whipple precedure
TRANSCRIPT
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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 cys-
tadenocarcinomas, 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 proce-
dure, 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
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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 peri-
toneal 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 pancreaticoduo-
denectomy. The root of the transverse mesocolon also should be examined to determine whether there is direct tumor exten-sion 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.
Pancreaticoduodenectomy (Pylorus-Preserving Whipple Procedure) 285
1
Stomach
Spleen
Gallbladder
Liver
Gastrohepaticligament
Celiac axis
Duodenum
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Once tumor dissemina-
tion has been ruled out, the
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 tumorhas not extended beyond the uncinate process
to involve the superior mesenteric artery. For
this reason, an extensive kocherization should
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 per-
forming this maneuver, one feels tumor extend-
ing over to and involving the superior mesen-
teric artery, the lesion is not resectable.
286 Atlas of Gastrointestinal Surgery: Pancreas
2
3
Stomach
Kocherizedduodenum
Tumor
Pancreas
Duodenum
Head ofpancreas
Inferiorvenacava
Aorta
Uncinateprocess
Superiormesenteric
v. and a.
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One next needs to identify the
portal vein and to be certain the
portal and superior mesenteric veins
are not involved with tumor. The
quickest way to accomplish this is
to mobilize the gallbladder and
divide the common hepatic duct
(4). The gallbladder 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 pallia-
tive double bypass is to be car-
ried out. Therefore, the common
hepatic duct can be divided early.
This allows one to immediately come
down upon and identify the portal vein.
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 lig-
ating 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
remains in the hepatic artery. In some instances,
when the celiac axis is partially or completely
occluded either by atherosclerosis or the arcuate
Pancreaticoduodenectomy (Pylorus-Preserving Whipple Procedure) 287
4
5
Commonhepaticductdivided
Gastroduodnala. divided
Gallbladder
Commonbile duct
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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 life-
threatening 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 deter-
mine 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.
Another anomaly that is less frequent but even more difficult to recognize, is a replaced common hepatic artery off the
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 loca-
tion 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.
288 Atlas of Gastrointestinal Surgery: Pancreas
6 7
Replaced right hepatic a.
Replaced
right
hepatic a.
Replaced common
hepatic a.
(off superior
mesenteric a.)
Gastroduodenal a.
Gastroduodenal a.
Hepatic aa.L. hepatic a.
Splenic a.R. gastric a.
L. gastric a.
Replaced common heaptic a.
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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 origi-
nate from the anterior surface of the
portal vein and enter the posterior
neck of the pancreas, so this dissec-
tion 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.
Next, the third portion of the duodenum iskocherized extensively. The first structure that is iden-
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
mesenteric vein, rather than going through the lesser
sac. We do not enter the lesser sac during a pylorus-
preserving pancreaticoduodenectomy. Once the
superior mesenteric vein is identified as it passes ante-
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.
Pancreaticoduodenectomy (Pylorus-Preserving Whipple Procedure) 289
9
8
Portal v.
Superiormesenteric v.
Superiormesenteric
v.
Superior
mesentericv.
Superior
mesenterica.
Portal v.
Neck ofpancreas
Neck ofpancreas
R. gastroepiploic v.
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This venous structure is almost always
present, coming off the anterior, or
anterior left lateral, aspect of thesuperior 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
direct involvement by tumor of these major
structures, proceeding with the operative pro-
cedure 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 gastroin-
testinal anastomosis GIA stapler (11). At
times, the dissection of the neck of the pan-
creas off the portal and superior mesenteric
veins can be enhanced by dividing the duode-
num at an earlier stage.
290 Atlas of Gastrointestinal Surgery: Pancreas
10
11
Portal v.
Dissection ofpancreas offsuperiormesenteric v.
Dissection ofpancreatic neckoff portal v.
Gastroduodenal a.
Splenic v.
Superiormesenteric v
First portion of
duodenumdivided
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At this point, the neck of the
pancreas can be divided. We gener-
ally pass a small Penrose drainunderneath the neck of the pancreas,
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 relative-
ly 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 nor-
mal, care has to be taken to achieve hemosta-
sis from a variety of bleeding vessels.
