Whipple procedure

An upper midline incision provides adequate exposure in most patients; rarely, a bi-subcostal
incision is needed. If a staging laparoscopy is not performed, the initial incision should be small, to
do a visual and manual inspection for metastatic disease, particularly when operating for cancer.
Once metastatic disease is ruled out, the incision should be lengthened. Once retractors are
applied, a wide Kocher maneuver is performed to the level of the aorta. This enables an
assessment of the retroperitoneum and relationship of the mass with the SMA. At this time, the
SMA can also be inspected from the ligament of Treitz and dissected on its right lateral
surface to exclude any tumor
infiltration. This approach has been termed the artery-first approach and may help to avoid R2
resections because any tumor infiltration of the central arteries can be diagnosed early during
exploration.

The authors do not routinely perform this particular maneuver, as high quality preoperative
imaging and careful palpation in the operating room are typically adequate in excluding gross
SMA involvement

Access to the lesser sac can be achieved by one of two ways.

The more common method is division of the gastrocolic ligament, which often is the more direct
approach to the lesser sac. This can, however, result in ischemia of the distal omentum as the
branches from the gastroepiploic arcade are divided.

Instead, the authors prefer to lift the omentum off the transverse colon and mesocolon to
enter the lesser sac. This technique results in a healthy perfused omentum that later can be
used to cover the pancreatic and biliary anastomoses at the conclusion of the operation, usually
obviating the need for a drain. Careful dissection in the avascular plane between the hepatic
flexure and the duodenum and extension of the Kocher maneuver separates the third part of the
duodenum from the colonic mesentery. The avascular plane between the gastroepiploic and
middle colic veins is divided as it leads to the SMV at the inferior edge of the pancreas. The
gastroepiploic vein may be ligated at this point; however, reserving this until after the pancreatic
neck has been divided can make this maneuver more efficient. The SMV is now identified, and
early development of the tunnel between the pancreatic neck and SMV-PV confluence should
be achieved.

Development of the subpancreatic tunnel. The peritoneal attachments at the inferior border of
the pancreas are incised and a cleavage plane over the superior mesenteric vein and behind the
pancreas (the so-called “tunnel of love”) is developed.
Development of the subpancreatic tunnel allows the surgeon to dissect posterior to the pancreatic
neck and separate the tissues from the underlying portal vein. It is vital that the portal vein be
identified at this portion of the case to be certain it is not involved with tumor. Note the clamp is
behind the pancreas, over the SMV/PV

When a very large gallbladder and common duct are encountered in the presence of an
obstructive jaundice, it may be helpful to aspirate the contents of the gallbladder to enhance the
exposure and at the same time to localize accurately the site of obstruction by injecting
radiopaque contrast material into the biliary system. A point for the needle aspiration should be
selected on the underside of the fundus, since this area may be required for a
cholecystoenterostomy if resection is found to be contraindicated. Since
the bile is often thick and inspissated, a rather large-bore needle, such as an 18- or 20-gauge, is
useful, and as much bile as possible is aspirated.

 The needle is left in place, 50 to 150 mL of iodinated contrast medium is injected, and the
patient is made ready for a cholangiogram. A purse-string suture is placed in the wall of the
gallbladder around the needle so that the opening in the gallbladder can be closed as the needle
is withdrawn.
 Attention is now turned to the supraduodenal compartment. Mobilization of the superior part
of the duodenum is continued in an effort to isolate as long a segment of the common duct as
possible. This can be accomplished by gently spreading a right-angle clamp about the dilated
common duct and meticulously controlling all bleeding (figure 13).
 An effort should be made to free this portion of the common duct completely and it is
encircle with a vessel loop. The surgeon can then palpate behind the duodenum with the index
finger in an effort to develop a cleavage plane between the duodenum and portal vein, and
at the same time to determine more accurately whether there is fixation by the tumor to this
vein.

 Once the surgeon is sure that resection is safe without injury to the portal vein,
he or she proceeds to ligate the blood supply necessary for antrectomy. The
right gastroepiploic vessels should be ligated and tied (figure 14).
 Following this, the antrum can be encircled with tape, gentle medial and downward
traction is applied to the stomach, and the right gastric vessels are identified
(figure 15). An alternate procedure that saves the antrum and pylorus may be chosen at this
point.
 If there is a question about resectability, the division of the stomach should be deferred until
the plan is established between the rest of the pancreas and the portal vein. Since peptic
ulceration is one of the late complications following radical amputation of the head of the
pancreas and duodenum, it is essential to control the acid-producing ability of the remaining
stomach.
 This can be accomplished by use of proton pump inhibitors or other medications to suppress
acid production after surgery or by truncal vagotomy and hemigastrectomy, which ensures
complete removal of the antrum. This is accomplished if the resection includes all of the
stomach distal to the third vein on the lesser curvature and the area on the greater
curvature where the gastroepiploic vessels are nearest the gastric wall.
 Some prefer to add vagotomy to the hemigastrectomy. Others prefer to conserve
the entire stomach, including the pylorus and a short segment of the duodenum without
vagotomy. The removal of the antrum greatly assists in the subsequent exposure of the more
difficult portion of the resection.
 Most surgeons now use a linear stapling instrument or a cutting linear stapler with deeper
gastric staples. A truncal vagotomy is sometimes performed

