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Whipple Procedure for Multiple Endocrine Neoplasia of the Pancreas

Keith Lillemoe, MD, Andrew Loehrer, MD
Massachusetts General Hospital

Transcriptions

CHAPTER 1

Alright. Knife, please. So why don’t we just go from about right here down to the very top of the umbilicus? Alright, we’re starting. Incision. Now as I said, I prefer the midline, but you can do this through a subcostal, bilateral subcostal, whatever - whatever you prefer. Just going to find the midline for you. Remember, we - I don’t know if we did this the other day but - but just - while you're shaving off the fat, you don’t make an incision in the anterior? I actually try to find it first. Which is right there. You can do the rest with a cautery. Dissect! I always try to spend a little extra time getting in the abdomen just because it's - if you stay in the midline, then you don't have to worry about where the anterior sheath is and the posterior sheath, and at the end of the case when you're tired and just want to close fast, it's just…

Stand it up just a little bit underneath the incision if you can. Okay, and down here just a little more. There we are. Go ahead and put your fingers in. Okay, good. Let’s go ahead and take the falciform up right through here. A couple Kellys, please. Take it all the way up to there. Metz. Long Metz to Laura. Your NG tube is perfect, so you can tape it. You know, the imaging doesn’t show any metastatic disease, but obviously, these things can metastasize. So we want to take a look and feel and be okay. Looks over there to be okay. Okay, let’s have the Bookwalter retractor, please. Take another one over here. Thank you, Andrew. So take - let's take this down now, just a little bit more. Cautery. Okay. Alright, you have one more? Okay, big tug on that, Andrew. Okay, so exploration reveals no metastatic disease,so now we're going to mobilize the right colon out of the - white line of Toldt off the liver.

CHAPTER 2

Bovie with the extender. Yeah. Yes, please. So you can just put your finger right here - you can feel the mass. It’s like a little golf ball sticking out of her pancreas already. We're just taking down a few adhesions of the colon to the liver. So here’s the vena cava starting to show its way through. We're already starting our Kocher maneuver to some extent. Little bleeder right there. Yeah, little further over here then. She's helping us. The head of the pancreas is going to be almost out of the wound here in a second or two. Okay. Take that little bit there. So I extend my Kocher maneuver all the way to the ligament of Treitz. So he's going to eventually pop through closer to - right there, yeah - going to eventually pop through and be to the opposite side. When he does that, he's going to have - now I've got the duodenum in my fingers. Right there - I think you'll be through if you get through there. Stay right on that edge of the duodenum right - right there. That stuff can all go there. Take that over there. Alright. You're just about there, Andrew. See that little space? Go right through that. Okay. Good. Now take all that. All that can go. Now that’s the IMV right there, so take just a little bit more of that right there.

Okay, so now we're going to go over here just to show you the anatomy on the ligament of Treitz side. Here's the ligament of Treitz. Here's the IMV - right there. So if you look, here's the inferior mesenteric vein coming up. We don’t know where it joins the splenic or whatever, but it's certainly right there visible. So we've got most of the ligament of Treitz mobilized, but - but Andrew just popped through right here. Okay, I think that's good enough. So drop all that back there again. Push everything back. So here's the duodenum, the C Loop of the duodenum. Here's the head of the pancreas, and here's the mass right here - clearly, sort of almost golf ball sized lesion. Sort of soft and plump but looks like it's well away from any of the vessels, but now that's where we're going to go next - is to identify the SMV So in my mind, this is a key component of the case because this is where you can get in to tear little vessels and cause bleeding. But somebody as thin as she is, we really shouldn't have that problem, so if we just go nice and slow...

Most of this stuff without radiation - without cancer - you can almost just push away. There's a vessel there that you want to stay away from. See? See, all these vessels are sort of hidden down. Let’s work all the way up here. The more you mobilize, the - the more the vein just is going to pop right out. Okay, let’s go over here. Right on that edge - that’s all nothing I think. Okay, all that stuff - so there’s your ligament of Treitz right there, so take all that down.

There are lots of ways to find the superior mesenteric vein, but see it's starting to come in here. You can follow the middle colic branches down, but the key to me is mobilizing it so that you're not working in a hole and start seeing its branches. So gentleman, we’re coming right now to the SMV, exposing it nicely in right in the middle of the field, and there's typically - typically three branches. Okay, I'm going to say that to you, and I want you to count them for me, alright Laura? Okay. So beautiful. You see this little branch right here? There's usually the three branches. There's one that goes to the head of the pancreas. There's - this one is actually not the one. This is sort of a lateral branch. So there's usually this trunk right here. This trunk usually comes up straight anteriorly, and there's three branches off of that. So there's one here going to the head of the pancreas, one here going to the colon, and then the gastroepiploic branch will come down at some point too, so. Okay so, going to just keep gently exposing these. But it’s that trunk, and once you get that trunk ligated, you should have really everything exposed.

So the first branch - can I have a right angle, please? 2-0 silk tie. So, we’ll take that one later, but that's like - almost like the first jejunal branch. But this one… Okay. And if you remember, I want you to pull it over there, and then we'll clamp on the specimen side. Okay, tie. Now he's going to cut the tissue first. Now you can cut the suture. Can I have another tie? Get the other one. Okay, cut. Perfect. So one thing very important when you cut, okay? Particularly here, is don't jerk back until you've - you've seen the sutures cut, because if you cut one and you jerk back and it sticks, you could avulse that tie, and all of a sudden we got a little hole in the - look over here. I see a little ble - blood coming from someplace, so hold this up for me. Cut. That’s not one of the major branches, but it's oozing pretty good, so. Just because we don't want to lose any extra blood, and we don't want to… What we're - no, we’re getting the major branches of the SMV - have nothing really to do with the tumor. They're just the natural branches to the head of the pancreas, so. The tumor doesn't - I mean, obviously, the tumor’s vascular, but it's not - these are not direct tumor branches.

