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19 Open Whipple
umbilical tape, or Penrose drain can be passed through the tunnel for ease of identication and later retraction (Fig.19.1b).
335
Specimen Removal
The neck of the pancreas is then transected over the previously developed tunnel
over the PV.The superior and inferior pancreatic vessels can be suture ligated to
limit bleeding during neck transection. The pancreatic parenchyma may be divided
either sharply or with electrocautery; the main pancreatic duct should be identied
and the duct itself should be divided sharply.
Attention is then turned to freeing and removing the planned specimen.
Proximally, either the antrum of the stomach is divided into the classic Whipple, or
the rst portion of the duodenum is divided 1 or 2cm distal to the pylorus in the
pylorus-preserving Whipple. Distally, the jejunum is transected distal to the ligament of Treitz. The exact location of jejunal transection is dependent on the planned
route for reconstruction and should be chosen such that biliopancreatic limb can
reach the planned region for anastomosis in a tension-free manner. The jejunum is
mobilized proximally from its mesentery close to the bowel wall until the ligament
of Treitz, which is then divided. At this point, the duodenum and proximal jejunum
should be completely freed from the remaining intestine and its attachments. Next,
the uncinate process and lateral neck of the pancreas are carefully mobilized and
dissected from the SMA and SMV/PV, with identication and ligation of the vein of
Belcher (posterosuperior pancreaticoduodenal vein). At this point, any remaining
attachments to the uncinate and specimen are divided, and the Whipple specimen is
removed from the operative eld (Fig.19.4).
Vascular Resection
If a venous resection is needed, rst the SMV should be fully dissected, and control
of the inferior mesenteric vein (IMV), splenic vein, and left gastric vein should be
achieved. Ligation of these veins may be necessary to fully resect the lesion. The PV
and/or SMV can then be clamped proximally and distally, and the involved portion
of the SMV or PV is then divided and removed with the specimen.
In some cases, the tumor may only just barely involve the lateral wall of the
PV-SMV, in which case a tangential or primary repair of the vein may be considered, as long as it does not result in signicant narrowing of the vein. However,
more commonly a segmental vein resection is needed and thus reconstruction
required. If there is adequate length of the portal vein, the PV may be reconstructed
in an end-to-end fashion without the need for a graft. The right triangular ligament
of the liver may also be divided for mobilization to further advance the reach of the
proximal end of the vein.
336
Fig. 19.4 After the
Whipple specimen has
been removed, the
PV-SMV conuence can
be clearly visualized. X
marks the transected bile
duct [16]
R. C. Kim et al.
If there is inadequate length for a tension-free, primary end-to-end anastomosis
of the resected vein, a conduit may be utilized using another donor vessel. Options
include the internal jugular (IJ) vein or the superior femoral vein. The IJ may be
harvested via an anterior neck incision along the sternocleidomastoid muscle. The
supercial femoral vein may be harvested through a groin incision. If possible, the
deep femoral vein should be preserved to avoid inadequate drainage of the lower
extremity. The supercial femoral vein is typically narrower than the IJ, and choice
of donor site should be dependent on patient-specic anatomy and SMV or PV caliper. Use of the left renal vein and cadaveric or synthetic grafts has also been
described.
Reconstruction
In preparation for the reconstruction portion of the operation, the biliopancreatic
limb of the jejunum can be brought up the right upper quadrant either retromesenteric via the ligament of Treitz or antimesenteric in the retrocolic space through a
defect in the mesocolon to the right of the middle colic vessels.
Pancreaticojejunostomy
There are several variations in techniques and approaches to the pancreaticojejunostomy. To date, there has not been any consistent data supporting the superiority of
one approach over others with regard to the rate of pancreatic leak or stula. The
techniques can mainly be categorized into duct-to-mucosa techniques and invagination or “dunking” techniques.
The duct-to-mucosa pancreaticojejunostomy is most commonly performed in a
two-layered, end-to-side fashion. The original duct-to-mucosa technique was
19 Open Whipple
337
described by Cattel and Warren in 1956 with variations still in use [20]. The tissue
is freed around the pancreatic stump. A posterior layer of interrupted sutures is
placed between the posterior pancreatic capsule and seromuscular layer of the jejunum. An enterotomy is made opposite to the pancreatic duct. Interrupted sutures are
then placed between the pancreatic duct including some of the surrounding pancreatic parenchyma and full thickness, including the mucosa, of the jejunal enterotomy.
