“How I Do It”

Pancreaticoduodenectomy
Syed A. Ahmad, M.D., Andrew M. Lowy, M.D., Benjamin C. McIntyre, M.D.,
Jeffrey B. Matthews, M.D.

KEY WORDS: Whipple operation, pancreaticoduodenectomy, pancreatic cancer, chronic pancreatitis

INTRODUCTION (Fig. 1). For patients with extrahepatic biliary obstruc-

tion without an evident mass on thin section CT,
Since Whipple’s 1935 description of the two-stage
endoscopic retrograde cholangiopancreatography
operation that now bears his name,1 pancreaticoduo-
(ERCP) or endoscopic ultrasonography (EUS) is per-
denectomy has undergone a steady evolution. For-
formed. Routine tissue diagnosis is not necessary
merly plagued by high perioperative morbidity and
if the mass seems resectable and preoperative endo-
a mortality rate of approximately 30%, over the last
scopic or percutaneous transhepatic stenting is not
several decades, improvements in technique and peri-
endorsed. Preoperative laparoscopy is not routinely
operative care have allowed this operation to be per-
performed, because high-resolution spiral CT scans
formed with mortality rates of less than 2% and
adequately predict resectability and the presence of
major morbidity rates of 10%–15%.2 A number of
distant metastases.5 Surgical exploration with intent
reports have documented superior immediate results
to resect is offered to patients without evidence of
in centers that perform pancreaticoduodenectomy
extra-pancreatic disease, local invasion into the celiac
with high frequency, although the precise contribu-
or the superior mesenteric artery, or circumferen-
tion of surgical technique and surgeon experience
tial involvement of the portal-superior mesenteric
to the observed volume-outcome relationship is not
venous confluence.
defined.3 Numerous technical variations and options
For patients with chronic pancreatitis, a thin sec-
have been described for this complex operation. The
tion contrast-enhanced CT scan is performed to ex-
following description outlines the preferred method
clude complications related to pancreatitis such as
at the University of Cincinnati.
pseudocyst formation and portal vein thrombosis.
Most patients undergo ERCP to delineate pancreatic
ductal anatomy.
PREOPERATIVE ASSESSMENT AND
MANAGEMENT
SURGICAL TECHNIQUE
Preoperative evaluation depends on the nature of
Exposure and Initial Mobilization
the underlying pancreatic disorder. In patients with
suspected neoplasia, a chest radiograph and a thin- Although a bilateral subcostal incision (Chevron
section (5 mm) intravenous contrast-enhanced ab- type) is also popular, a midline incision provides
dominal and pelvic computed tomograph (CT) are adequate exposure of the porta hepatis, ligament of
obtained. Acquisition of CT images is timed to Treitz, and the periampullary region while avoiding
sequentially maximize visualization of vascular struc- bilateral division of the rectus abdominus, which is
tures and hepatic parenchyma (early hepatic arterial, otherwise associated with wound complications, post-
portal venous, and delayed hepatic venous phases)4 operative pain, and postoperative weakness of the

From the Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio.
Reprint requests: Jeffrey B. Matthews, M.D., Christian R. Holmes Professor and Chairman, Department of Surgery, University of Cincinnati
College of Medicine, 231 Albert Sabin Way, P.O. Box 670558, Cincinnati, OH 45267. e-mail: matthejb@ucmail.edu

! 2005 The Society for Surgery of the Alimentary Tract 1091-255X/05/$—see front matter
138 Published by Elsevier Inc. doi:10.1016/j.gassur.2004.01.004
Vol. 9, No. 1
2005 Pancreaticoduodenectomy 139

fibrofatty tissue overlying the kidney and retroperito-

neum. The line of dissection of the posterior peri-
toneum is then extended into the porta-hepatis. A
laparotomy pad is placed over the transverse colon,
which is retracted under the abdominal wall using
a medium-length right-angled retractor blade. This
blade is positioned at the base of the transverse meso-
colon over the inferior vena cava, being certain to
avoid venous compression or excessive traction on
the superior mesenteric vein. Careful placement of
this retractor creates substantial working space
around the duodenum and uncinate process and is
useful later in the dissection. A fourth short-length
right-angled blade over a laparotomy pad is used
to retract the stomach to the left under the left costal
margin.