He'll take a small Metz, please. Here's the branch coming down from the colon there. So the one we haven't seen is the… So let me have a Schnidt, please. And there’s the trunk, right there. Leaving a little bit underneath that trunk. Okay, so pull it towards me. And then, okay. So that's branch number two. Just letting you know - the tips aren’t great. I didn’t hear you complaining about it though.

Okay, so hold that up one more time. I want to find the gastroepiploic now. So Laura, once you get those branches ligated, then there's no anterior branches to the - to the portal vein SMV, so you can just sort of gently push this through. So we got the - sort of the tunnel underneath the - under - underneath the neck of the pancreas exposed, and I think what happened is we took the the gastroepiploic branch when we took that. I think that comes down from up here too. Alright, so let's leave that alone for a while.

CHAPTER 3

Okay. So now we - we've completed the dissection below the level of the neck of the pancreas. Now we need to complete it to be a - above it, and to do that, since we're sure we're going to be doing a Whipple, we're going to mobilize the biliary tree, divide the common bile duct, expose the portal vein from anteriorly, and then move laterally. So pair of DeBakey's to Laurel, please. Alright, you ever done this? No, I have not. Great, it’s like taking a hard-boiled egg, and you're going to take the shell off, so grab this tissue here - it's very paper-thin - and just excise it a little bit through the tissue there. Okay. A little bit deeper. Okay, good. So there's your levels, so go through that. Okay, take all that off - this, right. Yeah, I think you're doing great, but in a few seconds when it starts getting difficult, we - we need to change our exposure - both of us. So take all this down. Keep going there. Keep going. Okay, so eventually, we’re going to come to two structures, right? You know what those two structures are? I’m not sure - you’ve got to find the cystic duct and the cystic artery. Right. So, take a little bit more of that. So here's the common bile duct, the blue duct. Here's the cystic duct probably coming in here. We haven't seen it yet, so we want to expose this just a little bit more.

Work from where you have the plane going, okay? So there's your cystic duct right there, right? Okay, so let's just have a silk tie. Let go. Okay, so you pull that up. Now I think if you let Andrew take this like this and widen this out, you'll see that the cystic duct is probably down here. So that's probably the cystic artery there, that you have, and this is probably the cystic duct here. So let's go ahead and ligate that, so can you tie that for me, please? Sure.

Alright, so we - we've ligated that one structure. Now let me have a right angle again. Now, we’re going to not ligate the cystic duct, but if we were just taking out the gallbladder, we just clamp here, clamp here. But we're going to use that to get around the common duct. Alright, so we're going to try to open this face up. Here's the common bile duct. So we want to open this up just a little bit more so that we can get around the common bile duct. I would tie this too. 2-0 tie. Little tiny structure there - could be… Alright, so. So now let's try to open this up just a little bit, so I'll pick that tissue up and just score it the slightest bit. I don’t think there’s anything - you can buzz through that I think. Nice petite cystic duct. Oh, see this stuff here, Andrew? Clean that off.

So we’re behind the common bile duct, lateral to the portal vein. Is there any structures that we should be cognizant of there as - as we’re mobilizing this stuff up? See all that stuff back there? Just take that. So kind of in this area behind the common bile duct, adjacent to the portal vein on the right. So the hepatic artery’s here. You can see the hepatic artery pumping. Let's just imagine the - the - there’s a force structure running - vessel loop, please - there's a force structure running right below where my clamp would be. So this is a - we're passing a loop around the common bile duct. Here. Snap. Snap. So have you ever heard of a replaced right hepatic artery? No, I haven't. So a replaced hepatic artery comes off the - the SMA and runs right up along here, and so it's an anomaly that’s pl - present in about 18% of people. And when you're doing Whipple, you got to be cognizant of it because as you're doing all this dissection we're about ready to do, you can injure it.

Andrew, I think, I'm ready to divide the bile duct here. Let's take it right at where the cystic duct comes in. So let's pull it this way like this. Take a little bit more of this stuff here. You can see the hepatic artery just pulsating away there. You can see them on the CT scan if they've done a nice arterial phase study, and to be honest with you, on this young lady, it - I'm sure it was well enough done study. So if we see somebody who, you know, is being worked up for pancreatic cancer, and we want to see where all the vessels are and stuff, we are very insistent that we have dual phase. So just divide that. So we’re going to divide the common bile duct. Here, I just divided with a cautery. You have a - like, a - a bulldog? Little bulldog? You want a curve, or you want the little…? Curve would be fine. So this is the problem with this young lady. Look at how tiny this bile duct is - not going to be fun to reconstruct at some point, but…

So Andrew, just pick that up. Now the nice thing about this lady as opposed to - just pick up the bile duct this way. Take the bulldog - is she doesn't have a stent in, so my guess is her bile is totally sterile. Okay? So we got her gallbladder here, so then there's all this lymph. Hold that please. There’s all this lymph node tissue to the right, and this is where the replaced right hepatic would be if we felt for it. And we're going to be just a little careful. You have the harmonic? So we're going to go through this with the harmonic just for hemostasis because there are little lymph nodes and little vessels in here and… Stay away from the vein. Okay, go a little bit further. Actually, cautery would be fine here. Yeah. Bovie, please. Use the harmonic for those lateral lymphatics? Probably do it with - yeah, we’ll use it multiple times through the course, but anything that looks like it could have a vessel in it may. Like this - we might do this with it. Harmonic, please. We’ll be going back and forth. There’s the portal vein behind us here. Pull that over there, Andrew. Cautery a little bit more here.

