Pancreaticoduodenectomy (Whipple)

High-Yield Pearls

Confirm SMA and SMV involvement on cross-sectional imaging before committing to resection.
Review variant hepatic arterial anatomy, especially replaced right hepatic artery.
Discuss plan for pancreaticojejunostomy technique (duct-to-mucosa vs. dunk).

Pre-op briefing with anesthesia to coordinate central access and hemodynamic monitoring.
Confirm availability of cell saver and vascular instruments.
Explore abdomen, rule out metastasis, and mobilize hepatic flexure.
Control gastroduodenal artery early and test hepatic arterial flow before transection.
Kocherize duodenum and assess SMA/SMV involvement.
Divide pancreas at neck with frozen section and protect SMV/PV confluence.
Resect specimen with en bloc gallbladder and bile duct.
Perform pancreaticojejunostomy with stent placement as indicated.
Construct hepaticojejunostomy and antecolic gastrojejunostomy.
Place drains near PJ and HJ, confirm hemostasis, and plan ICU disposition.

What are the key anatomic boundaries of the triangle of Whipple?: Cystic duct superiorly, common hepatic duct medially, and common bile duct laterally.
How do you manage a soft pancreas with small duct intraoperatively?: Use duct-to-mucosa anastomosis with internal stent and reinforce with external sutures or dunk technique depending on texture.
List the components of the Whipple reconstruction.: Pancreaticojejunostomy, hepaticojejunostomy, and gastrojejunostomy.

Arterial variants: Identify replaced hepatic and right gastric arteries to avoid ischemic complications.
Venous structures: SMV-PV confluence and tributaries (IPDV, gastrocolic trunk) demand protection during uncinate dissection.

Capture your own rehearsal script here—focus on vascular steps, reconstruction order, and bailout thresholds for conversion to vascular resection.

Review surgeon-specific anastomotic preferences during pre-op huddle.
Clarify DVT prophylaxis restart timing because this attending prefers early postoperative anticoagulation.