An anterior layer of interrupted sutures is then made between the anterior pancreatic
capsule and seromuscular layer of the jejunum.
In the Blumgart technique [21], the rst layer consists of transpancreatic horizontal mattress-style sutures approximately 2cm from the cut surface of the pancreas. For each suture, the suture is rst passed through and through and
perpendicularly (straightening the needle may help to achieve this) to the pancreas
from anterior to posterior. A small seromuscular bite is then taken along the jejunum
approximately 3cm away from the transected edge of the bowel. The suture is then
passed again perpendicularly through the pancreas posterior to anterior. The needle
should kept on the suture later for the nal anterior layer. A probe may be placed in
the pancreatic duct during the creation of this layer in order to ensure patency. The
inner duct-to-mucosa layer is then completed; a small enterotomy is made in the
jejunum approximately 1cm away from the line of horizontal sutures. The pancreatic duct is then sewed to the enterotomy in an interrupted fashion. The posterior
wall of the duct is completed rst, the tension between the ends removed with the
previously made horizontal mattress-type sutures, then the anterior wall. Once this
inner layer is tied down and complete, the previously placed horizontal mattress
transpancreatic sutures are tied down. The layer is then nished by taking another
small seromuscular bite of the jejunum, anterior to the now anastomosed enterotomy, and tied down. The inferior most stitch is completed with two seromuscular
jejunal bites, rst vertically through the jejunum, with the needle directed anteriorly,
then horizontally up toward the pancreas. The superior most stitch is completed in a
similar fashion, with rst a vertical jejunal bite, then a horizontal bite again directed
back toward the pancreas. This allows the jejunum to fold over the anterior surface
of the pancreas.
In the invagination pancreaticojejunostomy, all the cut edge of the pancreatic
parenchyma is invaginated or “dunked” into the lumen of the jejunum. First, a posterior row of interrupted sutures are made from the pancreatic capsule, 1–2cm back
from the cut surface of the pancreas, to the jejunum using seromuscular bites. Then,
a large enough enterotomy is made in the jejunum such that the entire cut surface of
the pancreas can be approximated to the jejunal lumen. An inner layer of running
locking suture is then made, taking full thickness jejunal bites and large bites of
both pancreatic parenchyma and capsule. Finally, an anterior layer of seromuscular
sutures are completed similar to the rst posterior layer, rolling the jejunum onto the
pancreatic capsule and fully “dunking” the pancreas. While the superiority of ductto- mucosa vs invagination techniques has been debated, the ability to perform both
types is useful for adapting to differences in pancreatic duct size and texture [22].
As mentioned earlier, there are many other approaches to the pancreaticojejunostomy, or modications of the techniques described above. Some surgeons also place
338
R. C. Kim et al.
a stent or small pediatric feeding tube through the anastomosis as a guide. Leaving
an internal stent has fallen out of favor as it has not been shown to decrease pancreatic stula rates, in fact may increase the risk for them, and postoperative stent
complications and migration may occur [23]. However, externalized pancreatic duct
stents and omission of prophylactic octreotide have been shown to be effective risk
mitigation strategies for situations at high risk for the development of clinically
relevant postoperative pancreatic stulas [24]. Regardless of which method is used,
attention should be focused on maintaining good technique and the tenets of any
safe anastomosis, including but not limited to careful tissue handling, tension-free
layout, adequate perfusion, and no occlusion or distal obstruction.
Hepaticojejunostomy
There are also multiple approaches to the hepaticojejunostomy, although not as
numerous as for the pancreaticojejunostomy. The end-to-side anastomosis is made
distally along the biliopancreatic limb, is typically single-layered, full thickness,
and may be performed in a continuous, interrupted, or mixed fashion. Leaving
enough length between the two anastomoses may be useful, particularly in benign
cases, in the event future revision to either anastomosis is needed. Theoretically, this
may also reduce the risk of activation of the pancreatic enzymes by bile if there is
an anastomotic leak.
The “corner” stitches are rst placed, at the 3 o’clock and 9 o’clock positions. If
done in an interrupted fashion, placing the anterior sutures in the bile duct rst can
assist with holding the duct open while suturing the posterior wall. Once the anastomosis is completed, the jejunum is tacked to the mesocolon to prevent internal
herniation as well as to maintain a tension-free layout to the anastomoses.
Gastro- or Duodeno-Jejunostomy
Whether a classic or pylorus-preserving Whipple is to be performed should depend
on the extent of the tumor. There has been no consistent data showing any difference
in oncologic outcomes with either procedure, and the rate of delayed gastric emptying and other functional complications are similar in both approaches [25, 26].
