Whipple’s operation

Introduction

Pancreatico-duodenectomy was first performed by

Kausch in 1908 and popularized by Allen Oldfather
Whipple in the 1930s (who performed 37
procedures).
A whipple procedure also known as
pancreaticoduodenectomy is a complex operation to
remove the head of the pancreas, the first part of the
small intestine (duodenum) the gallbladder and the
bile duct
 After removal of these structures the remaining
pancreas, bile duct and the intestine is sutured back
into the intestine to direct the gastrointestinal
secretions back into the gut.
Whipple procedure may be done in various ways:
- Open surgery
- Laparoscopic surgery
- Robotic surgery
 Indications

Cancer of the head of the pancreas

Cancer of the duodenum
Cholangiocarcinoma
Cancer of the ampulla
Rarely done for chronic pancreatitis, benign tumor
of the head of the pancreas.
Extensive pancreatic and duodenal trauma.
Mostly performed in the pancreas cancers involving
the head of the pancreas. It is only performed if the
neoplasm is localized, did not invade the
neighboring structure and matastasize.
Sadly less than 20% of cases are localized upon
diagnosis. Whipple procedure can only be
performed in this minority.
 Contraindications

Liver metastases
Invasion of the base of the colonic mesentery
Invasion of the hepatoduodenal ligament
Invasion of the gastroduodenal, hepatic or superior
mesenteric arteries.
Metastases to the portal vein
Metastases to aorta or vena cava.
 Complications

Common
Delayed gastric emptying
Pancreatic fistula/leakage   
Intra-abdominal abscess   
Hemorrhage   
Wound infection
Metabolic
–  Diabetes
– Pancreatic exocrine insufficiency
 
Uncommon complications:
Fistula
– Biliary
– Duodenal
– Gastric
Organ failure
– Cardiac
– Hepatic
– Pulmonary
– Renal
Pancreatitis
Marginal ulceration  
 After PD

Due to improved surgical skill and peri-operative care

Mortality rate 20-40% in earlier days
During the past decades, dramatically decreased and
currently is between 0-4% in experienced centers.
Complications rate is still 30-40%
Causes of mortality
• Post-operative pancreatic or biliary fistula,
hemorrhage or infection.
• If a pancreatic leakage occurs, 20-40% die
 Management of complications

Delayed gastric emptying: due to disruption of the

gastroduodenal neural network, decreased motilin level
(produced from the enterochromaffin cells of
duodenum and proximal jejunum) reduce the gastric
motility
Mgmt includes:
– NG gastrostomy tube decompression
– TPN or enteral nutrition
– Administration of erythromysin (motilin agonist)
– Prokinetic agents (metoclopramide)
Pancreatic fistula/leakage:
– In clinically stable patient TPN and close
observation
– Administration of somatostatin analogue
(octreotide) reduce pancreatic secretion
– In unstable cases: complete pancreatectomy,
placement of additional drains
– Poor prognosis
Intraabdominal abscess:
Controlling the cause such as fistula
Ultrasonographic or CT guided percutaneous catheter
drainage
Placement of addition drain
Pancreatogenic diabetes:
30-40% of the pancreatic parenchymal mass is
resected
Some may develop hyperglycemia and glucosuria
Mgmt includes:
– Dietary adjustment
– OHA
– Parenteral insulin
Pancreatic exocrine insufficiency: Related to
obstruction of the pancreatic duct
Mgmt includes:
– Exogenous pancreatic enzyme supplementation
such ass creon, pancrease, viokase
Wound infection:
Antibiotics: prophylaxis and post-op
Wound care
 Nursing Management

Pre operative Management:

Provide routine preoperative nursing care.
Provide pre operative counseling about surgical and
anesthetic procedures which may diminish fear and
anxiety and enhance post operative recovery and
discharge.
Clarify teaching and learning as needed.
Provide psychological support for client and family.
 Post-operative management:

Immediate post operative assessment:

– Airway patency
– Level of consciousness
– Vital signs
– Wound check
– Fluid balance ( I/V drip, CVP line, nasogastric
tube, wound drain, catheter)
– Pain( pain score, positioning, analgesia)
– General appearance (colour, pallor, sweating,
shivering).
 Nursing Intervention