So there's the hepatic artery here, so is there another structure we’re thinking about looking for at some point? So we’d be looking for the gastroduodenal artery. Right. Actually, probably right in about now. Tie. You want me to tie that or ligature? We'll tie it - just put a tie around it first though. Just going to pull it up that way. Just trying to make sure what that is before we tie it - could be the GDA right there. Just - just clamp it for right now. We’re not going to tie it quite yet. Do you have a clamp? No, just a snap. So the reason I’m - I - I don't like clamping anything until I've actually found the GDA for couple reasons. Number one, so my - like her, it can be pretty small. So I - I'm pretty sure I know where the hepatic is, and I'm pretty sure that's just a little venous branch - but I want to actually know that I'm getting around the GDA before I take it.

Work down here just a little bit. Pick up some of that stuff there, Andrew. You just pull that over there. So my guess is that the GDA is right there. But - and so we’ll eventually ligate that stuff. Bovie, please. Pick this stuff up again, Andrew. Tie that. Okay, why don’t you get us a disposable GIA 60? Can I have a tie, please? We’ll need one reload on it.

CHAPTER 4

Okay, so here's the pylorus right here. Go ahead and take a feel of the - feel the pylorus. Go ahead. So there's two kinds of resection. There's the classic pancreaticoduodenectomy or the pylorus-preserving. But it's been looked at by multiple prospective randomized trials, and nobody has ever shown an advantage - one over the other - with respect to delayed gastric emptying, with respect to complications, with respect to anything. So you - basically, people just do what they feel most comfortable doing. So what we’re taking right now is the right gastric. You can probably take that with a tie. I - most - every one of those randomized studies have shown that the pylorus-preserving actually is faster to do than - than the classic because you have basically two staple lines with the classic. You have the lesser curvature and the suture - scissors - Metzenbaum's to Andrew. As you’ll see, we'll have a small, single duodenal anastomosis to do. Okay, get your scissors back. Okay, so now we have to find the gastroepiploic on this side. And I would probably... Harmonic? Or tie? Harmonic for that.

Do you wait a certain amount of time before using Reglan? So I usually - one. Postoperative day one would be a little early, but if - if the purpose of your question is to ask me do I worry about giving it too early - I would take that with a tie. Ah, never mind - go ahead, use the harmonic. That’s fine. I don't think that’s… I don't worry that it causes more propulsion or issues with your anastomosis, so no. But usually, you know, people get the NG tube out - and their stomachs are empty when they take it out, and it takes a day or so to get to the point where they start feeling - you can take that too. Alright, let’s go back over here. Let’s have a - do you have a Penrose drain? We should be able to clean this off a little bit better.

Okay. So we try to get about 4 centimeters of duodenum. So here's your pylorus right here. Alright, looks like about 4 centimeters, so Andrew I think you can just take a little bit more - mobilize a little bit more. Okay, so GIA… Yeah, slide up just a little bit now. Okay, good. That's perfect. Alright, so now, here's our specimen this way. The gastroepiploic is right in here. The gastroepiploic is of course an extension of the gastroduodenal, right? So here's probably the gastroepiploic right here. The gastroepiploic vein - you can see how that comes down right there. I bet you - right there - I bet you if you follow it down to where we have it ligated on that other side, we - we have it because I promised it would be three branches and… Metz. That’s good enough.

Alright, so now we're going to push the stomach out of the way - that works - and by doing that, you see how we push it down, it actually kind of brings the - the neck of the pancreas up. So let's work along this edge here a little bit more. Pickups to me. So the hepatic artery is right here, Laura. I think the GDA is right here, so this little bit of nothing that we've been holding all along can now go. And I'm going to clamp this side, and you can tie that. Again, this is a big lymph node. It's not that big in her, but when you operate on somebody with pancreatic cancer who’s had jaundice, that lymph node's sometimes very enlarged. And so when they do an endoscopic ultrasound, they’ll come back and say large peri - lower portal lymph nodes.

I think I’d take that. Yep, that's a vein. 2-0 tie. So it's right, really at the head of the pancreas right after the SMV portal vein - I guess it's a portal vein at this point - passes under the neck of the pancreas, and it comes out - starts running up along the porta. Sort of - there's a fairly substantial venous branch that - that feeds into the - sort of the head of the pancreas. Again, if you don't look for it and you just sort of blast your finger through there and try to dissect that plane, it can be avulsed very, very quickly, so part of avoiding complication - operative complications - is having had them all before. So you learn where to look and where these problems can exist. And that vein is a very consistent finding, and it's pretty much always there and sometimes - that was kind of long - but sometimes, it's sort of - kind of short. Yep. See, there it is. It's - it's tiny. See that little lumen right there? Yeah. Okay, so what I want you to give Andrew - a 5-0 prolene, please. GDA being oversewn with a 5-0 Prolene suture ligature.

