1. Pancreaticoduodenectomy
“Whipple”

2. Relevant Anatomy

3. Relevant Anatomy

4. Relevant Anatomy

5. 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.

6. 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

7. 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.

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

9. Surgical Intervention

10. Special Considerations
Takes 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.

11. 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

12. 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; # Drains

13. Special Instruments
Curved Oschner
Payr

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

15. 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)

16. 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.

17. 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 active drains (Hemovac) are placed behind the pancreatic biliary anastomoses
Abdomen is closed.

18. 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

19. Works Cited
Surgical Technology for the Surgical Technologist
Fourth Edition