Pancreatoduodenectomy

The following are “knows” from the syllabus

• Pancreatoduodenectomy

• Biliary-enteric anastomosis and gastro-enterostomy

• Whipple’s – en bloc resection of pancreatic head, duodenum, CBD, distal stomach and lymph nodes.

• Incision

  • Midline or rooftop incision
  • Thorough abdominal exploration to rule out metastasis

• Exposure

  • Take right side gastrocolic ligament
  • Mobilisation of right colon exposing 3^rd/4^th part of duodenum, with extended kocherisation performed.
  • Allows palpation of tumour in head of pancreas and exposes left renal vein.
  • Resectability is assessed; if extensive involvement of confluence of PV/SMV may render unresectable
    • Short segments of PV can be resected
    • Relationship of tumour to first jejunal branch of SMV is critical determinant; if involved, unlikely be able to reconstruct SMV

• Stomach or duodenum division

  • Conventional Whipple
    • Distal stomach resected – nodes along greater and lesser curve included
    • Stomach transected at antrum along with omentum.
  • Pylorus-preserving pancreatico-duodenectomy (PPPDR)
    • Stomach preserved, duodenum divided 2 cm distal to pylorus

• PLND + dissection CBD

  • Station 8 (common hepatic)
  • Follow that along divide the GDA
    • Making sure to not take the right hepatic by mistake
  • Dissect PV from CBD
  • 12a and 12p nodes
  • Cholecystectomy - do this at some point.. now is a good time -
  • Identify transection point for CBD

• Inferior

  • Mobilise inferior pancreatic border to get to neck

• Jejunum

  • Proximal jejunum along with mesentery is transected
  • Mobilised duodenum and jejunum delivered back under ligament of Treitz.

• Pancreatic head dissection

  • Uncinate process dissected from SMV/SMA vessels

• Transection

  • Pancreas is transected between four stay sutures (to help with haemostasis marginal arteries).
    • If any doubt of pancreatic margin, should be sent for frozen section.

• Divide the bile duct

  • And send the specimen for histology

• Reconstruction

  • Pancreaticojejunostomy: duct-to-mucosa or invagination technique
  • Hepaticojejunostomy: end-to-side to same jejunal loop
  • Gastrojejunostomy or duodenojejunostomy: antecolic or retrocolic

Pylorus-preserving pancreatico-duodenectomy (PPPDR)

• Intact pylorus limits nutritional deficiencies, dumping and bile reflux.
• No difference in overall survival, morbidity or mortality.
• Whipple’s associated with less delayed gastric emptying.
• PPPDR results in less operating time, intraoperative blood loss and transfusions.
• Right gastric artery preserved.
• Duodenum transected at least 2 cm distal to pylorus.
• Reconstruction with duodenojejunostomy or gastrojejunostomy.