Answer: B. Posterior mobilization of the duodenum

Explanation

Gastric pull-up involves mobilization of the stomach to create a well-vascularized conduit for esophageal replacement. Important steps include entering the lesser sac, dividing relevant gastric attachments and vessels while preserving the right gastroepiploic vascular arcade, and enlarging the esophageal hiatus when necessary to facilitate passage of the conduit.

Posterior mobilization of the duodenum, performed by the Kocher manoeuvre, is not a routine essential step in standard gastric conduit mobilization. It may be performed selectively when additional duodenal mobilization is required.

Why other options are incorrect

• A. Entering the lesser sac: Helps mobilize the greater curvature and provides access to the posterior surface of the stomach.
• C. Dilatation of the esophageal hiatus: The hiatus may need enlargement to allow safe passage of the gastric conduit into the chest without compression.
• D. Ligation of the lesser curvature vessels: Division of the left gastric vessels and relevant lesser-curvature attachments facilitates mobilization while preserving the right gastroepiploic artery as the principal blood supply to a standard gastric conduit.

High-yield teaching points

• The right gastroepiploic artery is the principal vascular supply of a standard gastric conduit.
• The left gastric vessels are divided during routine conduit preparation.
• The Kocher manoeuvre mobilizes the duodenum and is performed selectively, rather than routinely, during gastric pull-up.
• Avoid twisting, tension, or compression of the conduit during its passage through the hiatus.