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).
Pancreaticoduodenectomy (Pylorus-Preserving Whipple Procedure) 291
12
13
Portal v.
Superiormesenteric v.
Tumor
Pancreatichead
Duodenum
Pancreas
divided
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The superior mesenteric and portal veins are then dissected off the uncinate
process. Again, this is generally done with very little need to ligate and divide sub-
stantial vessels. The superior pancreaticoduodenal vein draining into the portal vein,
also known as the vein of Belcher, is a fairly constant landmark and needs to be
identified, doubly ligated and divided. In addition, more distally on the superior
mesenteric vein, near the inferior border of the uncinate process, the first jejunal
branch is a constant landmark, arising from the right lateral border of the supe-
rior mesenteric vein, and coursing around and posterior to the superior
mesenteric artery to the proximal jejunum, to the left of the mesenteric ves-
sels. This generally has to be ligated and divided (14).
A good deal of the dissection of the superior mesenteric and por-
tal veins off the uncinate process, however, can be done gently,
but bluntly. The uncinate process of the pancreas ends flush
against the right lateral border of the superior mesenteric
artery. In most instances, the dissection and division of
the uncinate process should be flush with the superi-
or mesenteric artery, cleaning approximately 180
degrees of the arterys circumference (15).
There are several sizable arterial branches that
have to be identified, ligated and divided.
Finally, the first jejunal venous branch, as itcourses underneath the superior mesenteric
artery to pass to the proximal jejunum, often
has to be doubly ligated and divided for a
second time (16).
292 Atlas of Gastrointestinal Surgery: Pancreas
14
15
16
Vein of Belcher
Vein of Belcher
First jejunalbranch divided(first time)
First jejunalbranch divided(second time)
Superior
mesentericv.
Superiormesenterica.
Superiormesenteric v.
Superiormesenteric a.
Superiormesenteric v.
Superior
mesenteric v.
Superiormesenteric a.
Uncinateprocessdivided
Hepatic a.
Neck of
pancreas
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One then retracts cephalad the transverse
colon and identifies the ligament of Treitz
and the proximal jejunum. The proximal
jejunum at a convenient point distal to the
ligament of Treitz, in the middle of a large
arcade, is divided with a GIA stapler
(17). The mesentery to the proximal
jejunum and fourth and third portions of the
duodenum are then doubly clamped,
divided and ligated with 2-0 silk.
Since the third portion of the duode-
num has been extensively kocherized
and mobilized during the earlier
part of the dissection, and since
the uncinate process has been
completely divided during the ear-
lier dissection, this dissection
below the transverse mesocolon to
completely mobilize the specimen
proceeds easily and quickly. Once
the jejunum is divided and themesentery is clamped, divided
and ligated down to the ligament
of Treitz, the proximal jejunum is
passed underneath the superior
mesenteric vessels over to the right
side of the abdomen, and the
specimen is removed from the
operative field (18).
Pancreaticoduodenectomy (Pylorus-Preserving Whipple Procedure) 293
17
18
Jejunumdivided
Mesenterydivided
Transverse
colon
First portion of
duodenum
Common hepatic a.
Commonhepatic duct
Duodenum
Pancreatichead
Uncinate
process
Transverse colon
Jejunum
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The specimen consists of the distal
portion of the first part of the duode-
num, all of the second, third and
fourth portions of the duodenum, and
approximately 10 cm of proximal
jejunum. In addition, the neck, head
and all of the uncinate process of the
pancreas are included, as are the gall-
bladder and distal biliary tree (19).
There are a variety of ways to
perform the pancreaticojejunostomy.
Many have been used very effec-
tively, with a reasonably low inci-
dence of pancreatic leakage and with low morbidity and mortality. We prefer to invaginate the end of the pancreas into
the side of the jejunum. Other pancreatic surgeons prefer to perform a duct to mucosa pancreaticojejunostomy, also in an
end-to-side fashion. Whether or not to stent the anastomosis with a small polyethylene tube is still under debate. We will
demonstrate the invagination technique with an end-to-side pancreaticojejunostomy (20), which also includes a duct-to-
jejunal mucosal anastomosis; we will also demonstrate a duct-to-mucosa anastomosis; finally, we will demonstrate teh invagi-
nation technique.