So why are we doing that? I mean, we have a tie on it. It's not bleeding. Well, I know that's… You know that's? It’s one of the feared complications of a pancreaticocutaneous fistula is a GDA pseudoaneurysm. Absolutely right. So this at least minimizes the chance, right? And if you were going to say high, low, or medium risk of developing a pancreatic fistula or perianastomotic abscess, would you say this lady's high, low, or medium risk? She’s a high risk. Yeah, I’d say she's high risk. She's got a - she'll have a tiny duct. She'll have a soft pancreas. You're right. This is a safety net. It’s belt and suspenders on the GDA artery in case she gets a leak so that it's less apt to blow out. Alright, so Andrew, let’s take your cautery and just divide it. You see where that tie is there? Just divide it right there. We’re dividing the pancreas with a cautery right now. We're just going to go perpendicular? Yeah, perfectly perpendicular. Now if this was an adenocarcinoma, I'd send this margin, but I think that's pretty unrealistic that we have any concerns about it. It’s going to bleed a little bit, which is normal, because there are little vessels in the pancreas.

Okay. So here's the edge of the pancreas right here. At some point we'll find the pancreatic duct, but we’re just going to have him dry this up now. Okay. So we're just going to take a little wafer across here. Can - you can do this. As Andrew said, it's - the gland is kind of like warm butter as you cut through it. Okay, so lay this down here, and I want you to put a 3-0 pop-off silk in that tissue right there, okay? This is a fresh transected end of the pancreas. We're just - it’s very well vascularized. There's the pancreatic duct - very small. We’ll show it to you in just a second. Can I have a little probe, please? Just hold on one second, Andrew. See the duct right there? There’s the pancreatic duct right there. So long as it’s not - yep, let’s zoom in on the pancreatic duct. Put a little probe in it here. It just slides right in like that. Okay, good.

CHAPTER 5

You think of the pancreas like this is the neck, right? We just divided the neck. We flipped it over, so the tumor’s here where my knuckles are. So the uncinate goes like this, and it's under the SMV - and it abuts up against the SMA. And again, because we're not really particularly concerned about cancer invading this, we’re just going to mobilize this and just blast right through all of this with the harmonic and should have the specimen out reasonably soon. So now we're going to go to the proximal jejunum. Bovie, yeah. So there's your ligament of Treitz right here. Let’s all confirm - see, ligament of Treitz. All we want is enough length to reach up there. Don't need a big resection, so Andrew, just pop through right there. Okay, and just hit your harmonic and start going through all these. This way - to my side of course.

So you can divide the jejunal branches with ties or clips or - you know, I - I found that the harmonic works about as well as anything. I don't think so. Stitch marks the true pancreatic resection margin. Oh, yeah? Okay, let’s take the GIA and cut here. So who'll be - do you know who's covering this surface? I do not. I’ll make sure to let you know though. Alright. Okay, so - so we've divided the bowel in two places. We divided the bile duct. We’ve divided the pancreas. So all that’s left to divide is the uncinate. Harmonic. So - so - just - if you could reach over - Bovie, please. Take that stuff with it - Bovie. Okay, probably back to the harmonic now.You just stay right on the bowel. You see those big vessels there? You don't want to get into those in any way, so…

So one philosophy I have about doing surgery is you always try to work where it's easy, and once it starts getting hard somewhere, then you go to someplace where it's easier. So now again, in this lady you see how mobile the uncinate is - so see this big vessel running here? Yeah. That's the first jejunal branch. It feeds off all of those things. Take this stuff here laterally. So that's a branch we may end up taking - almost always end up taking it when you have an uncinate cancer, but you take it right when it comes off the SMV. We’ll show it to you later.

So now we're at the ligament of Treitz. We're actually mobilizing the third and fourth portion of the duodenum now. This is the tumor starting to come through. So we're going to drop this back under here. Look at it - somebody stole her pancreas, right? It’s no longer there. You - you reach - you pull this through and look how much she's mobilized like this. So now we can just pick - we can just pick this up. It’s tethered by the uncinate. And so this is the first jejunal branch, and so if you got a cancer of the uncinate, it's - it's - you got to peel it right off of there and - or you sometimes get in it.

So now we can just save that branch by slowly going through all of this. Let’s actually tie that, Andrew. Okay. Yeah. The mass is right there, and - and again, because it's neuroendocrine tumor, we don't have to worry. It's - it's unlikely to have any invasion, and the CT imaging shows that this is just all normal pancreatic parenchyma. You don't have to really peel the uncinate process off the artery and vein. Most of the time when you do this in a pancreatic cancer in a 60-year-old male, you're - tie - you know, not holding the specimen outside of the abdomen, and this is just so mobile and non-fixed. Her biggest risk is - is recurrent tumors in the rest of her gland. And, you know, she's had endoscopic ultrasound. The CT doesn't show anything, but the endoscopic ultrasound shows there's a little tiny, other lesion that's in the tail of the pancreas. It’s like 4 or 5 millimeters.

Okay so there's - there's one other thing we got to be thinking about. Do you know what that might be, Laura? Turn. Okay, yep. Down here? Yep, down here. So again, in my finger, on my left hand, is the root of the mesentery. The SMA and the SMV is right there. So what other structure as we’re div - dividing through this uncinate are we looking for or thinking about? 15 blade again. So the blood supply of the head of the pancreas is the gastroduodenal, the superior pancreaticoduodenal, and the inferior pancreaticoduodenal, and you can usually find that here. There’s usually a short direct branch that comes right off of it, so - so let's go up to the top again a little bit. Take her gallbladder up. Can I have a Kelly again?