Portal Dissection
Fig. 1. A contrast-enhanced thin-section CT scan of the pan- Next, attention is turned to the portal dissec-
creas shows the relationship of the tumor (T) to the superior tion. The cystic duct and common bile duct (CBD)
mesenteric artery (A) and vein (V).
are identified and the cystic artery is clamped, divi-
ded, and doubly ligated. A cholecystectomy is per-
formed. The CBD is then encircled with a silastic
abdominal wall. The liver and peritoneal surfaces vessel loop. The common hepatic duct is then divided
are carefully examined for metastatic deposits to ex- just above its junction with the cystic duct and the
clude stage IV disease. Placement of retractors is divided distal common duct is mobilized toward
crucial for optimal exposure and safe dissection. the pancreatic head. Early division of the CBD allows
We usually choose a self-retaining retractor system, rapid and simple exposure of the anterior surface
which is affixed to the operating table just beneath of the portal vein. A superior pancreaticoduodenal
the right armboard as far superiorly as possible, being branch of the portal vein is usually identified at this
certain to avoid hyperextension of the right arm. A level and care must be taken not to avulse this branch.
large segmented circular ring is used. A bladder-blade Lateral to the portal vein, fibro-fatty and lymphatic
retractor is used to retract the right costal margin tissue is usually present and care must be taken to
superolaterally. We separate the umbilical/falciform assure that an aberrant right hepatic artery is not
ligament from the abdominal wall to create a vascu- present within this area. Early division of the CBD
larized pedicle that is later used to cover the gastro- and identification of the portal vein also helps to
duodenal artery stump.6 Next, we incise the posterior expose the proper hepatic artery and its gastroduode-
peritoneum along the C-sweep of the duodenum ex- nal branch (GDA). A large lymph node is usually
tending laterally to mobilize the hepatic flexure of present in the hepatoduodenal ligament and the he-
the colon and to separate the duodenum from the base patic artery can usually be found just cephalad to this
of the transverse mesocolon. A deep right-angled lymph node. The proper and common hepatic artery
retractor blade is inserted over a laparotomy pad to is then identified proximal and distal to the gastroduo-
retract the hepatic flexure inferolaterally. The duo- denal artery (GDA). The GDA is then temporarily
denum and pancreatic head are then extensively mo- compressed to confirm its identity and to ensure that
bilized (Kocher maneuver) from their retroperitoneal pulsatile arterial flow to the liver via the hepatic artery
attachments to the level of the superior mesenteric will be present after division of the GDA. Preserva-
vein (SMV) anteriorly and the left renal vein posterio- tion of arterial flow to the liver is particularly critical
laterally (Fig. 2). The mobilization is sufficiently ex- in jaundiced patients who have reduced hepatic isch-
tensive that it becomes possible to incise the ligament emic tolerance. The GDA is then clamped, divided,
of Trietz behind the superior mesenteric vessels from tied, and additionally suture ligated. The possibility
its supracolic aspect. This maneuver allows the distal of the rare but potentially catastrophic complication
duodenum and uncinate process of the pancreas to of postoperative hemorrhage from a GDA pseudo-
be delivered from the depths of the retroperitoneum aneurysm should be recalled during this step. Gentle
and aids exposure. We do not routinely dissect the initial development of the supraduodenal avascular
 Journal of
140 Ahmad et al. Gastrointestinal Surgery

Fig. 2. The duodenum and the pancreatic head are extensively mobilized (Kocher maneuver) from their
retroperitoneal attachments to the level of the superior mesenteric vein (SMV) anteriorly and the left renal
vein posteriorly. RV ! left renal vein, B ! common bile duct, A ! hepatic artery, PV ! portal vein.

