Whipple Procedure for Carcinoma of the Pancreas - Part 2
Tags: General Surgery
Table of Contents
This article is the second in a 2 part series. Part 1 of the procedure is detailed in the first article.
(Anesthesia and Positioning as per Part 1 of Article)
Mobilization and Division of Proximal Extent of Duodenum
- Mobilize Pylorus and and Perform Partial Omentectomy
- Gastroduodenal artery identified at its insertion into hepatic artery.
- 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.
- Divide Stomach 2 cm proximal to pyloric valve using gastro-intestinal stapling device.
Mobilization and Division of Jejunum
- Jejunum Divided using GI Stapler
- Mobilize Ligament of Treitz
- The Ligament of Treitz is identified and 10–15cm distal to this an appropriate vascular arcade is identified.
- It is then mobilized with dissection of the 3rd and 4th portions of the duodenum.
- This is brought under the superior mesenteric vessels to the right upper quadrant.
Mobilization and Division of Pancreas
- Divide Pancreas
- Suture ligate superior and inferior pancreaticoduodenal vessels used for vascular control and traction.
- Once under neck of pancreas, divide pancreas.
- Portal vein separated from uncinate process of pancreas via blunt and sharp dissection.
- Mobilize Head and Uncinate Process off the Portal and Superior Mesenteric Veins
- This includes taking the retroperitoneal tissue posterior to the superior mesenteric artery.
- Small branches of the vessels either clipped or cauterized.
- 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.
- The Pancreatic Specimen is Removed and the Margin is Marked
- Identify Pancreatic Duct
- Note: Proximal end of jejunum is brought through defect in transverse mesocolon.
- 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.
- Silastic Stent is Placed through the Anastomosis
- 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.
- This loop is sutured to the mesenteric defect to prevent an internal hernia.
- A distal loop of jejunum approximately 20 cm distal to defect in the transverse mesocolon is brought either retrocoloic or antecolic.
- Small enterotomy in the jejunum and a gastrotomy on the posterior wall of the stomach are made.
- performed via the enterotomy and gastrotomy using a gastrointestinal stapler to create a common wall.
- Defect in gastrojejunostomy is oversewn with interrupted 3-0 Vicryl suture.
- Place Gastrojejunostomy Tube (or Separate Gastrostomy and Jejunostomy Tubes)
- Purstring of 3.0 Vicryl made on anterior wall of stomach close to great curve.
- Perform Gastrostomy
- 5 mm incision made in left upper quadrant and G-J tube brought through.
- Place tube into stomach threading it through the distal loop of jejunum until the ballon is in the stomach.
- Tie down purstring.
- Blow up ballon and pull up to abdominal wall.
- Fascia Closed with Running #1 PDS after Abdomen Copiously Irrigated
- Skin Reapproximated using Skin Staples