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282 Atlas of Gastrointestinal Surgery: Pancreas
Kocherized
duodenum
Gall bladder
Pseudocyst
Liver
Stomach
A parallel opening into
the duodenum is made,
also with the electrocautery
(2). A posterior inner con-
tinuous locking layer of 3-0
synthetic absorbable suture is
1
Duodenectomy
Outer layer
of posterior
row
Cystotomy
placed (3) and then brought anteri-
orly in a Connell fashion. This row is
placed for hemostasis, as well as for good
approximation of the cyst wall and duodenum.
Inner layer
of posterior
row
Pseudocyst
Duodenum
2
Duodenum
3
The outer layer of the anterior row is placed,
again utilizing 3-0 silk sutures (4). The anastomosis is drained with a closed suction drain. The
inset demonstrates the anatomic relationship
Drainage of Pancreatic Pseudocyst into the Duodenum 283
Outer layer of
anterior row
between the head of the pancreas and the pancreatic duct, the pseudocyst, and the duodenum with
the cystoduodenostomy (5).
Another approach for draining a pseudocyst into the
duodenum involves performing a duodenotomy, and then
entering the pseudocyst via the medial aspect of the duodenum.
In our estimation, this results in potential risk to either the bile duct or
pancreatic duct, and the description provided here is a much safer technique.
Pseudocyst
5
Stomach
4
Duodenum
Superior
mesenteric a.
Pancreatic
duct
Superior
mesenteric v.
Pancreaticoduodenectomy
(Pylorus-Preserving Whipple Procedure)
Operative Indications:
Pancreaticoduodenectomy, or the Whipple procedure, may be indicated for a variety of benign and malignant diseases. It
is most commonly performed for one of the four periampullary adenocarcinomas arising in the head of the pancreas, the
ampulla, the distal bile duct, or the duodenum. The procedure is also utilized for less common neoplasms that may arise in
the head of the pancreas. These include the cystic neoplasms, both serous and mucinous cystadenomas and mucinous cystadenocarcinomas, intraductal papillary mucinous neoplasms, islet cell tumors (both benign and malignant), and solid and
pseudopapillary neoplasms (Hamoudi tumor). Benign ampullary and duodenal adenomas may also occasionally require a
pancreaticoduodenectomy for management. There are also a handful of rare tumors, including gastrointestinal stromal tumors
and acinar cell tumors, that are treatable by pancreaticoduodenectomy. Some pancreatic surgeons feel that pancreaticoduo-
denectomy is the procedure of choice for chronic pancreatitis when a dilated duct is not present and a Puestow procedure, therefore, cannot be performed. It is a particularly attractive operation for chronic pancreatitis when the disease is
most severe in the head and uncinate process, with less extensive involvement of the body and tail of the gland. Rarely,
pancreaticoduodenectomy may be indicated for extensive pancreatic and duodenal trauma, when it is felt that duodenal
repair and pancreatic drainage would be inadequate surgical management. In most instances, however, a pancreaticoduo-
denectomy is performed for a malignant neoplasm arising in the periampullary region. The
pylorus-preserving modification of the classic Whipple procedure has become our standard,
and it is utilized in over 80% of the pancreaticoduodenectomies done for neoplasms.
Operative Technique:
The operative procedure can be performed through either a bilateral subcostal or an upper
abdominal midline incision. Once the abdomen is entered, a thorough exploration must be
Gall bladder
Pancreaticoduodenectomy (Pylorus-Preserving Whipple Procedure) 285
Gastrohepatic
ligament
Liver
Celiac axis
Spleen
Stomach
Duodenum
1
carried out to detect any evidence of tumor
spread outside the limits of resection. The liver is carefully
examined, as are all serosal surfaces for metastatic spread or peritoneal dissemination. Ultrasound can be further used to clear the liver. In
addition, lymph node spread outside the boundaries of resection should be
determined (1). Involvement of the periportal and celiac axis lymph nodes used to be considered a contraindication for
resection. Today, however, these areas can easily be included in the lymphadenectomy accompanying a pancreaticoduodenectomy. The root of the transverse mesocolon also should be examined to determine whether there is direct tumor extension into this area. The root of the transverse mesocolon, if involved, can often be excised along with a segment of the
middle colic artery. Generally, the marginal artery of the transverse colon will continue to supply adequate blood to the
transverse colon, even in the instance when a segment of middle colic artery has to be excised.