plane between the anterior border of the portal vein omitted if chronic inflammation makes dissection
and posterior aspect of the pancreas is begun. between the SMV and pancreas unsafe. This maneu-
ver facilitates division of the pancreas, but does not
Identification of the Superior Mesenteric Vein confirm resectability; this is more typically deter-
mined by tumor involvement at the lateral and poste-
The retractors over the transverse colon and stom- rior aspect of the SMV/portal vein.
ach are repositioned to allow delivery of the transverse
colon and omentum into the wound. The greater
omentum is then separated from the transverse
mesocolon by electrocautery, allowing access to the
Division of the Stomach and Jejunum
lesser sac through this largely avascular plane. Once
the transverse mesocolon is completely separated, We only infrequently perform pyloric-preserva-
the lower border of the pancreas is encountered. The tion with pancreaticoduodenectomy preferring a
middle colic vein is then followed distally and the standard distal gastric resection. At this stage of the
infra-pancreatic portion of the superior mesenteric procedure, then, a transection point on the greater
vein (SMV) is identified by incising the posterior curvature is chosen at the junction of the left and
peritoneum. It is important to identify and ligate the right gastroepiploic arteries on the greater curvature
right gastroepiploic vein early after identification of and, on the lesser curvature, a point is chosen at
the SMV, as it is otherwise easily avulsed. In some the gastric incisura angularis. The Ligasure bipolar
instances, it may also be wise to divide the middle colic device (Valleylab, Boulder, CO) is useful for dividing
vein to prevent undue traction on it. A plane of dis- the omentum between the gastroepiploic vessels. The
section is then created between the anterior surface descending branch of the left gastric artery is gener-
of the SMV and the posterior aspect of the pancreas. ally suture-ligated. The stomach is then transected
This plane is connected to the supraduodenal portal with a linear cutting gastrointestinal anastomosis
vein dissection and a 1/4-inch Penrose drain is passed (GIA) stapler (Ethicon, Inc., Cincinnati, OH) using
behind the neck of the gland. This step can be two firings of a blue (3.8 mm) cartridge, although a
Vol. 9, No. 1
2005 Pancreaticoduodenectomy 141

green (4.8 mm) cartridge can be used if the gastric exposing the retroperitoneal attachment of the unci-
wall is thicker. The staple line at the lesser curvature nate to the SMA.
is oversewn with 3-0 silk Lembert sutures. These su- The SMA is completely exposed and mobilized
tures are left uncut so that they may be used for to its aortic origin. For oncologic operations, the
traction, which helps exposure for the later gastro- uncinate process is separated from the right lateral
jejunal anastomosis. The proximal stomach is then wall of the SMA via serial ligation and division of the
retracted under the left costal margin behind a lapa- soft tissue attaching the uncinate to the SMA. This
rotomy pad and a short right-angled retractor blade. technique assures the best chance of obtaining a
Next, the ligament of Treitz is exposed and fully cancer-free retroperitoneal margin (the soft tissue
incised. The jejunum is divided with a linear cutting along the proximal 3–4 cm of the SMA). A positive
GIA stapler approximately 8–10 cm distal to the liga- retroperitoneal margin is associated with decreased
ment of Treitz, and the proximal mesojejunum and survival and every effort to achieve full tumor clear-
mesoduodenum are divided with a vascular load ance must be made.7 Once the entire specimen is
(white 2.5 mm load) GIA stapler. The Ligasure can separated from the SMA and removed, the retroperi-
also be used to divide the duodeno-jejunal mesentery. toneal margin is identified for the pathologist with a
Once the distal duodenum and proximal jejunum are marking suture. When the operation is performed
completely mobilized from their retroperitoneal at- for chronic pancreatitis or when retroperitoneal
tachments, the devascularized segment is reflected clearance is less critical, the soft tissue connecting
behind the superior mesenteric vessels into the su- the uncinate to the right lateral wall of the SMA can
pracolic compartment. The distal transected end of be divided en masse with the use of a vascular load
the proximal jejunum is oversewn with 3-0 silk Lemb- GIA linear cutter (Fig. 3), provided the tissue is not
ert sutures, which are left long for traction. overly thickened from chronic inflammation and
Division of the Pancreas
Figure-of-eight 2-0 silk stay sutures are placed on
the superior and inferior borders of the pancreas both
along the medial and lateral borders of the SMV
and portal vein. Upward tension on the previously
placed Penrose drain prevents iatrogenic injury to
the SMV during transection of the pancreas, which
is performed with electrocautery. The pancreatic duct
is usually identified two-thirds of the way up from
the inferior border and two-thirds of the way down
from the surface of the pancreas. Bleeding from the
pancreatic parenchyma is controlled with electrocau-
tery. The left pancreas is mobilized approximately
3–4 cm off of the splenic vein to facilitate suture
placement during the later pancreatico-jejunal anas-
tomosis. The next step of the operation is perhaps the
most difficult and most important in terms of onco-
logic principles and involves separating the pancreatic
head from the SMV and the superior mesenteric artery
(SMA). The transected pancreatic head is separated
from the SMV by individual ligation of the small
venous branches to the pancreatic head and uncinate
process. These venous tributaries are very fragile and
care must be taken not to accidentally avulse these
branches. At the inferior aspect, the first jejunal tribu-
tary is identified. This vessel courses behind the SMA
approximately 80% of the time. All venous tributaries
from this branch to the uncinate process are con- Fig. 3. When the operation is performed for chronic pancre-
trolled and divided so as to carefully preserve this atitis, the soft tissue connecting the uncinate process of the
first jejunal tributary. Once the SMV is completely pancreas to the right lateral wall of the superior mesenteric
separated from the pancreatic head and uncinate pro- artery (SMA) is divided en masse with the use of a vascular
cess, the SMV and portal vein are retracted medially, load GIA linear cutter.
 Journal of
142 Ahmad et al. Gastrointestinal Surgery