 If there is oozing between the staples, it is controlled by interrupted sutures of 0000 silk.
The upper half of the approximated gastric outlet is inverted by a layer of interrupted 00 silk
mattress sutures (figure 18). A sufficient length of the gastric outlet near the greater
curvature is retained to provide a stoma approximately two
to three fingers wide. This portion of the gastric wall should not be excised
 until the final steps of the anastomosis, although it may be necessary to apply several sutures
along the line of the clips to control oozing.
 A very critical point now involves the identification of the common hepatic artery and the
gastroduodenal artery, which runs downward over the pancreas behind the duodenum (figure
19a). The common hepatic artery may be located by palpation just above the pancreas.

 The peritoneum over it is carefully incised and this major artery clearly visualized in order
to avoid its injury. By blunt dissection, the surrounding tissue is separated
until the origin of the gastroduodenal artery is visualized. This vessel must
be identified clearly and doubly ligated (figure 19b). The lumen of the common hepatic artery
must not be encroached upon.
 The tissues about the right gastric artery also must be freed gently and separated upward,
as shown by the dotted line (figure 19b).
Following the ligation of these two vessels, blunt dissection with a long right-angle clamp may be
undertaken to further free the region of the common duct and portal vein (figure 20). Since these
patients are often rather emaciated, there is relatively little tissue to be separated away from
the portal vein.
Great care should be taken gently to develop a cleavage plane over the portal vein, which will
permit the surgeon to introduce carefully a blunt-nosed clamp, such as a right-angle clamp, behind
the pancreas and to open and close the clamp as the tissues are separated from the underlying
portal vein.

 It may be safer and easier for the surgeon to introduce the index finger directly behind the
pancreas and over the portal vein. Considerable time should be spent in manipulating the
pancreas off the portal vein. This can be done since no vessels enter from the anterior
surface of the portal vein. The tissues about the inferior surface of the pancreas may need to
 be incised so that the finger can be introduced completely underneath the pancreas and come
out inferiorly near the region of the middle colic vein

 Better exposure is gained if the body and tail of the pancreas have been mobilized to
serve as traction for the delicate dissection around the portal vein. Otherwise, the
subsequent technical details of the procedure can be enhanced if the pancreas is divided at
this point.

 Once an appropriate site of transection over the portal vein (PV) canal is chosen, it is
helpful to place hemostatic transfixion sutures on each side of the proposed plane.

 There are reproducible horizontal arterial arcades a few millimeters within the superior
and inferior borders of the pancreas. A 2-0 silk, figure-of-eight suture is deeply placed
into each border and on each side of the transection plane (total of four). Care must be
taken to not place these too deeply in to the parenchyma on the left (stay) side, such
that the pancreatic duct is inadvertently occluded. This is not a concern on the right side
where the pancreatic head specimen will ultimately be removed.

 Once tied down, these sutures are not cut but rather maintained long on a snap to aid in
leverage of the distal gland during the reconstruction phase

A blunt-nosed right-angle clamp is passed between the anterior surface of the portal vein and the
neck of the pancreas. The pancreas is divided with electrocautery (figure 22). There is usually
one sizable bleeding point above the pancreatic duct (figure 23) and at least two other vessels
below the pancreatic duct.

The
se are controlled with suture ligatures of fine silk or electrocautery, making certain not to
occlude the pancreatic duct. Although there is debate about the value of obtaining a negative
microscopic margin at neck some surgeons continue to obtain a tissue sample for frozen
section. In this case a knife is used to take a 2-mm cross section of the divided pancreas for
frozen section to ensure negative margins. If the margin is
positive, additional pancreas should be removed.

 The duodenum and head of the pancreas to be excised are grasped primarily with the surgeon’s
left hand as she proceeds gently to identify the friable vessels entering the head of the
pancreas from the right side of the portal vein
With the index finger of the left hand above and the thumb below compressing the specimen to be
excised, the surgeon applies right-angle clamps in pairs to the strand of tissue that extends
from the portal vein into the pancreas (figure 24).

Within this strand of tissue, there are a number of small veins that must
be ligated very carefully otherwise troublesome bleeding occur.

