Pancreaticoduodenectomy (Whipple procedure): Techniques

Pancreaticoduodenectomy (Whipple procedure): Techniques

Author
Howard A Reber, MD
Section Editor
Stanley W Ashley, MD
Deputy Editor
Kathryn A Collins, MD, PhD, FACS
Disclosures
All topics are updated as new evidence becomes available and our peer review process is complete.
Literature review current through: Mar 2013. | This topic last updated: Nov 7, 2012.
INTRODUCTION The standard operation for pancreatic cancer within the head or uncinate process of the pancreas is
pancreaticoduodenectomy, also called the "Whipple procedure." Although first performed by the German surgeon Kausch in 1909,
the operation was popularized by Dr. Allen Whipple, who performed 37 pancreaticoduodenectomies during his career [ 1,2 ].
A standard pancreaticoduodenectomy involves a distal gastrectomy with removal of the pancreatic head, duodenum, first 15 cm of
the jejunum, common bile duct, and gallbladder ( figure 1 ). A pylorus-preserving pancreaticoduodenectomy preserves the gastric
antrum, pylorus, and the proximal 2 to 3 cm of the duodenum, which is anastomosed to the jejunum to restore gastrointestinal
continuity ( figure 2 ).
Pancreaticoduodenectomy is a complex, high risk surgical procedure. The lowest operative mortality rates and best long term
cancer outcomes have been demonstrated at high volume centers [ 3,4 ]. (See "Surgery in the treatment of exocrine pancreatic
cancer and prognosis", section on 'Perioperative morbidity and mortality' .)
In experienced hands, the median operative time for the Whipple procedure is 5.5 hours, with a median blood loss of 350 mL and
mortality of less than 4 percent [ 2 ].
The technique of pancreaticoduodenectomy will be discussed here. An overview of the surgical management of cancers involving
the exocrine pancreas is presented in detail elsewhere. (See "Surgery in the treatment of exocrine pancreatic cancer and
prognosis" .)
Please note that technical details such as suture choice presented here reflect the author's preferences and are not meant to imply
that these are requirements for successful surgical outcomes.
INDICATIONS The most common indication for pancreaticoduodenectomy is the presence of a malignant or premalignant
neoplasm in the head of the pancreas or one of the other periampullary structures (bile duct, ampulla, or duodenum) [ 5-7 ]. These
neoplasms are discussed in detail separately. (See "Surgery in the treatment of exocrine pancreatic cancer and
prognosis" and "Treatment of ampullary adenomas" and "Ampullary carcinoma: Epidemiology, clinical manifestations, diagnosis and
staging" and"Treatment of localized cholangiocarcinoma: Surgical management and adjuvant therapy" and "Treatment of small
bowel neoplasms" .)
Painful chronic pancreatitis is also effectively treated by this operation [ 8 ]. (See "Treatment of chronic pancreatitis" .)
PREOPERATIVE EVALUATION
General health status Evaluation must include a thorough assessment of the patient's ability to tolerate the operation and is
not based on age alone [ 9,10 ]. As in all patients about to undergo major surgery, it is important to optimize cardiac, pulmonary,
and renal function preoperatively. This can usually be done in the outpatient setting. A detailed description of the medical evaluation
of preoperative patients can be found elsewhere. (See "Preoperative management of patients with cancer" .)
Imaging All patients undergo careful preoperative evaluation including a high resolution computerized tomographic (CT) scan
with 1-2 mm cuts through the pancreas during the early arterial phase (pancreatic protocol) [ 11-14 ]. In some centers, magnetic
resonance imaging (MRI) or magnetic resonance imaging cholangiopancreatography (MRCP) are used. In patients with malignant
disease where the CT scan raises a question about vascular involvement by the tumor, endoscopic ultrasound (EUS) may be
indicated to better delineate the local extent of the lesion and its relationship to the adjacent vessels. EUS-guided fine needle
aspirate is also the best modality for obtaining a tissue diagnosis, although this is not required routinely [ 15 ].
Preoperative imaging evaluation to assess resectability, the role of EUS, and radiographic staging are discussed in detail elsewhere.
(See "Clinical manifestations, diagnosis, and staging of exocrine pancreatic cancer", section on 'Imaging studies' and "Endoscopic
ultrasound in the staging of exocrine pancreatic cancer" .)
Nutritional status Although many of these patients have lost weight, most are still adequately nourished to safely undergo the
operation. However, if the serum albumin is <3 g/dL, or if surgery must be delayed for more than two weeks, we prescribe
supplemental nutrition [ 16 ]. (See "The role of parenteral and enteral/oral nutritional support in patients with cancer", section on
'The perioperative setting' .)

Nutrition can usually be provided enterally, but occasionally parenteral alimentation is indicated [ 16 ]. (See "Perioperative
nutritional support" and "The role of parenteral and enteral/oral nutritional support in patients with cancer" .)
Pancreatic enzyme replacement may also be useful, given that some of these patients have pancreatic exocrine insufficiency related
either to underlying chronic pancreatitis or, sometimes, to the cancer itself (eg, a pancreatic head cancer causing obstruction of the
main pancreatic duct). (See "Treatment of chronic pancreatitis", section on 'Pancreatic enzyme supplements' and "Exocrine
pancreatic cancer: Palliation of symptoms", section on 'Malabsorption and weight loss' .)
