Whipple's procedure - Indications, Steps, Complications

Whipple's Procedure - Explaining the History of Whipple's Procedure, Indications, Contraindications, Step wise detailed procedure, Complications, Perioperative Management.
The Presentation Includes Detailed Step wise approach to the procedure assisted with Pictorial Representation of The steps

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Whipple’s Procedure
- Dr. Vikas V

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Allen Oldfather Whipple

First report (1935):

3 Staged Procedure

3 patients

2 died post-op

First one-stage resection
3/8/1940

Whipple’s total experience: 37
cases

30 periampullary tumors

7 chronic pancreatitis

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Introduction

Pancreaticoduodenectomy was first formally described by Whipple, Parsons, and
Mullins in 1935 in the Annals of Surgery.

The original operation was completed in two stages. The first stage consisted of a
gastroenterostomy, ligation of the common duct, and cholecystogastrostomy.

Three to 4 weeks later, the descending portion of the duodenum and a portion of the
pancreatic head were resected and the ducts of Wirsung and Santorini were ligated

By 1945, modifications of the two-stage procedure were numerous, and Whipple
himself “condemned” the operation advocating, instead, the one-stage procedure with
choledochojejunostomy and implantation of the pancreatic duct into the jejunum.

A Whipple procedure — also known as a pancreaticoduodenectomy — is a complex
operation to remove the head of the pancreas, the first part of the small intestine
(duodenum), the gallbladder and the bile duct

The Whipple procedure is used to treat tumors and other disorders of the pancreas,
intestine and bile duct.

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Whipple’s Thoughts on Procedure
Urged the following factors be considered:
The threat of disease
The operative risk
The probability of cure
The assurance of relief of symptoms
Patient ability to adapt to GI dysfunction
Quality of the resident staff
Experience, skill & integrity of the surgeon

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Indications

Curative Treatment For Periampullary Carcinoma

Carcinoma of 2nd part of the duodenum

Carcinoma of ampulla, distal CBD

Chronic pancreatitis with disease involving mainly
head of pancreas with severe pain

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Contraindications

Liver Secondaries

Peritoneal secondaries

Celiac lymph node involvement;

Involvement of the SMA or root of the mesentery.

Significant deep infiltration of portal vein

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PROCEDURE -

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
Removal of the pancreatic head, duodenum,gallbladder, and bile duct with or
without removal of the gastric antrum.

Manoeuvres -
Kocher’s
Manoeuvre
PANCREATICO -
DUODENECTOMY

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
Manoeuvre to check for Tumor infltration to
SMV

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Surgical Resection

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Step 1 –
Cattle Braasch
Manoeuvre
exposing SMV

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Step 1 – Cattle Braasch Manoeuvre
exposing SMV

The lesser sac is entered, and the hepatic flexure of the colon is taken down.

The inferior body of the pancreas is identified at the level of the proximal body of the gland.
The visceral peritoneum and root of mesentery is incised from this point, in a lateral
direction, heading toward the junction of the second and third portions of the duodenum in
an effort to expose the anterior wall of the superior mesenteric vein (SMV).

The SMV is exposed at the inferior border of the neck of the pancreas adjacent to the
uncinate process. The middle colic vein and gastroepiploic vein often arise from a common
trunk which occasionally also involves the right colic vein

Any or all of these veins may require ligation and division to safely expose the SMV. When
the need for venous resection is anticipated, the entire right colon and the root of the small-
bowel mesentery are mobilized in the fashion of Cattell and Braasch.

This involves incision of the visceral peritoneum to the ligament of Treitz and allows
anterior reflection of the colon off of the duodenum and pancreatic head.

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Step 2 -
Extended Kocher
Manoeuvre
( Assess Operability by
feeling Uncinate, SMV
and coeliac axis )

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Step 2 : Extended Kocher Manoeuvre
(Assess Operability by feeling Uncinate, SMV & celiac
axis )

A Kocher maneuver has been performed by first identifying the inferior
vena cava (IVC) at the level of the proximal portion of the transverse
segment of the duodenum (D3).

