Pancreaticoduodenectomy (Whipple Procedure)

Definition
  • Removal of the head of the pancreas, the very proximal portion of the jejunum, the distal third of the stomach, and the distal half of the common bile duct, with reestablishment of continuity of the biliary, pancreatic, and gastrointestinal tracts.
Specific Technique
  • No touch technique
Discussion
  • The procedure is usually performed for regional malignancy and benign, obstructive, or chronic pancreatitis.
Position
  • Supine, with arms extended on armboards
Incision Site
  • Transverse, midline, or paramedian incision
Packs/ Drapes
  • Laparotomy pack
  • Transverse Lap sheet
  • Four folded towels
Instrumentation
  • Major Lap tray
  • Biliary instruments
  • Intestinal tray
  • Harrington retractors
  • Hemoclip/ surgiclip
  • Internal stapling instruments
Supplies/ Equipment
  • Basin set
  • Blades – (2) #10, (1) #15
  • Electrosurgical unit; suction
  • Hemoclips/ surgiclips
  • Dissector sponges
  • Needle counter
  • Internal staples
  • Drains – for retractors: Penrose 1 inch.
  • For drainage: HemoVac, Jackson Pratt, etc
  • Sutures – surgeon’s preference
  • Solutions – saline, water
  • Medications – Hemostatic agents, etc.
Procedure Overview
  • The abdomen is opened and explored; the operability of the findings is assessed.
  • The distal portion of the stomach, extrahepatic biliary tract, head of the pancreas and entire duodenum are immobilized. (With a total pancreatectomy, a splenectomy and cholecystectomy with vagotomy may be indicated.) If the tumor has invaded the base of the mesocolon, portal vein, aorta, vena cave, or superior mesenteric vessels, this procedure is usually abandoned, and a lesser procedure (usually a bypass of the biliary tree and/ or stomach will be performed.
  • The proximal end of the jejunum is anastomosed to the distal pancreas.
  • The common bile duct is anastomosed to the jejunum with an end-to-side technique.
  • The distal stomach is anastomosed to the jejunum (also end-to-side).
  • Stapling instruments may be used to mobilize and transect multiple blood vessels and in transaction of the stomach and to perform the gastrojejunal anastomosis.
  • Additionally, various plastic stents may be placed in the biliary or pancreatic anastomosis.
  • The wound is irrigated, drains inserted and secured, and the abdomen is closed in layers.
Perioperative Nursing Considerations
  • Verify with the blood bank the number of available units.
  • Accurate intake and output recording is essential for adequate replacement therapy.
  • Instruments that have touched “dirty” areas must be isolated (no-touch technique).
  • Scrub person should receive specimens in a basin.
  • Have appropriate stents available, unopened.
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