Operative management in patient of pancreatic cancer: Whipple procedure

Operative slide on whipple procedure done for pancreatic carcinoma

1. Whipple`s procedure By: Dr. Kuldeep(JR3) MODERATOR: Dr. Vishal Saxena(M.S.)

2. INDICATIONS Periampullary carcinoma: carcinoma haed of pancreas, carcinoma 2 nd part of duodenum,distal CBD chalangiocarcinoma , carcinoma of ampulla of vater Chronic pancreatitis with disease involving head of pancreas with severe pain Trauma

3. Preoperative evaluation Preoperative evaluation should include a detailed history and physical examination (including functional status), chest imaging, laboratory studies including tumor markers (CA 19-9 and CEA), contrast-enhanced pancreas-protocol computed tomography (CT) of the abdomen and further evaluation of comorbid conditions as indicated. CT allows assessment of the tumor’s relationship to the superior mesenteric artery (SMA), the superior mesenteric vein (SMV) and SMV-portal vein confluence (SMVPV), the celiac artery (CA), and hepatic artery (HA). CT also defines any arterial or venous aberrations (replaced left or right HA, inferior mesenteric vein [IMV] draining directly into the SMV, jejunal branch ofthe SMV draining anterior to the SMA, etc.) and highlights potential lymph node or extrapancreatic metastases. Clinicians can then place the patient into one of four categories based on appropriately performed CT imaging: (1) resectable , (2) borderline resectable , (3) locally advanced (now to include type A and type B), and (4) metastatic.

4. CT allows assessment of the tumor’s relationship to the superior mesenteric artery (SMA), the superior mesenteric vein (SMV) and SMV-portal vein confluence (SMVPV), the celiac artery (CA), and hepatic artery (HA). CT also defines any arterial or venous aberrations (replaced left or right HA, inferior mesenteric vein [IMV] draining directly into the SMV, jejunal branch ofthe SMV draining anterior to the SMA, etc.) and highlights potential lymph node or extrapancreatic metastases. Clinicians can then place the patient into one of four categories based on appropriately performed CT imaging: (1) resectable , (2) borderline resectable , (3) locally advanced (now to include type A and type B), and (4) metastatic.

5. Pancreaticoduodenectomy involves removal of the pancreatic head, duodenum, gallbladder, and bile duct with or without removal of the gastric antrum and lymph nodes. POSITION : supine with arms out. ANESTHESIA: GA+EA INCISION: Upper midline/Roof top incision

6. The whole operative procedure is done in 3 phases, 1. exploration and assessment 2.Resection 3.Reconstruction – Triple anastmosis (PJ, HJ, GJ) Initial 2 Phases are done in 6 steps which are followed by reconstruction phase Before exploration we do laparoscopy to assess the peritoneal mets , ascites , liver, extrapancreatic mets and resectability EXPLORATION: is done by roof top incision Kocher maneuver: is performed to allow assessment of the relationship of the tumor to the SMA by palpation. By mobilizing the pancreatic head and duodenum from their retroperitoneal attachments, the surgeon attempts to palpate a plane of normal tissue between the firm tumor and the posterior pulsation of the SMA. This step is a crude assessment subject to individual surgeon bias. The relationship of the tumor to the right lateral wall of the SMA is the most critical aspect of the pretreatment staging evaluation . Cattell Braasch manuever is done only in venous involvement , deep abdominal cavity, obese patient, for adequate exposure.

7. 1 Step First we enter the lesser sac through the greater omentum and we reach on anterior surface of pancreas. Now we mobilize the hepatic flexure of colon from retroperitoneal attachment. Inferior body of pancreas is identified at the level of head and neck junction and visceral peritoneum and root of mesentery is incised at this point and extend toward junction of 2 nd and 3 rd part of duodenum to expose the SMV. During the exposure of smv we encounter middle colic vein and gastroepiploic vein.these are ligated and divided for better exposure of SMV.