scarring. Once the specimen has been removed, frozen pursestring suture is placed through which a 5 French
section analysis of the transected pancreas margin pediatric feeding tube is introduced into the jejunal
and common bile duct margin is performed to ensure lumen. This tube is brought out opposite the main
an R0 resection. If these margins are positive, addi- pancreatic duct via a small enterotomy approximately
tional mobilization and retransection is performed. the size of the duct. The tube is advanced well into the
pancreatic duct and the chromic pursestring suture is
Reconstruction tied down. A duct-to-mucosa anastomosis is fash-
A retrocolic pancreatico-jejunal anastomosis is the ioned using 6-0 double-armed polydioxanone surgi-
first step of reconstruction. The proximal jejunum is cal suture (PDS) placed in a horizontal mattress
advanced through a mesenteric defect created to the fashion. This stent can be grasped with fine DeBakey
left of the middle colic vessels and a two-layer end- forceps (Aesculap, Center Valley, PA) to expose the
to-side duct-to-mucosa anastomosis is constructed duct for accurate suture placement. At least one
starting approximately 6–8 cm distal to the jejunal suture is placed in each quadrant of the duct. The su-
staple line. The posterior wall is created by a modified tures are placed so that knots will be on the outside
mattress technique using a 3-0 Vicryl suture that is for the anterior row and inside for the posterior row,
passed full-thickness through the pancreatic paren- which facilitates tying these knots securely. As these
chyma from anterior to posterior, horizontally through sutures are tied, the posterior-wall Vicryl sutures
the seromuscular layers of the jejunum, and then back are held up to ensure lack of tension. These posterior
full-thickness through the pancreas from posterior to wall mattress sutures are then tied to secure the
anterior. Three to four such sutures are placed, being back wall. The pancreatic stent is secured at the site of
careful to avoid the main pancreatic duct, and each its exit from the jejunum with interrupted 3-0 silk
suture is tagged with a hemostat (Fig. 4). This tech- sutures using the Witzel technique and later exteri-
nique allows secure placement of the posterior row orized through the abdominal wall through a separate
sutures, which are not tied until the inner duct- stab wound and secured to the skin (Fig. 5). The anas-
to-mucosa anastomosis is completed. Near the proxi- tomosis is completed with an anterior row of simple
mal stapled end of jejunum, a 3-0 chromic catgut 3-0 Vicryl sutures.
Next, approximately 10–20 cm distal to the pancre-
atic anastomosis, an end-to-side single layer hepatico-
jejunostomy is performed. This is created using
interrupted 4-0 polydioxanone (PDS) sutures imple-
menting the technique described by Blumgart and

Fig. 4. The posterior layer of the pancreatico-jejunal anasto-

mosis is created by a modified mattress technique using 3-
0 Vicryl sutures that are passed full-thickness through the
pancreatic parenchyma from anterior to posterior, horizon-
tally through the seromuscular layer of the jejunum, and
then back full-thickness through the pancreas from poste- Fig. 5. The pancreatic stent is secured to the proximal jejunal
rior to anterior (inset). A duct-to-mucosa anastomosis is fash- wall with interrupted 3-0 silk sutures using the Witzel tech-
ioned using a 6-0 double-armed polydioxanone (PDS) suture nique and later exteriorized through the abdominal wall
placed in horizontal mattress fashion. through a separate stab wound and secured to the skin (inset).
Vol. 9, No. 1
2005 Pancreaticoduodenectomy 143