One can then mobilize the duodenum and pancreatic head off of the IVC
in a cephalad direction, thereby removing all soft tissues anterior to the
IVC.

The right gonadal vein is usually preserved, if possible, as it serves as a
good landmark to help prevent inadvertent injury to the underlying ureter
(which is usually posterior and slightly lateral to the gonadal vein).

Note that the Kocher maneuver is continued to the left lateral border of
the aorta (AO).

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Step 3 - Portal Dissection

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Step 3 - Portal Dissection

Dissection of the porta hepatis begins with identification of the common
hepatic artery (CHA), by removal of the large lymph node, which commonly
sits anterior to this vessel.

The CHA is then followed distally to allow identification and ligation and
division of Rt Gastric artery and gastroduodenal artery (GDA).

This allows the CHA-proper hepatic artery to be mobilized cephalad and
medial off of the underlying anterior surface of portal vein (PV).

The PV is always identified prior to division of the common hepatic duct
(CHD). Careful palpation of the porta hepatis prior to division of the bile duct
should alert one to the possibility of an accessory or replaced right hepatic
artery traveling posterior to the bile duct and lateral to the portal vein.

The CHD is divided at the level of the cystic duct. SMV, superior mesenteric
vein.

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Step 4 – Transection of Stomach

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Step 4 – Transection of Stomach

The antrum of the stomach is resected with the main specimen by dividing
the stomach at the level of the third or fourth transverse vein on the lesser
curvature. CHA, common hepatic artery; CHD, common hepatic duct;
SMA, superior mesenteric artery; SMV, superior mesenteric vein.

When opening the lesser omentum, one should specifically look for an
accessory or replaced left hepatic A arising from the left gastric A. Overly
aggressive division of filmy lesser omentum in a caudal direction can
easily injure a replaced left hepatic A.

Pylorus-preservation Surgery – Avoided in
bulky pancreatic head tumors,
duodenal tumors involving the 1st or 2nd portions of the duodenum,
lesions associated with grossly positive pyloric or peripyloric LN

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Pylorus Preservation Surgery

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Step 5 –
Transect
Jejunum,
dissect
Ligament of
Trietz, rotating
duodenum
under
Mesentric
Vessels

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Step 5 – Transect Jejunum,
dissect Ligament of Trietz,
rotating duodenum under Mesentric Vessels

Transection of the jejunum with a linear GIA stapler 10 cm distal to the
ligament of Treitz is followed by ligation and division of its mesentery.

The loose attachments of the ligament of Treitz are taken down, and the
fourth and third portions of the duodenum are mobilized by dividing their
short mesenteric vessels.

The duodenum and jejunum are then reflected underneath the
mesenteric vessels in preparation for the final and most important part of
pancreaticoduodenectomy.

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Step 6 – Transect Pancreas &
Complete retroperitoneal dissection by removing specimen
from SMA

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
The pancreatic head and uncinate process are separated from the superior
mesenteric-portal vein confluence.

The pancreas has been transected at the level of the portal vein and the
pancreatic head is reflected laterally, allowing identification of small venous
tributaries from the portal vein and superior mesenteric vein (SMV).

These tributaries are ligated and divided. There is one fairly constant
venous tributary of the portal vein to the most cephalad pancreatic head
often referred to as the superior pancreaticoduodenal vein.

Some surgeons prefer to leave this venous branch intact until they have
divided at least one of the more caudal inferior pancreaticoduodenal
arteries (off of the SMA), thereby minimizing venous hypertension in the
specimen which contributes to increased blood loss during this portion of
the dissection

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
The SMV usually bifurcates into two main branches, one to the ileum
and one to the jejunum. Adequate venous return from the small bowel
requires that one or the other of these two main SMV-tributaries is intact.

The jejunal branch of the SMV (often referred to as the first jejunal
branch) drains the proximal jejunum, travels posterior to the superior
mesenteric artery (SMA), and enters SMV along its posterolateral wall.

The jejunal branch usually has a few venous tributaries that drain the
uncinate process (inset). If necessary, the jejunal branch can be divided.