In the case of a classic Whipple, a gastrojejunostomy is created in a side-to-side
or end-to-side fashion. If a pylorus-preserving Whipple is performed, a duodenojejunostomy is created either in an isoperistaltic side-to-side or end-to-side fashion.
This is completed in a standard, handsewn, two-layered intestinal reconstruction
approach, with a continuous inner mucosal layer and a seromuscular, interrupted
outer layer. The anastomosis is made approximately 30–50cm downstream of the
hepaticojejunostomy. A <30-degree vertical efferent limb ow angle and a gastrojejunal anastomosis are associated with lower delayed gastric emptying rates [27].
The gastro/duodenojejunal anastomosis completes the reconstruction portion of the
surgery.
19 Open Whipple
339
Final Steps
The abdomen is irrigated and inspected for hemostasis. The omentum and/or falciform ligament can be placed between the GDA stump and the pancreatic and biliary
anastomoses to help mitigate complications in case of an anastomotic leak.
There has historically been mixed data in the literature regarding routine intraperitoneal drainage after Whipple, with some studies failing to show a clear benet
[28, 29]. However, more recently, a multi-institutional randomized controlled trial
demonstrated that intraperitoneal drainage improved both the frequency and severity of postoperative complications. The study itself was also halted early as interval
analysis showed a higher risk for mortality in patients without intraperitoneal drains
(12% vs 3%) [30]. Routine nasogastric decompression has also not been shown to
decrease risk of postoperative complications such as aspiration or anastomotic leak,
and thus is not strictly necessary [31]. Intraoperative percutaneous feeding tube
placement has also been associated with increased postoperative morbidity in retrospective studies [32, 33]. Ultimately, the decision to place of any of these adjuncts
at the end of the surgery should be dependent on patient-specic factors and surgeon’s preference.
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2. Halsted WS.Contributions to the surgery of the bile passages, especially of the common bileduct. Boston Med Surg J. 1899;141(26):645–54.
3. Whipple AO, Parsons WB, Mullins CR.Treatment of carcinoma of the ampulla of Vater. Ann
Surg. 1935;102(4):763–79.
4. Whipple AO. Observations on radical surgery for lesions of the pancreas. Surg Gynecol
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5. Hunt VC.Surgical management of carcinoma of the ampulla of vater and of the periampullary
portion of the duodenum. Ann Surg. 1941;114(4):570–602.
6. Are C, Dhir M, Ravipati L.History of pancreaticoduodenectomy: early misconceptions, initial
milestones and the pioneers. HPB (Oxford). 2011;13(6):377–84.
7. Traverso LW, Longmire WP Jr. Preservation of the pylorus in pancreaticoduodenectomy. Surg
Gynecol Obstet. 1978;146(6):959–62.
8. Watson K. Carcinoma of ampulla of Vater successful radical resection. Br J Surg.
1944;31(124):368–73.
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J Cancer Res. 2015;27(4):332–48.
10. Gordon TA, Bowman HM, Tielsch JM, Bass EB, Burleyson GP, Cameron JL.Statewide
regionalization of pancreaticoduodenectomy and its effect on in-hospital mortality. Ann Surg.
1998;228(1):71–8.
11. Winter JM, Cameron JL, Campbell KA, etal. 1423 pancreaticoduodenectomies for pancreatic cancer: a single-institution experience. J Gastrointest Surg. 2006;10(9):1199–210; discussion 210–1.
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12. Hunt GC, Faigel DO.Assessment of EUS for diagnosing, staging, and determining resectability of pancreatic cancer: a review. Gastrointest Endosc. 2002;55(2):232–7.
13. Varadarajulu S, Eloubeidi MA.The role of endoscopic ultrasonography in the evaluation of
pancreatico-biliary cancer. Surg Clin North Am. 2010;90(2):251–63.
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15. Clancy TE, Baker EH, Maegawa FA, Raoof M, Winslow E, House MG.AHPBA guidelines
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16. Logarajah SI, Jackson T, Darwish M, etal. Whipple pancreatoduodenectomy: a technical illustration. Surg Open Sci. 2022;7:62–7.
17. Staśkiewicz G, Torres K, Denisow M, Torres A, Czekajska-Chehab E, Drop A.Clinically relevant anatomical parameters of the replaced right hepatic artery (RRHA). Surg Radiol Anat.