Stenting Because obstructive jaundice can cause defects in hepatic, renal, and immune function, it was hoped that preoperative
relief of the jaundice would correct these defects and decrease postoperative morbidity and mortality rates.
Uncertainty as to the benefit of preoperative drainage has led to differing approaches. Some surgeons routinely decompress
jaundiced patients with an endoscopically placed stent prior to surgery. However, others reserve biliary decompression for selected
patients in whom surgery will be delayed for longer than two weeks and those with debilitating pruritus or cholangitis. This subject
is addressed elsewhere. (See "Exocrine pancreatic cancer: Palliation of symptoms", section on 'Stents' and "Surgery in the
treatment of exocrine pancreatic cancer and prognosis", section on 'Role of biliary drainage' .)
If stenting is performed for jaundiced patients, a plastic biliary stent (at least 10 French) should be placed endoscopically, keeping
the proximal end of the stent at or below the level of the cystic duct takeoff. (French refers to a measurement of tubing
circumference. One French is approximately one third of a millimeter: 0.013 inch). Metal stents often incite a severe inflammatory
reaction and may be incorporated into the bile duct wall, making it difficult to remove them at the time of surgery. A metal stent
that is placed too high in the duct can complicate or even prevent the resection. Ideally, the use of a metal rather than plastic stent
in a patient who is a candidate for resection should be reviewed with the surgeon prior to placement.
Bowel preparation Patients are instructed to begin a clear liquid diet two days prior to surgery and are given a standard
mechanical bowel cleansing preparation one day before surgery. We employ the classic Nichols-Condon bowel preparation, which
calls for neomycin (1 gm) and an erythromycin base (1 gm) at 1 pm, 2 pm, and 11 pm the day before surgery, in combination with
mechanical cleansing (cathartics and enemas) [ 17 ].
Antibiotics Patients should receive prophylactic antibiotics within a one hour "window" before the initial incision [ 18,19 ]. The
recommended antibiotics are cefazolin (1 to 2 g intravenously) or, in patients allergic to penicillins and
cephalosporins, clindamycin plus one of the following: ciprofloxacin , levofloxacin , gentamicin , or aztreonam . Antibiotics are
continued for 24 hours postoperatively. (See "Overview of control measures to prevent surgical site infection" .)
Deep venous thrombosis prophylaxis All patients receive 5000 units aqueous heparin subcutaneously preoperatively. Thighlength sequential compression devices are applied. (See "Prevention of venous thromboembolic disease in surgical patients" .)
SURGEON'S SAFETY CHECKLIST FOR PANCREATICODUODENECTOMY
Surgical consent includes the possibility that completion of the pancreatic resection may not be possible if there is
unrecognized metastatic or locally advanced unresectable disease. Discussion with the patient should include the
possibility of pancreatic fistula, a leak from the biliary anastomosis, intraabdominal abscess, delayed gastric emptying,
small bowel obstruction, and postoperative bleeding.
The patient has been typed and crossed in case transfusion is needed.
Anesthetic concerns specific to the patient have been reviewed.
Proper staplers and drains are available.
Prophylactic antibiotics have been administered.
Imaging studies have been reviewed and are displayed in the operating room.
Appropriate deep venous thromboembolism (DVT) prophylaxis has been ordered.
A Foley catheter is placed in the bladder.
SURGICAL TECHNIQUE Almost all of our patients undergo a pylorus-preserving pancreaticoduodenectomy [ 20,21 ]. A
standard Whipple operation is performed if the tumor involves the proximal duodenum, pylorus, or gastric antrum. There is a 15
percent incidence of delayed gastric emptying following either standard or pylorus-preserving pancreaticoduodenectomy, in our
experience.
There is no evidence to support benefit from extended lymphadenectomy, and we do not perform extended lymph node dissection.
(See "Surgery in the treatment of exocrine pancreatic cancer and prognosis", section on 'Ultraradical surgery' .)

Summary of surgical steps The following maneuvers are performed, usually in the following sequence ( figure 3 ). Each is
described in detail below:
Assessment of the abdomen for metastatic disease
Mobilization of the duodenum and the head of the pancreas, with identification of the superior mesenteric vein (SMV)
Mobilization of the stomach and proximal duodenum, with transection of the proximal duodenum (or stomach) as soon as
the decision for resection has been made
Skeletonization of the structures of the porta hepatis
Cholecystectomy and division of the bile duct
Mobilization and division of the proximal jejunum
Transection of the neck of the pancreas and division of the remaining attachments of the specimen to the SMV and PV,
and the superior mesenteric artery (SMA)
Reconstruction of gastrointestinal continuity ( figure 4 )
Patient positioning The patient is placed in the supine position.
Staging laparoscopy In 10 to 15 percent of cases, small hepatic or peritoneal metastases, which were not evident from the
preoperative studies, may be found at exploration. For this reason, some surgeons prefer to begin the operation with laparoscopy,
which permits examination of the liver and peritoneal surfaces, and biopsy of any suspicious areas. If a metastatic tumor is found,
laparotomy may be avoided.