286 Atlas of Gastrointestinal Surgery: Pancreas
2
Stomach
Kocherized
duodenum
Duodenum
Head of
pancreas
Superior
mesenteric
v. and a.
Once tumor dissemina-
tion has been ruled out, the
Pancreas
duodenum is extensively mobi-
lized. The duodenum, head of the
pancreas, and tumor are generally
easily elevated off the inferior vena cava
and aorta. Direct extension posteriorly into
these structures is very unusual. This maneuver
is important, however, to be certain the tumor
has not extended beyond the uncinate process
to involve the superior mesenteric artery. For
this reason, an extensive kocherization should
Tumor
Inferior
vena
cava
Uncinate
process
3
Aorta
be performed so that one can palpate the
superior mesenteric artery and be reasonably
comfortable that there is normal uncinate
process adjacent to it (2, 3). If, upon performing this maneuver, one feels tumor extending over to and involving the superior mesenteric artery, the lesion is not resectable.
One next needs to identify the
portal vein and to be certain the
portal and superior mesenteric veins
are not involved with tumor. The
Pancreaticoduodenectomy (Pylorus-Preserving Whipple Procedure) 287
quickest way to accomplish this is
to mobilize the gall bladder and
divide the common hepatic duct
(4). The gall bladder is no longer
considered an acceptable means
of decompressing the biliary tree
into a jejunal loop if the tumor
proves to be unresectable. The
hepaticojejunostomy is the biliary
bypass of choice even if a palliative double bypass is to be carried out. Therefore, the common
hepatic duct can be divided early.
This allows one to immediately come
4
Common
hepatic
duct
divided
Gall bladder
Common
bile duct
down upon and identify the portal vein.
Gastroduodenal a.
divided
The next step usually involves dividing the
gastroduodenal artery, passing inferiorly from the
common hepatic artery (5). This vessel passes
anterior to the portal vein, just at the point
where the portal vein passes posterior to the
duodenum and neck of the pancreas. Prior to ligating and dividing the gastroduodenal artery, it
should be occluded with either a vessel loop or
a bulldog clamp, to be certain that a good pulse
5
remains in the hepatic artery. In some instances,
when the celiac axis is partially or completely
occluded either by atherosclerosis or the arcuate
288 Atlas of Gastrointestinal Surgery: Pancreas
ligament, the hepatic artery is fed by the gastroduodenal artery through the arcade originating from the superior mesenteric
artery. In this instance, if one divides the gastroduodenal artery, there is risk of liver ischemia and necrosis, and serious lifethreatening morbidity. One therefore has to be certain that a good pulse remains in the hepatic artery before division of
the gastroduodenal artery.
At this point, one should also check for a replaced right hepatic artery (6)—a right hepatic artery originating from the
superior mesenteric artery rather than from the common hepatic artery. In the past, angiography was performed to determine this anomaly prior to surgery. That is no longer felt necessary because, with great accuracy, one can easily identify a
replaced right hepatic artery at the time of surgery.
This vessel will be found originating from the superior mesenteric artery (SMA), just after the take-off of the SMA
from the aorta. The replaced right hepatic artery then passes up to the liver just lateral to, and posterior to, the biliary
tree. With the use of three dimensional CT scans, this anomaly can usually be identified preoperatively.
superior mesenteric artery. In this instance, a sizable vessel passes anterior to the portal vein just at the point where the
portal vein passes behind the first portion of the duodenum and the neck of the pancreas (7). This is in the usual location of the gastroduodenal artery. This also has to be identified and carefully preserved, because division of this vessel
would be particularly disastrous, disrupting the blood supply to the liver.
Replaced
right
hepatic a.
