CHAPTER 88: PANCREATICODUODENECTOMY (WHIPPLE PROCEDURE)

INDICATIONS

The head of the pancreas is usually removed for malignancy involving the ampulla of Vater, the lower end of the common duct, the head of the pancreas, or the duodenum. With increasing frequency, Whipple is indicated for the risk of malignancy associated with the presence of a cystic neoplasm with worrisome features. Far less frequently, the procedure is carried out to manage intractable pain associated with a chronic calcific pancreatitis or for massive trauma when there has been irreparable “burst” damage to the head of the pancreas, the ductal structures, and the duodenum. In the presence of malignancy, the resection is indicated in the absence of proven metastases and if the tumor is of such a limited size that the portal vein is not involved beyond the ability of the surgeon to accomplish a safe vascular resection and repair. Total pancreatectomy may be considered in some cases due to central location of a malignant tumor or extensive main duct involvement by papillary mucinous epithelium (IPMN). While, total pancreatectomy decreases the incidence of postoperative complications related to the leakage of pancreatic juice from an anastomosis, the subsequent endocrinopathy can be profound. The patient should be made aware of the problem of diabetes mellitus after operation as well as the need for daily pancreatic enzyme replacement.

PREOPERATIVE PREPARATION

Patients will have had imaging including CT, MRI, and possibly endoscopic ultrasound prior to the procedure. Some patients may have had biliary stents placed by an endoscopic or transhepatic route. The electrolyte levels should be returned to normal and particular care should be taken that the INR is normal and that renal function is not impaired, as shown by creatinine and blood urea nitrogen levels. Patients with jaundice may have occult vitamin K deficiency that may not become apparent until blood loss occurs. Unexpected blood loss can be substantial so blood should be available for transfusion as needed, preferably via a central venous catheter. It is advisable to have a catheter in the bladder in order to follow the postoperative hourly output of urine. Antibiotic therapy should be started prior to operation. This is particularly important for patients with stents, as they are prone to wound infections.

ANESTHESIA

A nasogastric tube is inserted. General anesthesia with endotracheal intubation is recommended.

POSITION

The patient is placed supine on the table with the feet slightly lower than the head. Facilities should be available for performing a cholangiogram or pancreaticogram.

OPERATIVE PREPARATION

The skin should be shaved from the level of the nipples well out over the chest wall and down over the abdomen, including the flanks.

INCISION AND EXPOSURE

Diagnostic laparoscopy is indicated in some patients to identify metastatic disease that may have been missed by preoperative ...