The major drawbacks of laparoscopy are the additional time and expense required for the procedure and the inability to determine
the presence of vascular invasion that precludes an attempt at resection. The latter requires more extensive dissection and is aided
by the tactile senses only available during laparotomy.
We restrict the use of laparoscopy to cases where there is a high likelihood of unresectability that has not been confirmed
preoperatively. Examples include some patients with pancreatic cancer and CT evidence of liver surface or other intraperitoneal
metastases that have not been proven with biopsy; patients with pancreatic body or tail cancers, all of whom have a very low
chance of having a resectable lesion; and patients with pancreatic cancer and ascites, which is probably due to unrecognized
peritoneal metastases.
In the event that unresectable disease is encountered at the time of laparoscopy, and the patient has unrelieved obstructive
jaundice and is at risk for gastric outlet obstruction, palliative gastric and biliary bypasses may be done laparoscopically in many
cases [ 22 ]. The data on surgical bypass versus nonsurgical palliation (ie, stenting) for biliary or gastric outlet obstruction in
patients with pancreatic cancer are presented elsewhere. (See "Exocrine pancreatic cancer: Palliation of symptoms", section on
'Jaundice' and "Exocrine pancreatic cancer: Palliation of symptoms", section on 'Duodenal obstruction' .)
Incision The operation is performed either through a midline or a bilateral subcostal incision. The latter is preferred in obese
patients. (See "Principles of abdominal wall incisions" .)
Assessment of metastatic disease After the abdomen has been entered, an initial assessment of the peritoneal cavity is
performed. Both lobes of the liver are inspected and palpated and all of the peritoneal surfaces are assessed for metastatic disease.
The transverse colon is elevated and its mesocolon, especially overlying the duodenum and head of the pancreas, is inspected.
Occasionally the tumor will have grown through the mesocolon at this point, where it can be seen and palpated as a firm nodularity.
If this is present, it suggests the possibility that the SMV may also be involved by tumor. The areas of the ligament of Treitz, the
proximal jejunum, and the root of the small bowel mesentery are also inspected.
A biopsy with frozen section should be taken of any suspicious lesion to rule out metastatic disease. If none is found, any adhesions
that may interfere with later exposure are cut, and a self retaining retractor is placed.
Mobilization of the duodenum and pancreatic head We use a self-retaining Bookwalter type retractor. Two deep Richardson
retractors are placed first:
Retractor 1 - retracts the gallbladder and the right lobe of the liver cranially
Retractor 2 - retracts the left lobe

We usually begin by performing an extensive Kocher maneuver to mobilize the duodenum and the head of the pancreas. The vena
cava and the aorta are cleaned of soft tissue in the process; the left renal vein is exposed, but we do not routinely remove the soft
tissue and nodes between the vena cava and aorta. Indeed, if the tumor is adherent to these structures or if the nodes are firm and
appear to be involved by tumor, we confirm the presence of cancer by biopsy. Tumor involvement here is considered a
contraindication to resection.
As the duodenal mobilization proceeds distally, the hepatic flexure of the colon must be separated from it, which begins to identify
its mesocolon as a distinct structure.
It is helpful at this point to place another retractor:
Retractor 3 - pulls the hepatic flexure and right colon caudally
Now the mobilization of the third and fourth portions of the duodenum continues until an opening is made in the peritoneum caudal
to the duodenum and anterior to the aorta, to the left side of the peritoneal cavity. This allows the surgeon to place a finger through
to the area where the ligament of Treitz and proximal jejunum will be dealt with later in the operation. This maneuver usually
signals the end of the duodenal mobilization and attention is now turned to the anterior aspect of the head of the pancreas and the
still adherent portion of the transverse mesocolon, which needs to be separated further to expose the SMV.
Identification of the superior mesenteric vein (SMV) Careful inspection of the anterior aspect of the exposed pancreatic
head will reveal the avascular line of fusion between the mesocolon and the pancreas. The mesocolon should be separated from the
head of the pancreas along this line and reflected medially to expose the SMV that runs along the right lateral margin of this tissue.
The SMV limits further medial separation of the transverse mesocolon from the neck of the pancreas and the retroperitoneal third
part of the duodenum. The plane of dissection on the vein should be at the level of its adventitia, and it is important to incise
through the fibrous and avascular capsule that surrounds the vein in order to reach this plane. Several venous tributaries from the
head of the pancreas run directly into the vein and the larger ones should be ligated in continuity and divided at this point. The
middle colic vein usually is preserved (it can be sacrificed if it is involved by tumor), but either now or at a later stage in the
dissection, the large gastroepiploic vein from the greater curve of the stomach should be divided close to where it enters the SMV.
The gastroepiploic vein may also join the middle colic vein where the two run together for a short distance as the gastrocolic trunk,
which then enters the SMV as a single vessel.
Once the SMV has been cleaned of adherent tissue and the larger tributaries from the pancreas proximal to the middle colic vein
have been divided, we usually begin the dissection of the stomach and proximal duodenum. Separation of the neck of the pancreas
from the vein is usually postponed until after that dissection has been done.
Mobilization of the stomach and proximal duodenum The stomach is elevated and pulled caudally and the gastrocolic
omentum is opened to enter the lesser sac, taking care to preserve the gastroepiploic arcade of vessels along the greater curve.
