General Surgery

Whipple's Procedure (Pancreaticoduodenectomy)

OPERATION: Pancreaticoduodenectomy (Whipple's Procedure) [/ Pylorus-Preserving Pancreaticoduodenectomy]
ANAESTHETIC: General anaesthesia with epidural
ANTIBIOTICS: Gentamicin and Metronidazole at induction
POSITION: Supine. VTE prophylaxis. Urinary catheter. NG tube.

INDICATION:
[Pancreatic head / periampullary / duodenal / distal bile duct cancer / chronic pancreatitis]. Staging confirmed resectable. Consent including discussion of significant morbidity and mortality.

INCISION: Upper midline / bilateral subcostal (rooftop).

PROCEDURE:
WHO Checklist performed. Abdomen explored for metastatic disease [liver, peritoneum, para-aortic nodes] — no distant metastases identified.

ASSESSMENT OF RESECTABILITY:
Portal and superior mesenteric veins assessed — no tumour involvement / limited involvement managed by [vascular reconstruction]. Superior mesenteric artery assessed — not involved.

RESECTION PHASE:
Kocher manoeuvre performed mobilising duodenum and head of pancreas. Hepatoduodenal ligament dissected. Cholecystectomy performed. Common hepatic duct divided. Gastroduodenal artery ligated and divided. [Standard Whipple: antrum and pylorus divided with GIA stapler / Pylorus-preserving: duodenum divided 3 cm distal to pylorus]. Superior mesenteric vein freed from pancreatic neck. Pancreatic neck transected with diathermy or knife over a sling. Uncinate process dissected off superior mesenteric artery, dividing inferior pancreaticoduodenal vessels. Specimen delivered.

RECONSTRUCTION:
[Modified Child's reconstruction]:
Pancreaticojejunostomy: end-to-side [duct-to-mucosa / invagination] technique with 4/0 PDS. Pancreatic duct stented [if duct <3 mm].
Hepaticojejunostomy: end-to-side with interrupted 4/0 PDS.
Gastrojejunostomy / duodenojejunostomy: end-to-side or side-to-side with GIA stapler + continuous PDS.

[Feeding jejunostomy inserted].
Drains placed adjacent to pancreatic and biliary anastomoses.

FINDINGS:
[Tumour location, size, macroscopic resection margin assessment]. Vessels [involved / not involved]. Lymph nodes [describe].

SPECIMEN: Whipple's specimen [orientated, inked] to histopathology.
EBL: [Volume] ml. COMPLICATIONS: None.

POST-OPERATIVE INSTRUCTIONS:
Level 2 / HDU care. NG tube until functioning. Drain amylase measured on day 1 and day 3. Enhanced recovery. VTE extended prophylaxis. Outpatient review with histology.