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

From the Guidelines

The Whipple procedure involves a meticulous and complex series of steps, including medial dissection of pancreatic head lesions, mobilization of the PV and SMV, and potential vascular resection and/or reconstruction, with the ultimate goal of achieving an R0 resection. The procedure begins with careful assessment of the extent of disease, followed by mobilization of the pancreatic head from the surrounding structures, including the portal vein (PV) and superior mesenteric vein (SMV) [ 1 ]. This is achieved through complete mobilization of the PV and SMV from the uncinate process, assuming no evidence of tumor infiltration, and skeletalization of the lateral, posterior, and anterior borders of the superior mesenteric artery down to the level of the adventitia [ 1 ].

The next steps involve careful dissection to free the vein from the pancreatic head, if possible, and consideration of lateral venorrhaphy or complete portal or SMV resection and reconstruction to achieve an R0 resection [ 1 ]. The surgeon must also assess the need for arterial resection, although this approach is not universally accepted and requires judicious utilization [ 1 ].

Some key steps in the Whipple procedure include:

• Medial dissection of pancreatic head lesions
• Mobilization of the PV and SMV
• Potential vascular resection and/or reconstruction
• Achievement of an R0 resection through meticulous perivascular dissection and recognition of the need for extra-pancreatic organ resection [ 1 ]
• Reconstruction of the digestive tract, including attachment of the pancreatic duct to the jejunum and reconnection of the bile duct and stomach to the jejunum.

Overall, the Whipple procedure is a complex and nuanced operation that requires careful planning and execution to achieve optimal outcomes, with the primary goal of achieving an R0 resection and improving patient morbidity, mortality, and quality of life [ 1 ].

From the Research

Steps of a Whipple Procedure

The Whipple procedure, also known as a pancreatoduodenectomy, is a complex surgical operation that involves the removal of the head of the pancreas, the duodenum, the gallbladder, and a portion of the bile duct 2. The steps of the procedure can be outlined as follows:

• Preoperative assessment and preparation, including imaging studies and laboratory tests to evaluate the patient's overall health and the extent of the disease 3
• Administration of anesthesia and positioning of the patient on the operating table
• Incision and exposure of the abdominal cavity
• Mobilization of the duodenum and pancreas
• Division of the bile duct, pancreatic duct, and other structures
• Removal of the specimen, including the head of the pancreas, duodenum, and gallbladder
• Reconstruction of the gastrointestinal tract, including the creation of a pancreaticojejunostomy, hepaticojejunostomy, and gastrojejunostomy 4
• Closure of the incision and recovery from anesthesia

Key Considerations

The Whipple procedure is a complex and challenging operation that requires careful planning and execution. Some key considerations include:

• The importance of preoperative assessment and preparation to ensure that the patient is a suitable candidate for the procedure 5
• The need for meticulous surgical technique to minimize the risk of complications, such as pancreatic fistula and delayed gastric emptying 6
• The importance of postoperative care and management to optimize recovery and outcomes

Surgical Techniques

Different surgical techniques may be used to perform the Whipple procedure, including:

• Open versus minimally invasive approaches
• Pylorus-preserving versus standard Whipple procedures
• Different methods for reconstructing the gastrointestinal tract, such as pancreaticojejunostomy and hepaticojejunostomy 2, 4