What are the steps of the Whipple procedure (Pancreaticoduodenectomy)?

From the Guidelines

The Whipple procedure, also known as pancreaticoduodenectomy, involves several key steps to remove cancerous or diseased tissue from the pancreatic head region, including resection of the gallbladder, distal stomach, duodenum, head of the pancreas, and distal common bile duct, followed by reconstruction with pancreaticojejunostomy, hepaticojejunostomy, and gastrojejunostomy, as recommended by the most recent guidelines 1. The procedure typically starts with an incision in the abdomen and assessment of the area to confirm the tumor is resectable.

• The surgeon then removes the gallbladder (cholecystectomy),
• followed by removal of the distal (lower) portion of the stomach,
• the entire duodenum,
• the head of the pancreas, and
• the distal common bile duct. Nearby lymph nodes are also removed for staging purposes. After the resection phase, the surgeon begins the reconstruction phase by connecting the remaining pancreas to the jejunum (pancreaticojejunostomy),
• attaching the bile duct to the jejunum (hepaticojejunostomy), and
• connecting the remaining stomach to the jejunum (gastrojejunostomy). These connections restore digestive continuity, allowing food to mix with pancreatic enzymes and bile. The procedure typically takes 5-7 hours and requires meticulous technique to minimize complications such as pancreatic leaks, which can occur due to the soft texture of the pancreas and its enzyme-rich secretions, as noted in previous studies 1. Patients typically remain hospitalized for 7-10 days following surgery and require close monitoring for potential complications including delayed gastric emptying, infection, and bleeding. Dissection of the right hemi-circumference of the SMA to the right of the coeliac trunk is recommended to obtain a good medial clearance and to improve the rate of R0 resection 1. In the event of vein involvement, complete venous resection (PV or SMV) followed by reconstruction to obtain R0 resection is possible, although it is associated with a lower rate of R0 resection and poor survival, likely due to the inherent aggressiveness of the tumour 1. Arterial resections during pancreatoduodenectomy are associated with increased morbidity and mortality, and are not recommended 1. Minimally invasive techniques can reduce the morbidity of pancreatectomies, but data relating to these techniques are insufficient, particularly in relation to oncological results, and therefore open surgery remains the standard of care 1.

From the Research

Overview of the Whipple Procedure

• The Whipple procedure, also known as pancreaticoduodenectomy, is a major surgery performed in tertiary care centers 2.
• The procedure has undergone significant evolution over the years, with improvements in staging, surgical techniques, and postoperative care 3.

Steps and Parameters of the Whipple Procedure

• The procedure involves the removal of the head of the pancreas, the duodenum, the gallbladder, and a portion of the bile duct 2.
• Preoperative parameters include demographic data, presenting symptoms, physical signs, past medical history, and preoperative stenting details 2.
• Operative parameters include intra-operative duration of surgery, blood loss during surgery, and postoperative course and complications 2.
• Postoperative parameters include hospital stay, complications, and histological diagnosis 2.

Complications and Outcomes

• The major postoperative complication is pancreatic fistula, which occurs in approximately 12% of cases 2.
• Other complications include septic shock, cardiac and pulmonary complications, and digestive sequelae 2, 3.
• The most common histological diagnosis is adenocarcinoma of the pancreas, which accounts for approximately 33.3% of cases 2.
• The 5-year survival rate for adenocarcinoma of the pancreas is approximately 20%, while long-term survival rates for other periampullary tumors are approximately 40% 3.