Whipple procedure

The Whipple procedure actually has several name. It can also be called the pancreaticoduodenectomy, pancreatoduodenectomy or the Kausch-Whipple procedure. It is most often called the Whipple procedure because Allen Whipple in 1935 performed the first documented surgery removing the gall bladder, the common bile duct, the head of the pancreas and the first (superior) part and the second (descending) part of the duodenum. The procedure is most often used to remove cancer from the head of the pancreas.

History of Procedure
The history of the Whipple procedure starts back in the late 19th century. In the year 1898, an Italian surgeon, named Alessandro Codivilla, performed the first documented surgery that involved the removal of part of the pancreas. Eleven years later in 1909, another surgeon named Walther Kausch performed the procedure for the removal of the ampulla of Vater, which is where the common bile duct and the pancreatic duct join together, because of cancer. But it was not until 1935 when the man whom the surgical procedure is now named after performed an improved version of the procedure. He was the first surgeon to perform a complete removal of the entire duodenum and the removal of a big part of the head of the pancreas. In New York, at the Columbia-Presbyterian Medical Center, Allen Whipple enhanced the techniques required to perform the surgical procedure. While Allen Whipple did improve the procedure, it was not perfect. The first patient that the surgery was performed on died only 36 hours later. The next two patients did do better. The second patient lived for an entire 9 months, but died of cholangitis. The third patient survived longer. He lived for two years, but the cancer that was supposed to be completely removed spread to his liver.

Throughout the years the procedure improved dramatically. When Allen Whipple performed the procedure it was still a two-stage procedure. About five years later, the procedure was performed for the first time as a one-stage procedure. Vitamin K, that was not discovered until 1940, was found to help stop the bleeding in patients that were jaundiced. The invention of blood banks also greatly aided in the survival rate of patients for this and many other procedures. Even though the surgery was improved, the procedure still had a high death rate and many surgeons refused to perform it. In the year 1970, the death rate for the Whipple procedure was 25%. Since then, even more improvements have been made in the medical field that have reduced the death rate at a place with surgeon with experience to about 4%. In 2003, technological advances allowed surgeons to perform a robotic assisted procedure that eliminated hand tremor, had three dimensional vision and better magnification and precision. The improvements because of the robotic assistance the surgery was made minimally invasive and more and more hospitals began to use it. Now, the robotic-assisted Whipple has made more than two -thirds of those with pancreatic cancer candidates for the procedure.

Anatomy Involved
The Whipple procedure involves the removal of a number of organs and organ parts from the abdominal cavity. Several small segments of the alimentary canal are removed and other organs are removed as well. There are actually two different types of the Whipple procedure.The pylorus-sparing Whipple and the conventional Whipple are both variants of the Whipple procedure. Both whipple procedures are very similar. The only difference is that in the the pylorus-sparing Whipple, the distal segment (antrum) of the stomach is not removed. In the conventional whipple, a surgeon performing the Whipple procedure  would remove the gall bladder, the common bile duct, the head of the pancreas, the first (superior) part and the second (descending) part of the duodenum and the entire distal segment (antrum) of the stomach. Again, the only difference is that the distal segment (antrum) of the stomach is removed in the conventional Whipple and stays intact in the pylorus-sparing Whipple. The surgeon may also remove several of the lymph nodes in the area. It depends on the surgeon and the patient’s situation if all or some or only a few of the lymph nodes in the area are resected. However, studies have shown that because removing all of the lymph nodes in the area requires a more extensive surgery, it is not usually beneficial to the patient to do a complete lymphadenectomy, a removal of lymph nodes. The reason that the duodenum must be removed during the whipple has to do with arterial blood supply. Because the Whipple calls for the removal of the pancreas the duodenum of the small intestine must also be removed. The head of the pancreas that is removed during the procedure shares blood supply with the duodenum. For the removal of the head of the pancreas, its blood supply must be cut off. When its blood supply, the superior pancreaticoduodenal artery and inferior pancreaticoduodenal artery, are cut off, the duodenum is also left without blood supply and so for necrosis to not occur, the duodenum must be removed. Because the common bile duct is removed a new connection for bile drainage of bile produced in the liver must be created. A connection is usually made from the remaining part of the pancreas to the jejunum or the stomach. The procedure begins with an incision. Depending on the situation a vertical midline incision or a subcostal transverse incision is done. If the reason for the operation is pancreatic cancer, the organs around the area are searched to see if it has spread. If cancer is found outside the field of planned field of resection other surgical plans must be made. If everything is fine, the surgery will continue and the surgeon will take measures to have more vision. The retroperitoneal bed and the ligament of Treitz are then separated from the head of the pancreas and the duodenum. If needed, palpitations are done to the superior mesenteric artery. A suture is placed on the duodenum to mark where it will be resected. Then, the surgeon takes out the gall bladder. The bile ducts are transected and the distal bile duct is sutured. The gastroduodenal artery is divided to better see the pancreas. The blood supply of the duodenum and head of the pancreas is cut off and the duodenum is removed. Then, the head of the pancreas is removed. After that, using 5 Fr tube and sutures, the pancreas and the jejunum are sutured together. As mentioned earlier, the surgeon then makes a bile drainage connection from the hepatic duct to the jejunum. Then, depending on the type of Whipple, the distal segment (antrum) of the stomach is removed. The stomach is then sutured on to the Jejunum so the alimentary canal can function properly. Then after all the loose ends are tied up the abdominal wall is closed.

