. This technique has been used on a number of occasions over the last decade with excellent results. Key words: avulsion injury, gastrocolic trunk, portal vein. Abbreviation: SMV, superior mesenteric vein. INTRODUCTION The fusion of greater omentum with transverse mesocolon is of significant clinical importance as it provides an access plane to foregut and mid-gut structures. At the base of the mesocolon a constant vein crosses the plane to drain the right colon into the portal vein or the superior mesenteric vein (SMV), where it is prone to damage. An appreciation of the finer details of surgical anatomy of this area is essential for the safe and adequate mobili- zation of the greater omentum from the transverse colon. At the base of the transverse mesocolon, the superior right colic vein joins the right gastroepiploic vein and the anterior superior pan- creaticoduodenal vein to form a gastrocolic trunk also known as the trunk of Henle. 1 This trunk varies in size and length and may drain either into the portal or the superior mesenteric vein as illus- trated (Fig. 1). 2,3 The gastrocolic vein or any of its tributaries can be easily injured when mobilizing the greater omentum from the transverse mesocolon during pancreatic, gastric or colonic sur- gery. Some of these avulsion injuries can result in lacerations into portal vein itself and the resulting haemorrhage can be torrential. We describe a technique to control this type of portal venous injury. METHODS When the gastrocolic trunk or any of its tributaries are avulsed, the ensuing haemorrhage can obscure the surgical field making any further progress difficult and dangerous. Initially, we try to confirm the site of bleeding by gently compressing the local area with finger pressure and clearing the blood from the operative field. Once damage to the venous structures is confirmed, gentle compression is reapplied with a sponge. At this point, the second part of the duodenum is mobilized by Kocher’s manoeuvre. 4 A rather limited Kocher’s manoeuvre is performed to provide enough access to enable the surgeon to place his left hand behind the pancreas and the third part of the J. S. Samra DPhil, FRACS; R. C. Smith MD, FRACS. Correspondence: Professor R. C. Smith, Suite 5, Level 5, North Shore Private Hospital, Westbourne Street, St Leonards, NSW 2065, Australia. Email: rsmith@med.usyd.edu.au Accepted for publication 14 April 2003. Fig. 1. The duodenum is mobilized and the greater omentum is sep- arated from the transverse colon to expose the anterior surface of the pancreas. The right gastroepiploic vein (A) and the right colic vein (B) from the gastrocolic trunk (C) to join the superior mesenteric vein (D). The anterior inferior pancreaticoduodenal vein (E) is very variable both in its size and course and it usually terminates either by joining the right gastroepiploic vein or the right colic vein.