How the Whipple Procedure (Pancreaticoduodenectomy) is Performed
The Whipple procedure involves removal of the pancreatic head, duodenum, distal stomach (or pylorus preservation), common bile duct, gallbladder, and regional lymph nodes, followed by reconstruction with pancreaticojejunostomy, hepaticojejunostomy, and gastrojejunostomy or duodenojejunostomy. 1
Preoperative Assessment and Planning
- Resectability determination is based on radiographic assessment of tumor contact with peripancreatic vessels (superior mesenteric artery, celiac axis, portal vein, superior mesenteric vein), with resectable tumors showing clear fat planes around these vessels 2, 3
- Patients with jaundice requiring neoadjuvant therapy need preoperative biliary drainage, preferably with short self-expanding metal stents due to ease of placement and minimal interference with subsequent resection 1, 3
- For patients proceeding directly to surgery without neoadjuvant therapy, biliary drainage should be used selectively only for symptomatic patients or those with cholangitis, as drainage increases postoperative complications 2
Key Surgical Steps and Technical Details
Initial Exploration and Mobilization
- Intraoperative assessment for vascular involvement of the portal vein, superior mesenteric vein, and superior mesenteric artery must be performed before committing to resection 1
- Complete mobilization of the portal vein and superior mesenteric vein from the uncinate process is essential for proper medial dissection of pancreatic head lesions 2, 1
Critical Dissection Technique
- Skeletonization of the superior mesenteric artery down to the level of the adventitia along its lateral, posterior, and anterior borders maximizes uncinate yield and achieves adequate radial margins 2, 1
- This meticulous perivascular dissection of the superior mesenteric artery represents the most technically difficult and oncologically important stage of the procedure 4
- The "artery-first approach" or "SMA-first approach" focuses on this maneuver early in the operation, before pancreatic transection (the irreversible stage) 4
Resection Components
- Standard gastric division occurs at the level of the pylorus or distal stomach in classic Whipple, while pylorus-preserving technique divides the duodenum distal to the pylorus 1
- The procedure removes the pancreatic head, part of the small intestine, a portion of the stomach, common bile duct, gallbladder, and nearby lymph nodes 1
Vascular Considerations
- Venous resection and reconstruction may be necessary when tumor tethering or infiltration of the portal vein or superior mesenteric vein is encountered, even if not evident on preoperative imaging 2
- Differentiation between tumor infiltration and tumor-related desmoplasia is frequently impossible intraoperatively, requiring aggressive approach to partial or complete vein excision when infiltration is suspected 2
- Data support liberal use of vein resection, as survival outcomes are similar to R0 resections without venous involvement 1
- Arterial resection may be judiciously utilized in very select populations, though further data are needed 2, 1
Lymphadenectomy
- Extended regional lymphadenectomy is not recommended as routine practice, as multiple randomized controlled trials showed no survival advantage 1, 3
- Sampling of aortocaval and common hepatic artery nodes for prognostic information should be considered 1
Primary Surgical Goal
- Achievement of R0 resection (margin-negative with no tumor cells within 1 mm of all resection margins) is the primary objective, as margin-positive specimens are associated with poor long-term survival 2, 3
- Seven margins must be identified and assessed: anterior, posterior, medial/superior mesenteric groove, superior mesenteric artery, pancreatic transection, bile duct, and enteric 1, 3
- Tumor clearance should be reported in millimeters for all margins to allow proper prognostic assessment 1, 3
Reconstruction Phase
- Reconstruction involves creation of three anastomoses: pancreaticojejunostomy (pancreas to jejunum), hepaticojejunostomy (bile duct to jejunum), and gastrojejunostomy or duodenojejunostomy (stomach or duodenum to jejunum) 5
- End-to-side duct-to-mucosa pancreaticojejunostomy with internal pancreatic stent is commonly performed, though no single technique has definitively solved the problem of postoperative pancreatic fistula 5
Critical Pitfalls to Avoid
- Inadequate dissection of the uncinate process leads to positive margins and decreased survival 1
- Failure to identify and address vascular involvement results in incomplete resection 1
- Tumors in the pancreatic neck present particular challenges as the type of resection often cannot be determined until laparotomy 1
- The need for lateral venorrhaphy or complete portal/superior mesenteric vein resection to achieve R0 resection is often unknown until division of the pancreatic neck has occurred 2