PROCEDURE AT A GLANCE

PERIOP BRIEFING
Whipple procedure

INDICATIONS FOR PROCEDURE PATIENT POSITIONING

• Indications for a Whipple procedure, also called a
pancreaticoduodenectomy, include
o malignant lesions of the pancreas head, ampulla of
Vater, distal portion of the common bile duct, or
duodenum; and
o pain from chronic pancreatitis located in the pancreas
head and not amenable to other treatments.1
• During a Whipple procedure, the pancreas head, the
duodenum, part of the jejunum, the distal portion of
the stomach, and the lower portion of the common
bile duct are removed, after which continuity of the
pancreatic, biliary, and gastrointestinal tract systems are
reestablished.1,2
PREPARING FOR PROCEDURE
• The perioperative RN should confirm that blood typing
and crossmatching were performed for the patient and
that blood products are available2 according to the
needs of the anesthesia professional.
• The perioperative RN should ensure basic laparotomy
and gastrointestinal instruments, a self-retaining
abdominal retractor, gastrointestinal anastomosis and
thoracoabdominal stapling devices, and appropriate
drains and catheters are available.1,2
• The patient’s abdomen is prepped from the nipples to
midway down the thighs.2
The patient is placed in a supine position.2
BASIC WORKFLOW FOR PROCEDURE
To perform a Whipple procedure via an open
approach, the surgeon will
1. make a midline or bilateral subcostal incision;
2. confirm disease resectability;
3. incise the peritoneal reflection to mobilize
the duodenum;
4. dissect loose areolar tissue;
5. divide the gastrocolic ligament and
gastrohepatic omentum;
6. clamp, divide, and ligate the gastroduodenal
and right gastric arteries;
7. mobilize the prepyloric portion of the
stomach;
8. clamp the middle segment of the stomach;
9. reflect the duodenum;
10. divide the common bile duct;
11. clamp the jejunum;
12. divide the duodenojejunal flexure, pancreas,
and inferior pancreaticoduodenal artery;
13. anastomose the pancreas, bile duct, and
duodenum to the jejunum;
14. place drains;
15. close the incision; and
16. apply dressings.1,2

Before Surgery After Surgery

Gall bladder
Stomach Bile duct
Bile duct
Stomach

Pancreas Small
intestine
Tumor Pancreas

Duodenum

Small intestine

doi: 10.1002/aorn.12432
© AORN, Inc, 2018 November 2018 Vol 108 No 5 • Periop Briefing | P11
PERIOP BRIEFING
WHIPPLE PROCEDURE
PRO CED URA L VA RIATIO NS
• A Whipple procedure can be performed via a
laparoscopic approach.3
• The morbidity, mortality, and oncologic
outcomes associated with the laparoscopic
approach are similar to those associated with the
open approach.3
• To perform a laparoscopic Whipple procedure,
the surgeon will
1. place trocars for distal resection and in the
medioclavicular line lateral to the right
rectus sheath;
2. perform dissection as in the open approach;
3. perform anastomosis with the assistance of a
laparotomy retractor ring;
4. perform hepaticojejunostomy and
pancreaticogastrostomy; and
5. staple the gastroenterostomy.2
• A Whipple procedure also can be performed
via robotic surgery, and although this is a
newer approach, it has some advantages over
laparoscopy, including greater instrument range
of motion, three-dimensional visualization, and
ergonomic benefits for staff members.4
• Other surgical options to treat pancreatic lesions
or disorders include distal pancreatectomy and
total pancreatectomy.3
• In distal pancreatectomy, the pancreas tail, a
portion of the pancreas body, and the spleen are
removed to treat neuroendocrine tumors in the
pancreas tail or body.3,5
• In total pancreatectomy, the entire pancreas,
the gallbladder, part of the stomach and small
intestine, and the spleen are removed to treat
cancer that has spread throughout the entire
pancreas.3,5
P12 | Periop Briefing
POSSIBLE COMPLICATIONS
• Mortality rates for a Whipple procedure are
approximately 2 to 3 percent.6
• Up to 40 percent of patients will have at least one
postoperative complication.6
• Complications associated with a Whipple procedure
include
o infection,
o hemorrhage,
o venous thromboembolism,
o abscess,
o pseudocyst,
o biloma,
o delayed gastric emptying,
o anastomotic leak,
o temporary or permanent diabetes,
o pancreatic fistula,
o nutritional malabsorption, and
o weight loss.1,3,6
POSTOPERATIVE RECOVERY COURSE
• Patients will typically be hospitalized for one to two
weeks.6
• Most patients can return to normal activities after
approximately six weeks.3,5
• Five-year survival rates after the Whipple procedure are
approximately 20 percent in patients with pancreatic
cancer and approximately 40 percent in those whose
cancer has not spread to the lymph nodes.6
• Many patients will still require chemotherapy and
radiation after the surgery, which improves survival rates
by 10 percent.6
• Stomach and bowel paralysis will likely occur for a few
days postoperatively, which will require a feeding tube.6
• Insulin injections may be needed until the pancreas
recovers from surgical alterations.7
 PERIOP BRIEFING
WHIPPLE PROCEDURE

REF ERENCE S
1. Osborne NH, Colletti LM. Pancreaticoduodenectomy. In: Minter R, Doherty GM. Current Procedures Surgery. New York, NY:
McGraw-Hill Education; 2010:121-130.
2. Neil JA. Surgery of the liver, biliary tract, pancreas, liver, and spleen. In: Rothrock JC, ed. Alexander’s Care of the Patient in
Surgery. 16th ed. St. Louis, MO: Elsevier Mosby; 2018:342-375.
3. Whipple procedure. Mayo Clinic. https://www.mayoclinic.org/tests-procedures/whipple-procedure/about/pac-20385054.
Published March 27, 2018. Accessed September 26, 2018.
4. Baker EH, Ross SW, Seshadri R, et al. Robotic pancreaticoduodenectomy for pancreatic adenocarcinoma: role in 2014 and
beyond. J Gastrointest Oncol. 2015;6(4):396-405.
5. Surgery for pancreatic cancer. American Cancer Society. https://www.cancer.org/cancer/pancreatic-cancer/treating/surgery.
html. Revised May 31, 2016. Accessed September 26, 2018.
6. Villines Z. Whipple procedure: what you need to know. Medical News Today. https://www.medicalnewstoday.com/
articles/318451.php. Reviewed July 17, 2017. Accessed September 26, 2018.
7. Whipple procedure. Canadian Cancer Society. http://www.cancer.ca/en/cancer-information/diagnosis-and-treatment/tests-
and-procedures/whipple-procedure/?region=on. Accessed September 26, 2018.

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