And now if - again, if we were worried about this margin, we would be mobilizing the SMV up further, and we would be, you know, basically peeling it right off the SMA. So again there's this big branch we've been dealing with all along. Small bowel venous drainage is such that this is not a big deal to take it, but if you can preserve it, you might as well. See, as I put my finger right here, you can see the pulse right - of the SMA below.

Okay, I think we’re going to find an artery in here, so let's just go real slow. I think there's the inferior pancreaticoduodenal artery right there. You see it’s bleeding a little bit. Little arterial... Take that. Flip it around behind here - the other side. Get around it. Then let me clamp it. Do that with the harmonic. I think right there you can see there's a vessel. Right there. So let’s just… Good. Good. Specimen out. 2-0 silk tie. Okay so, Whipple specimen for pancreatic neuroendocrine tumor. So here, here. We want the standard, we’ll - we'll send the pancreatic neck, and then we want the standard margins. Can I have a stitch?

I just - I just call it the uncinate margin, so tell him uncinate margin marked by a stitch. And we don't need any frozen sections, but they just want it for permanent. Now just put your hand underneath here and just feel the SMA, and you can see the relationship of the SMA, SMV, and the uncinate. Okay good. So lift it up like - put your fingers under here. That's the whole blood supply of the small intestine, large and - I mean, small intestine, SMV, and SMA right there. Alright can we have some irrigation, please? So this is the field of resection. Here's the pancreatic neck. Here's the hepatic artery with the GDA ligated. Here's the portal vein, SMV. Here's the uncinate. Here's the vena cava. So we will mobilize the neck of the pancreas a little bit.You'll see the splenic vein in a few minutes. Yeah, go ahead. Pour it in.

How about the argon up here to deduct her layer? Pretty dry honestly. A little bit up there off of the vena cava. See now this is what's nice about the argon. You can just dry right over the top of this - the vena cava. You don't have to worry about burning a hole in it. So here's the jejunum. Here's the colon. Here’s where we’ll bring this through in a minute. Here's the ligament of Treitz. So we want to go back here and look at all our little vessels here. They all seem to be pretty good. Hold this up. Hold this up. So this is where the ligament of Treitz was. Here’s the IMV right here. So - then we’re going to close this up, so pop-off silk to me. The goal is to do this with creating as little bleeding as possible, and I've hit a little blood vessel on both.

Pretty much always have to close this up. As you can see, it’s a - certainly a place where the bile duct could herniate through and create a problem. Cut. Scissors. Whenever you close a hole in the mesentery, you try to make as small of filmy stitch as you can that sticks to the - that doesn't tear through because every stitch you put into the mesentery you risk hitting a blood vessel with it. So… So we close that up. Scissors. The variability in how long a Whipple takes is based on how hard it is to take it out, and we - I can look at the clock right now and say we’ll be closed in 2 hours, okay, because I know how - exactly how long it takes to do - put it back together. So the variability is - is, you know, how tough it is, how much bleeding you get into, whether you have to peel it off the SMV, have to do a venous resection or reconstruction. At this point, it's all pretty standard. You see this little thing here, Andrew? Take your argon and just dry the surface of the uncinate a little bit. There's a little vessel right there.

You ever seen argon used before? I've seen this on the liver. Okay, yeah. Do you know the principle of the argon? I don’t. So what is argon? It's a gas, right? It's one of the noble gases. Yeah. Feel the gas? So that's the gas. So that's what transmits the - the electric current. This is hooked up to the same machine as the cautery is except instead of using metal - but the principles are it doesn't penetrate the tissues as much, so it's less apt - oh, there’s a little bleeder there in the pancreas, so I have to dry that up for you. It doesn't penetrate the tissue.

Alright, so now we want to mobilize the pancreas up a little bit, so stick all the colon down. Perfect. So let's get our harmonic now and mobilize the gland a little bit to the left. So again, here's the SMV portal complex here. And the - there are some little branches that come in here. So we're mobilizing the pancreatic remnant to facilitate our anastomosis. Yep, just slide it over there. Stay close to the pancreas - you don't want to get near the artery.

CHAPTER 6

So can we have that little probe again, please? Argon, please. Right - right there is right on the edge. Okay, good. You’ve got to be careful. That's right where the duct is too. You suck for me? Okay so I'll take this, and Andrew will take the first of them. So, the first thing we're going to do is tack open the pancreatic duct. So he's going to take - going to take a double-arm. He's going to put a tacking stitch at - at 2 o’clock and 10 o’clock on the pancreatic duct. Alright so, Andrew won't be able to do it with that in there probably, so I want you to fix your eyes right on where that hole is. DeBakey to me. And then I’m going to pull the… Can I have it up here? Okay. I have - I have two DeBakey's. Can I have a DeBakey? So you want to go inside out in the duct. Good. Going to grab this tissue - pry it down. Okay, good. Snap. So drive the needle into the lumen of the duct, para - adjacent to the probe. Take that. Perfect. Okay, you got it? Okay, go ahead and take the probe out now. I did. Snap.

Alright, now we're going to make our enterotomy. So - Bovie, please. So DeBakey to me. And they're not very big, so about right here. PDS. Now remember how you matured this the last time? Phil, just a single arm - 5-0 PDS. So what he's doing now is he’s tacking open the enterotomy. So that we can make sure we have mucosa to mucosa rather than mucosa to submucosa or, so. Just a couple little stitches, two or three ties. Sort of makes it so it's easier to work. Yep. Get your scissors so you can cut for Andrew. So I like this step, a lot. I think it’s something that's just an added step - takes a couple min - I mean, it takes an extra minute or so but - cut! It makes it a lot easier. That's good.