The most feared complication during this part of theoperation is a
tangential laceration of the jejunal branch extending posterior to the
SMA. In an attempt to control such an injury, poorly placed sutures may
result in an injury to the SMA

Very rarely the jejunal branch will travel anterior to the SMA, which
simplifies this part of the operation.

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
Medial retraction of the superior mesenteric-portal vein confluence
facilitates dissection of the soft tissues adjacent to the lateral wall of the
proximal superior mesenteric artery (SMA); this site represents the SMA
margin.

The inferior pancreaticoduodenal artery (or arteries) is identified at its
origin from the SMA, ligated, and divided.

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Summary Of Pancreatic Resection

To summarize, the operation as described above emphasizes full
mobilization of SMV-PV confluence, exposure of SMA, and removal of all
mesenteric soft tissue and perineural tissue to the right of this vessel.

Dissection of the specimen from the proximal SMA is necessary to obtain a
negative SMA margin and therefore is the most important technical aspect
of this operation.

Direct exposure of the SMA should be a routine part of pancreatico-
duodenectomy, will minimize the risk for iatrogenic injury of this vessel, and
will ensure direct ligation of the IPDA(s), thereby minimizing the chance for
postoperative intra-abdominal hemorrhage.

The high incidence of local recurrence following pancreaticoduodenectomy
mandates that greater attention be paid to the SMA margin, which again, is
the soft tissue margin along the right lateral border of the proximal 3 to 4 cm
of the SMA.

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Vascular Resection – Splenic V resection

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
Sometimes segmental venous resection is required and the decision is made to
divide the splenic vein. In the early experience with resection and reconstruction
of the superior mesenteric- portal vein (SMPV) confluence, splenic vein ligation
was routine.

Currently, we ligate the splenic vein only when the tumor involves the splenic
vein confluence. By dividing the splenic vein, the superior mesenteric artery
(SMA), which is identified medial to the superior mesenteric vein (SMV), can be
exposed to its origin from the aorta and the pancreatic head removed from the
right lateral border of the SMA.

This dissection is considerably more difficult when the splenic vein-SMV portal
vein confluence is intact. The tumor is then attached only by the SMPV
confluence, which can be divided proximal and distal to the involved segment.

Reconstruction is performed (during infl ow occlusion) by an end-to-end
anastomosis of the portal vein and the SMV with 6-0 interrupted Prolene sutures

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
Sometimes segmental venous resection is required and the splenic vein
is preserved.

The intact splenic vein tethers the portal vein, making a primary
anastomosis impossible in most cases.

An interposition graft is used to repair the segment of vein which is
removed; the left internal jugular vein from the neck is used for the graft
in most case

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PANCREATIC , BILIARY &
GASTROINTESTINAL RECONSTRUCTION

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Step 1 – End to side
PancreaticoJejunostomy

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
The pancreatic remnant is mobilized from the retroperitoneum and
splenic vein for a distance of 2 to 2.5 cm.

The transected jejunum is brought through a generous incision in the
transverse mesocolon to the left of the middle colic vessels.

A two-layer, end-to-side, duct-to-mucosa retrocolic
pancreaticojejunostomy is performed with (when the pancreatic duct is
not dilated) or without a small stent.

When used, the Silastic stent (Dow Corning, Midland), (4 to 5 cm long) is
sewn to the pancreatic duct with a single absorbable monofilament
suture.

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Step 2 – End to Side
CholedochoJejunostomy

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
A one-layer, end-to-side hepaticojejunostomy is performed with 4-0 or
5-0 absorbable monofilament sutures distal to the
pancreaticojejunostomy.

A stent is rarely placed in this anastomosis.

Care is taken to allow enough distance between the pancreatic and
biliary anastomoses, so the falciform ligament can be placed between
the anastomoses anterior to the hepatic artery and posterior to the
jejunal limb.

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Step 3 –
Gastro -
Jejunostom
y

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
Starting from the greater curvature, 6 to 8 cm of the gastric staple line is
removed.

