Whipple Procedure: Location of Tumors Treated
The Whipple procedure (pancreatoduodenectomy) is primarily used for tumors located in the head of the pancreas. 1
Anatomical Considerations for Surgical Approach
- Patients with tumors in the head of the pancreas typically present with jaundice and are treated with open or minimally invasive pancreatoduodenectomy (Whipple procedure) 1
- Tumors of the pancreatic body and tail cause symptoms late in their development, making them usually advanced at diagnosis and rarely resectable 1
- When tumors in the pancreatic tail are resectable, distal pancreatectomy (removal of the tail and body of the pancreas along with the spleen) is the procedure of choice, not Whipple 1
- If cancer diffusely involves the pancreas or is present at multiple sites, a total pancreatectomy may be required instead 1
Surgical Details of the Whipple Procedure
- The Whipple procedure involves removal of the head of the pancreas, part of the small intestine, a portion of the stomach, the common bile duct, the gallbladder, and nearby lymph nodes 1
- Achievement of a margin-negative (R0) resection is the primary goal of surgery, requiring meticulous perivascular dissection of the lesion 1
- Medial dissection of pancreatic head lesions requires complete mobilization of the portal and superior mesenteric veins from the uncinate process 1
- Skeletonization of the lateral, posterior, and anterior borders of the superior mesenteric artery maximizes uncinate yield and radial margin 1
Special Considerations
- Tumors located in the pancreatic neck (anterior to the superior mesenteric vessels) present a particular challenge because the type of resection is often not determined until laparotomy 1
- For tumors in the head of the pancreas that extend to involve the portal vein, vein resection and reconstruction may be necessary to achieve negative margins 1
- Extended lymphadenectomy is not recommended as a routine part of the Whipple procedure, as data from several randomized controlled trials did not show any survival advantage 1
- Preoperative biliary drainage may be necessary for patients with jaundice who will receive neoadjuvant therapy before surgery 1
Pathological Evaluation
- Standardized pathologic assessment and reporting is critical for accurate staging and determination of margin status 1, 2
- The International Study Group of Pancreatic Surgery recommends identifying seven margins: anterior, posterior, medial/superior mesenteric groove, superior mesenteric artery, pancreatic transection, bile duct, and enteric 1
- Tumor clearance should be reported in millimeters for all margins to allow for proper prognostic assessment 1
The Whipple procedure represents the standard surgical approach for tumors in the head of the pancreas, while different surgical approaches are used for tumors in other locations of the pancreas.