2015;37(10):1225–31.
18. Sayyed R, Baig M, Khan A, Niazi IK, Syed AA, Hanif F.Hepatic arterial system anomalies encountered during pancreaticoduodenectomy - our experience. J Pak Med Assoc.
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19. Dandekar U, Dandekar K, Chavan S.Right hepatic artery: a cadaver investigation and its clinical signicance. Anat Res Int. 2015;2015:412595.
20. Warren KW, Cattell RB. Basic techniques in pancreatic surgery. Surg Clin North Am.
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23. Winter JM, Cameron JL, Campbell KA, etal. Does pancreatic duct stenting decrease the rate
of pancreatic stula following pancreaticoduodenectomy? Results of a prospective randomized trial. J Gastrointest Surg. 2006;10(9):1280–90; discussion 90.
24. Ecker BL, McMillan MT, Asbun HJ, etal. Characterization and optimal management of highrisk pancreatic anastomoses during pancreatoduodenectomy. Ann Surg. 2018;267(4):608–16.
25. Horstmann O, Markus PM, Ghadimi MB, Becker H.Pylorus preservation has no impact on
delayed gastric emptying after pancreatic head resection. Pancreas. 2004;28(1):69–74.
26. Seiler CA, Wagner M, Sadowski C, Kulli C, Büchler MW.Randomized prospective trial of
pylorus-preserving vs. classic duodenopancreatectomy (Whipple procedure): initial clinical
results. J Gastrointest Surg. 2000;4(5):443–52.
27. Jung JP, Zenati MS, Dhir M, etal. Use of video review to investigate technical factors that
may be associated with delayed gastric emptying after pancreaticoduodenectomy. JAMA Surg.
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28. Conlon KC, Labow D, Leung D, etal. Prospective randomized clinical trial of the value of
intraperitoneal drainage after pancreatic resection. Ann Surg. 2001;234(4):487–93; discussion 493–4.
29. McMillan MT, Fisher WE, Van Buren G 2nd, et al. The value of drains as a stula mitigation strategy for pancreatoduodenectomy: something for everyone? Results of a randomized
prospective multi-institutional study. J Gastrointest Surg. 2015;19(1):21–30; discussion 30–1.
30. Van Buren G 2nd, Bloomston M, Hughes SJ, et al. A randomized prospective multicenter
trial of pancreaticoduodenectomy with and without routine intraperitoneal drainage. Ann Surg.
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19 Open Whipple
31. Cheatham ML, Chapman WC, Key SP, Sawyers JL.A meta-analysis of selective versus routine nasogastric decompression after elective laparotomy. Ann Surg. 1995;221(5):469–76; discussion 476–8.
32. Sou M, Al-Temimi M, Nguyen TK, et al. Friend or foe? Feeding tube placement at the
time of pancreatoduodenectomy: propensity score case-matched analysis. Surg Endosc.
2022;36(5):2994–3000.
33. Nussbaum DP, Zani S, Penne K, etal. Feeding jejunostomy tube placement in patients undergoing pancreaticoduodenectomy: an ongoing dilemma. J Gastrointest Surg. 2014;18(10):1752–9.
341
Chapter 20
Laparoscopic Pancreatoduodenectomy
NúriaLluís, DomenechAsbun, andHoracioJ.Asbun
Beginnings ofLaparoscopic Pancreatoduodenectomy
On average, 17years elapsed from conception to application of a clinical novelty
[1]. Despite the onset of laparoscopic surgery in the mid-1980s, it would be several
decades later before laparoscopic pancreatoduodenectomy (LPD) became an
accepted operation by pancreatic surgeons. Its implementation required adequate
technological advancements and the courage of pioneering surgeons, whose vision
and commitment made LPD a feasible and safe technique (Fig. 20.1). LPD has
evolved over the last two decades, as detailed in the historic pearls below.
In 1994, Gagner etal. [2] published the rst description of LPD in a patient with
chronic pancreatitis. However, early experiences with LPD were discouraging due
to the lack of proper minimally invasive equipment and surgical expertise that were
still being developed at the time. In 2007, Palanivelu etal. [3] published the rst
series, including 42 patients with mainly malignant pancreatic diseases, and reported
5-year survival rates ranging from 19.1% to 50%, depending on tumor type and
lymph node positivity. In 2010, Kendrick etal. [4] reported 62 patients with different types of malignant and benign diseases and described a median length of hospital stay of 7days, with 42% of postoperative morbidity events, and one death. In
2012, Asbun etal. [5] compared the outcomes of 215 patients who underwent an
open pancreatoduodenectomy (OPD) and 53 patients who underwent a laparoscopic
approach, and reported that LPD was feasible, without differences in overall or
pancreas-specic complications, and a higher lymph node retrieval rate when compared with the open approach.