Okay, so let's have the pediatric feeding tube next. And a curved Mayo, please. So one of the things I haven't - I have done is I have adapted - Dr. Fernandez in the team here put this little pancreatic feeding tube in. I don't do it on all, but when I have a tiny duct like this, it helps a little bit - and there's level one data that actually supports this. And let's have a - biggest right angle that you have. Bovie. Okay. Alright, now let’s have the - another 5-0 PDS. Double-arm this time. Why don’t you hold these two over here. I think we're pushing it. I’ll hold it. You actually gently push the stand in. Is there a smaller Stanton of 5? Why don’t you give us a 3? Yeah, this is - feel that friction as opposed to resistance. So this is a 10, so if you can find 8, Andrew. Inside out on the duct. Right there. So this would be a lady who you’d say, “Wow, this would be a great case to do a laparos - robotic or laparoscopic Whipple on." The problem is - is doing this anastomosis. I guess you would - let me have a snap. Obviously, the magnification of the - of the - of the robot might help, but certainly not the case. So inside out right there.

I watched the video of a friend of mine doing a robotic Whipple. And they do it in three stitches - the pancreatic anastomosis in three stitches. So 6 o’clock now Andrew - or maybe not even 6 o’clock. We only have four in there, so do this one close to 5. Close to 5 o'clock? Snap. How's that - watch that. Won't have much length there. Okay, take that. You actually hold it up there. I'll try to get the… Okay. How long do you leave this in? A week or so. Two weeks or so probably. Do you guys fix it up? No, we - it's actually, be perc - be a... yeah. So that's - that's one. Okay, just a second. Let’s get this. I’ve got it wrapped around here. So there's one. Is yours tight? Okay, go ahead and tighten yours - tie yours. Long Metz to me. So after we place the back wall of the sutures, we put the catheter or stent inside, and then we tie them down. And then we’ll place the anterior or lateral stitches to complete the mucosal to mucosal anastomosis.

Okay, so empty needle holder to Andrew. So remember these were the stays we placed. These are double-arm sutures, so we can always put the stitch from the inside out. Okay, so Andrew you want to get it about right there. And have you to catch the - perfect. Okay. Snap. Okay. So Andrew, what have we forgotten to do? Tie this. The second layer? Yeah, go ahead. We forgot to do the posterior external layer. Yeah. I was so focused on putting that stent in, but - so what we usually do is we tack the seromuscular layer of the - the pancreas - of the bowel to the pancreas posteriorly. Now the good news is she's mobile enough that we’ll be able, I think, to do that. So we'll take some 3-0 silks next. So actually before we do that, let's have the 4-0 chromic. Do you have a 4-0 chromic?

Right, so I'm cutting the last stitch at 12 o’clock on the pancreatic mucosal mucosal anastomosis right here. A pop-off silk then. So first stitch, Andrew - I want you to go through the - like here, right at… It might be easier for me to go - on the pancreas side? Okay - I think. Yeah, well that’s what I was saying, so right through to the - right there. Try to go posteriorly? Yeah. This is going to be a corner stitch, so it's really a lateral stitch. Seromuscular. So you have two of these by any chance? Actually, do - I'll tell you what. Give him a 3-0 Vicryl first. A 3-0 silk - give him a 3-0 silk first. I got this. Yeah, keep it there - keep it in there. We’ll do a purse string with this silk first So this will be to secure this catheter. We only need one. So this is a purse string around the stent, and we're going to secure it with a 4-0 chromic. And the reason we use the chromic to secure it is the chromic will dissolve in a lot faster, so when we want to pull this out in two or three weeks, it's - it'll sort of melt away.

Okay, so then another silk here to here. Okay, so there - get that back wall right there. So we made the best - no, no - not through the face of the gland - through the… Back away from the face of the gland. So I think we made the best out of what little mess up I made by… And fortunately, we had a - a very well mobilized gland and not too deep a hole. This layer, the next layer, we try to do what we call invaginate or dunk the gland into the side of the bowel. The way he does that is by putting the stitches back, so like a Lembert silk from here to here and here to here, and then we'll flip it over as we tie it. So. Okay, so probably four stitches. Not quite that far above it. There to there.

You want a lateral there or is that right? Yeah, actually one lateral would be good. Like, it just looks like we have a little bit of exposure there. It's so soft I can see just the exact crease of where I need to go. Between lobules. No, that’s good. I’d actually even go all the way to the corner so that you sew to yourself, so put it right - right there, maybe. So it looks like, one, two, in between. Actually, you know what? I’d put two in there because there’s such a big gap. Needle in. Okay, so then I take this one, and you got one more to tie there. And you - as he ties this, he pushes the knot towards the left shoulder, and that - so you see how it invaginates the - the end of the… And I try to sort of pull the two edges together, so - because any resistance, these stitches will just tear right through the soft pancreas. Alright, so this is your pancreatic anastomosis, end-to-side mucosa mucosal two layer anastomosis with a little pancreatic stent.

