Procedure Planned: 

Whipple w/o PV Resection, LN excision x2, Celiac/SMA

Axis  Lymphadenectomy, Pancreaticojejunostomy, Hepaticojejunostomy, Gastrojejunostomy,
Omentectomy, Reduction of hernia, Diaphragmatic hernia repair with biologic mesh, b/l TAP
blocks
 
Script:

 Patient is Supine on gel warmer, LEFT arm tucked, SCD and compression stockings, Foley
to gravity, NGT to LCWS.  SQ heparin, Rocephin, Flagyl, Gabapentin in PACU, Tylenol
PR.  
 Prep & Drape: 
o Clipper shave - chest to pubic tubercle
o Drapes - Bottom, Top, Side, Side
o Ioban once the drapes are on
o 4 snaps to create pockets once ioban is on
o marker to draw incision and skin approximation lines
o 2 suctions 
o 1 cautery normal tip, no extension required for this case 
 settings 40/40 standard
o Aquamantys at 180 
o EnSeal fine tip device on usual settings
o everything coming off bottom of bed
 Timeout: confirm we have blood available, that abx are given, right patient right site. 
Any questions/concerns from anesthesia and OR staff.  If everyone is good, will begin.
 Midline incision 10 blade used
o xiphoid to 2 finger breaths below umbilicus, enter abdominal cavity
o may need to extend in some larger patients for better exposure
 Clear off any adhesions upon entry
o patient has a virgin abdomen, not expecting anything dramatic here
 Deploy Bookwalter retractor with Bookwalter extension
o post on left side above elbow
o once post is locked to table confirm with anesthesia that all of their lines are still
running and probes are ok.
 Examine cavity for evidence of mets, special attention to the small bowel mesentery and
liver, most likely places for mets.  
o Anything suspicious gets sent for fast frozen
 if positive -- case is aborted.  If family present, I will ask that they get
brought to a private room to discuss once patient is closed  
 if negative or no biopsy warranted we press on
o Looking at patient's recent scan it is very likely we will be moving forward to the
full whipple
 Mobilize contents out of the left chest and ask Anesthesia to place TEE probe to monitor
for any cardiac changes while mo
 o In order to do the Gastro-Jejunosotomy without a Roux En Y will need to be able
to mobilize the stomach back into the abdomen
o Will discuss with anesthesia whether they think a split intubation (Right & Left
lobes) is appropriate for this case
o Once this is done will continue with the whipple
o Mesh will be placed after all the reconstructive anastomoses of the whipple and
irrigation
 Cattell Braasch maneuver - medial rotation of ascending colon and part of transverse
colon - dissect caudally to cephalad
o take down hepatic flexure
 Omentectomy performed, sent for permanent
 Kocher maneuver started - mobilization of the duodenum 2nd/3rd and 4th portions 
o mainly cautery and enseal used here, should be an avascular plane
o reflect it medially until underside of pancreas is exposed
o follow cephalad until you walk into the distal aspect of bile duct 
o follow medial and caudally until you reach posterior aspect of ligament of treitz
 Open up the lesser sac using with the Enseal handheld device to expose pancreas and
mobilize the stomach
o follow around the greater curvature of stomach, until stomach reflects easily
upward
 this requires taking about 1/3-2/3 of short gastric vessels, normally 
 This will likely look very distorted because of the stretch on the
short gastrics from the hernia
 Next, open up pars flaccida under left lobe of liver at the angle of the stomach, will likely
have taken down left triangular ligament of liver during chest mobilization 
o There is no replaced anatomy on imaging
o clear off a landing zone for stapler to be used later for distal gastrectomy 
 When clearing off landing zone, the anterior aspect of the pancreas should become
evident
o Wrap umbilical tape around stomach and reflect cranially
o Use malleable bookwalter attachment to reflect colon caudally
 moist sponge as buffer
 Dissect out plane on inferior edge of pancreas, 
o Will start near the tail, go from medial to lateral
o If lots of adipose tissue, may request ultrasound but this is uncommon
o walk up to the medial edge of the PV
 dissect anteriorly
 there are always a couple of colonic, gastric and pancreatic branches that
need to be tied or sewn.
o sometimes the IMV can get in the way as it traverses in this area on its way to
splenic vein medial to PV
 try to preserve if possible, its okay to take if you have to but not ideal
 Begin creation of retropancreatic PV tunnel
 o ***This will likely be most dangerous part of case, as the patient has had
unresolving pancreatitis. Lipase as of today is >300.
o reflect pancreas upward, creating a plane between pancreas and PV.  
 once retropancreatic can use a tonsil 
o tie off any branches 1-2 cm before the the tunnel 
o use a fine tip instrument like a tonsil to create tunnel, nothin dull or blunt
o have surgicel ready to go and spoon clamps just in case, as well as, single are 6-0
prolene
 this is most dangerous part of case
 Porta dissection 
o Find hepatic artery (HA) LN and excise 
 send for permanent specimen NOT fast frozen
 HA should be just posterior to LN 
 Walk back along the HA until we find the GDA 
o dissect out GDA for 2-3 cm
 Test clamp GDA with bulldogs
o wait 2 min and observe the liver
o if there is a flow issue, would have IR place stent immediately following surgery,
would not extubate
 Per scan, this should not be an issue
 Tie off and clip the GDA on both sides and divide
o leave a stump on HA >0.5cm 
o A GDA stump blowout is a feared and fatal complication from a whipple
procedure
 usually see POD 5, heraldic bleed, needs IR covered stent emergently, 
o Taking of the GDA is the point of no return for this operation.  Once done,
WE are committed to the operation, up until this point we can abort safely
 Reflect the GDA stump laterally
