Steps of Whipple's Procedure.
A simple and lucid explanation and techniques of Operative procedures in GI Surgery.
Whipple reported the 1st successful case of pancreaticoduodenectomy in 1935. This operation was done in two stages and over a period of 70 years the operative mortality has decreased from 20-30% to less than 1%. Even now best results are seen in high volume centers which perform more than 20 Whipple's operation in 1 year.
Indications of Whipple's procedure
- Carcinoma Head of Pancreas
- Duodenal and ampullary tumors
- Lower end cholangiocarcinoma
- Mass forming chronic pancreatitis in head of pancreas
- Grade IV pancreatic injuries
I have tried to enumerate the Whipple procedure steps and hopefully you can mention them in your operative notes.
Preop preparation of the patient
1. Hydrate them well
2. Prophylactic antibiotic
3. Pre operative drainage for relieving jaundice is not required in periampullary tumors
4. Manage coagulopathy associated with obstructive jaundice
1. Abdomen is opened from the Bilateral Subcostal incision. (Chevron's Incision)
2. Abdominal cavity is explored for metastasis especially in liver, base of mesentary, mesocolon and pelvis.
Now the actual Whipple Procedure steps begin:
3. Kocher's maneuver is performed and duodenum along with the head of pancreas mobilized to the midline. This step exposes the IVC. All tissue anterior to the IVC has to be removed and sent with the specimen.
4. Cattell braasch maneuver is the next step and hepatic flexure of colon is brought down completely expsoing the retroperitoneum and separating hepatic flexure of colon from the liver.
5. Superior Mesenteric Vein is seen passing from the mesentary to its course to join the portal vein.
Creation of Tunnel of Love
6. At this step attempt may be made to try and create the tunnel between the Superior mesenteric vein and pancreas but if it is problematic it may be attempted at the later stage. It is at this crucial time the resectability for Pancreaticoduodenectomy is decided.
7.Dissection is started at the free border of lesser sac and Common bile duct, Right hepatic artery and portal vein are identified. At this step special care is taken to identify and safeguard accessory or replaced Right hepatic artery. This artery is easily found posterolateral to the portal vein.
8. Gall bladder is dissected from the liver bed and followed onto the cystic duct, Common bile duct is divided at the junction with the cystic duct.
9. The Right hepatic artery is traced back and just above the duodenum Gastro duodenal artery is tied off.
10. The hepatoduodenal ligament is dissected easily as its a vascular and next after clearing the lesser curve of stomach and greater curve, stomach is usually transected with a linear cutter.
11. The portal vein is now seen clearly and the tunnel between it and pancreas is fashioned.
12. The pancreas is now cut and separated from the portal vein. There are many ways to do it and recently we have been doing it with a vascular stapler.
The resected specimen looks like this Whipple's Cut Specimen.
Read about latest MCQs on Carcinoma Pancreas here.
Pancreaticojejunostomy can be done duct to mucosa or pancreas can be dunked into the jejunum. Another technique is pancreaticogastrostomy. Both have similar results and comparable leak results. The choice depends on surgeon 's training and experience
Hepaticojejunostomy is next- Done in single layer and can be performed in interrupted or continuous fashion
Gastrojejunostomy is the final step of reconstruction
Feeding Jejunostomy is done because of high incidence of delayed gastric emptying (20%)
Drains may or may not be placed depending on surgeon's experience and abdomen is closed.