Medical Indications
Reasons for a Whipple procedure vary. There are several reason why a person might need one. A curative treatment for periampullary cancer is the number one reason for the procedure to be performed. Periampullary cancer is located in the duodenum, the bile ducts and the head of the pancreas, which are all removed during a Whipple procedure. Pancreatic cancer on the head of the pancreas in general is usually treated with a whipple procedure. If a malignant tumor is found in the pancreas, a Whipple might be the person’s only option. If the cancer is found to be metastatic and advanced then the person is not a candidate for the procedure. Of the patients with pancreatic cancer only 15-20% are eligible for the Whipple procedure. Another cancer that can be treated with the Whipple procedure is Cholangiocarcinoma, which is bile duct cancer. But the surgery may also require removal of part of the liver depending on if the cancer has spread or not. The Whipple procedure is also used to sometimes treat Chronic Pancreatitis. The procedure is used to to relieve duct obstruction to lessen the usual presented pain. The Whipple procedure may also be performed if blunt abdominal trauma has occurred. When trauma has damaged any of the organs significantly and it results in bleeding, a Whipple procedure has been performed a few times.

Contraindications
A reason that the patient should not have the Whipple procedure done is if the patient has cancer and it has metastasized significantly. If the cancer has spread to other nearby organs not removed in the Whipple procedure than it is not recommended that a Whipple be performed. Also, if the cancer has spread to the abdominal wall the procedure is not recommended. At the beginning of the Whipple procedure, surgeons inspect the other organs located near the organs and tissues that will be removed. Before the procedure a surgeon may choose to do a diagnostic laparoscopy, which involves a small incision and a camera to see if cancer has spread. The diagnostic laparoscopy saves the patient and the surgeon from an unnecessary large incision at the beginning of the procedure that would not help anyways.

Postoperative Care
After the surgery, patients can only eat through a nasogastric tube for the first day. The second day after surgery it is removed and clear liquids may be taken. After a while soft solids that are low in fats may be giving in small portions. The drains that were placed in surgery are removed if no complications have arisen. Patients are also monitored for Pancreatic Fistulas. If the patient experiences delayed gastric emptying, a test called a Gastrografin contrast upper gastrointestinal study must be run to determine if there is an obstruction. If an obstruction is ruled out the condition will eventually go away. It can take up to 4 weeks for it to be cleared up. Pain medications given for discomfort after surgery are limited of they interfere with the mobility of the intestines. During this period, supportive measures should be taken. Light movement is encouraged as soon as possible after surgery.

Video
A Walkthough of the Whipple Procedure 4Zxvm3MSb8k