Major vessels are ligated and divided, and an opening is created so that the avascular adhesions from the posterior surface of the
stomach to the pancreas can be exposed and lysed with electrocautery. As we develop the dissection distally toward the pylorus,
the avascular attachments of the transverse mesocolon to the gastrocolic omentum can be separated. Transillumination of the
tissue allows for identification of the gastroepiploic vein, which should be ligated and divided before it enters the SMV or joins with
the middle colic vein.
The gastroepiploic artery should also be ligated and divided. The dissection of the posterior duodenum should continue at least 1 to
2 cm past the gastroduodenal artery where it can be seen and felt on the surface of the pancreas. By this time the dissection should
have reached the same level and be in the same plane as the earlier dissection of the SMV and where the vein disappears beneath
the neck of the pancreas. Now we incise along the inferior margin of the pancreas for a distance of about 3 to 4 cm along the body
of the gland. This allows us to deepen the dissection to the left of the neck of the gland and to reach the level where the later
pancreaticojejunal anastomosis will take place. At this point the dissection is usually through fatty areolar tissue, but occasionally a
vessel will be encountered that should be ligated and divided.
Transection of the proximal duodenum or stomach By this time, it is often evident that the tumor is resectable (ie, the
tumor mass can be palpated and its position away from the SMV and PV can be confirmed). If this is the case, we next mobilize the
lesser curve side of the distal stomach and proximal duodenum, and ligate and divide the right gastric and duodenal vessels to a
point opposite where the duodenum was mobilized and its surface cleaned on the greater curve side. This is done a centimeter or so
away from the duodenum so as to preserve collateral vessels to the gastroduodenal wall, and in a fashion that avoids injury to the
nerve of Latarjet. When the duodenum has been cleaned circumferentially, it is then transected with a stapling device.
Over 90 percent of our resections are done as pylorus-preserving operations, but if a standard pancreaticoduodenectomy is to be
done, the duodenal dissection just described is not necessary, and the stomach is transected at the level of the gastric antrum.
Then the gastric staple line starting from the lesser curve side is buried using 3-0 seromuscular non-absorbable (silk) sutures,
stopping about 4 to 5 cm from the greater curve margin. This will be the site of the eventual gastrojejunostomy (Hofmeister) during
the later gastrointestinal reconstruction.
Retractor 4 - The preserved stomach (and duodenum) is then retracted toward the left upper quadrant. This provides
wide exposure of the hepatoduodenal ligament, which is dissected next.

If it is still uncertain whether resection is possible after the duodenum has been cleaned circumferentially, we would delay duodenal
transection until later in the operation.
Skeletonization of the portal structures The hepatoduodenal ligament is dissected next. The soft tissue of the gastrohepatic
ligament is opened in an avascular area to the left of the hepatic artery. The hepatic artery is then cleaned of its attached tissues
which contain fat, lymphatic channels and lymph nodes. The right gastric and gastroduodenal arteries are ligated and divided close
to their origins; the gastroduodenal artery stump is secured with both a 2-0 silk tie and a metal clip. (Occasionally, the right gastric
artery is particularly large and well developed, which suggests that it should be preserved to maintain the blood supply of the distal
stomach and duodenum.) This dissection is carried caudally to the superior border of the pancreas which is also cleaned of adherent
tissue.
The lymph nodes that typically are found along the superior border of the neck of the pancreas, where the pancreatic transection
will later occur, should be removed. This dissection should be sufficiently deep to expose the splenic artery as it begins its course
toward the spleen, and the anterior surface of the PV. If there is still a question about whether the tumor is adherent to the anterior
surface of the PV, this can be resolved since the SMV below and the PV above are now exposed. The anterior surface of the PV is
then cleaned cranially along with the right and left hepatic arteries to the level at which the bile duct will be transected.
Cholecystectomy and division of the bile duct Next the gallbladder is removed. This requires replacement of Retractor 1
with a more shallow retractor to expose the undersurface of the liver. (See 'Mobilization of the duodenum and pancreatic
head' above.) The original retractor is replaced after the cholecystectomy.
We next transect the common hepatic duct. A right angled dissecting clamp is inserted behind it, keeping close to its posterior
surface, and a vessel loop is pulled through the opening. At this time the surgeon should feel for arterial pulsation along the right
lateral or posterior surface of the bile duct. This may be due to the presence of a replaced right hepatic artery or an early division of
the hepatic artery into right and left hepatic arteries. One must be careful to not injure the artery during this and subsequent
dissection. The duct is elevated so that a curved bulldog clamp can be applied to its proximal portion. The distal part is clamped and
the duct is cut. If a stent had been placed preoperatively, it is removed at this time. The distal duct is suture ligated and the ends of
the sutures cut long to aid the pathologist in identifying the bile duct margin after the specimen has been removed. The proximal
duct usually does not bleed since the bulldog clamp effectively compresses the vessels that run along its wall, and it remains in
place until later.
Finally, the soft tissue and lymph nodes behind the bile duct are cut, separated from it, and allowed to remain in continuity with the
specimen. Because this tissue is quite vascular, it needs to be ligated as it is separated piece by piece from the tissues that are to
remain. Finally we pass a 1/4 inch Penrose drain behind the neck of the pancreas and anterior to the SMV/PV. This protects the
vessels later when the neck of the pancreas is transected.
