Whipple Pancreaticoduodenectomy

The patient is a [age]-year-old [male/female] with [pancreatic head / periampullary / ampullary] [carcinoma/mass] presenting for resection. Preoperative staging demonstrated [cT_N_M_]. The tumor was deemed [resectable/borderline resectable] on cross-sectional imaging without evidence of [SMA/SMV/portal vein] involvement precluding resection. [Neoadjuvant therapy was/was not completed.] The risks, benefits, and alternatives were discussed with the patient, and informed consent was obtained.

A [mass/tumor] was palpable in the [pancreatic head/ampulla/distal bile duct]. The superior mesenteric vein (SMV) and portal vein were [patent and uninvolved / with [< 180 degree] abutment requiring [vein resection/patch repair]]. The superior mesenteric artery was [uninvolved] with a [clear/narrow] fat plane. The hepatic artery was [normal / with replaced right hepatic artery from the SMA, which was preserved]. No evidence of peritoneal or hepatic metastases. [Additional findings or none].

The patient was brought to the operating room and placed supine. General endotracheal anesthesia was induced. Foley catheter and nasogastric tube were placed. A surgical timeout was performed confirming patient identity, procedure, operative site, allergies, and administration of prophylactic antibiotics.

The abdomen was prepped and draped in sterile fashion. An upper midline laparotomy was performed. Abdominal exploration confirmed resectability — no peritoneal deposits, no hepatic metastases, and no vascular involvement precluding resection. A self-retaining retractor was placed.

The hepatoduodenal ligament was dissected. The common bile duct was encircled. A cholecystectomy was performed. The common hepatic duct was divided just above the cystic duct insertion. The gastroduodenal artery was identified, ligated with [2-0 silk / hem-o-lok], and divided at its origin from the proper hepatic artery.

The duodenum was mobilized via an extended Kocher maneuver sweeping the duodenum and pancreatic head off the retroperitoneum and inferior vena cava. The SMV was identified below the neck of the pancreas. A tunnel was developed between the posterior surface of the pancreatic neck and the anterior surface of the SMV/portal vein confluence.

The stomach was divided just proximal to the pylorus (classic technique) [or the pylorus was preserved and the duodenum divided 1-2 cm distal to the pylorus (pylorus-preserving technique)] using a GIA stapler. The jejunum was divided approximately 10-15 cm distal to the ligament of Treitz with a GIA stapler. The proximal jejunum was passed under the superior mesenteric vessels to the right. The uncinate process was dissected off the superior mesenteric artery (SMA), dividing the pancreatic head/uncinate tributaries with [hem-o-lok clips/ties]. The pancreatic neck was divided over the SMV using [electrocautery/scalpel], and a [3-0 Prolene] stitch was placed in the main pancreatic duct for identification. The specimen was removed.

Reconstruction was performed in a retrocolic or antecolic Roux-en-Y fashion with the jejunum brought through a defect in the transverse mesocolon. The pancreatic anastomosis (pancreaticojejunostomy, [duct-to-mucosa / invagination technique]) was constructed first with an interrupted outer layer of [3-0 silk] and a duct-to-mucosa inner layer of [4-0 PDS] over a [5-Fr pancreatic duct stent]. The hepaticojejunostomy was constructed as a single-layer end-to-side anastomosis with [4-0 PDS] interrupted sutures. The duodenojejunostomy (or gastrojejunostomy) was constructed as a two-layer end-to-side anastomosis [___] cm distal to the hepaticojejunostomy.

The abdomen was irrigated. Hemostasis was confirmed. Two closed suction drains were placed adjacent to the pancreatic anastomosis and hepaticojejunostomy. The nasogastric tube was repositioned. The fascia was closed with running [#1 PDS]. Skin was closed with [staples]. Sterile dressings were applied.