o This should expose the PV posteriorly
o The GDA is the gateway to the PV
 Finish off the retro-panc tunnel from the superior aspect of pancreas at PV egress site 
o Place an umbilical tape through the tunnel
 snap both ends together
 Disconnect everything
 Open cholecystectomy - top down approach
o cautery at 60 spray, will use aquamantys here
o 2-0 or 3-0 silk ties on passers for the cystic duct and artery
o specimen to be sent for permanent 
 Excise whipple node, usually inferomedially along CBD, it always bleeds 
o Whipple node to be sent for permanent
o Specimen label "Whipple node - peri-portal LN
 Transect the extrahepatic bile duct right at the liver edge
o will be part of en-bloc specimen
 Irrigate the intrahepatic bile ducts
o patient has PTC, planning to keep and will remove before patient leaves the
hospital
 Using Echeleon stapler, Green loads, transect the distal stomach
o communicate with anesthesia, make sure NGT is out of the firing zone
o will likely take 3-4 staple firings
o will oversew staple line with 4-0 PDS x2
o Tuck proximal up by the spleen to get out of our way for reconstruction
 Finish off kocher maneuver all the way to and beyond ligament of treitz
 Create a plane between the SB and SB mesentery
o Transect small bowel with Echeleon stapler blue load x1 
o Oversew the staying end of the bowel with 4-0 PDS, no need to do this on
specimen side
o Walk the SB back through the ligament, freeing the mesentery with EnSeal and
silk ties
 Place hemostatic figure of 8 stitches with 4-0 vicryl on SH in pancreas 
o 2 on the specimen side, superior and inferior
o 2 on the staying side - these get cut with long tails for retraction 
o x4 stitches 
 Transect the pancreas along neck line, dissociating the head and uncinate from the body
and tail. 
o Cautery to 60 spray and aquamantys
o Will try to transect duct with a 15blade if we see it, there is some ductal dilation
so we should be able to easily see it.
o Pancreas specimen is reflected laterally, working way along the PVs lateral
aspect tying off all PV branches, sparing first jejunal branch if possible
 This lateral aspect is where tumors love to stick to the PV and sometimes
require PV resections
 Patient had pancreas protocol contrast CT, I do not think we will need to
resect PV
 If we do will ask for someone to get bovine pericardium in the room
o When complete, hand off entire specimen for permanent
 Specimen name: Head and uncinate of pancreas, distal stomach,
duodenum, common bile duct.  I will leave only superior stitch on
pancreas specimen for pathology orientation 
 Check for hemostasis
o may place surgicel around PV
o DO NOT leave surgicel in, if patient needs a scan for any reason post-op this will
look like an air containing abscess
o I will use large clips to make an "X" for locational support for cone beam
radiation purposes  
 Perform lymphadenectomy along celiac/SMA axis
 Close ligament of treitz defect with 4-0 PDS, combo running and interrupted
 o 4-6 sutures required
 Transilluminate colonic mesentery with headlight, identify middle colic, make defect to
right of middle colic
 Bring small bowel proximal free edge up through defect
 Make small enterotomy in proximal bowel and tack the mucosa up with 6-0 prolene
stitches, compass rose
 Pancreaticojejunostomy (PJ) - End to Side
o 2 layers
 inner layer will be with interrupted 6-0 prolenes - will need like 20 6-0
prolenes double arm with shods after each one
 outer layer will be with 4-0 vicryl
 I plan to use a stent - will need a 3.5 Fr umbilical vein catheter
 I throw the external posterior wall stitches first and leave snapped, then
posterior inner wall, tie posterior inner wall, tie posterior outter wall,
then do inner anterior wall, followed by outter anterior wall.  Between
inner walls, I will place a stent 
 stent is just a pediatric feeding tube cut to length usually 10cm or
so
 will stay forever
 will secure to SB with 6-0 prolene stitch
 PJ should be perfect, all knots tied on the bowel side.
 This anas takes a while, PLEASE DO NOT CHNAGE TECHS during this anas,
lots of needles on the field
 Will need at least 10 shods, sometimes up to 20 depending on size of
pancreatic duct
 Walk down the SB about 10cm or so 
o Make small enterotomy that is size appropriate for the CBD
o tack the mucosa with 6-0 prolene single arm, make a compass rose, same as for
PJ
o no tails on the knots
 Hepaticojejunostomy (HJ) - End to Side 
o 1 layer 
 6-0 PDS x2, running, parachute technique with flexible pinning stitch in
lateral corner
 NO STENT
 leave a clean white raytech posterior to HJ for leak detection
 Close defect in colonic mesentery after we are sure the PJ and HJ are under no tension
o will use 4-6   4-0 PDS to do this
 Create defect in colonic mesentery to the LEFT of middle colic
o Pull stomach down 
 Gastrojejunostomy (GJ)  Side to side 
o running 4-0 PDS for both layers
 Will need 6, 4-0 PDS for this
  Will place a coretrack feeding tube before we do the front walls
 Depending on how stomach sits we may end up doing a Roux over a
Omega loop, TBD at time of surgery
 Benefit of the Roux is can be under less tension higher up in the
abdomen, downside is an extra anastomosis that can leak and
stricture
 Pull NGT across anastomosis before sewing anterior inner layer closed
o Ask anesthesia to please secure NGT once in desired position 
o Usually remove NGT POD 1or 2 
 Close colonic mesenteric defect with 4-0 PDS, multiple interrupted stitches same as the
other defect
 Close small bowel defect with a combination of running and interrupted 4-0 PDS where
we resected bowel earlier
 Check HJ raytech 
o if stained with bile, repair with 6-0 prolene interrupted stitches
o if no bile, remove raytech, washout the belly with hot hot hot STERILE WATER
 Sterile Water has lytic properties for free cells which can destroy any free
cancer cells