Mobilization and division of the proximal jejunum Next, the ligament of Treitz and the proximal jejunum are exposed,
which requires modifying the original exposure. The transverse and splenic flexures of the colon are retracted cranially and the
distal small bowel, covered with moist laparotomy pads, is retracted caudally.
Next the transverse and splenic flexures of the colon should be retracted cranially by repositioning Retractors 2 and 4 so that the
colon can be placed behind them. (See'Mobilization of the duodenum and pancreatic head' above.) This allows for the exposure of
the opening in the peritoneum created earlier during the Kocher maneuver, the entire root of the small bowel mesentery, the
ligament of Treitz, and the inferior mesenteric vein.
Staying anterior and medial to the vein at all times, the avascular peritoneal folds that form the ligament of Treitz are cut with
electrocautery. Then the mesentery of the proximal jejunum is displayed and the vascular arcades of the bowel are ligated and
divided beginning about 6 to 8 inches from the ligament of Treitz. When a large enough opening has been created in the mesentery,
an automatic stapler is inserted through it and the jejunum is divided. Then the stapled end of the distal segment is turned in with
seromuscular silk sutures. With an Allis clamp providing tension on the proximal stapled end of the jejunum, the vessels in the
mesentery are ligated and divided, progressing proximally until the retroperitoneal portion of the duodenum has been reached.
These repetitive maneuvers are hastened with the use of the Harmonic Scalpel.
Now the proximal duodenal-jejunal segment, which is part of the specimen, is delivered to the right side through the peritoneal
opening. We then release the retractors holding the colon and small bowel and reposition them for the final phase of the resection.
The small bowel is returned to the peritoneal cavity, the transverse and splenic flexures of the colon are released from Retractors 2
and 4, and the colon too is replaced into the abdomen covering the small bowel. Retractors 1, 2, and 4 are repositioned to elevate
the right and left lobes of the liver and retract the stomach, as they did initially. (See 'Mobilization of the duodenum and pancreatic
head' above and 'Transection of the proximal duodenum or stomach' above.)
Retractors 5 and 6 - These retractors are then placed along the patient's left side to flatten and keep in place the colon
and its mesocolon. Even in obese patients, this provides excellent exposure.
Transection of the pancreatic neck The neck of the pancreas is elevated from the underlying vein with the help of the
Penrose drain. In a soft pancreas, hemostatic synthetic, nonabsorbable polypropylene suture (Prolene) (3-0) are placed through the
pancreatic parenchyma at both the inferior and superior margin of the pancreas, on either side of the proposed line of transection

(ie, four sutures total), which usually overlies the vein. On the specimen side, the sutures can be placed so as to occlude most or all
of the pancreatic parenchyma and the duct.
On the side of the pancreas that will remain, the surgeon should try to avoid placing the superior margin suture in a way that might
obstruct the pancreatic duct, which normally is situated closer to that margin and quite posterior in the gland. All of the sutures are
tied tightly, but care should be taken to avoid tearing the pancreatic parenchyma. Next the pancreatic parenchyma is divided with
electrocautery. Any bleeding can usually be stopped with electrocoagulation; if not, vascular suture should be used (4-0 or 5-0).
When the transection is complete, the Penrose drain is removed.
Division of attachments to the SMV, SMA and PV The surgeon, who stands on the patient's left side, grasps the duodenum
and head of the pancreas in the left hand and retracts it away from the PV. The dissection begins at the cranial end of the specimen
progressing distally, and the remaining attachments to the PV/SMV and retroperitoneal tissues are ligated and divided. The surgeon
defines each bit of tissue for transection by separating it from surrounding structures with a right-angled clamp, into which the first
assistant places 2-0 silk ties that are pulled through the opening. The clamp is then applied to the side of the tissue that is to
remain, the assistant ties the specimen side, the surgeon cuts the tissue, and the assistant then ties the tissue in the clamp. This
process is repeated until the entire specimen is free. Individual vessels that can be seen entering into the SMV or PV are tied in
continuity, usually with 4-0 silk, and cut. Occasionally vascular suture ligatures of 4-0 or 5-0 synthetic, nonabsorbable
polypropylene suture (Prolene) may be required to stop bleeding from the veins themselves or tissue deep to them ( figure 3 ).
Occasionally, the tumor will be found to be adherent to the right lateral or posterior part of the SMV or PV, which was not suspected
before the neck of the pancreas was divided. In this circumstance, the segment of involved vein should be resected, either as a
lateral venorrhaphy or a segmental resection of a cylinder of the vessel. In the latter case, end to end anastomoses are almost
always possible even if a length of 2 to 3 cm of vein is removed. Vascular clamps prevent bleeding, while venous continuity is
restored with suture of 5-0 Prolene.
The entire specimen is then sent to the pathology laboratory for frozen section examination of the resection margins (duodenal,
jejunal, pancreas, bile duct). If invasive cancer is seen in any of them, more tissue is resected until a negative margin is obtained.
During the time that it takes for the specimen to be examined, the operative field is irrigated with warm saline, meticulous
hemostasis is assured, and the pancreatic anastomosis is begun.