Another anomaly that is less frequent but even more difficult to recognize, is a replaced common hepatic artery off the
Replaced right hepatic a.
L. hepatic a.
R. gastric a.
L. gastric a.
Splenic a.
Gastroduodenal a.
Gastroduodenal a.
Replaced common heaptic a.
Hepatic aa.
Replaced common
hepatic a.
(off superior
mesenteric a.)
6 7
Once the common hepatic duct and
the gastroduodenal artery have been
divided, one can easily dissect the
anterior surface of the portal vein off
the posterior surface of the neck of the
pancreas (8). The insertion of a vein
retractor on the neck of the pancreas will
allow excellent exposure for this dissection
(inset). It is unusual for veins to originate from the anterior surface of the
portal vein and enter the posterior
Pancreaticoduodenectomy (Pylorus-Preserving Whipple Procedure) 289
Portal v.
Portal v.
Superior
mesenteric
v.
neck of the pancreas, so this dissection can often proceed fairly rapidly
and bluntly, without risk. Occasionally,
however, a coronary vein or a superior
pancreaticoduodenal vein (vein of Belcher), will
come off the anterior surface of the portal vein, and one
has to be aware of these possibilities.
Neck of
pancreas
Neck of
pancreas
Superior
mesenteric v.
8
Next, the third portion of the duodenum is
kocherized extensively. The first structure that is iden-
9
tified crossing anterior to the third portion of the
duodenum is the superior mesenteric vein. This is a
much easier route by which to identify the superior
Superior
mesenteric
v.
Superior
mesenteric
a.
mesenteric vein, rather than going through the lesser
sac. We do not enter the lesser sac during a pyloruspreserving pancreaticoduodenectomy. Once the
superior mesenteric vein is identified as it passes ante-
R. gastroepiploic v.
rior to the third portion of the duodenum, its anteri-
or surface is cleaned up under the neck of the pancreas (9).
Again, the use of a vein retractor on the neck of the pancreas is
helpful in exposing the superior mesenteric vein for this dissection.
The anterior surface of the vein is usually free of significant venous
branches, except for the origin of the right gastroepiploic vein.
290 Atlas of Gastrointestinal Surgery: Pancreas
Portal v.
This venous structure is almost always
present, coming off the anterior, or
anterior left lateral, aspect of the
superior mesenteric vein just below
the neck of the pancreas, and has to
be carefully dissected, ligated and
divided.
Once this large venous structure has
been divided, the dissections between
the portal vein from above and the
superior mesenteric vein from below can
easily be connected (10). After this is
accomplished without any evidence of
Dissection of
pancreatic neck
off portal v.
10
Splenic v.
Superior
mesenteric v.
direct involvement by tumor of these major
structures, proceeding with the operative procedure is appropriate.
The first portion of the duodenum is then
mobilized and dissected free, off the neck of
the pancreas. It is divided with a gastrointestinal anastomosis (GIA) stapler (11). At
times, the dissection of the neck of the pancreas off the portal and superior mesenteric
veins can be enhanced by dividing the duodenum at an earlier stage.
Dissection of
pancreas off
superior
mesenteric v.
Gastroduodenal a.
11
First portion of
duodenum
divided
At this point, the neck of the
pancreas can be divided. We generally pass a small Penrose drain
underneath the neck of the pancreas,
Pancreaticoduodenectomy (Pylorus-Preserving Whipple Procedure) 291
Portal v.
12
and then, using the electrocautery,
divide the gland down to the
Penrose drain (12). If the pancreatic
duct has been occluded by tumor, and
the gland is fibrotic, this division is relatively bloodless. But if the patient has an
ampullary tumor, or another neoplasm that
has not obstructed the pancreatic duct, and
the pancreatic parenchymal is relatively normal, care has to be taken to achieve hemostasis from a variety of bleeding vessels.
Pancreas
divided
Duodenum
Pancreatic
head
Superior
mesenteric v.
Tumor
13
Once the neck of the pancreas has been
divided, a neck margin should be sent for
frozen section to be certain that the margin
is free of tumor (13).