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The Anatomy of the


Non-metastatic periampullary carcinoma of
the pancreas
Procedure is otherwise known as Pylorus-
Preserving Pancreaticoduodenectomy
The goal of this dissection was to expose
and free all the upper abdominal structures
required to perform a Whipple
Procedure vs. My
I made an inverse
The peritoneal cavity is Mercedes cut in order to
entered through an explore the abdomen
upper midline incision or
a bilateral subcostal
I performed a dissection
of the lateral peritoneal
Kocher maneuver and attachments of the
mobilization of the duodenum to allow
duodenum and the head inspection of the
of the pancreas from the duodenum, pancreas,
underlying inferior vena and other retroperitoneal
cava and aorta. structures over to the
great vessels.
My Dissection, cont.

To make exploration easier, the following

steps not part of the Whipple procedure
were performed:
Separation of the greater omentum from the
inferior border of the stomach

Division of the stomach and first part of the

duodenum by cutting through the pylorus
My Dissection, cont.

The portal triad was carefully and

meticulously cleaned and exposed. It
consists of:
Portal vein
Hepatic artery
Bile duct
More of Procedure vs My
In a classic Whipple As stated before the
procedure, an gut was transected at
antrectomy is the pylorus for
performed. purposes of
The neck of the
pancreas is then With a scalpel, I too
divided with the divided the uncinate
electrocautery process, thus
exposing the main
pancreatic duct.
Partial removal of the
Duodenum and Mesentey
According to ACS, once the uncinate process has been
completely divided, the specimen is attached only by the third
portion of the duodenum. The proximal jejunum and the ligament
of Treitz, along with the fourth portion of the duodenum, are
dissected free, and the dissection is continued until it meets the
right-side upper abdominal dissection. The proximal jejunum is
divided with a stapler approximately 10 to 12 cm from the ligament
of Treitz.

I didnt remove the duodenum, as I wanted to leave in evidence

that the Kocher manuever was performed.

The bile duct, the pancreatic neck, and

the uncinate margins should be sent for
frozen-section analysis.

I left these in, as part of the goal of the

dissection was to visualize them.
Restoring Continuity
Bring the end of the divided jejunum through
the transverse mesocolon to the right of the
middle colic vessels in a retrocolic fashion and
to perform an end-to-side

A small enterotomy, matching the size of the

pancreatic duct, is made in the jejunum, and an
inner layer of sutures is placed to create a
duct-to-mucosa anastomosis
Final Steps

Also according to ACS, the biliary-enteric

anastomosis is performed 6 to 10 cm
distal to the pancreaticojejunostomy.

Approximately 15 cm distal to the biliary-

enteric anastomosis, an end-to-side
duodenojejunostomy is performed.
What else I did
Careful visualization of vessels, especially the
gastroduodenal artery is vital during a Whipple. During
my dissection I took care to carefully and clearly expose
the following arteries:
Common Hepatic
Right and Left
Left Gastric