8. 2 nd Step ( Kocher’S Maneuver) Kocher’s maneuver is started from the transverse part of duodenum by identifying the IVC and mobilizing the duodenum and pancreatic head from IVC and Aorta. Division of visceral peritoneum right to root of mesentery is done to expose SMA. Here we remove the fibrofatty tissue and lymph node. Here we palpate the normal tissue plane between the pancreas and SMA.(If SMA is not palpable saperately from tumor mass than it’s unresectable tumor. Dissection is continued from Rt gonadal vein to left renal vein and left lateral surface of aorta and superiorly up to foramen of Winslow. Right gonadal vessels are important landmark to save guard the rt ureter .

9. 3 rd Step Here we dissect the CHA(common hepatic artery) upto the rt gastric artery and gastroduodenal artery by removing the lymph node. Here we palpate for replaced rt hepatic artery and other abberant vessels than we ligate and divide the GDA and rt gastric artery and proper hepatic artery is identified and mobilized from PV. Anterior surface of Portal vein is exposed than hepatic duct is divided at the junction of cystic duct. Now PV is dissected from 1 st part of duodenum, neck of pancreas. By extending the Kocherization we dissect the 3 rd and 4 th part of duodenum with dissection of SMV up to junction of PV by ant retraction of neck of pancreas. Here we create the tunnel of love by blunt dissection and NG passed through it. Bile sample is taken for culture and sensitivity. If stent is in situ than remove it. Bulldog clamp is applied on proximal stamp of hepatic duct. Cholecystectomy is done after ligation and division of cystic artery and cystic duct.

10. 4 th Step The stomach is divided by gastrointestinal clamp at the level of 3 rd or 4 th transverse vein on lesser curvature to confluence of gastroepiploic vein at greater curvature after ligation of terminal branches of left gastric artery. Omentum at greater curvature is divided by harmonic scalpel.

11. 5 th Step After the division of mesentery proximal jejunum(up to 10 cm from DJ) and 4 th part of duodenum, We mobilize the duodenum and jejunum and pass them to rt side below the SM Vessels.

12. 6 th Step After traction suture placement on superior and inferior border of pancreas, pancreas is transected at the level of portal vein. After ligation of small tributaries of SMV on posterior surface of pancreatic head and uncinate process we dissect the head head of pancreas and uncinate process from SMV and confluence of SMV-PV. Now we dissect the SMA and IPDA by retracting the SMV ,PV medially than IPDA is ligated after proper dissection of it. After ligation of first Jejunal branch (posterior to SMA) for SMV , we mobilize the SMV. Here SMA is assessed for tumor involvement and SMA is dissected from uncinate process at it’s origin from Aorta(proximal 3-4 cm).SMA margin is marked.

13. PANCREATIC, BILIARY, AND GASTROINTESTINAL RECONSTRUCTION Pancreaticojejunostomy . Transected jejunum is brought near to pancreatic duct through a incision in mesocolon which is left to middle colic vessels in mesentery. A two- layer, end-to-side, duct-to-mucosa retrocolic pancreaticojejunostomy is performed after mobilization of 2-2.5 cm proximal remnant pancreas from Splenic vessels. Outer layer is sutured by prolene 3.0 rb between parenchyma and capsule of pancreas to seromuscular at antimesentric border of jejunum in interrupted fashion. 2 nd layer is sutured duct to mucosa(between pancreatic duct and full thickness of jejunum) by prolene 5.0 rb in interrupted fashion.

14. Hepaticojejunostomy After taking two stay suture HJ is done in single layer end to side,10 cm distal to PJ in full thickness interrupted fashion by 4.0 RB absorbable suture.

15. Gastrojejunostomy GJ is done anticolic , end to side,in two layer by silk 3.0RB, Starting with greater curvature on stomach and 50 cm distal to HJ.

16. After reconstruction, we put two abdominal drain one in subhepatic and 2 nd near to PJ. Abdomen is closed. Excised tissue is sent for HPE to pathology department.

17. COMPLICATIONS Bleeding Pancreatic leak/fistula/collection Bile leak Anastomotic dehiscence Post-op pancreatitis Subphrenic abscess Sepsis Cholangitis Delayed gastric emptying SMA/SMV/PV thrombosis LATE: steatorrhoea , dumping syndrome, diabetes( upto 30%), recurrence

18. THANK YOU