KBW’s Need to Know for medical students
(not a how to do it and not comprehensive by any means)
I do like to harp on about Whipple’s operation, it is a lengthy and difficult procedure and even in the best hands and best centres (Bighospital is once such place) has a high rate of complications and death. Even if you survive the operation the outlook can remain poor as the type of cancers that require a Whipple’s are aggressive and deadly (pancreatic cancers, cholangiocarcinoma).
What is a Whipple’s operation?
Professor Allen Whipple was an American (born in Iran) who described the operation of pancreaticoduodenectomy, more widely known by it’s eponymous name and also described Whipple’s triad. He is not the same Whipple as Whipple’s disease but apparently the two were great friends. He modified the operation from his original two stage procedure into the classic operation that we now perform.
The aim of this operation is to remove en bloc the head of pancreas, the duodenum, with attached first part of jejunum and the distal portion of stomach, the common bile duct the surrounding nodes and vessels that are attached and as a separate specimen the gallbladder and cystic duct. Continuity of the bowel and biliary system is then restored via a series of joins called anastomoses. The cut body of pancreas is sutured onto the small intestines (the panreaticojejunostomy) and the top end of resected common bile duct is sutured onto the small intestine (the hepaticojejunostomy) a bit further down stream to restore the flow of bile and pancreatic juices into the gut. Then the stomach is joined onto the small intestines (gastrojejunostomy) to allow food to pass in and finally there is a join between the small intestinal loops (enteroenterostomy) to prevent biliary reflux up into the stomach.
This operation takes about 6hours (on a good day) so make sure you have had your breakfast and make sure you have had a look at your anatomy books.
Image 1: The pancreas
First off you have to get down to the retroperitoneum where the pancreas lies hidden and innocuous looking like cooked cod roe under a layer of fat and peritoneum. To do this you need to make a rooftop incision and then move the right colon away (just like you do for a right hemicolectomy). Then you have to come from the superficial, main abdominal compartment down into the lesser sac onto the pancreas snuggled in the c of the duodenum. The duodenum is freed from the fixed position all plastered down and flipped over (kocherised) to lift all the business up.
Arterial blood supply from coeliac trunk (lienal means splenic)
Then we need to come under the pancreas, we define the vascular anatomy; firstly you find the SMV (superior mesenteric vein). Then the most complex area, a little cube of clockwork known as the porta hepatis. Find the common hepatic and then the GDA (gastroduodenal artery) the right hepatic artery, cystic artery and gallbladder (it is removed). We like to sling the vessels such as the GDA prior to division and also the common bile duct. It should all look rather beautiful and like an anatomy prosection at this point. Then, in order to get on with things you start by dividing the stomach proximal to the pylorus and dividing the jejunum, then you separate the pancreas from its vascular supply (nasty little veins that bleed like stink and you fear for the SMV and the portal vein) you then divide it and remove the specimen with all the lymph nodes and fat.
Image 3: This shows how the anatomy looks in situ
This area of the body has the most complex and difficult anatomy to get your head around, there are also annoyingly, lots of variations of normal. There is no easy way to fix this in your head, it takes lots of study, plenty of time in theatre, time looking at scans and I also think the passage of years to fully grasp. I have not grasped it fully yet and have seen it a fair bit.
This series of intraoperative photographs is fantastic and shows beautifully the operative view that you will see.
After removal of the specimen you join it all back up. Pancreas to jejunum, common bile duct to jejunum, stomach to jejunum and then jejunum to jejunum. We are not routine Roux loopers in Bighospital. Some of the joins can be stapled or hand sewn, it is down to surgeon preference. Every student should watch a Whipple’s as it is truly amazing and inspirational even if you are a career immunologist, just make sure you eat a big breakfast and read your anatomy before hand. I am repeating myself because this part is important, read and eat students, read and eat.
You will not be able to get it all correct here, if you know all this you will please even the most fussy of HPB surgeons; and my god, are they ever fussy.