The end-to-side invagination anastomosis is carried out in two layers: an outer interrupted layer of 3-0 silk and an inner
continuous layer of 3-0 synthetic absorbable material. The jejunum is brought up into the lesser sac through a rent in thetransverse mesocolon, generally through the bare area of transverse mesocolon that resided over the junction of the second
and third portions of the duodenum. The outer row of the posterior layer is placed first. The 3-0 silks are placed through
the posterior surface of the pancreas, and then through the jejunum (21).
294 Atlas of Gastrointestinal Surgery: Pancreas
19
20
21
Pancreas
Pancreaticojejunostomy
Resection specimen
Outer layer ofposterior row
Jejunum
Duodenum
Proximaljejunum
Gallbladder
Distalbiliarytree
Uncincateprocess
Head and neck of pancreas
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When all sutures have been placed, they are secured. A
jejunotomy is then performed. The inner posterior layer of
the anastomosis consists of a continuous 3-0 synthetic
absorbable suture placed in a locking fashion (22). The
pancreatic duct is included in this inner layer. If it is a nor-
mal-sized duct, only two or three throws are placed
through the duct. If the duct is dilated, however, several
throws are placed through and through the dilated pan-
creatic duct. Thus, this technique combines both the
invagination technique as well as a duct-to-mucosa anasto-
mosis. The inner layer of the anterior row of the anastomosis is
performed next. This consists of an over-and-over suture passing
from above to below, through the capsule of the pancreas and out
through the divided parenchyma, and then from inside out on the
jejunum. Again, the pancreatic duct is incorporated in several throws
of this inner layer of the anterior row (23). When this has been com-
pleted, the outer interrupted layer of 3-0 silk sutures is placed such
that some of the jejunum is drawn over to cover the anastomosis (24).
Pancreaticoduodenectomy (Pylorus-Preserving Whipple Procedure) 295
22 23
24
Inner layer oifanterior row
Inner layer of
posterior row
Pancreatic ductincluded in inner layer
Outer layer ofanterior row
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This is performed by passing the
silk sutures through the capsule of
the pancreas about 1 cm from the
anastomosis, then out at the anas-
tomosis, and then through and
through the jejunum about a cen-
timeter away from the anastomosis.
This anastomosis results in invagina-
tion of the end of the pancreas into
the side of the jejunum, utilizing two lay-
ers, and also incorporates the pancreatic duct
(25). This anastomosis can also be performed
in an end-to-end fashion, when the pancreat-
ic remnant has a relatively small diameter, and
the jejunal diameter is of sufficient size. The
anastomosis is performed in an identical fash-
ion as the end-to-side anastomosis.
For the duct-to-mucosa anastomosis, the
outer layer is placed exactly as it is for the
invagination technique. The next step createsa jejunotomy the same size and exactly adja-
cent to the pancreatic duct (26). The duct-
to-mucosa anastomosis is performed with
interrupted 5-0 synthetic absorbable suture
material. The posterior row is placed first, the
sutures passing from inside out on the duct
side and outside in on the mucosal side.
Once all posterior row sutures have been
placed, they are secured (27).
296 Atlas of Gastrointestinal Surgery: Pancreas
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26
27
Jejunum
Jejunotomy(small)
Invaginatedpancreas
Posteriorduct-to-mucosarow
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Next, one can choose to place a stent or
not. We demonstrate a stent created from a
No. 8 French pediatric feeding tube, 8 cm in
length, being secured with one of the 5-0
sutures previously placed in the posterior row
(28 29). The anterior row of the duct-to-
mucosa anastomosis is completed by placing a
row of interrupted 5-0 synthetic absorbable
sutures from outside in on the duct, and insideout on the jejunal mucosa (30). The outer
anterior layer is completed with an interrupted
row of 3-0 silk sutures placed in a Lembert
fashion (31).