Reconstruction of gastrointestinal continuity
Pancreatic anastomosis An end to side pancreaticojejunostomy is performed first, usually by bringing the jejunum behind the
SMA and SMV, in a position similar to that occupied originally by the retroperitoneal duodenum [ 23 ]. However, in patients with
cancers arising in the third or fourth part of the duodenum, we prefer to bring the jejunum through a hole in the transverse
mesocolon instead. This minimizes the potential for later obstruction of the jejunum if the cancer should recur in the
retroperitoneum ( figure 4 ).
The cut end of the pancreas is mobilized from the retroperitoneal tissues for a distance of 2 to 3 cm, which may require ligation and
division of a few venous tributaries to the splenic vein. The pancreatic duct is probed and its patency assured past the point where
the Prolene hemostatic suture had been placed earlier in the superior margin of the gland. Depending on the size of the duct, a 5 or
8 French Pediatric Feeding tube is inserted well into the duct so that it can be easily seen during the anastomosis (French refers to a
measurement of tubing circumference. One French is approximately one third of a millimeter: .013 inch). We do not use a
pancreatic duct stent, so this tube will be removed when the anastomosis is almost complete.
The two layer anastomosis is begun by placing a posterior row of three or four 3-0 or 4-0 horizontal silk mattress sutures from the
pancreas to the bowel; after they are all placed, the sutures are tied as the first assistant brings the bowel to the pancreas to
minimize the chances that the pancreatic parenchyma will tear. They are placed horizontally so that when they are tied, any
pancreatic parenchymal vessels (which generally run transversely) are likely to be compressed; this minimizes bleeding from needle
placement. The jejunum is then opened with electrocautery about 1 cm anterior to the line where the silk sutures have been tied.
Two 3-0 or 4-0 polydioxanone (PDS) sutures are then placed at the posterosuperior margin of the anastomosis, each end is tied,
and the short end is cut. Both of these sutures are placed from the mucosal side of the bowel and then through the pancreatic
parenchyma about 1 cm back from the cut edge of the pancreas. The first suture will be continued as the posterior row, and should
be placed through the lumen of the pancreatic duct as it passes near the duct, and then through the full thickness of the bowel wall
about 5 mm from the cut edge. This usually requires two or three sutures placed into the duct lumen in this fashion, even with the
largest ducts. This posterior row suture is held after the inferior corner of the anastomosis is completed. Then the second suture is
brought from the inside of the bowel lumen where it was tied, through the bowel wall so that the anterior row of sutures can be
placed. Again, the sutures are placed through the lumen of the pancreatic duct before traversing the full thickness of the anterior
bowel wall.
The feeding tube helps to identify the duct lumen and aids in suture placement. When the sutures progress past the duct, the
feeding tube should be removed. When the anterior row of sutures reaches the posterior one, the two PDS sutures are tied to each
other. The anastomosis is completed with the placement of the anterior row of 3-0 or 4-0 silk sutures in a fashion similar to the
posterior row. The assistant again brings the bowel wall up to the pancreas as the sutures are tied to minimize the chance that the
pancreas will tear. This anastomosis results in the invagination of the cut end of the pancreas into the lumen of the bowel.
Biliary anastomosis The hepatico (choledocho) jejunal anastomosis is performed next at a sufficient distance from the
pancreas to avoid tension on the suture line, but not too long to allow kinking of the bowel. The bulldog clamp is removed from the

bile duct, a bile culture is taken, and hemostasis is obtained. A single layer anastomosis using interrupted sutures of 4-0 or 5-0
polydioxanone (PDS) is performed. (If the duct is 2 cm or more in diameter, running sutures are also satisfactory.) Initially, the
sutures are placed through the anterior wall of the duct about 2 to 3 mm from the edge, and from the outside of the duct into its
lumen. The corner sutures are placed first, then the middle, etc. so as to place them evenly along the length of the anastomosis,
and at a distance of about 4 to 5 mm from each other. These sutures are held with the needles attached until the posterior row of
sutures has been placed, which is done next.
The bowel lumen is opened with electrocautery for a length equivalent to that of the bile duct diameter, and the sutures are placed
between the duct and the jejunum and tied with the knots placed inside the lumen of the duct. Finally, the anterior row of sutures
that had been placed on the bile duct side are placed through the bowel wall and tied. Here the knots are on the outside. If the duct
is smaller than 1 cm in diameter, a small T tube inserted through the wall of the bile duct proximal to the anastomosis. The distal
limb of the T-tube lies in the jejunal limb. The tube is removed in the office three to four weeks later, usually without a prior
cholangiogram.
Duodenal anastomosis Finally, an antecolic duodeno(gastro)jejunostomy is constructed approximately 30 cm distal to the
choledochojejunostomy, in a standard two-layer fashion.
Drains and closure A closed suction drain (eg, #10 Jackson Pratt) is placed close to both the pancreatic and hepatic duct
anastomoses. The drain is led behind the stomach, between the pancreaticojejunostomy and the left lobe of the liver, with the tip
placed behind the hepaticojejunostomy, then brought out of the abdomen on the left side. The T-tube is brought out of the
abdomen on the right side. The drain and T-tube are sutured to the skin. After this the abdomen is irrigated and closed.
(See "Principles of abdominal wall closure" .)