All areas should be ligated to keep the specimen as free of clamps as possible while the third
portion of the duodenum is freed from the region of the ligament of Treitz and the superior
mesenteric vein and artery (figure 25).
This can be one of the most difficult steps in the procedure. An incision into the peritoneum
about the third portion of the duodenum produces an opening directly into the general
peritoneal cavity, through which the upper jejunum eventually will be pulled for the anastomosis
(figure 25). The blood supply in the mesentery to the third part of the duodenum and adjacent
jejunum is very short, and it is often difficult to mobilize the area about the ligament of
Treitz with a minimal loss of blood.

Small bits of the mesentery near the duodenal wall are incorporated between pairs of small
curved clamps, and the contents are ligated as this area of the duodenum is further freed (figure
26).
 The attachment of the duodenum that tends to fix the duodenum beneath the inferior
mesenteric vein may be identified more easily and clamped if a portion of the upper jejunum is
pulled through the opening made in the transverse mesocolon in the region of the ligament of
Treitz (figure 27).
 The remaining short mesenteric attachments, including arterial branches going into the inferior
mesenteric artery, can then be clamped carefully with curved clamps if a portion of the upper
jejunum is pulled through the opening made in the mesocolon (figure 28).
 Alternatively, the surgeon may choose to dissect the ligament of Treitz and proximal jejunum
from the left side of the mesentery. This approach is preferred in obese patients in whom
exposure in this area is difficult.
 Since the gallbladder is often quite large and distended, it should be removed to provide
additional room and prevent late complication from gallstone formation (figure 29). Many
surgeons prefer to remove the gallbladder prior to dissection of the porta hepatis and
identification of the common bile duct.
 Attention is now directed toward further mobilization of the upper jejunum in the region of the
ligament of Treitz (figure 30). Usually, the peritoneum has been opened from above the colon,
just about where the dotted line is shown. The upper jejunum is grasped with Babcock forceps
and the bowel held up in order to enhance the visualization of the arcades providing the rich
blood supply to the jejunum.
 Incisions are made through the avascular portion of these arcades, so that
two or three of the basic arcades can be divided and double ligated to enhance the
mobilization of the upper jejunum (figure 31).

 The arcade to be divided must be identified very carefully, and no vessels

should be ligated in the mesentery near the mesenteric border of the bowel, since the blood
supply to that segment may be compromised. When a segment of the mesentery of the upper
jejunum has been divided, the jejunum is brought up through the opening in the mesocolon
underneath the superior (figure 31). About 1 cm of the mesenteric border is
freed of blood supply and the jejunum divided with a cutting linear stapler
(GIA). The specimen is removed and the jejunal arm is brought up through
the opening in the mesocolon must be long enough to reach well up into the
gallbladder fossa without undue tension or compromise of the blood supply.

 If there appears to be considerable tension, the bowel should be returned back below the
colon and additional mesentery divided.

The bile and pancreatic ducts are arranged to empty their alkaline juices into the jejunum
before the acid gastric juice as a measure of protection against peptic ulceration.
The mobilized jejunum can be used safely in a variety of ways for the several anastomoses
required. The end of the jejunum can be closed and anchored up into the region of the gallbladder
bed, followed by direct anastomosis with the dilated common duct and pancreatic duct within a
very short distance of the closed end of the jejunum.

The jejunum is then anastomosed to the partly closed end of the gastric pouch (figure 32a).

Some prefer to implant the open end of the pancreas directly into the open end of the jejunum
(figure 32b). Unless the pancreatic duct is quite large, this is perhaps a simpler procedure than
that in figure 32a. Alternatively, a pancreaticogastrostomy may be performed. The common duct
then is anastomosed to the jejunum and at an easy point of approximation to the stomach.

The end of the jejunum then should be anchored to the tissues medial to the common duct or
even up into the lower portion of the closed liver bed.

Great care should be taken, however, that sutures do not include the right hepatic artery, which
may curve upward into this area. The end of the common duct is then anchored with interrupted
0000 sutures to the serosa of the jejunum.
Reconstruction = separately written

Sutures of 0000 size are used to fix either side of the end of the common duct to maintain the
wall under slight tension as a row of interrupted sutures is placed to anchor it to the serosa of the
jejunum. The fixed angle sutures are allowed to remain for traction (figure 33), while an incision is
made into the adjacent jejunal wall a little shorter than the diameter of the lumen of the common
duct (figure 33).

