Step by step pancreatic cancer surgery|Whipple’s Procedure| Pancreaticoduodenectomy

Preoperative Management
Although many patients with pancreatic malignancies will have lost substantial body weight, there is no evidence that preoperative nutritional repletion with total parenteral nutrition reduces perioperative complications or mortality. In the now uncommon case in which high-grade jaundice is associated with coagulation defects, preoperative administration of vitamin K and intraoperative fresh-frozen plasma are used as needed. Bowel preparation is unnecessary unless colonic resection is anticipated. Broad-spectrum antibiotics germane to biliary flora are given prior to skin incision and continued for one dose postoperatively.

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Pancreaticoduodenectomy: General Considerations
This operation, whether performed as a classic Whipple procedure or as a pylorus-preserving variation, should incur a 30-day in-hospital mortality rate of less than 5%. Although the majority of surgeons worldwide may, at present, favor the pylorus-preserving modification of pancreaticoduodenectomy, it has been our experience that the postoperative length of hospital stay is significantly longer with the pylorus-preserving operation because of a higher incidence of delayed gastric emptying in approximately one third of patients. Because there is neither a nutritional advantage conferred nor any difference in cure rates between the two operations, we have favored the traditional antrectomy.

There has been recent interest in extending the operation to include tissues outside the standard field of dissection, retroperitoneal lymph nodes, and the nerve plexuses along the superior mesenteric artery. Popularized in Japan, this extended dissection has shown no benefit in clinical trials in Europe and the United States. In addition, circumferential dissection of the nerve plexuses around the artery frequently leads to debilitating diarrhea and gastrointestinal dysfunction.

Lateral or segmental resection of the portal or superior mesenteric vein may allow completion of the pancreaticoduodenectomy but has not convincingly increased the rate of cure even if an R0 resection (negative margin) is accomplished.

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Operative Technique
Step 1

Either a vertical midline incision, our preference, or a bilateral subcostal transverse incision can be used with equal access. The liver and peritoneal surfaces are examined for unexpected extrapancreatic metastases. Intraoperative ultrasonography of the liver may be used selectively when the findings are suspicious but indeterminate by palpation. Routine biopsy of apparently normal regional lymph nodes is unnecessary, but suspicious lesions and enlarged lymph nodes outside the planned field of dissection should be biopsied and examined by frozen section and the resection aborted if positive for metastatic cancer. Positive lymph nodes within the planned field of resection are not considered a contraindication to pancreaticoduodenectomy.

Step 2

The hepatic flexure of the colon is mobilized from its retroperitoneal attachments to access the third and fourth portions of the duodenum. Extensive mobilization of the entire right colon and small bowel mesentery (Cattell-Braasch maneuver) is unnecessary except for lesions involving the fourth portion of the duodenum or for the approach to mobilization and resection of a segment of the superior mesenteric vein. The duodenum and head of the pancreas are separated from the retroperitoneal bed medially past the aorta and distally to the ligament of Treitz. It is now possible to palpate the superior mesenteric artery posteriorly as it originates from the aorta and to establish that the cleft between the artery and uncinate process of the pancreas is not obliterated by tumor (Fig. 1). A silk suture placed in the duodenum to mark the junction of the third and fourth portions is particularly helpful for identification of the proximal point of devascularization of the duodenum later when working back from the transected jejunum (step 7).

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Fig. 1
The duodenum and head of the pancreas are extensively mobilized and medially rotated away from the inferior vena cava and aorta. Posterior extension of the tumor is rare. The relationship between the tumor and the superior mesenteric artery is established by palpation.
Step 3

The gallbladder is removed if still present. The bile duct is dissected free from the adjacent portal structures and divided above the cystic duct entry across the common hepatic duct. This proximal point of division minimizes the risk of a positive biliary resection margin consequent to the tendency of periampullary cancers to infiltrate cephalad along the submucosal lymphatic channels of the bile duct. The proximal bile duct is left unclamped to avoid trauma to the duct, but the distal bile duct

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  Pancreatic Cancer