CHAPTER 7

So here's a little bile duct - appropriately small. Let's pick it up - a little bile coming out. Now pick it up, and let's try to just mobilize it up a little bit - maybe just with the cautery. Very tiny bile duct. I’ll hold it now. You take the other stuff off the tie. Let go. You have any of those 5-0's left? Why don’t you give us a couple 5-0's? Double armed. So let’s do the same thing - the two in 10 o’clock. Okay, small enterotomy here. Not much bigger than the other one. I want these small needles though. I want the long - long Metz.

So any questions so far? Well, I was wondering about the - the anastomosis, the pancreaticojejunostomy. With a the smaller duct, you might have to just bury the pancreas? Well that - if you can't find the duct, that's what you do - is the full invagination, but if you can find the duct and you can put some stitches in it, I think it minimizes the chances it’ll stricture and cause problems and - okay - and - but if you can't find the duct at all, you’re exactly right - I - I would have just invaginated the whole thing. So even if it’s small, if it’s there, it’s best to still do it. Well, you know, there are some people - I mean, Dr. Yeo at Jefferson and Dr. Cameron at Hopkins do that for all of them. They don't do the invagination - or they don't do the mucosal-mucosal on any patient. And Yeo actually did a study that showed that it was no advantage or disadvantage - one over the other. So, in fact, it suggested that it was even a higher incidence of complications / leaks with mucosal-mucosal anastomosis, but it was a bit of a flawed study.

Break to this corner here. Inside - inside-out on a… Okay, now outside-in. Can I have that probe again? Actually, do you have - you don't have the big stylers, do you? You want to try one? Yeah, let me see one. Good so, s - snap. And scissors. Okay. Okay, so right at 6 o’clock. Okay, good. Another snap. Another stitch. Yes, we will need more. Probably just one or two - yeah, one more. Okay, go ahead and cut it off and tie him up. Cut right here. Two needles back here. Can I have a splash? Empty - empty - empty needle holder next. Alright, so let's see if we got an adequate anastomosis here. Looks pretty good, huh? Yeah, I think… Left tuck, right tuck. Okay. And then the bowel side is okay? Pretty sure it's okay since I can see it. Yep. Okay, so you want this one here, and - coming up here - so this is double arm. Excuse me, you want to go inside-out on the - on the bowel. I think we need one there at 12. Yeah, we’re going to put a couple in between. This is the corner stitch, so…

So then that goes to - inside-out over here. No, I'll need another stitch. Cut this one out. I'll get you scissors - just cut this one out. We dropped one, did we? Okay, so we need two more between here, so I would go inside-out on both sides, so use your double arm, so. We need one more. Yep. This is a forehand for me. It's a backhand for you. I was trying to say how easy it is for me to do a forehand, and of course, I made it hard. Take those two. Put the snap on it. Alright, so inside-out on the bile duct. Snap. Cut. Should be two this time. Okay, so tie that. Scissors to me. Alright, I’ll cut these. It’s just easier for me to get in and out.

Okay, so we've been working for an hour and got the two hardest anastomoses done. What do you know about drains after Whipple? I usually leave them in until postoperative day 3. Okay. Again, depending on what's coming out of them and what the amylase is and what the - what it looks like. There's been a recently published randomized controlled trial looking at drain versus no drain, and it came down very strong in favor of needing drains. Alright, we'll take another squirt of irrigation in a second. Yeah, drains are a lot like religion. Everybody believes what they believe in. So, irrigation. Go ahead. Okay, I'm alright with that. Now here's where it becomes interesting. Gotta take this out. So here's our - here’s our limb, right here. Seems to be good. Quite a window to close. Yeah, it’s a little bigger window than we’d like.

CHAPTER 8

Pop. You mind if I - no, I think that - no, I don’t mind, but I think we can just close it. Just close it around the - yeah, so go to the - go to the apex of the bowel, right there. And then small bite. There’s a vessel that’s running right there. I'm good with that. Why don’t you put a couple in there? Just tie them - tie them as you go. You go down. Stitch, thank you. So whenever you have a mesenteric defect, you bring a loop through, you always have to secure it because of the risk that everything could just peristalsis right up through there, and your whole small bowel could be up in that anastomosis at some point. Okay, so put one more right there next to the mesentery at the lowest aspect of that. All the way down to the - yep. Catch a little bit of the mesocolon too, yeah. I think one - one right in the middle should do it there, Andrew.

Okay, so here's your pancreaticobiliary limb. I don’t see any bile leaking. Looks pretty good there. Here’s our… So now, hold this up. Now we got to find our duodenum, which is right here. So we want to bring the anastomosis - is going to be done anti-colic. So we could have done it before we brought it there, but a lot of us - you know, everybody has again a bias. I like to do it anti-colic because I do think that protects against delayed gastric emptying. So just take the cautery. Bovie. So just make a little hole right there. Okay, so take your harmonic and just make it about the size of a loop of small bowel. Can I have a - the harmonic, please? You take it - if you take it straight down, there's a vessel that you'll miss. Yep, towards me a little bit, right there. Okay, that ought to do it.

Alright, so here's where it comes through, so hold that up. I’m going to bring it through this other little defect that we just made, like this. Look to make sure it’s not twisted. It's coming straight up. Okay, so then you - you hold it like that, Andrew. And then this comes up like this. Can I have a silk stitch, please? Okay, alright. Right on the antimesenteric border. Yep. It's about as easy an anastomosis as you can do because it's end-to-side and pretty good size match. Stitch, and snap. And you do two corners first, correct? Yep - right, but I don’t make it - about right there. Don’t take it too far because it’ll stretch. DeBakey's to me. Another snap. Okay, so pull this back, like this. Let me show you. So you want to do - you want to make your enterotomy right here. So you go - yep. I go right in the middle. Bring it almost up to the staple line, not quite - pretty close. Stitch. Okay. So you just do that? So you just fire straight across? Yep. Okay. Alright, get your corner one. Tie it. Need two 3-0 Vicryl on the SH needles, swedged on. Snap. Okay, now I’m going to hand you a pair, but you need to prove to me that it's a pair by sliding them a little bit. Okay. Prove to yourself - not me.

