Whipples Procedure

Pancreaticoduodenectomy (Whipple Procedure)

Objective

In case of:

•   To remove the head of the pancreas

•   The entire duodenum

•   The very proximal portion of the jejunum

•   The distal third of the stomach

•   The distal half of the common bile duct

•   Re-establishment of continuity of the biliary, pancreatic and gastrointestinal tracts.

Position

Supine.

Anesthesia

General.

Procedure

   1.  A transverse, midline, or paramedian incision.

   2.  Operability is assessed.

   3.  Kocherise duodenum.

   4.  Mobilize common bile duct-carry out a cholecystectomy.

   5.  Divide the bile duct at the level of the common hepatic duct level.

   6.  Divide right gastric and gastroduodenal artery to reach the portal vein.

   7.  The superior mesenteric vein is identified at the inferior border of the pancreas.

   8.  Define a plane between pancreas and the portal vein.

   9.  The distal stomach, extrahepatic biliary tract.

10.  The distal stomach, the distal common bile duct, and the neck of the pancreas are resected.

11.  The proximal end of the jejunum is anastomosed to the distal pancreas.

12.  The common bile duct is anastomosed to the jejunum in end-to-side fashion.

13.  The distal stomach is anastomosed to the jejunum also in end-to-side fashion.

14.  The wound is drained.

15.  The abdomen is closed in layers.

Instruments

•   General set

•   Biliary tract set

•   Gastrointestinal set

•   Deep instruments set (available)

•   Harringtom retractors (Fig. 9.26)

•           Hemoclip appliers (variety of sizes and lengths) (Fig. 17.25)

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PANCREATIC CYST DRAINAGE

Drainage of Pancreatic Cyst (Pseudocyst)

Objective

To drain a pseudocyst by anastomosing the cyst wall to an adjacent hollow organ, marsupialization.

Position

Supine.

Anesthesia

General.

Procedure

1.  A vertical or transverse incision.

2.  The cyst is identified and anastomosed to an adjacent viscus. An incision is made into the anterior wall of hollow viscus (e.g. stomach) to gain access to the posterior wall to which the anastomosis is made.

3.  Prior to suturing the cyst, the contents are aspirated.

4.  The abdomen is closed in layers. A drain may be used.

Instruments

•   General set

•   Biliary tract set

•           Hemoclip appliers (variety of sizes and lengths) (Fig. 17.25)

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Pancreatico-jejunostomy

Pancreato-Jejunostomy

Objective

In case of:

•   Chronic pancreatitis with a dilated pancreatic duct

•   An anastomosis of jejunumotomy to pancreatic duct.

Position

Supine.

Anesthesia

General.

Incision

Midline.

Procedure

1.  Expose anterior surface of pancreas through the lesser sac.

2.  Mobilize pancreas.

3.  Identify pancreatic duct and cut it along the length of the pancreas.

4.  Carry out a lateral pancreaticojejunal anastomosis (Roux-en-Y) in two layers using nonabsorbable suture.

5.  Close wound in layer with drainage.

Instruments

•   General set, 1

•   Gastrointestinal set, 1

•   Deep set, 1.

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Distal Pancreatectomy

Distal Pancreatectomy

Objective

In case of:

•   Tumors of body and tail of pancreas

•   Traumatic injury of body and tail

•   Chronic pancreatitis localized to body and tail.

Position

Supine.

Anesthesia

General.

Incision

Midline.

Procedure

•   Mobilize spleen and pancreas

•   Ligate splenic vein at its junction with SMV with vascular sutures

•   Ligate splenic artery at the same level

•   Divide pancreas in a fish-mouth manner

•   Close pancreatic duct with a nonabsorbable suture, e.g. prolene

•   Approximate anterior and posterior surfaces of the pancreas using interrupted nonabsorbable sutures

•   Drain pancreatic bed

•   Close wound in layer.

Instruments

•   General set, 1

•   Gastrointestinal set, 1

•   Deep set, 1

•   Hemoclip applier (Fig. 17.25).

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Abdomino-pereneal Resection

Abdominoperineal Resection

Objective

In case of rectal cancer to remove the rectum anal canal.

Position

Lithotomy Trendelenburg. Urethral catheter in site.

Anesthesia

General.

Procedure

1.  The operation is done synchromously by two teams.

2.  The rectum is mobilized as for an anterior resection down to the levator one.

3.  The anus is closed with subcutaneous purse string.

4.  A circumferential incision is made and deepened through the ischis-rectal fossa.

5.  Posteriorly the Waldeyer’s fascia is divided to enter the presacral space and the levator ani is divided.

6.  Anteriorly the incision is deepened.

7.  Using the catheter as a guide to expose the retroprostatic space where the encircling fibers of the puborectalis are divided.

8.  The abdomen and perineum are closed after reconstituting the peritoneum and colon brought out through the rectus sheath. It is now sutured as a colostomy with interrupted mucocutaneous catgut sutures.

Instruments

•   General sets, 2 (one for perineal approach)

•   Deep sets, 1

•   Gastrointestinal set, 1

•   Cope crushing clamps (Fig. 8.72).

Any questions be sent to drmmkapur@gmail.com

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