Steps of Whipple Surgery (Pancreatoduodenectomy)
The Whipple procedure (pancreatoduodenectomy) is a complex surgical operation that involves the removal of the head of the pancreas, the first portion of the duodenum, the gallbladder, and the bile duct, followed by reconstruction with multiple anastomoses to restore gastrointestinal continuity. 1
Preoperative Considerations
- Biliary drainage may be required before surgery in jaundiced patients, particularly if neoadjuvant therapy is planned 1
- Surgery should be performed at specialized centers by high-volume surgeons to minimize mortality 2
Surgical Steps
1. Exploration and Assessment
- Thorough abdominal exploration to confirm resectability
- Assessment for metastatic disease or local invasion that would preclude resection
- Evaluation of vascular involvement (portal vein, superior mesenteric vein, superior mesenteric artery)
2. Mobilization and Dissection
- Medial dissection of pancreatic head lesions through complete mobilization of the portal and superior mesenteric veins from the uncinate process 1
- Kocher maneuver to mobilize the duodenum and head of pancreas
- Skeletonization of the lateral, posterior, and anterior borders of the superior mesenteric artery down to the level of the adventitia 1
- Division of the gastrocolic ligament to enter the lesser sac
3. Resection Phase
- Division of the stomach (in standard Whipple) or preservation of the pylorus (in pylorus-preserving variant)
- Transection of the jejunum distal to the ligament of Treitz
- Cholecystectomy and division of the common bile duct above the cystic duct junction
- Division of the pancreatic neck anterior to the portal vein
- Complete mobilization and division of the uncinate process from the superior mesenteric vessels
4. Vascular Considerations
- Assessment for potential vascular resection and reconstruction if tumor adherence is present
- Careful evaluation of portal or superior mesenteric vein involvement after division of pancreatic neck 1
- Lateral venorrhaphy or complete vein resection and reconstruction may be necessary to achieve negative margins 1
5. Reconstruction Phase
- Pancreaticojejunostomy (anastomosis between pancreatic remnant and jejunum)
- Hepaticojejunostomy (anastomosis between bile duct and jejunum)
- Gastrojejunostomy or duodenojejunostomy (depending on whether pylorus is preserved)
6. Lymph Node Dissection
- Standard lymphadenectomy rather than extended regional lymphadenectomy 1
- Consideration for sampling aortocaval and common hepatic artery nodes 1
Surgical Variations
- Standard Whipple: Includes distal gastrectomy with gastrojejunostomy
- Pylorus-preserving Whipple: Preserves the entire stomach and pylorus
- Total pancreatectomy: Indicated when cancer diffusely involves the pancreas 1
Technical Pearls
- The goal of surgery is to achieve a margin-negative (R0) resection 1
- Meticulous perivascular dissection is critical to maximize uncinate yield and radial margin 1
- Differentiation between tumor infiltration and tumor-related desmoplasia of the vein wall may be difficult to determine intraoperatively 1
Potential Complications
- Delayed gastric emptying (10-25% of patients) 2
- Pancreatic fistula (most frequent complication, 13%) 3
- Small bowel obstruction 2
- Intra-abdominal bleeding (most frequent indication for reoperation) 3
Postoperative Care
- Regular assessment by hepatobiliary surgeon or surgical oncologist 2
- Monitoring of nutritional parameters 2
- Multimodal approach to optimize bowel function 2
The Whipple procedure has evolved significantly since its introduction, with mortality decreasing from 45% to less than 1% in specialized centers 3. Advances in surgical technique, perioperative care, and the development of minimally invasive approaches have contributed to improved outcomes 4.