Annals of Hepato-Biliary-Pancreatic Surgery

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Fig. 4.

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Fig. 4. (A) Peritoneal attachments. The procedure of laparoscopic ‘D2 first’ approach involves opening of the lesser sac and dissection along the virgin, non-inflamed, fused embryonal avascular planes of the transverse mesocolon (Mc) and the leaves of the greater omentum to identify the second of the duodenum and then to enter the general peritoneal cavity. This identifies the critical structures during laparoscopic cholecystectomy—colon and duodenum. Thus, helps in separating the colon from the gallbladder (GB). (B) Bare area of the duodenum, corresponding to the Mc (block arrow) and the pancreas (line arrows). To the left of the bare area is the lesser sac and to the right is the greater sac or the generalized peritoneal cavity. Laparoscopic ‘D2 first’ approach involves traversing from the lesser sac to the greater sac. (C) Diagrammatic representation showing adhesions between the GB and the transverse colon (TC) and the first part of the duodenum (D1). The area (triangle) between the Mc and the second part of the duodenum (D2) is free from adhesions with maintained tissue planes, this forms the basis of laparoscopic ‘D2 first’ approach.
Ann Hepatobiliary Pancreat Surg 2021;25:523-7
© 2021 Ann Hepatobiliary Pancreat Surg