Whipple

ANATOMY
Portal triad: CBD, Portal vein is medial to CBD, hepatic artery is medial to portal vein.

1.Position the patient supine.
2.Make a midline incision from xiphoid process to 10cm below the umbilicus.
3.Conduct a laparotomy looking for liver metastases, root of SB mesentery for invasion and coeliac axis nodes that will contraindicate resection.
4.Incise the gastrocolic omentum leaving omentum attached over the antrum as this part will be excised and inspect the anterior surface of the pancreas. Mobilize the hepatic flexure of colon.
5.Perform a Kocher manouvre to the point where the superior mesenteric vein crosses D3 (this can also be found by tracing the middle colic vein). Invasion of the superior mesenteric vein and IVC is also a contraindication to resection.
6.Incise the gastrohepatic omentum and identify the common hepatic artery as it raises a fold of peritoneum in the posterior wall of the lesser sac. Sweep any nodes downwards towards the specimen.
7.Identify and ligate the origin of the gastroduodenal artery. Continue dissecting medially and identify and ligate the right gastric artery.
8.Identify the shiny surface of the portal vein immediately deep to the above ligated vessels. Gently free the portal vein from the overlying pancreas using a peanut sponge. This can also be done with a finger from above and one from below deep to the gland and superficial to the superior mesenteric vein.
9.With one hand from above the gland and below/behind the portal vein as well another hand from the front deep to the SMV feel the uncinate process to determine if the posterior surfaces of portal vein or superior mesenteric vessels are involved. This will imply irresectability.
10.Extend the incision over the hepatic artery to the porta and expose the CBD and hepatic duct dissecting it away from the hepatic artery and portal vein.
11.Perform a cholecystectomy and divide the hepatic duct below a non-crushing clamp.
12.Perform an antrectomy using a GIA80 (4.8mm staples), ligating the vascular arcades along the lesser and greater curves; and complete the longitudinal division of the omentum in line with the specimen.
13.Identify the line of division of pancreas 3cm to the left of the superior mesenteric vessels and transect the pancreas (mindful of the splenic vein deep to the pancreas, which does not need to be ligated) using a TA60 (3.5mm staples) with division of the gland on the staying side. Insert a plastic catheter into the pancreatic duct to prevent its occlusion.
14.Retract the specimen to the patient’s right to reveal the anterior surface of the superior mesenteric vessels. Ligate branches of SMA (running deep to the SMV) and SMV heading to the posterior surface of the head of the pancreas. Ensure there is not an anomalous right hepatic artery.
15.Divide the uncinate process with a TA60 (3.5mm staples) stapler or divide across it with diathermy if it terminates in some fibroareolar tissue.
16.Divide the ligament of Trietz and ligate the branches from the SMA to the proximal 6-8cm of jejunum. This will necessitate creating a window in the transverse mesocolon to the left or right of the middle colic vessels.
17.Transect the proximal jejunum where the roux loop starts with a TA60 (3.5mm staples) and reinforce the staple line with 4/0 PDS.
18.Dissect and deliver the specimen incorporating the antrum, head of pancreas/uncinate process and bile duct with D1-4.
19.Create the roux limb, pass 12-13cm of jejunum through the mesocolon and construct an end to side pancreaticojejunostomy about 3cm from the stump at the anti-mesenteric border. Place a layer of sutures from the posterior capsule of pancreas to seromuscular layer of jejunum using 4/0 prolene. Make a small enterotomy opposite the duct and anastomose the duct using 6/0 prolene (use vascular loops) around a plastic tube (8-10F paediatric feeding tube brought in through the abdominal wall, via an enterotomy in the jejunum 10cm proximally), starting with posterior layer, then advancing the tube and completing the anterior wall. Once the posterior wall is complete, secure the feeding tube to prevent dislodgement using 3/0 plain gut. Then, finally suture the anterior capsule of the pancreas to the jejunum.
20.Make a small choledochotomy 3cm proximal to the cut end and bring through a 16-18F T-tube, taking it through the abdominal wall prior to completing the anastomosis. Make an enterotomy 20cm distal to the pancreaticojejunostomy of similar diameter and perform an end to side hepaticojejunostomy using a single layer of 5/0 PDS. Tie the knots of the posterior layer in the lumen using full thickness on both sides followed by the anterior layer using full thickness of duct and sero-muscular jejunum.
21.Bring up a jejunal loop (at least 20cm distal to the hepaticojejunostomy) in an anti-colic fashion and fashion a hand-sewn gastrojejunostomy using 3/0 PDS on the left side of the stomach after excising the staple line. Reinforce the staple line on the right side of the stomach with a continuous 3/0 PDS.
22.Tunnel the pancreatic trans-anastomotic tube and suture to the abdominal wall as in a feeding jejunostomy. A further option is also to place a feeding jejunostomy distal to the gastrojejunostomy.
23.Suture the T-tube and pancreatic trans-anastomotic tube to the abdominal wall and perform lavage and closure following placement of a large closed suction drain adjacent to the hepatic and pancreatic anastomoses.