 Place 19 round JP through the RLQ abdominal wall, let it sit posterior to HJ and PJ
o secure to skin with 3-0 nylon stitch 
o no drain used for GJ unless we have some serious concern about it or the patient
 Irrigate some more - Call for TAP block meds from pharmacy when we start fastening
the mesh in place.
 Will measure the defect in the left diaphragm and ask for a biologic mesh size and
suture 2-0 prolenes, will need a lot of these >10
o Will fasten biologic in place with the prolenes
o Will make sure a second drain is in close proximity to this mesh through the LUQ
o Goal is to have 5cm of coverage of the mesh with the defect
 Ask team to begin their instrument, sponge and needle counts
 Run bowel, make sure no twists or kinks or injuries
 Last check for hemostasis
 Perform bilateral TAP blocks intraop under direct visualizations
 If counts are good, begin closing
o let anesthesia know closing has started 
o let anesthesia know when fascia is closed
 If there are any issues with counts, will get an xray and wait for radiology to clear us to
close
 Will breakdown the Bookwalter
o leave ring attached to bar until case is over in case we need to rapidly deploy
o all blades are handed back
o post stays on until we are ready to wake up the patient
  Close fascia 
o 1 layer, running 
 #1 PDS looped single arm x2 
 SQ approximation
o 1 layer, interrupted 
 4-0 vicryl, single arm x 6 
 Subcuticular Skin 
o 1 layer 
 5-0 monocryl x3
 Steri-strips cut in 1/3s with mastasol placed perpendicular to incision
 Dry sterile dressing for incision and drain sponge for JP sites, tape to secure it all in place
o JPs to be trimmed short, on bulb suction 