POSTOPERATIVE CARE The patients do not need to be transferred to an intensive care unit as a routine postoperatively. The
nasogastric tube is removed on the morning of the first postoperative day and the patient is encouraged to ambulate. A clear liquid
diet is usually started on the fifth postoperative day and most patients are able to advance to a regular diet over the next 24 to 48
hours. Most patients are released from the hospital within 7 to 10 days of operation.
If there is no suspicion of a pancreatic or bile fistula, the drain should be removed after the patient is eating solid food. If there is
any suspicion of a pancreatic leak, the amylase concentration of the fluid is measured to confirm the diagnosis and the patient is
sent home with the drain in place. The patient continues an oral diet and the drain is removed in the outpatient clinic once the
drainage has stopped. In our experience, all of these fistulas close spontaneously, usually within four to six weeks after discharge
[24 ]. Although one study of 114 patients reported lower rates of complications with early drain removal in patients at low risk of
pancreatic fistula (drainage fluid amylase value of 5000 U/L), most surgeons tailor drain care to the individual patients progress
[ 25 ]. (See "Clinical features, diagnosis, and prevention of pancreatic fistulas" .)
Most patients who have undergone pancreaticoduodenectomy will not need pancreatic enzyme supplementation. Many patients will
have several bowel movements a day for some weeks following discharge from the hospital, and if this is problematic, it can be
treated symptomatically ( table 1 ). As the GI tract "readjusts," bowel frequency almost always decreases and most patients end up
with two to three formed movements daily.
If steatorrhea is evident with oily floating stools, then pancreatic enzyme supplements should be prescribed in a quantity sufficient
to provide at least 30,000 units of lipase with each meal, along with an antacid secretory inhibitor to decrease gastric acid secretion
( table 1 ). One-half of this dose should be administered with snacks. It is almost never necessary to limit fat intake. If this
approach does not provide relief, the patient is referred to a gastroenterologist for management of the problem. (See "Overview of
the treatment of malabsorption" and "Treatment of chronic pancreatitis" .)
COMPLICATIONS
Vomiting Vomiting after oral intake is resumed could be due to delayed gastric emptying. The mean incidence of delayed
gastric emptying is 17 percent although the range varies widely among trials [ 26 ].
To manage postoperative vomiting, a nasogastric tube is reinserted and an abdominal CT scan is obtained. Rarely, this reveals a
fluid collection near the stomach, which may represent an undrained pancreatic fistula or other process. Percutaneous drainage and
culture of the fluid should be done.
Although delayed gastric emptying can be due to several causes, it is important to not overlook a fistula, which is a treatable
condition. Gastric function usually returns when the fluid collection is treated appropriately, or after a period of nasogastric suction if
no other abnormalities are found. We also would administer a gastric promotility agent if gastric emptying is delayed.
(See "Malignancy-associated gastroparesis: Pathophysiology and management" and "Treatment of delayed gastric emptying" .)
Bile leaks Bile leaks from the choledochal-jejunal anastomosis occur in 1 to 2 percent of cases, and are heralded by the
appearance of bile in the drain fluid. If this occurs, the drain should be left in place until the leak stops. If it is still present when the
patient is ready for discharge, the patient can go home with the drain in place. It can be removed in the office when there is no
longer any bile present. If there is no evidence of a biliary leak, the biliary drain is removed the day after the patient begins oral
intake.
Pancreatic fistula Pancreatic fistulas are defined by the International Study Group on Pancreatic Fistula Definition as a drain
output of any measurable volume of fluid on or after postoperative day three with an amylase content greater than 3 times the
serum amylase [ 27 ]. A pancreatic fistula complicates 2 to 22 percent of pancreaticoduodenectomy operations, when the

pancreaticojejunostomy does not heal [ 28 ]. Pancreatic fistulas can lead to sepsis and hemorrhage. These complications are
associated with mortality of 20 to 40 percent, prolonged hospitalization and increased hospital expenses [ 28 ]. (See "Clinical
features, diagnosis, and prevention of pancreatic fistulas" .)
Pancreatic leaks are more common when the pancreatic parenchyma is soft and holds sutures poorly (eg, cysts, ampullary cancers
that do not obstruct the pancreatic duct), and when the pancreatic duct is small. In patients with pancreatic cancer where the
pancreatic duct is commonly obstructed by the tumor, the pancreas is firm and a pancreatic fistula is uncommon. There is no clear
evidence favoring any specific pancreaticoenteric anastomosis or pancreatic ductal obliteration to prevent fistula formation [ 28 ].
BORDERLINE RESECTABLE DISEASE There is not universal agreement on the criteria for the definition of borderline
resectable disease. Some reserve the term "borderline resectable" for cases where there is focal (less than one-half of the
circumference) tumor abutment of the visceral arteries or short-segment occlusion of the SMV or SMV/portal vein confluence [ 2931 ]. Others suggest that venous narrowing without occlusion be included in the definition of borderline resectable disease [ 32 ].
Several groups have issued guidelines to define resectability based on imaging studies [ 33,34 ]. This is discussed in detail
elsewhere (see "Clinical manifestations, diagnosis, and staging of exocrine pancreatic cancer", section on 'Definitions of
unresectable and borderline resectable disease' ).