A series of interrupted 4-0 or 5-0 absorbable sutures is used to accurately approximate the
mucosa of the jejunum to the common duct. Placement of the interrupted sutures in the closure of
the anterior layer is then performed (figure 34). The catheter also ensures a sizable stoma. This
is a single-layer anastomosis. The peritoneum, which tends to be thickened over the region of the
common duct, is anchored with interrupted sutures to the serosa of the jejunum, starting beyond
the angles of the anastomosis and extending anteriorly parallel with the anastomosis (figure 35),
which holds the divided end of the pancreas (figure 36). The posterior capsule of the pancreas is
anchored with interrupted 000 sutures to the serosa of the jejunum (figure 37). There should be
no tension and preferably some redundancy of the jejunum between the several sites of
anastomosis. The patency and size of the pancreatic duct are determined by
inserting a soft rubber catheter. With the catheter in place to serve as a stent, the margins of
the duct are freed for a short distance to facilitate an accurate anastomosis to the jejunal
mucosa. A very small opening related to the size of the pancreatic duct is made into the lumen of
the jejunum, and interrupted 00000 or 000000 sutures are placed at both angles (figure 39).

The catheter is rotated to the left while the posterior layer of sutures is placed, and it is then
inserted into the lumen of the bowel as the anterior layer of sutures finally is completed. The
catheter serves as a stent and makes it easier to place the sutures more accurately through the
mucosa of the jejunum as well as the pancreatic duct. When this anastomosis has been completed,
the capsule of the pancreas is anchored to the serosa to seal off the raw end of the gland against
the wall of the jejunum (figure 40).
Some prefer to insert the open end of the pancreas into the open end of the jejunum, especially
when the pancreatic duct is quite small (figure 41a). The margins near the cut end of the pancreas
should be freed for several centimeters in preparation for telescoping the end of the
jejunum over it, and all bleeding points should be ligated carefully. The end of the jejunum is
usually large enough to admit the end of the pancreas. If not, it may be necessary to incise the full
thickness of the jejunum along the antimesenteric border to make the opening large enough to
match easily the size of the end of the pancreas. After all bleeding is controlled, the mucosa of
the jejunum is sewed to the capsule of the pancreas in a manner similar to an end-to-end
anastomosis. A small, soft rubber catheter can be inserted into the lumen of the pancreatic duct
to ensure its patency during the completion of the anastomosis. It is subsequently removed before
closure of the gastrojejunostomy. An additional one or two layers of interrupted nonabsorbable
sutures are placed to pull the jejunal wall up over the capsule of the pancreas for approximately
1 cm (figure 41b). The common duct and gastric anastomosis to the jejunum are not altered.
The gastrojejunal anastomosis may be made over the entire length of the gastric outlet, or the
outlet may be partly closed and the stoma limited in size. The full thickness of the gastric wall,
including the staples, is excised to provide a stoma three to four fingers wide (figure 42). Any
retained gastric contents are aspirated, and all bleeding points in the mucosa of the gastric wall
are controlled. The serosa of the jejunum near the mesenteric border then is anchored to the
posterior wall of the stomach from one curvature to the other with 000 silk (figure 43). The
jejunum should be approximatedloosely so that there is some laxity between the anastomosis of
the pancreas and the gastric wall in the region of the lesser curvature. An opening about
two fingers wide is made in the jejunum, and the gastrojejunal mucosa is
approximated with interrupted 0000 absorbable sutures (figure 43). The
gastrojejunal anastomosis is then completed with a layer of interrupted
0000 nonabsorbable sutures, with the knots buried on the inside. The second layer of the
gastrojejunal anastomosis is then completed with a layer
of interrupted 000 sutures from one curvature to the other (figure 44).
The opening in the mesocolon should be approximated to the jejunal wall(
figure 44) to prevent prolapse of small bowel up through this opening.
The opening about the region of the ligament of Treitz should be closed with
ooo silk. A gastrostomy tube and feeding jejunostomy may be indicated in
the malnourished patient. Closed-suction drains are placed adjacent to the
choledochojejunostomy and pancreaticojejunostomy.
CLOSURE The abdominal wall is closed in the routine manner. In the
presence of emaciation or in the older age group, it may be advisable to
close the fascia with figure-of-eight stitch or by the addition of numerous
retention sutures.
POSTOPERATIVE CARE It is of paramount importance, especially in
the jaundiced patient, to make certain that the blood volume is restored
at all times. Fluid balance is sustained by administration of 5% Ringer’s
lactate solution. Blood sugar and amylase levels are obtained. The hourly
urine output should be watched carefully and should be maintained at 30
to 40 mL/h. The administration of intravenous fluids should be balanced
throughout the 24-hour period. Urinary output and the replacement of gastric drainage will
determine the amount of fluids required.
The patient’s weight must be watched carefully, and an adequate daily
caloric and vitamin intake assured. Blood sugar levels should be determined at regular intervals. If
a feeding jejunostomy tube has been inserted,
tube feedings by continuous infusion may be started 24 to 48 hours after
surgery. Initial infusion rate should be slow and gradually increased. The
output from the closed suction drains should be monitored and determination of amylase
concentration performed after starting oral intake, usually 5
to 7 days after surgery. The drains are removed if there is no bile in the drain
fluid and if the amylase is less than that of serum.