 
Patient Dispo:  Should be able to extubate and go to PACU then ICU for first 36hrs.  Dr. Drexler
is on for atrium ICU and was notified this morning about the patient.
 
 
 
 
OR Equipment
 
Trays
1.      Liver Tray _ NO THOMPSON retractor NEEDED
2.      Liver Micro Tray
3.      My Scanlan Tray
4.      A long and short baby right angle (Ron knows the ones I am talking about)
5.      Long and short Metz scissors
6.      Bookwalter retractor with the largest oval ring
7.      Bookwalter extension
8.      Cardiac white towel x 6
 
 
Ties
** Always give ties on a passer please
 
0      36in
2-0  36in
3-0  36in
 
Umbilical tape x2
 
Vessel Loop x2
 
 Suture
 
4-0 PDS 36 in double arm on a RB-1   Qty 1 box in the room
 
6-0 PDS BV-1, double arm 30in   Qty x4
 
6-0 Prolene RB-2 , 30 inch length   Qty x30, have more in the room
 
4-0 Prolene on RB-1, 36in QTY x8
 
#1 PDS looped x2 for closing
 
3-0 Nylon available for drain stitches
 
5-0 Monocryl x3 for skin closure
 
4-0 Vicryl for subcutaneous dermal stitches  x6
 
2-0  Prolenes  x1 box
 
Mastasol and sterip strips cut in thirds
 
 
Clips
 
Big, Med, Small rack of clips x1 with extras in the room
 
 
 
Toys
1.      En Seal with fine dissecting tip 14 inch shaft
 
2.      Aquamantys
 
3.      Echelon Stapler (please do not open until asked for but please have in the room)
a.       4 green loads
b.      4 blue loads
c.       2 white loads
 
4.      19 round JPs in the room x3
 
5.      Spinal needle for TAP block
 
6.      Two suctions
 
7.      1 cautery
 
8.      Umbilical vein catheter – 3.5 Fr
 
9.      Cardiac white towel x6
 
10.  Biologic Mesh
 
 
Drapes
 
1.      Foot, head, side, side
2.      Ioban
3.      Cardiac white towels
 
 
         Patient left arm tucked, no sleds, right arm can be out for anesthesia access
 
         Foley
 
         Warming pad
 
         SCD and stockings
 
         Surgicel and Fibrillar open and available
 
         NGT on suction throughout the case
 
         Coretrack feeding tube