What would your thoughts be about ketorolac for her? I don't have any problem with that. Cautery. We just amputate the staple line. Oh, we - we're talking about the use of that as a - you know what a chemical swank discectomy pain block is? You know, for pancreatic cancer pain - where you inject - Yeah, I’ve seen it done basically, you know, just for that. Yeah. Well there’s a member of your faculty - a member of your faculty feels that it would - it might help with postoperative pain. It makes a lot of sense. It doesn’t to me. No? Because - the reason it doesn't to me is that it affects the visceral fibers, so - right - a little dot, dot - and last I heard, the pancreas didn't really feel any pain when you put a stitch in it. The bowel doesn't feel any pain unless it's distended. Alright, straight through. I'll get the back wall. Another scissors. Tie it. Yep. Right here in the corner. Okay, so lock it as you go. Fire it straight across, yep. If you enter the needle at a right angle to the mucosa - just drive it straight through, you get full thickness. Perfect. Maybe just a tad bit closer than that.

See I - I wouldn’t have brought it through like that. I'd have just fired it. You'd have just fired it? Just take it out. Take it out. Take it out. Just seemed like we were at the corner there. When you get to the corner, you fire it straight out like that. So you, what you do is you hold - hold this open like this, and line it up so you can just fire it straight across. Got it. And now fire it straight out towards this corner. Pull it - pull it all the way through. Okay, and then right back in the corner. Outside-in right in the corner again. Okay, now pull it through and start your Connell on the top. Okay, why don’t you stop here to give this - please, Laura, hold that. It's not hard - just give a little tension on it and kind of hold it like that. Okay, so you're inside now, so you want to bring it outside in the corner. Start now here? No, I'd just go around the corner one more time, just inside. Good, now - now bring it up. So you got a pretty good size match there, so now you can start your canal on the top. You can maybe do it in one stitch - or one throw - top meaning the duodenum thing.

I mean, I'm outside-in. You go outside-in in here, right? Yeah, but I’d go on the duodenum - yeah. And just pull it back, and do it in one throw - do it in one throw. Okay, so put your thing in there, and just take one more like you just did. So the inside - you probably have to do that in two. I would just do a - one more simple? Just do a Lembert - a transverse Lembert or Halsted stitch right there. Snugger - a little bit more snug than that. Good, thanks. Scissors. So that's perfect. That stitch you just put in was perfect because you don't want it - you want to consider it - say you got two mountains here: the mountain on the small bowel and the mountain on the duodenum. So you enter at the apex of the mountain on the small bowel, come down to the valley, pull back, and re-engage down in the valley - and pull it up. Because if you just pull it back and just get that little more depth, you get a lot more thickness on the bowel without advancing. You know, you don't want to turn it over because that creates an edema in the anastomosis. Put one in between those two, would you? I know there’s that vein right there, but just miss it. Just fire it straight across.

Okay, next stitch to me. Okay, so Andrew, you hold that corner up for me. You just do that coming out of this corner just to make sure - just because I can expose it for you as well as you can expose it for me and… Okay, now you wonder why we made that little hole in the me - omentum, right? We pull that down. We can just lay the omentum right over it. So stitch. So it kind of protects the anastomosis in case the patient gets a little fascial wound infection like that. It - so it just catches a little bit of the jejunum.

CHAPTER 9

Can I have the heavy scissors please? Cut. Take the other one. Okay. Yeah, it's a - picked it up in Baltimore on Broadway, a monument they use, a pretty common instrument there. Big secondary market, the techs would take these and sell them on the streets. Lift up now. Okay, so… Looks to be alright, huh? Okay, so now let's - I take one drain. Pull it through here. First one, the lower one, and we can kind of lay it all the way underneath the pancreas. Hold that up. Underneath the biliary tree. Curved Mayo's, please. Make sure this is… Okay, so that lays - we're over the bile duct. Right here next to the pancreatic anastomosis. So cut a little bit of that right there. Sort of stick it underneath there - top goes anterior. Here's where I want us to get - right underneath there. Flipping around left and right. Pickups to me. It’s a little high - is my problem. Please, hold that. Doesn’t want to lay where I want it to lay. That’s good. That’s good, right there. So you cut a little bit more off - that’s part of the problem. Scissors.

Alright, now those scissors as he said. She has a little tiny puncture wound, right - right there, straight down. Got them. You have one more silk or Vicryl or anything like that? 3-0 Vicryl. Pull it a little bit? Yeah - yeah, right here. You all done with all your cases? I have one more this afternoon. Okay. Good, well this went pretty well for this little girl. Yeah, that would be great. I don’t want to cover the tube, I want to cover the enterotomy - because when we pull it out, I want it to seal to the enterotomy, so… So - is Caitlin still on nights? Drain the stitch. Careful now. Yep. Some nylon? Yeah, that’ll be good. So secure that one first, and I'll take one PDS loop and a wide malleable. Alright, can we have the other number one PDS? Alright gentleman, I think we're done.