Pancreaticoduodenectomy (Whipple)

Why are we operating?

The biggest scheduled operation in general surgery: resection of the pancreatic head and everything plumbed into it, then three anastomoses to put the plumbing back.

Indication: Resectable malignancy of the pancreatic head, ampulla, distal bile duct or duodenum.

The operation in 4 steps

1. 01Assessing resectability

   Staging laparoscopy or early open assessment: peritoneum, liver, and the tumour's relationship to the superior mesenteric vessels.

   Why: The operation is only worth its morbidity if the tumour can come out with clear margins; vascular involvement and occult metastases are sought before any bridge is burned.

2. 02Kocherisation and dissection

   The duodenum and pancreatic head are lifted off the vena cava and aorta, the porta hepatis dissected, gallbladder and bile duct taken, and the neck of pancreas tunnelled off the portal vein.

   Why: Each move answers a question the scan could not: does the tumour let go of the cava, the artery, the vein? The operation stays reversible for as long as possible, because the point of no return here is measured in anastomoses.

3. 03The resection

   Distal stomach (or duodenum in pylorus-preserving form), bile duct, pancreatic neck and jejunum are divided; the specimen comes out with its uncinate margin freed from the mesenteric vessels.

   Why: The uncinate dissection along the artery is where margins are won and lost, and where the operation's bleeding risk concentrates.

4. 04Reconstruction

   One jejunal limb takes all three joins: pancreas to jejunum, bile duct to jejunum, stomach to jejunum.

   Why: The pancreatic anastomosis is the operation's Achilles heel: a soft gland with a small duct leaks digestive enzymes, and everything about the technique is arranged to protect it.

Danger zones

• Common bile duct

  The structure every biliary operation is designed not to injure; misidentification is the field's defining catastrophe.

• Right hepatic artery

  Crosses the triangle aberrantly in about one in seven patients, hugging the cystic duct.

• Duct of Luschka

  A small subvesical duct in the liver bed; missed, it declares itself as a postoperative bile leak.

• Duodenum

  Sits just below the porta, thermal injury from diathermy can present days later as a leak.

Anatomy you need

The pancreatic head sits in the duodenal C with the bile duct through it: one tumour, four organs, one specimen.

What can go wrong

• Anastomotic leak

  Day 3–7: tachycardia, fever, abdominal pain, ileus that fails to resolve, or subtle deterioration that 'doesn't add up'.

• Postoperative bleeding

  Tachycardia first, hypotension late; falling urine output; a distending abdomen or rising drain output.

• Intra-abdominal abscess

  Swinging fevers, malaise, and localized pain from day 5 onward, classically after perforated appendicitis.

• Venous thromboembolism

  Unilateral leg swelling, or sudden dyspnoea, pleuritic pain, tachycardia, sometimes the only sign is unexplained hypoxia.