What are the operative steps involved in a Whipple's procedure?

Operative Steps of the Whipple Procedure (Pancreaticoduodenectomy)

The Whipple procedure involves systematic 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, with the primary goal of achieving margin-negative (R0) resection. 1

Preoperative Considerations

• Preoperative biliary drainage may be necessary for patients with jaundice who will receive neoadjuvant therapy before surgery 1
• Short, self-expanding metal stents are preferred for preoperative biliary decompression due to their ease of placement, minimal interference with subsequent resection, and longer patency rates 2

Standard Operative Steps

1. Exploration and Assessment

• Begin with thorough abdominal exploration to confirm resectability and absence of metastatic disease 1
• Assess for vascular involvement, particularly of the portal vein, superior mesenteric vein, and superior mesenteric artery 2

2. Mobilization and Exposure

• Perform Kocher maneuver to mobilize the duodenum and head of the pancreas 1
• Complete mobilization of the portal and superior mesenteric veins from the uncinate process is essential for proper medial dissection of pancreatic head lesions 2

3. Biliary and Gastric Dissection

• Divide the common bile duct at the superior border of the pancreas 1
• Depending on whether performing standard or pylorus-preserving Whipple:
  • Standard: Divide the stomach at the level of the pylorus or distal stomach 2
  • Pylorus-preserving: Preserve the pylorus and divide the duodenum distal to it 2

4. Pancreatic Transection

• Divide the pancreatic neck anterior to the portal vein 1
• Skeletonize the lateral, posterior, and anterior borders of the superior mesenteric artery down to the adventitia to maximize uncinate yield and achieve negative radial margins 2

5. Uncinate Process Dissection

• Perform meticulous dissection of the uncinate process from the superior mesenteric vessels 2
• Optimal dissection is achieved using ultrasonic or thermal dissectors (Harmonic scalpel or LigaSure) rather than stapler or clamp-and-cut techniques 2
• Division of retroperitoneal tissues between uncinate process and superior mesenteric artery with stapler may leave up to 43% of soft tissue in situ, increasing risk of R1 resection 2

6. Specimen Removal

• Complete the resection by removing the specimen en bloc, including the head of pancreas, duodenum, distal bile duct, gallbladder, and regional lymph nodes 1

7. Reconstruction

• Create three anastomoses in the following order:
  • Pancreaticojejunostomy (pancreatic remnant to jejunum) 1
  • Hepaticojejunostomy (bile duct to jejunum) 1
  • Gastrojejunostomy or duodenojejunostomy (stomach or preserved duodenum to jejunum) 1

Special Considerations

Vascular Involvement

• If tumor infiltration into the portal or superior mesenteric vein is suspected, partial or complete vein resection and reconstruction may be necessary 2
• Judicious use of hepatic arterial resection and reconstruction may be reasonable in very select populations 2
• Liberal use of vein resection when infiltration is suspected is supported by data showing similar survival to R0 resections without venous involvement 2

Lymph Node Management

• Extended regional lymphadenectomy is not recommended as routine practice as it does not improve survival 2
• Consider sampling of aortocaval and common hepatic artery nodes for prognostic information 2

Potential Complications

• Pancreatic fistula is the most common major postoperative complication (reported in up to 12% of cases) 3
• Other complications include delayed gastric emptying, hemorrhage, and biliary leaks 3
• Mortality rates in experienced centers are now less than 5%, though slightly higher rates may be seen in less experienced centers 3

Pitfalls to Avoid

• Inadequate dissection of the uncinate process can lead to positive margins and decreased survival 2
• Failure to identify and address vascular involvement can result in incomplete resection 2
• Tumors located in the pancreatic neck present a particular challenge because the type of resection is often not determined until laparotomy 2