A posterior row of 3-0 silk sutures is followed by a full-thickness inner
layer of running monofi lament sutures; the anterior row of silk sutures
completes the anastomosis.

The distance between the biliary and gastric anastomoses should be at
least 50 cm, thereby allowing the jejunum to assume its antecolic
position without tension, and also preventing bile reflux cholangitis

The jejunal limb should be aligned so that the efferent limb is adjacent to
the greater curvature of the stomach.

A 10-Fr feeding jejunostomy tube may be placed distal to the
gastrojejunostomy.

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Step 4 – Jejunostomy Drains

The use of drains remains an active area of controversy in the field of
pancreatic surgery, and many surgeons still drain both the
hepaticojejunostomy and the pancreaticojejunostomy.

In patients who received neoadjuvant chemoradiation, the pancreas
becomes firm, which results in fewer pancreatic leaks and thus the
pancreaticojejunostomy need not be drained in this setting.

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Completed Reconstruction after
Pancreaticoduodenectomy

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PERIOPERATIVE MANAGEMENT

Prolonged postoperative IV antibiotic use in the absence of documented or
suspected infection is discouraged.

Epidural catheters can aid in postoperative pain control, provided they are
meticulously managed.

NSAIDs may also be added for synergy (usually begun postoperative day 1),
provided urine output is adequate, creatinine is normal, and there are no other
contraindications to their use.

Patients with vascular resections/reconstructions are prescribed Aspirin, 325
mg per rectum daily, beginning in the recovery room and prophylactic
subcutaneous Heparin if the INR is 1.5 or less.

Drain removal is based on the absence of bile or amylase-rich fluid in the drains
and reasonably low outputs.

If this drain output is serous and 200 to 300 mL for 24 hours, it can be removed.

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
For patients with jejunostomy tubes, jejunostomy feeding is initiated at a
rate of 10 mL/h on postoperative day 2 or 3 and then increased daily if
gastrointestinal function has returned.

With the institution of an oral diet, jejunostomy feeding is converted from
continuous to night time administration.

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Complications

Fevers occurring after postoperative days 3 to 4 demand careful evaluation.

Potential sources of fever include those common to all major abdominal surgery:
pneumonia, deep venous thrombosis, central line sepsis, urinary tract infection,
and wound infection.

Patients who undergo pancreaticojejunostomy are at risk for the development of
intraabdominal abscess as a result of leakage from the pancreatic anastomosis.

Because leaks from either the biliary or gastric anastomoses are very uncommon,
intraabdominal sepsis is considered to be due to a pancreatic anastomotic leak
until proven otherwise.

Pancreaticojejunostomy anastomotic leaks generally close once adequate
drainage is established.

Octreotide and antibiotics are utilized when treating established pancreatic
anastomotic leaks that have required percutaneous drainage.

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
Postoperative gastrointestinal or drain tract bleeding should prompt
immediate evaluation with arteriography.

While uncommon, an arterial-enteric fistula occasionally occurs in the
postoperative setting (rarely before postoperative day 10).

The most common cause is a pancreatic anastomotic leak with surrounding
inflammation and infection resulting in blowout of the GDA stump

Gastrointestinal or drain tract bleeding represents a true emergency; the only
patients likely to survive are those in whom the diagnosis is made
immediately.

The hepatic artery may be embolized or potentially stented if possible.

Surgical control of hemorrhage from the stump of the GDA is exceedingly
difficult in a postoperative pancreaticoduodenectomy patient and carries a
higher mortality than that associated with hepatic artery embolization.
Complications

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Summary

A detailed preoperative assessment of resectability prevents needless
laparotomy in patients with advanced pancreatic cancer, and a
standardized technique of tumor resection minimizes perioperative
complications.

Pancreaticoduodenectomy is divided into six well-defined maneuvers.

Attention to detail and a standardized approach to postoperative care
minimize patient morbidity and hospital stay.

A Careful attention to patient selection for surgery, preoperative
assessment of resectability, surgical technique, and postoperative care
is necessary for the best outcome