Pancreaticoduodenectomy is also known as Whipple's procedure.

Preoperative Preparation

• For tumours, staging for loco-regional spread & distant metastases with CT scanning, ERCP, endoscopic ultrasound & laparoscopy.
• In obstructed jaundice, correct any clotting defects, give Vitamin K & maintain a diuresis.

Procedure

• After a full laparotomy has excluded metastases, the next steps will confirm respectability.
• The hepatic flexure of colon is first mobilised from in front of the duodenum & pancreas & they, in turn, are fully mobilised or 'Kocherised' off the IVC, right kidney & aorta.
• The supraduodenal portion of the CBD is now displayed & separated with encircling tapes from the hepatic artery in the free border of the lesser omentum. Behind & between these two structures the portal vein will be found.
• Pass a blunt dissector gently down in front of the portal vein, behind the duodenum & neck of pancreas to emerge in front of the superior mesenteric vein. Provided this passage is clear & there is no other local spread, the resection can proceed.
• Continue mobilsation of duodenum around third & fourth parts to the ligament of Treitz.
• Take care to avoid damage to the middle colic vessels
• Some perform a cholecystectomy but it is not imperative.
• Divide the right gastric vessels & mobilise the lesser curvature of stomach.
• Next, divide the gastroduodenal artery close to its origin & then the common bile duct above the pancreas.
• Prepare the greater curvature & then divide the stomach using a linear cutting stapler.
• Before dividing the nect of the pancreas, in front of the portal vein, place stay sutures in the upper & lower border of the pancreas on each side of the planned line of resection to control bleeding & then divide the pancreas.
• Individually ligate & divide the delicate small veins entering the right side of the portal vein from the pancreas.
• Carefully free the third part of the duodenum from the ligament of Treitz & the superior mesenteric vein. Mobilise & divide the upper jejunum & pass it through the window in the mesocolon behind the mesenteric vessels to the right, & remove the specimen.
• Prepare the upper jejunum & mobilise it so that it easily reaches the hilum of the liver.
• Close the free end of the jejunum & anastomose the common bile duct to the jejunum, end-to-side. Next, anastomose the cut end of the pancreatic duct to the kekunum lower down. Re-enforce this by suturing the capsule of the pancreas to the serosa of the jejunum around the pancreatic anastomosis.
• Finally, construct a gastro-jejunal anastomosis distal to the previous two anastomoses. All anastomoses are carried out with synthetic absorbable sutures.

Main Postoperative Complications

Include haemorrhage, anastomotic leak & pancreatic fistula formation.