Pylorus-Preserving Pancreaticoduodenectomy (Whipple Procedure) Technique

Updated: Aug 30, 2016
  • Author: Roshni L Venugopal, MD, MS; Chief Editor: Kurt E Roberts, MD  more...
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Technique

Approach Considerations

The steps for completion of a pylorus-preserving pancreaticoduodenectomy (PPPD), or Whipple procedure, can be thought of as a clockwise journey. The surgeon begins at the ascending colon and hepatic flexure to obtain exposure of the superior mesenteric vein (SMV), then moves to the porta hepatis for cholecystectomy and portal lymph node dissection, followed by transection of the stomach or proximal duodenum. He or she then proceeds to jejunal transection and, finally, pancreatic transection, with completion of retroperitoneal dissection and removal of the specimen en bloc.

The reconstructions can be performed in a counterclockwise direction: The surgeon starts with creation of jejunal feeding access and then proceeds to creation of the pancreaticojejunal, choledochojejunal, and enterojejunal anastomoses. Venous reconstructions are also undertaken in select patients.

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Whipple Procedure

An example of a PPPD is shown in the video below.

Pylorus-preserving pancreaticoduodenectomy (Whipple procedure). Procedure performed by John Chabot, MD, Columbia University Medical Center, New York, NY. Video courtesy of ColumbiaDoctors (https://www.columbiadoctors.org).

Laparotomy and abdominal exploration

Laparotomy is performed with a generous midline incision or bilateral subcostal incisions. The liver is palpated, the peritoneum is inspected, and the paraortic lymph nodes and the root of the mesentery are evaluated.

Intraoperative hepatic ultrasonography may be used when preoperative imaging is not definitive. In addition, abdominal exploration may be undertaken as staging laparoscopy before laparotomy in patients with advanced disease who are suspected of being at risk for radiographically silent metastatic disease.

Exposure of superior mesenteric artery and extended kocherization

A self-retaining retractor facilitates general exposure of the operative field. The falciform ligament is identified and preserved for later use (to protect the gastroduodenal artery [GDA] stump). The ascending colon and hepatic flexure are mobilized by using a Cattell-Brasch maneuver or right medial visceral rotation to expose the third and fourth portions of the duodenum.

The lesser sac is then opened and entered. Here, the middle colic vein is encountered and ligated, facilitating exposure of the SMV. The gastroepiploic vein is often seen entering common trunk with the middle colic vein and can be ligated when encountered.

Next, an extended Kocher maneuver is performed from the right ureter and right gonadal vein junction (which is ligated and mobilized) until the aorta and the crossing left renal vein are identified. Intervening lymphatic tissues should be mobilized as well. Here, the superior mesenteric artery (SMA) should be identifiable.

Cholecystectomy and portal dissection

The celiac axis is located, and the right gastric artery is identified and preserved. The node of the common hepatic artery is removed, and the common hepatic artery is dissected proximal and distal to the GDA takeoff. This is done carefully (because the common hepatic artery is fragile), and the GDA is transected. Cholecystectomy is performed with transection of the specimen at the common hepatic duct just before the cystic duct takeoff. The common hepatic duct margin undergoes intraoperative pathologic analysis and is extended as necessary.

Given the anatomic variability of hepatic arterial circulation, the surgeon must look for a replaced right hepatic artery or replaced common hepatic artery. After the origins of the aforementioned are identified, medial retraction applied to the common hepatic artery exposes the anterior surface of the portal vein (PV). The PV is followed to its junction with the pancreatic neck, with the surgeon taking great care to avoid traction injury to the posterior pancreatic duodenal vein.

Duodenal transection if PPPD permissible

In concordance with accepted oncologic principles, bulky neoplasms of the pancreatic head, tumors progressing to the first or second part of the duodenum, or clinically positive regional lymph nodes noted at this juncture preclude pylorus preservation. If PPPD is implementable, then the duodenum is transected 2-3 cm distal to the pylorus. This duodenal cuff must be made long enough to withstand later revision during creation of the duodenojejunal anastomosis.

The gastroepiploic artery and vein are divided, and the right gastric artery is once again identified and protected. The duodenum is divided 2-3 cm distal to the pylorus. The jejunum is transected at least 10 cm distal to the ligament of Treitz. The mesenteries of both transected small-bowel stumps are divided as well, and the duodenum and jejunum are reflected below the mesenteric vessels.

Division of pancreas

The pancreas is transected about 2 cm distal to the pylorus at the level of the PV, thus exposing the underlying SMV-PV confluence. If the tumor is adherent to the PV, SMV, or SMV-PV confluence, the pancreatic division plane may have to be revised more distally in order to accommodate vein reconstruction. The tumor is carefully separated from the named venous structures. If the first jejunal branch of the SMV is lacerated here, the venous injury is difficult to control, and attempted repair of such an injury can damage the SMA.

The tumor is reflected rightward and separated from the right lateral border of the SMA; it is important to completely resect the uncinate process in order to achieve an R0 resection (ie, surgical margins negative for tumor). The SMA is then exposed by the retracted SMV-PV confluence, and it is dissected carefully to visualize the inferior pancreaticoduodenal artery. This must be ligated securely; failure to do so can cause retroperitoneal hemorrhage.

