Whipple Procedure for Carcinoma of the Pancreas - Part 2

Mobilization and Division of Proximal Extent of Duodenum

1. Mobilize Pylorus and and Perform Partial Omentectomy
   • Gastroduodenal artery identified at its insertion into hepatic artery.
   • After insuring good blood flow through common hepatic artery when occluded, gastroduodenal artery is divided using vascular stapling device. Alternatively, this may be done by suture ligation or clips.
2. Divide Stomach 2 cm proximal to pyloric valve using gastro-intestinal stapling device.

Mobilization and Division of Jejunum

3. Jejunum Divided using GI Stapler
4. Mobilize Ligament of Treitz
   • The Ligament of Treitz is identified and 10–15cm distal to this an appropriate vascular arcade is identified.
   • It is then mobilized with dissection of the 3^rd and 4^th portions of the duodenum.
   • This is brought under the superior mesenteric vessels to the right upper quadrant.

Mobilization and Division of Pancreas

5. Divide Pancreas
   • Suture ligate superior and inferior pancreaticoduodenal vessels used for vascular control and traction.
   • Once under neck of pancreas, divide pancreas.
   • Portal vein separated from uncinate process of pancreas via blunt and sharp dissection.
6. Mobilize Head and Uncinate Process off the Portal and Superior Mesenteric Veins
   • This includes taking the retroperitoneal tissue posterior to the superior mesenteric artery.
   • Small branches of the vessels either clipped or cauterized.
   • Once completely mobilized to the superior mesenteric artery, transect the remaining tissue with clips and electrocautery allowing en bloc resection of the pancreas and associated duodenum.
7. The Pancreatic Specimen is Removed and the Margin is Marked

Reconstruction

8. Identify Pancreatic Duct
   • Note: Proximal end of jejunum is brought through defect in transverse mesocolon.
9. Pancreaticojejunostomy
   • Performed by anastomosing duct to jejunum in a duct-to-mucosa fashion using 5-0 PDS suture for the mucosal anastomosis, and 3-0 Vicryl for a posterior layer and anterior. layer of pancreas to serosa for the second layer.
10. Silastic Stent is Placed through the Anastomosis
11. Hepaticojejunostomy
    • Performed distal to the pancreaticojejunostomy by creating another enterotomy and anastomosing the hepatic duct to the jejunum in an end-to-side fashion using 4-0 PDS suture.
    • This loop is sutured to the mesenteric defect to prevent an internal hernia.
    • A distal loop of jejunum approximately 20 cm distal to defect in the transverse mesocolon is brought either retrocoloic or antecolic.
    • Small enterotomy in the jejunum and a gastrotomy on the posterior wall of the stomach are made.
12. Gastrojejunostomy
    • performed via the enterotomy and gastrotomy using a gastrointestinal stapler to create a common wall.
    • Defect in gastrojejunostomy is oversewn with interrupted 3-0 Vicryl suture.
13. Place Gastrojejunostomy Tube (or Separate Gastrostomy and Jejunostomy Tubes)
    • Purstring of 3.0 Vicryl made on anterior wall of stomach close to great curve.
14. Perform Gastrostomy
    • 5 mm incision made in left upper quadrant and G-J tube brought through.
    • Place tube into stomach threading it through the distal loop of jejunum until the ballon is in the stomach.
    • Tie down purstring.
    • Blow up ballon and pull up to abdominal wall.

Closure

15. Fascia Closed with Running #1 PDS after Abdomen Copiously Irrigated
16. Skin Reapproximated using Skin Staples

Patient transported to either recovery room or ICU.