N. Lluís · D. Asbun · H. J. Asbun (*)
Division of Hepatobiliary and Pancreas Surgery, Miami Cancer Institute, Miami, FL, USA
e-mail: horacioa@baptisthealth.net; domenech.asbun@baptisthealth.net
Switzerland AG 2025
E. P. Ceppa et al. (eds.), The SAGES Manual of Evolving Techniques in
Pancreatic Surgery, https://doi.org/10.1007/978-3-031-78409-5_20
343© The Author(s), under exclusive license to Springer Nature
344
Fig. 20.1 Pioneer surgeons whose vision and commitment made laparoscopic pancreatoduodenectomy a feasible and safe technique
N. Lluís et al.
Comparing Outcomes Between Laparoscopic
andOpen Approach
Further research has delved into the comparison between the laparoscopic and open
approaches to pancreatoduodenectomy. Between 2017 and 2022, 19 studies used
propensity score matching analysis to compare outcomes of the two approaches
(Table 20.1). The most frequent short-term nding was that the laparoscopic
approach resulted in shorter hospital stays. Moreover, some studies noted a decrease
in readmission rates, delayed gastric emptying, pain, and use of painkillers.
However, there was a mixed result on pancreatic stula rate, with one study showing
a lower rate and another showing an increased rate. In most studies, postoperative
morbidity and mortality were similar for both approaches. In terms of oncological
outcomes, several studies reported that the laparoscopic approach achieved a comparable negative resection margin rate, with more lymph nodes harvested in one
study and fewer in another. Another study found similar tumor progression-free
survival, while several studies reported similar overall survival rates. Overall, these
ndings suggested that LPD achieves non-inferior short- and long-term outcomes
when compared to the open procedure.
The ndings were further consolidated through subsequent analyses of more
comprehensive data. A meta-analysis of eight studies revealed that there was no
signicant difference in the 5-year overall survival rate between both surgical
approaches. Furthermore, laparoscopic surgery was found to have a higher rate of
R0 resection and harvested lymph nodes when compared to the open approach [25].
In addition, for elderly patients, another meta-analysis reported no signicant differences in blood loss, postoperative pancreatic stula, and length of hospital
stay [26].
Specic benchmark outcomes were provided for LPD in an international multicenter study published in 2019 [27]. The outcomes of low-risk patients undergoing
LPD in three centers with expertise in minimally invasive surgery were compared to
the benchmark values obtained in low-risk patients undergoing open pancreatoduodenectomy in an international multicenter study. Operative time (benchmark <=7.5 h)
20 Laparoscopic Pancreatoduodenectomy
Table 20.1 Retrospective studies using propensity score matching analysis to compare outcomes
after laparoscopic versus open pancreatoduodenectomy
Author Country Year Design
Conrad [6] US 2017 Single-center Long-term,
Kutlu [7] US 2018 Multicenter,
NCDB
Lee [8] Korea 2018 Single-center Short-term,
Nassour [9] US 2018 Multicenter,
ACS-NSQIP
Park [10] Korea 2018 Single-center Short-term,
Shin [11] Korea 2019 Single-center Short- and
Primary
outcome
oncologic,
ADC
Short-term
according to
hospital
volume of PDs
benign and
borderline
disease
Short-term 334 lap,
acute kidney
injury
long-term,
elderly
(≥70years)
Baseline, nOutcomes after
40 lap,
25 open
430 lap,
4309
open
31 lap,
76 open
4150
open
177 lap,
632 open
56 lap,
270 open
PSM, lap vs open
• Similar overall
and recurrencefree survival
• The benets of
the lap vs open
approach (shorter
LOHS, fewer
readmissions)
were only
achieved in
hospitals with a
high volume of
cases (≥25 PDs
per year)
• Less
postoperative
pain
• Shorter LOHS
• Similar
morbidity and
mortality
• Decreased rate
of prolonged
LOHS
• Increased
readmission rate
• Shorter LOHS
• Similar
incidence of
postoperative
acute kidney
injury
• Lower
pancreatic stula
rate
• Less use of
painkillers
• Similar 3-year
overall survival
and disease-free
survival
345
(continued)