Removal and orientation of specimen

The specimen is removed en bloc and oriented for pathology. The retroperitoneal margin is inked for pathologic frozen section analysis. A grossly positive retroperitoneal margin represents a technical failure to achieve the intended R0 resection goal. A microscopically positive retroperitoneal margin can occur with 10-20% of pancreaticoduodenal resections.

Vascular reconstruction

Vascular reconstruction after PPPD is extensive and beyond the scope of this discussion. The reader is directed to the resources in the References section.

Pancreatic reconstruction

The pancreatic remnant is first mobilized along its length for a few centimeters. Then, the transected jejunum is brought through a defect in the transverse mesocolon adjacent to the middle colic vessels. A pancreaticojejunal anastomosis is created with the understanding that pancreatic fistula formation depends on the technical integrity of the anastomosis, as well as the quality of the pancreatic tissue.

A two-layer end-to-side pancreaticojejunostomy, also known as a duct-to-mucosa reconstruction, is performed. This indicates full-thickness pancreatic duct–to–jejunal wall closure.

First, the posterior outer row of interrupted seromuscular sutures is placed between the jejunal side wall and the pancreatic parenchyma. The jejunum is opened longitudinally anterior to this. The inner circumferential layer of interrupted, full-thickness sutures reapproximate the cut end of the pancreatic duct with jejunal wall. The posterior sutures are tied inside the anastomosis, a pancreatic stent is placed, and the remaining sutures are tied on the outside. The anterior outer layer of sutures is placed as a row of interrupted seromuscular sutures.

Alternatively, invagination of the distal pancreatic stump into the jejunum can be performed in an end-to-end or end-to-side manner. The inner layer of sutures is placed as described above, and the outer layer of sutures is placed to invaginate the pancreatic remnant. This is useful when the pancreatic duct is not dilated and when the parenchyma is too soft to hold against jejunal seromuscular sutures.

Biliary reconstruction

Hepaticojejunostomy is performed as a one-layer end-to-side anastomosis between the common hepatic duct remnant and a site on the jejunum distal to the pancreaticojejunal anastomosis. It is critical to align the bile duct and jejunum without tension before suture placement.

Enteric reconstruction

The jejunum is traced distal to the biliary reconstruction and brought to lie antecolically. The cuff of duodenum is revised, preserving at least 1.5 cm of postpyloric duodenum to preserve the blood supply to the anastomosis. An antecolic end-to-side anastomosis between the duodenum and jejunum is created with a single layer of continuous suture. Some have found antecolic gastrointestinal resconstruction to be associated with a lower incidence of delayed gastric emptying (DGE; see Complications) than retrocolic reconstruction [9] ; however, others have not. [10, 11]

Closing maneuvers

A feeding jejunostomy is created distal to the duodenojejunal anastomosis by using a Witzel technique to maintain postoperative enteral feeding access. Then, the falciform ligament is located and used to cover the GDA stump so as to prevent GDA pseudoaneurysm formation in the event of pancreatic leak (see Complications). As a rule, closed-suction transcutaneous drains are placed at the pancreatic anastomosis and biliary anastomosis, with additional drains per surgeon preference. The abdomen is closed in the standard fashion.

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Complications

Perioperative morbidity

The presence of DGE may necessitate prolonged nasogastric decompression or total parenteral nutrition (TPN) with enteral feeding access failure. [12] Use jejunal feedings for as long as necessary, and beware of aspiration.

Pancreatic leak with consequence may occur and may include pancreatic fluid collection, pancreatic fistula formation, intra-abdominal abscess, or sepsis.

GDA complications that may develop include pseudoaneurysm, GDA-enteric fistula, and GDA stump blowout with massive hemorrhage (eg, bleeding from abdominal drains, massive gastrointestinal [GI] bleeding). GDA stump blowout with massive hemorrhage is initiated by inflammation from pancreatic leak and rarely occurs before postoperative day 10. This condition is treated with selective angiography with stenting or embolization of the hepatic artery. Reoperation is performed only as a last resort.

Other perioperative problems include the following:

  • Feeding jejunal tube management failures (luminal rotation, dislodgment, obstruction)
  • Prolonged ileus
  • Small-bowel obstruction
  • Internal herniation of bowel
  • Small-bowel volvulus
  • Critical illness such as sepsis, respiratory failure, gastrointestinal bleeding, renal failure, and multisystem organ failure
  • Death (<4%)

Long-term morbidity

The following are included in the possible long-term morbidity of PPPD:

  • Recurrence of malignancy, such as local recurrence at the retroperitoneal margin or distal recurrence in the liver, peritoneum, or lungs
  • Pancreatic insufficiency - Exocrine (~40%), endocrine (~20%)
  • Pancreatic anastomotic stricture (recurrent pancreatitis, chronic pancreatic pain)
  • Anastomotic failure (any)
  • Anastomotic stricture (any)
  • Small-bowel obstruction
  • Internal herniation of bowel
  • Small-bowel volvulus
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