Kelley.8 If the bile duct has a diameter greater than throughout the postoperative stay for prophylaxis
approximately 1.5 cm, a running single-layer tech- against deep venous thrombosis. The nasogastric tube
nique is used. Finally, a two-layer antecolic gastroje- is removed on the first postoperative day and jejunos-
junostomy is performed. The previously placed lesser tomy tube feeds are initiated on postoperative day 3.
curvature silk sutures are used for traction and we use Patients are discharged with their pancreatic stent in
interrupted 3-0 silk Lembert sutures for the posterior place. The stent is clamped before they are sent home
wall. The greater curvature staple line is cut off and and typically removed 3 weeks postoperatively.
a 3–4 cm enterotomy is made. An inner running 3-0
polyglyconate monofilament (Maxon) or chromic REFERENCES
catgut is used (simple running posteriorally, Connell-
1. Whipple AO, Parsons WW, Mullin CR. Treatment of carci-
style anteriorly). The anterior wall is completed with noma of the ampulla of Vater. Ann Surg 1935;102:763–769.
3-0 silk Lembert sutures. A 3-0 silk suture secures 2. Yeo CJ, Cameron JL, Sohn TA, Lillemoe KD, Pitt HA,
the corner of the anastomosis near the angularis Talamini MA, Hruban RH, Ord SE, Sauter PK, Coleman J,
[“jammerecke” (angle-of-sorrow)]. This stitch incor- Zahurak ML, Grochow LB, Abrams RA. Six hundred fifty
porates a seromuscular bite of anterior wall stomach, consecutive pancreaticoduodenectomies in the 1990s. Ann
Surg 1997;226:248–260.
then jejunum, and then posterior wall stomach. 3. Birkmeyer JD, Warshaw AL, Finlayson SR, Grove MR,
We routinely place a 14 French feeding jejunostomy Tosteson AN. Relationship between hospital volume and late
tube in the mid-jejunum using the Stamm technique. survival after pancreaticoduodenectomy. Surgery 1999;126:
A gastrostomy tube is not used and closed-suction 178–183.
intraabdominal drains are not routinely placed. The 4. Raptopoulos V, Steer ML, Sheiman RG, Vrachliotis TG, Gou-
goutas CA, Movson JS. The use of helical CT and CT angiog-
vascularized umbilical ligament pedicle is positioned raphy to predict vascular involvement from pancreatic cancer:
between the gastroduodenal artery stump and the correlation with findings at surgery. Am J Roentgenol 1997;
proximal jejunum. The abdomen is then copiously 168:971–977.
irrigated with 4 gm/l cefazolin solution and the fascia 5. Saldinger PF, Reilly M, Reynolds K, Raptopoulos V, Chuttani
of the abdominal wall is closed using #1 looped PDS R, Steer ML, Matthews JB. Is CT angiography sufficient
for prediction of resectability of periampullary neoplasms? J
continuous sutures. The subcutaneous tissue is irri- GASTROINTEST SURG 2000;4:233–237.
gated with cefazolin solution and the skin is closed 6. Evans DB, Lee JE, Pisters PWT. Pancreaticoduodenectomy
with staples. (Whipple Operation) and Total Pancreatectomy for Cancer.
In Baker RJ, Fischer JE, eds. Mastery of Surgery. 4th ed. Phila-
delphia: Lippincott, Williams & Wilkins, 2001, pp 67–86.
POSTOPERATIVE MANAGEMENT 7. Leach SD, Lee JE, Charnsangavej C, Cleary KR, Lowy AM,
Fenoglio CJ, Pisters PT, Evans DB. Survival following pancre-
Our patients are monitored postoperatively in a aticoduodenectomy with resection of the superior mesenteric-
surgical intensive care or step-down unit for the first portal vein confluence for adenocarcinoma of the pancreatic
head. Br J Surg 1998;85:611–617.
24–48 hours. Prophylactic antibiotics are redosed in- 8. Blumgart LH, Kelley CJ. Hepaticojejunostomy in benign and
traoperatively after 4 hours and then continued for malignant high bile duct stricture: approaches to the left hepatic
the first 24 hours. Subcutaneous heparin is continued ducts. Br J Surg 1984;71:257–261.