Whipple procedure

Most whipple procedures are done for pancreas. Today we're operating for chronic pancreatitis, so we skipped the usual laparoscopy and proceeded directly to the midline incision. We initially mobilized the pancreas from the retroperitoneum and assess receptability. The next phase of the operation we proceed to dissecting the superior mesenteric vein, which is critical to assessing receptability. The vein is dissected out from beneath the neck of the pancreas and clearance made. We subsequently move to the hepatoduodenal ligament and identify the hepatic artery and gastroduodenal arteries. The gastroduodenal artery is divided,

which opens the access to the portal vein. At this point the bile duct is then divided, allowing further dissection down the portal vein. Once the hepatoduodenal ligament is completed, we divide the duodenum and proceed to divide the proximal jejunum. This now isolates the specimen to include only the connections to the pancreas. We divide the neck of the pancreas just over the portal vein. In this case a stent had been placed in the pancreatic duct, and that is divided in addition to the pancreas. The stent was maintaining patency of the pancreatic

duct. We separate the head of the pancreas from the portal vein, and then comes the most dangerous part of the operation. The unsonate process is immediately adjacent to the superior mesenteric artery and must be divided very carefully. There are large vessels in this tissue, despite the appearing innocence of the tissue. At this point the specimen is completely removed, and we can begin to prepare for the reconstruction. Now what remains is the superior mesenteric veins, planic vein, portal vein, and you can see the bile duct in the left upper corner. The superior

mesenteric artery is just below the specimen. Both ends are closed off by staple line, and the cut surface of the pancreas still has the stent. For the reconstruction we bring the duodenum through the transverse mesocolon and create a side to side pancreatic ogegenostomy as the first anastomosis. This is done in a dunked fashion using sutures in the outer layer placed well back on the pancreatic capsule. The inner layer of this dunked anastomosis is a fine absorbable material, and just the cut edge of pancreas is brought to the cut edge of

gejunal mucosa. As this anastomosis is completed, in the final stages of this anastomosis, the second layer is placed on the capsule of the pancreas, the gejunum is folded over to complete the dunking process. The next anastomosis is the biliary anastomosis. In this case we're dealing with a very small fine bile duct, so interrupted sutures of fine absorbable material are used to create the end to side colidocogegenostomy. Several centimeters downstream and end to side duodenugegenostomy is performed using a single layer absorbable running suture. To complete the operation I always place a gastrostomy tube for GI tract drainage and a single suction drainage

catheter adjacent to the colidocogegenostomy and pancreaticogegenostomy.