whipples.pptxnbgchgvjjnjknlkgftgjkndbncvbn

..

1. WHIPPLE’S PROCEDURE DR MANASA SRINIVAS JR3 , DEPARTMENT OF SURGERY KEMH - PAREL, MUMBAI.

2. WHIPPLE’S PROCEDURE First pancreaticoduodenectomy – 2 stages , 1935 , Allen Oldfather Whipple First stage- Gastroenterostomy, ligation of common duct, and cholecystogastrostomy 3-4 weeks later -descending part of the duodenum with part of pancreatic head were resected with ducts of Wirsung and Santorini ligated In 1945- single staged procedure with choledochojejunostomy with pancreaticojejunostomy advocated by whipples himself. Original – Pancreaticoduodenectomy (pylorus with duodenum , CBD , pancreatic head and gallbladder resected) with triple bypass – GJ/ HepJ or CJ /PJ Traverso - Longmire’s – PPPD ( maintain gastric emptying)

3. INDICATIONS (RESECTABILITY CRITERIA MET) Periampullary Carcinoma - 2cm area within major papilla of duodenum - Ampulla, distal CBD , MPD , including duodenal papilla and duodenal mucosa nearby. Ca head of pancreas – Ductal adenoca Chronic pancreatitis – head of pancreas

4. RESECTABILITY CRITERIA Other criterias - vardharajan / katz criteria Borderline resectability – neoadjuvant required Other criteria for unresectable ca- extraregional lymph node involved , distant mets -liver/peritoneal mets

5. INVESTIGATION AND PREOP PREP Albumin – preop high protein build up , oral/NJ Coagulation profile , correct anemia . Reduce bilirubin level – PTBD/ERCP- metal stents Baseline – CA 19.9, CEA . CECT (A+P) and (chest) – double duct sign – hypodense in portal phase , vascular relation , lymph node , distant mets PETCT – benign vs malignant mass . EUS – FNA / brush cytology , <2cm tumor better delineated , lymph node , vascular anatomy status. MRCP Mechanical bowel prep and gut antibiotics – metronidazole/neomycin DVT prophylaxis RT , Foleys , central line , arterial line – prolonged surgery.

6. STEPS Open / laparoscopic/ robotic Patient setup Staging laparoscopy – liver surface , peritoneum , coeliac lymph node, base of transverse mesocolon – ascites – for cytology .

7. Exposure – falciform tacking , GB fundus retraction , right up , mobilize right colon and hepatic flexure. Harmonic and bipoplar Knowledge on anatomical varaiations of arteries. 1. Enter into lesser sac – dividing gastrocolic ligament . Mesocolon incised on right end of lesser sac – creating a cleavage btw mesocolon and Rt GE pedicle Middle colic vessel identified - SMV Dissection to expose pancreas and 2 nd duodenum . Hepatic flexure mobilized downwards – cattell’s manoeuvre done.

8. 2. portal vein traced upwards along SMV behind the neck of pancreas 3. kocherisation – retropancreatic dissection – 2 nd duodenum and head of pancreas dissected away from gerotas away from toldt fascia and IVC – medially and anteriorly till left renal vein seen. 4. calots dissection and clipped . 5.anterior dissection of SM vessels – loop of henle , GE vein , accessory right colic vein , IPDA clipped 6. DJ flexure mobilized at treitz ligament – mesojejunum divided lateral to 1 st jejunal artery. 7.Pars lucida of hepatoduodenal ligament dissected- Division of antrum – blue 60mm endocartridge – , right GA at superior border of pylorus right GE artery

9. 8. periportal clearance – along CHA, portal vein , lateral caeliac nodes dissected to remove en bloc , GDA clipped 9. CHD divided proximal to cystic duct entry. SPV clipped.