Pancreatic neoplasia other than adenocarcinoma
Bile duct tumor (Klatskin tumor)
Traumatic Injury to pancreas
Chronic pain due to chronic pancreatitis – this is a rare cause of the the Whipple procedure being performed.
Upper midline – this generally runs from below the xiphoid process to below the umbilicus. Many very experienced pancreatic surgeons who have mastered this procedure and are comfortable with the important anatomy and the necessary steps to insure good exposure use this exposure.
Upper bilateral costal margin – this incision is also used to gain exposure to the upper abdomen and retroperitoneum. If the xiphoid (lower tip of the sternum) is prominent, many surgeons will resect this to improve visualization.
Surgical Details of Procedure
1. The incision is made through the skin with a No. 10 scalpel.
2. Dissection is done down through the subcutaneous tissue with Bovie cautery.
3. The fascia is appreciated and if a midline incision is used the partition between the rectus muscles is located.
4. A knife is used to gentle incise the tissues until the abdomen has been entered.
5. If a bilateral costal margin incision has been used the upper and lower layer level of fascia of the rectus musles is transected using Bovie cauter.
6. The rectus muscles are transected using Bovie cautery.
7. Regardless of the incision used to enter the abdomen the round ligament is grasped by two clamps, doubly ligated, and incised.
8. Most surgeons also divide the falciform ligament up and over the dome of the liver to facilitate exposure.
9. A large self-retaining retractor such as a Bookwalter or Thompson (Omni) retractor is placed.
10. If the reason for surgery is cancer a thorough search for metastatic disease outside of the field of operation is now performed.
11. The peritoneal surface, the liver, the area around the pancreas, the hepatoduoneal ligament (containing the hepatic artery, common bile duct, and portal vein), and the lymph nodes around the celiac axis are explored.
12. Many surgeons performing this operation always perform a cholecystectomy (gallbladder removal) and less frequently the gallbladder is not removed but an aspiration of bile and cholangiogram are performed.
13. If a cholecystectomy is performed this is usually done from a “top down” approach.
14. The top of the gallbladder is grasped with a clamp and gently retracted away from the liver.
15. The avascular fibrous tissue between the gallbladder and the liver is exposed and is incised using Bovie electrocautery.
16. The dissection is taken down to the gallbladder infundibulum where a diligent search for the cystic artery (a branch off the hepatic artery) is performed.
17. When identified the cystic artery is doubly ligated with 2-0 silk sutures and divided. Some surgeons also place a surgical clip on the side of the artery that is remaining.
18. It must be remembered that the cystic artery is sometimes bifurcated and ligation of one arterial structure does not rule out another arterial structure that must be controlled in this area.
19. The cystic duct is then visualized and dissected free of the surrounding fibrous tissue.
20. This is doubly ligated with 2-0 silk ties and incised with a fine Metzenbaum scissors or a knife. Many surgeons also place a surgical clip on the cystic duct stump.
21. The head of the pancreas and the duodenum are then mobilized through a Kocher maneuver.
22. The duodenum is located by first locating the pylyorus of the stomach and tracing this to the 1st and 2nd part of the duodenum.
23. The duodenum is grasped with two Babcock retractors and gently pulled medially.
24. This exposes the peritoneal tissue on the lateral wall of the duodenum and this tissue is incised.
25. Although this tissue plane is avascular, this must be done carefully as directly deep to this plane is the inferior vena cava.
26. Once the duodenum has been Kocherized, gentle blunt finger or gauze dissection is performed to separate the posterior side of the head of the the pancreas from the underlying vena cava and right kidney (this anatomic space is known as the foramen of Winslow).
27. As the blunt dissection is done through the foramen of Winslow a band of peritoneum will be appreciated that constitutes the lower border of the foramen.
28. Gentle retraction is placed on this tissue and it is carefully incised.
29. Attention is now turned to the distal second part of the duodenum and the third part of the duodenum to ascertain if the lesion if in the pancreas is resectable (removable).
30. If the lesion is resectable (removable) attention is then turned to toward freeing up the second and third part of the duodenum.
31. The middle colic vessels (artery and vein) as they travel to the hepatic flexure of the colon must be identified and carefully dissected free if they are in proximity to the second part of the duodenum.
32. The freeing of the third part of the duodenum can be difficult due to the short mesentery and must be done carefully.
33. After the duodenum is freed up, a portion of the proximal jejunum is resected (removed).
34. This is accomplished by making a window in the mesentery of the jejunum with a hemostat.
35. The mesentery is then cross-clamped and tied with 2-0 silk ties until the ligament of Treitz is reached.
36. The ligament of Treitz is cut with a Metzenbaum scissors.
37. Further mobilization of the pancreas is done by enteringthe lesser sac.
38. This is performed by lifting the omentum with an incision made between the stomach and the colon.
39. The omentum should be freed from the transverse colon until the splenic flexure is reached.
40. The entire underside of the pancreas must be visualized and palpated for masses (especially important if gastrinoma is suspected).
41. Attention is turned to the portal triad.
42. The surgeon then palpates posterior to the duodenum to ascertain if the portal vein is involved in the tumor mass.
43. If the tumor is judged to be resectable (removable) the common bile duct is dissected free with as much length retained as possible distal to cystic duct stump and transected.
44. Care must be taken to avoid injury to the portal vein and common hepatic artery.
45. Ligation of the blood vessels neccessary for antrectomy (removal of the stomach antrum) is performed.
46. The right gastroepiploic vessels are dissected free, doubly ligated with 2-0 silk ties, and divided.
47. The antrum is then encircled with an umbilical tape and gently retracted medially and downward.
48. The right gastric vessels are identified, doubly ligated with 2-0 silk ties, and divided.
49. In the classic Whipple procedure (as opposed to a pylorus-sparing pancreaticoduodenectomy or PPPD) a hemigastrectomy is performed to insure complete removal of the antrum to prevent the late complication of peptic ulceration.
50. The resection points on the stomach are located – the area on the lesser curvature where the third vein is located and the area on the greater curvature where the gastroepiploic vessels are nearest to the gastric wall.
51. A linear stapling device is placed across the stomach at above described points and the stomach is transected.
52. Most surgeons usually perform a truncal vagotomy.
53. The region of the esophagus is palpated.
54. The peritoneum is grasped and pulled up off the esophagus and then transected tranversevly.
55. The peritoneum is then bluntly dissected caudally (towards the head) with the surgeon’s finger covered in gauze.
56. The esophagus is then gently dissected free posteriorly by the surgeon using his index finger to encircle the esophagus.
57. The surgeon should expect some resistance on the right side of the esophagus from the gastrohepatic ligament.
58. This tissue in the gastrohepatic ligament should be divided to provide more exposure to the right (posterior) vagus nerve.
59. The esophagus is then gently pulled down into the abdomen and a search for the vagus nerves is done.
60. Because the nerves can not always be visualized, a technique of palpating by running the tip of the index finger over the esophagus usually results in finding a taut, wire-like structure on each side of the esophagus.
61. The left vagus nerve is usually found on the anterior esophagus (somewhat to the left of the midline) and the right vagus is found on the posterior esophagus.
62. The left vagus is then grasped with a nerve hook (e.g., de Takats nerve hook) and is dissected free with a Metzenbaum scissors.