Whipple surgery is the procedure conducted for operable cancers of the pancreas. The procedure involves removal of the head, neck and uncinate process of pancreas along with the lower end of stomach, pylorus, the distal common bile duct, the entire duodenum and often the gall bladder. The reconstruction procedure is also part of the procedure and is performed in the same sitting.
Examination in Whipple Procedure
The Whipple procedure is performed through a midline incision or a subcostal (below the ribs) incision. Malignant indications involves an exploration that is performed following the incision. The area surrounding the pancreas including the retroperitoneal area behind head of pancreas is carefully examined for any metastases (cancer spread) that would deem the patient inoperable, leading to the abortion of the surgical procedure.
Surgical Removal (Resection) in Whipple Procedure
Once the findings of the exploration are found to be in favor of surgery, the irreversible steps of the Whipple procedure are initiated. The gallbladder along with the cystic duct is usually removed in most of the patients (cholecystectomy) and the common bile duct is separated above the duodenum and removed (choledochectomy).
The stomach is divided at the level of the gastric antrum proximally and distally, the division is made at the level of the jejunum. The head, neck and the uncinate process of the pancreas is resected from the retroperitoneum. The resected portion, which will now include the parts of pancreas and the part of stomach and the duodenum, is removed en masse and a regional lymph node dissection is also performed.
Reconstruction in Whipple Procedure
The reconstruction procedure is initiated following the resection. This involves reattaching the pancreatic duct to the jejunum (pancreaticojejunostomy), the hepatic duct to the jejunum (hepaticojejunostomy) and the stomach to the jejunum (gastrojeunostomy).
- Pancreaticojejunostomy allows secretions of the remaining functional pancreas to reach the lumen of the gastrointestinal tract. It is done by end-to-side anastomosis (the divided end of the pancreatic duct reattached to the side of jejunum) or end-to-end (the divided ends of the pancreatic duct and jejunum are reattached).
- Hepaticojejunostomy allows for the passage of the biliary secretions to the gastrointestinal tract and is done by end-to-side anastomosis.
- Gastrojejunostomy is done by end-to-end anastomosis and allows for the uninterrupted passage of food from the stomach to jejunum. As delayed emptying of the stomach is expected following the surgery, a jejunal tube is sometimes placed for feeding. The abdomen is then closed often with an abdominal drain in place. The drains help to manage any minor leaks through the anastomosis.
Modified Whipple Surgery
A modified Whipple surgery is now being performed more commonly in operable periampullary carcinomas (cancers arising from the head of the pancreas, ampulla of vater, duodenum and distal common bile duct) and in painful chronic pancreatitis patients.
The modified Whipple surgery is the pylorus-preserving modification where the distal end of the stomach (pylorus) or the upper part of duodenum is not resected. The reconstruction procedure in the modified surgery involves reattaching the duodenum to jejunum (duodenojejunostomy), instead of a gastrojejunostomy as in the standard Whipple procedure.
This modified Whipple procedure is believed to provide better quality of life than standard Whipple procedure. It is a simpler procedure and can reduce the time required for the surgery. The intact stomach allows for better gastric digestion following the surgery. The modified procedure thus, can reduce the hospital stay following the surgery as the requirement of intravenous feeding is usually less when compared to the standard Whipple procedure.
A further modification of the Whipple procedure in which the duodenum and bile duct is preserved (duodenum preserving) is believed to give better results than the standard Whipple procedure.