Whipple Procedure for Carcinoma of the Pancreas - Part 1

Anesthesia

1. An epidural is placed for postoperative pain control in the operating room or pre-operative area.
2. General Anesthesia is given in the operating room.

Positioning

3. Patient placed in supine position with all bony prominences well padded.

Exposure and Approach

4. Abdominal midline incision extending from xiphoid to just below umbilicus. An alternative is a right subcostal incision.
5. Once abdomen entered, the entire peritoneum is inspected including the surface of the liver to insure no peritoneal metastasis. If found, procedure is aborted.
6. Hepatic flexure of right colon mobilized and reflected medially.
7. Duodenum identified.
8. Kocher maneuver performed, where incision of peritoneum is made along right border of duodenum, allowing reflection of the duodenum and head of the pancreas medially, or to the left of the patient. This allows for mobilization as well as palpating involvement of the retroperitoneum and SMA.

Inspection/Identification of Structures behind Duodenum

9. Determine if any lymphadenopathy is present.
10. Inspection and palpation of superior mesenteric artery.
11. Inspection of common bile duct.
12. Inspection of transverse mesocolon with mobilization of omentum off of transverse mesocolon and colon.
13. Lesser sac entered by incision of lesser omentum.
14. Identify middle colic vein flowing into the superior mesenteric vein.
15. Follow superior mesenteric vein under neck of pancreas to portal vein.

Cholecystectomy

16. Gallbladder mobilized in retrograde fashion.
17. Cystic artery cauterized and alternativel clipped.
18. Cystic duct mobilized to insertion into common bile duct.

Management of porta hepatis

19. Incise peritoneum overlying porta hepatis.
20. Identify hepatic artery and common hepatic duct as it joins with cystic duct to form common bile duct.
21. Mobilize common bile duct and transect just proximal to the insertion of the cystic duct.
22. Proline sutures placed on hepatic duct to prevent retraction into liver.

END of PART ONE (Part 2 Video to cover remaining steps)

Mobilization and Division of Proximal Extent of Duodenum

23. Mobilize Pylorus and and Perform Partial Omentectomy
    1. Gastroduodenal artery identified at its insertion into hepatic artery.
    2. After insuring good blood flow through common hepatic artery when occluded, gastroduodenal artery is divided using vascular stapling device. Alternatively, this may be done by suture ligation or clips.
24. Divide Stomach 2 cm proximal to pyloric valve using gastro-intestinal stapling device.

Mobilization and Division of Jejunum

25. Divide Jejunum with GI Stapler.
26. The Ligament of Treitz is identified and 10 – 15cm distal to this an appropriate vascular arcade is identified. The Ligament of Treitz is then mobilized with dissection of the 3^rd and 4^th portions of the duodenum. This is brought under the superior mesenteric vessels to the right upper quadrant.

Mobilization and Division of Pancreas

27. Suture ligate superior and inferior pancreaticoduodenal vessels used for vascular control and traction.
28. Once under neck of pancreas, divide pancreas.
29. Portal vein separated from uncinate process of pancreas via blunt and sharp dissection.
30. Mobilize head and uncinate process off the portal and superior mesenteric vein. This includes taking the retroperitoneal tissue posterior to the superior mesenteric artery. Small branches of the vessels either clipped or cauterized.
31. Once completely mobilized to the superior mesenteric artery, transect the remaining tissue with clips and electrocautery allowing en bloc resection of the pancreas and associated duodenum
32. The pancreatic margin on the specimen is marked for a frozen section.

Reconstruction

33. Proximal end of jejunum is brought through defect in transverse mesocolon.
34. Pancreatic duct identified.
35. Enterotomy performed in jejunum.
36. Pancreaticojejunostomy is performed by anastomosing duct to jejunum in a duct-to-mucosa fashion using 5-0 PDS suture for the mucosal anastomosis, and 3-0 Vicryl for a posterior layer and anterior. layer of pancreas to serosa for the second layer. A silastic stent is placed through the anastomosis prior to competion.
37. Hepaticojejunostomy is performed distal to the pancreaticojejunostomy by creating another enterotomy and anastomosing the hepatic duct to the jejunum in an end-to-side fashion using 4-0 PDS suture.
38. This loop is sutured to the mesenteric defect to prevent an internal hernia.
39. A distal loop of jejunum approximately 20 cm distal to defect in the transverse mesocolon is brought either retrocoloic or antecolic.
40. Small enterotomy in the jejunum and a gastrotomy on the posterior wall of the stomach are made.
41. Gastrojejunostomy performed via the enterotomy and gastrotomy using a gastrointestinal stapler to create a common wall.
42. Defect in gastrojejunostomy is oversewn with interrupted 3-0 Vicryl suture.
43. Gastrojejunostomy tube, or separate Gastrostomy and jejunostomy tubes placed.
44. Purstring of 3.0 Vicryl made on anterior wall of stomach close to great curve.
45. Gastrotomy made.
46. 5 mm incision made in left upper quadrant and G-J tube brought through.
47. Place tube into stomach threading it through the distal loop of jejunum until the ballon is in the stomach.
48. Tie down purstring.
49. Blow up ballon and pull up to abdominal wall.

Closure

50. Abdomen copiously irrigated.
51. Fascia closed in running fashion using #1 PDS suture.
52. Skin reapproximated using skin staples.
53. Patient transported to either recovery room or ICU.