Maintaining Airway, Breathing and

Circulation:
Patient should be positioned unless
contraindicated by their surgery in a lateral or
supine position with head in side without a
pillow under their head.
Remove excess mucous in the pharynx if
present by pharyngeal suctioning.
Administered oxygen therapy following
surgery to maintain oxygen saturation above
95% in order to sustain satisfactory levels of
oxygenation and to prevent hypoxia/
hypoxemia.
An intravenous access should be obtained and
saline should be infused.
Controlling Discomfort:
Control of pain is a major priority.
On the first few days after the operation, pain will
be controlled by an epidural.
Once the epidural is stopped, pain will be controlled
by oral medicine.
 In addition , the nurse should help the patient
initiate relaxation techniques (deep breathing,
imaginary and distraction techniques ) to help
with pain control.
Monitoring:
Blood pressure, Temperature, Pulse and
Breathing should be checked at least half
hourly on Day 0 and 2-4 hourly on Day 1 and
according to hospital policy till hospitalization.
Need to monitor blood sugar.
Maintaining fluid and electrolyte balance
As soon as the patient is received, the nurse should
institute monitoring related to fluid and electrolyte
status, cardiac output and renal status. This is a
critical need.
Monitoring include intake and output, daily weights,
daily electrolyte and blood urea nitrogen, creatinine
and hemodynamic measurement as necessary.
An indwelling catheter is monitored regularly
because decreased renal function can occur in
association with the hypotension and shock.
If the patient develops shock, management of
shock should be done.
Fluids, colloids or blood are given as necessary.
The nurse is responsible for administering these
and for monitoring the patient’s response to
them.
 Care of Drips, Drains and Tubes

After operation patient have several drips, drains

and tubes in place:
An intravenous (IV) drip is used to give fluids until
patient is able to drink normally. So, nurse should:
- Ensure cannula secured properly.
- Ensure prescribed fluid administered.
- Observe cannula site for signs of irritation, infection
and slowing of infusion rate.
- Date cannula, change every 72 hrs.
 A Naso-gastric (NG) tube allows any fluids to
be removed. This helps the area of the
operation to recover. So nurse should:
- Ensure tube attached correctly.
- Nasogastric tube on free drainage, drainage to
be measured and recorded on fluid balance
chart.
- Remove when tolerating free fluids.
An abdominal drain (Jackson Pratt Drains) tube
inserted near abdominal wound to help drain
off fluid and prevent swelling. The drains are
taken out when the incision stops draining.
So nurse should Make sure the drain is working to
prevent a collection of fluid inside the wound area
through proper emptying, stripping (to prevent the
tube from blocking) and recording the amount of
drainage.
Diet and Nutrition
The first five to six days after the surgery,
patient will be provided with intravenous fluids
until patient bowel function returns.
After patient bowel function have return to
normal surgeon will begin with a diet of clear
liquids and diet will progress to a regular diet
as patient tolerate it.
So nurse should assess the nutritional status of
the patient and provide diet to the patient as
prescribed.
After recovery the nurse should recommend
that the patients should ingest smaller meals
and snack between meals to allow better
absorption of the food and to minimize
symptoms of feeling of being bloated or
getting too full.
Care of Incision:

Nurse need to look surgical incision daily for any

sign of infection.
Dressing of the incision under aseptic technique.
Administering prescribed antibiotics timely to
prevent from the wound infection.
Discharge

When patient is eating a regular diet,

having bowel sounds, is not having a fever
and is not showing signs of infection, then
patient will be discharged.
Most patients usually go home 8 to 12 days
after the surgery.
 Patient Teaching

Avoid fatty, greasy or fried foods

Try to eat 5- 6 small meals per day
Minimize raw fruits/vegetables that can be hard to digest.
Avoid foods high in sugar
Pancreatic enzymes should be taken before each meal and
snack.
Care of drain tube if present
Care of surgical wound.
Importance of timely administration of prescribed medication.
Follow up.