Patients who are deemed to have borderline resectable pancreas cancer are potential candidates for downstaging with neoadjuvant
therapy and should be referred for medical oncology and radiation therapy consultation. Encasement (more than one-half of the
vessel circumference) or occlusion of the superior mesenteric vein (SMV) or the SMV-portal vein confluence used to be considered a
criterion for unresectability. However, many centers have demonstrated the feasibility of SMV reconstruction, and this is now
considered by many to represent borderline resectable disease [ 35 ]. However, such patients should undergo an attempt at
downstaging with neoadjuvant therapy before surgery. Although vascular resection and reconstruction at the time of the initial
exploration for pancreaticoduodenectomy is occasionally warranted, we prefer to postpone resection until after the patient has
received a prolonged course of neoadjuvant therapy (eg, six months) [ 36 ]. Anecdotal evidence suggests that the tumor inevitably
recurs if resection is performed in the presence of such locally extensive disease, unless neoadjuvant therapy has been given first.
Long term survivors are occasionally seen when resection is done after treatment, however. Although vascular resection adds a
measure of complexity to the standard pancreaticoduodenectomy, an experienced surgical team in a high volume center is able to
safely perform the procedure when that is required. (See "Management of locally advanced and borderline resectable exocrine
pancreatic cancer" and "Clinical manifestations, diagnosis, and staging of exocrine pancreatic cancer", section on 'Assessing
resectability' .)
PALLIATIVE SURGERY When the patient is found to have unresectable disease and the surgeon believes that downstaging
neoadjuvant therapy is unlikely to be successful (eg, liver or peritoneal metastases, very extensive local disease with complete
major vascular occlusion, etc.), surgical biliary and gastric bypass should be considered. Biliary bypass (cholecysto- or choledochojejunostomy) effectively relieve biliary obstruction and eliminate the need for a stent. If the gallbladder is used for the
decompression, the surgeon should be certain that the cystic duct is open and not likely to soon become obstructed by the cancer
as it grows. A prophylactic antecolic gastrojejunostomy should also be done in most patients who are likely to survive for more than
three months. It does not add to the morbidity of the operation.
INFORMATION FOR PATIENTS UpToDate offers two types of patient education materials, The Basics and Beyond the
Basics. The Basics patient education pieces are written in plain language, at the 5 th to 6 th grade reading level, and they answer the
four or five key questions a patient might have about a given condition. These articles are best for patients who want a general
overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated,
and more detailed. These articles are written at the 10 th to 12 th grade reading level and are best for patients who want in-depth
information and are comfortable with some medical jargon.
Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your
patients. (You can also locate patient education articles on a variety of subjects by searching on patient info and the keyword(s) of
interest.)
Beyond the Basics topics (see "Patient information: Pancreatic cancer (Beyond the Basics)" and "Patient information:
Chronic pancreatitis (Beyond the Basics)" )
SUMMARY AND RECOMMENDATIONS
A standard pancreaticoduodenectomy, (Whipple procedure) includes a distal gastrectomy with removal of the pancreatic
head, duodenum, first 15 cm of the jejunum, common bile duct, and gallbladder. A pylorus-preserving
pancreaticoduodenectomy preserves the gastric antrum, pylorus, and the proximal 2 to 3 cm of the duodenum, which
is anastomosed to the jejunum to restore gastrointestinal continuity. (See 'Introduction' above.)
The most common indication for pancreaticoduodenectomy is the presence of a neoplasm in the head of the pancreas or
one of the other periampullary structures (bile duct, ampulla, or duodenum). Painful chronic pancreatitis is also
effectively treated by this operation. (See 'Indications' above.)

 Preoperative imaging with high resolution computerized tomographic (CT) scan with 1 to 2 mm cuts through the pancreas
during the early arterial phase (pancreatic protocol) provides the best assessment of resectability. EUS-guided fine
needle aspirate is the best modality for obtaining a tissue diagnosis when appropriate. (See'Preoperative
evaluation' above.)
For patients with serum albumin <3 g/dL, or if surgery must be delayed for more than several weeks, supplemental
nutrition should be provided. (See 'Preoperative evaluation' above.)
We do not place biliary stents routinely. For patients with debilitating pruritus or cholangitis, or if surgery must be delayed
for more than several weeks and jaundice is present, a stent should be placed. If a metal stent is used, the proximal
end of the stent should be kept below the level of bifurcation of the common hepatic duct to avoid complicating the
surgical resection. (See 'Preoperative evaluation' above.)
For patients who are unresectable either because of distant metastases or vascular invasion, we suggest evaluation by a
medical and radiation oncologist for chemotherapy with or without radiation therapy. (See 'Borderline resectable
disease' above.)
For patients with a high likelihood of unresectability that has not been confirmed preoperatively, staging laparoscopy
permits examination of the liver and peritoneal surfaces and biopsy of any suspicious areas. If metastatic tumor is
found, laparotomy may be avoided. (See 'Surgical technique' above.)
If there is any suspicion of a pancreatic leak, the amylase concentration of the drain output is measured to confirm the
diagnosis and the drain should be kept in place until the drainage stops. (See 'Complications' above.)
For patients who develop postoperative vomiting, a nasogastric tube should be reinserted and an abdominal CT scan
obtained to look for a fluid collection causing delayed gastric emptying. If a collection is present it should be drained
and cultured. (See 'Complications' above.)

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