Pancreaticoduodenectomy “Whipple”

Relevant Anatomy

Relevant Anatomy

Relevant Anatomy

Physiology & Pathology A Carcinoma in the head of the pancreas (Pancreatic ductal adenocarcinoma) has caused an obstruction of bile drainage into the duodenum. The patient will go jaundice because the bile backs up into the circulation. Other signs and symptoms include constant dull pain in the epigastric region, malabsorption of nutrients leading to diarrhea and weight loss, nausea, vomiting, fever, respiratory problems, absence of normal bowel sounds, and diabetes.

Diagnostics Detection is commonly made through physical examination that reveals a large palpable mass, low serum bilirubin levels, abnormal radiographs of the abdomen, needle biopsy, CT scan, ERCP (Endoscopic Retrograde Cholangio-Pancreatography), and ultrasonography. Other signs include Jaundice, and/or malabsorption of nutrients. CT scan History and Physical Laboratory Blood tests

Surgical Intervention A Whipple consists of removal of the distal 1/3rd of the stomach, the gall bladder and its cystic duct (cholecystectomy), portions of the common bile duct, the head of the pancreas, the entire duodenum, 10 in. of the proximal jejunum, and regional lymph nodes. Reconstruction consists of attaching the pancreas to the jejunum (pancreaticojejunostomy), attaching the CBD to the jejunum (choledocojejunostomy) to allow digestive juices and bile respectively to flow into the gastrointestinal tract, and attaching the stomach to the jejunum (gastrojejunostomy) to allow food to pass through.

Wound Classification Class 2: Clean Contaminated Class 3: Contaminated, (if spillage from bowel or biliary tract occurs)

Surgical Intervention

Special Considerations Takes 5 - 6 hours, many units of blood and blood products may be necessary Hypothermia is a concern, forced-air warming device used Upon opening and exploration of the abdomen, if the surgeon discovers that the tumor has invaded the base of the mesocolon, aorta, vena cava, portal vein, or superior mesenteric vessels, the Whipple will not be performed and a bypass of the biliary tract and possibly the stomach will most likely be performed.

Pre op Supine General Anesthesia Foley Catheter if ordered Skin prep: Mid-chest to mid thighs and bilaterally as far as possible Drapes: Square off with four towels- mid-chest; lateral towels placed using anterior superior iliac spines as guides, pubic symphysis. Laparotomy Drape

Supplies and Instruments Laparotomy Drapes - Major Instrument Set Suture - 0,1-0, 2-0 silk - Peripheral Vascular Set Surgeon Specific - Deep Instruments - Harrington Dressings - Gastrointestinal Set Suction - Yankauer 2x - Retractors, (hand held, Self retain) Hemostatic agents - Ligating/ Hemoclip appliers Head Lamp - Staplers Blades #10 2x; #15 - Drains

Special Instruments Curved Oschner Payr

Incision Upper longitudinal midline (Identified as Incision “F”) Upper Paramedian (Identified as Incision “A”) Bilateral Subcostal Incision (Identified as Incision “C”)

Procedural Steps Incision is made - (Typically upper longitudinal) The abdomen is explored and the extent and resectability of the tumor is assessed. - If the tumor has spread and invaded key anatomical structures, it is considered unresectable and the procedure cannot be performed. Sponges are packed to protect anatomical structures. (Soaked in Saline) Entire Duodenum and head of pancreas are dissected free. Deep instruments may be used for resection, - STSR should prepare ties on passers ahead of time. Gastrohepatic omentum and ligament are clamped, divided and ligated Right Gastric and gastroduodenal arteries are ligated, (clamp 2x, tie 2x, cut)

Procedural Steps - Continued Distal section of the stomach is mobilized using scissors and electrosurgery. Hemoclips may be frequently used, due to the number of vessels that supply the stomach Two long Payr or Allen clamps are placed across the stomach, and it is resected. Surgeon may also use a linear stapler. Various stapling devices could be used throughout the procedure, STSR must be able to quickly reload the staplers for continuous use. The duodenum is retracted downward; CBD is identified and resected. The proximal end of the jejunum is clamped with two Allen clamps and divided with scissors (Metzenbalm) Area between the head and body of the pancreas is clamped with two Allens and divided - surgeons choice.

Procedural Steps - Continued. Again The duodenum may require further mobilization and the gastroduodenal artery is identified, clamped 2x, divided, and ligated - Allows specimen to be removed en bloc. Anastomoses are usually performed in the following order: Proximal end of jejunum is anastomosed to the pancreatic body CBD is anastomosed to the jejunum using end-to-side technique Distal Stomach is anastomosed to the jejunum using end-to-side technique The abdominal cavity is thoroughly irrigated with warm saline, lap sponges, and retractors are removed. 1 - 2 active drains (Hemovac) are placed behind the pancreatic biliary anastomoses Abdomen is closed.

Post Op Complications Death Abdominal Sepsis Pancreatic Fistula Formation Hemmohrage Possibility of Reoperation Post Op SSI Peptic Ulcer Formation Disrupted Nutrient Absorption Delayed Gastric Emptying

Works Cited https://jomi.com/article/15/whipple-procedure-carcinoma-pancreas/ https://en.wikipedia.org/wiki/Pancreaticoduodenectomy Surgical Technology for the Surgical Technologist Fourth Edition