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Whipple Procedure for Multiple Endocrine Neoplasia of the Pancreas

Keith Lillemoe, MD, Andrew Loehrer, MD
Massachusetts General Hospital
  1. Incision and Exposure
    1. Administer Anesthesia
      • Epidural anesthesia obtained in the holding area
      • General anesthesia obtained in the operating room
    2. Position Patient
      • Patient placed in the supine position with both arms outstretched to the side to allow for a Bookwalter retractor placement
      • Patient secured to the operating table as tilting the bed during various portions of the case can provide more adequate exposure
      • Nasogastric tube placed at the onset of the case to decompress the stomach
    3. Make Midline Incision
      • Procedure can be performed through an upper midline incision or a right subcostal (Kocher) incision, per surgeon’s discretion or comfort
      • Incision made from below the xiphoid process to above the umbilicus
    4. Mobilize Ascending and Transverse Colon
  2. Extended Kocher Maneuver
      • Upon entering the abdomen, the omentum, peritoneal lining, and liver are inspected for signs of metastatic disease. Any suspicious nodules should be excised and sent for frozen section evaluation by pathology.
    1. Identify Inferior Vena Cava
    2. Inspect Ligament of Treitz and Inferior Mesenteric Vein
    3. Inspect Duodenum, Head of Pancreas, and Tumor
    4. Identify Branches of Superior Mesenteric Vein to Pancreas, to Colon, and Gastroepiploic
      • Divide branches from SMV to head of pancreas
  3. Cholecystectomy and Portal Dissection
    1. Retrograde Mobilization of Gallbladder
    2. Identify Common Bile Duct
      • Should be at insertion of cystic duct
    3. Divide Common Bile Duct above Insertion of Cystic Duct
    4. Dissect Bile Duct Inferiorly to Insertion into Pancreas
    5. Identify Gastroduodenal Artery and Relationship to Hepatic Artery
      • Divide gastroduodenal artery
  4. Mobilization and Transection of Duodenum and Pancreas
      • Create plane posterior to pancreatic neck
    1. Mobilize Duodenum
    2. Identify and Divide Right Gastric and Gastroepiploic Arteries
    3. Divide Duodenum Distal to Pylorus
    4. Reflect Duodenum and Pancreatic Head to Show Pancreatic Neck
    5. Divide Pancreas at Level of Neck
    6. Identify Pancreatic Duct
  5. Mobilization and Division of Jejunum
    1. Identify Ligament of Treitz
    2. Divide Mesentery Distal to Ligament from Jejunum
    3. Divide Jejunum
    4. Mobilize Mesentery Proximal to Ligament of Treitz
    5. Reflect Duodenum and Head of Pancreas under Root of Mesentery
      • This exposes the superior mesenteric vessels and uncinate process
    6. Mobilize Uncinate Process Off of Mesenteric Vessels
    7. Divide Inferior Pancreaticoduodenal Artery
    8. Remove Specimen with En Bloc Duodenum and Head of Pancreas
    9. Oversew Defect at Ligament of Treitz
  6. Pancreatojejunostomy
      • Defect made in right transverse mesocolon
      • Jejunum delivered through defect into retrocolic space
    1. Evert Sutures Placed in Pancreatic Duct
    2. Create Enterotomy in Jejunum
    3. Place Stent through Anastomosis and into Pancreatic Duct
    4. Perform Anastomosis
      • Seromuscular layer of anastomosis performed with 3-0 silk
      • Mucosal layer performed with 5-0 double armed PDS
  7. Hepaticojejunostomy
    1. Create Enterotomy in Jejunum Distal to Pancreatic Anastomosis
      • Made several centimeters distal to pancreatojejunostomy enterotomy
    2. Perform Anastomosis
      • End to side anastomosis performed circumferentially with 5-0 PDS
  8. Duodenojejunostomy
    1. Close Mesentery Defect
      • Secure bowel at defect of transverse mesocolon with 3-0 silk
    2. Begin Anastomosis
      • Antecolic anastomosis performed with seromuscular layer using 3-0 silk and continuous mucosal layer using 3-0 PDS
    3. Complete Anastomosis
  9. Closure
    1. Place Blake Drains
      • Abdomen irrigated with antibiotic solution
      • Two 1/4-inch Blake drains placed both anterior and posterior to the biliary and pancreatic anastomoses
      • Pancreatic stent passed through a separate stab incision in anterior abdominal wall
      • Fascia closed with running #1 looped PDS suture
    2. Close Mesentery over Enterotomy
    3. Close Wound
      • Subcutaneous tissue irrigated with antibiotic solution
      • Marcaine injected for pain control
      • Drains secured with 3-0 nylon
      • Subcutaneous tissue closed with 3-0 Vicryl
      • Skin closed with subcuticular 4-0 Vicryl and Steri-Strips (could have used staples of Monacryl sutures instead)