Pancreaticoduodenectomy (Pylorus-Preserving Whipple Procedure) 297
28
29
30
31
Completed anastmosis
Stent
Stent placed inpancreatic ductand secured
Anteriorduct-to-mucosarow
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Finally, in the unusual
situation of a very thin, soft gland
in which the pancreatic duct can not be
identified, we resort to placing the end of
the pancreas into the end of the jejunum for a 5-
cm distance and then tacking the jejunum circumfer-
entially to the body of the gland. This is accom-
plished by mobilizing the end of the pancreas for a
5-cm distance and then placing stay sutures 2.5 cm
from the cut end on the superior and inferior bor-
ders. These stay sutures are tied, then passed into
the end of the jejunum and out the side, 2.5 cm
from its end (32).
When these are secured, the pancreas
is inserted into the jejunum for a 5-
cm distance. The end of the
jejunum is then sutured to the
body of the pancreas circumfer-entially with a series of interrupt-
ed 3-0 silk sutures (33).
298 Atlas of Gastrointestinal Surgery: Pancreas
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33
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Two to five centimeters distal to the pancreaticojejunostomy, the
hepaticojejunostomy is performed (34). This is carried out with a single
layer of interrupted 4-0 synthetic absorbable suture material. An appro-
priately sized enterotomy is performed, and the posterior row is placed
with through-and-through sutures passing from inside out on the jejunum
and outside in on the hepatic duct (35). When all sutures are placed,
they are secured. The anterior layer is then carried out, again first placing
all sutures before securing them. They pass from outside in on the jejunum,
and inside out on the hepatic duct (36).
Pancreaticoduodenectomy (Pylorus-Preserving Whipple Procedure) 299
34
35 36
Hepaticduct Anterior row
Posterior row
Hepaticojejunostomy
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The final anastomosis is an end-to-side duodenojejunostomy(37). If one leaves only a 2-cm cuff of duodenum on the pylorus, it
is not necessary to preserve the right gastric artery, although this is
always preferable. The right gastric artery is often small, arises from the
hepatic artery, and actually joins the first portion of the duodenum. In
most instances, the right gastric artery can be identified and preserved.
The duodenojejunostomy is performed with an outer interrupted layer
of 3-0 silk and an inner continuous layer of 3-0 synthetic absorbable
suture (38). Once the outer layer of the back row of the
anastomosis has been placed, these sutures are
secured and an enterotomy is made on the
side of the jejunum (39).
300 Atlas of Gastrointestinal Surgery: Pancreas
37
38
39
Duodenojejunostomy
HepaticojejunostomyJejunum
Stent placed inpancreatic duct
and secured
Outer layer ofposterior row
First portion ofduodenum
Stomach
Enterotomy
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The staple line on the first portion of the duodenum is thenexcised. The inner layer on the posterior row is a continuous
locking suture of 3-0 synthetic absorbable material (40).
This is continued onto the anterior row and placed in a
Connell fashion (41). The duodenojejunostomy is complet-
ed with an outer layer of interrupted 3-0 silk sutures (42).
Pancreaticoduodenectomy (Pylorus-Preserving Whipple Procedure) 301
41
42
40
Inner layer of
posterior row
Inner layer of
anterior row
Outer layer ofanterior row
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When performing the pylorus-preserving Whipple procedure, a
portion of the first part of the duodenum; all of the second,
third, and fourth parts of the duodenum; and the proximal
jejunum are resected, along with neck, head, and uncinate
process of the pancreas. Also removed are the gallbladder
and distal biliary tree (43). Although there are many ways
to perform the reconstruction following the resection, as
just demonstrated, we prefer the end-to-side pancreaticoje-
junostomy, the end-to-side hepaticojejunostomy, and then
an end-to-side duodenojejunostomy (44). Many surgeons
continue to prefer the classic Whipple, in which a hemigastrec-
tomy is performed instead of pylorus preservation (45).
302 Atlas of Gastrointestinal Surgery: Pancreas
43 44
45
ResectionReconstruction
Alternate: Hemigastrectomy
with gastrojejunostomy
End-to-sidepancreaticojejunostomy
End-to-sidehepaticojejunostomy
End-to-sideduodenojejunostomy
Proximaljejunum
Pancreas
Tumor
Duodenum
Distalbiliary
tree
Gallbladder
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Many pancreatic surgeons also feel that, in selected patients with
tumor involvement of the portal and/or superior mesenteric vein (but with
otherwise favorable tumors), resection of a segment of these venous structures
should be performed, along with venous reconstruction. If the tumor involves just
a very small area of the portal vein or superior mesenteric vein, a Satinsky clamp or
DeBakey clamp can partially occlude the venous structure, and a small ellipse of the
vein that is involved with the tumor can be excised (46). If this ellipse is small, the
venotomy can be closed with a continuous 5-0 synthetic non-absorbable suture (47). If
the ellipse is larger and its direct closure would result in narrowing of the superior mesenteric
vein, a vein patch can be utilized to maintain diameter (48).
Pancreaticoduodenectomy (Pylorus-Preserving Whipple Procedure) 303
46
47
48
Portal v.
Portal v.
Veinotomyclosed
Patch
Superiormesentericv.
Tumor involvement ofsuperior mesenteric v.
Superiormesentericv.
Inferiormesentericv.
Splenic v.
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In some patients, enough of the
vein is involved so that tangential
resection is not feasible. In these
instances, a segment of portal
and/or superior mesenteric vein gen-
erally has to be excised (49). In these
instances, if the segment includes the
splenic vein, the splenic vein can be ligated
and divided with impunity. After the segment
of superior mesenteric vein and portal vein is
excised, if it is 3 cm or less in length, a direct
end-to-end anastomosis can be performed
(50) If the segment is longer than 3 to 4 cm,
an interposition vein graft of either saphenous
vein or jugular vein is preferable (51). It is not
necessary to reimplant the splenic vein.
It has been controversial as to whether or not a retroperitoneal lymphadenectomy accompanying a pancreaticoduo-
denectomy is of benefit in prolonging survival after a resection for cancer of the pancreas. Some pancreatic surgeons have
felt an extensive retroperitoneal dissection, as well as dissection of the nodes sur rounding the celiac axis and porta hepatis,
has resulted in prolonged survival.When we perform a retroperitoneal lymphadenectomy, we first perform a classic Whipple including a hemigastrectomy
so that the prepyloric and pyloric lymph nodes are included. The retroperitoneal dissection then starts at the medial aspect
of the right kidney hilum and proceeds laterally to the left side of the aorta. It
304 Atlas of Gastrointestinal Surgery: Pancreas
49
50 51
Portal v.
Portal v. Portal v.
Tumor
Superior
mesentericv.
Superiormesentericv.
Superiormesentericv.
Interpositionvein graft
End-to-endanastomosis
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extends superiorly from the
portal vein to inferiorly at the takeoff of
the inferior mesenteric artery (52). In our experience,
when retroperitoneal nodes are positive, they general-
ly are in the caval-aortic groove. This dissection also
includes the tissues surrounding 180 degrees of the
circumference of the superior mesenteric artery. In
addition, the celiac axis lymph nodes are dissected
(53), and the dissection can pass laterally along the
hepatic artery into the porta hepatis. It remains contro-
versial as to whether or not such a retroperitoneal lym-
phadenectomy prolongs survival. In the largest single-insti-
tution, prospective randomized study carried out, radical
retroperitoneal lymphadenectomy was of no survival benefit.
Pancreaticoduodenectomy (Pylorus-Preserving Whipple Procedure) 305
52
53
Inferiorvenacava
Stomach
Alternative: Retroperitoneal lymphdenctomy
Superiormesenteric v.
Superiormesenteric a.Aorta
Hepatic duct
(clamped)
Right kidney
Inferior
mesenteric a.
Retroperitonealnodes
Celiac axis nodes