Key anatomy: head in C-loop, uncinate behind superior mesenteric vein (SMV)/lateral to superior mesenteric artery (SMA). Shared blood supply = must take duodenum with head.

Replaced right hepatic artery (RHA) from SMA in 12% — runs behind head/common bile duct (CBD). Must check preop imaging.

Trunk of Henle: variable anatomy, common trunk of right gastroepiploic vein (RGEV) + middle colic vein (MCV) into SMV. Important landmark in Step 1.

Lymphatic drainage follows blood supply — comprehensive lymphadenectomy is crucial for oncologic resection.

Splenic artery runs along upper margin of pancreas; splenic vein behind body/tail.

Main pancreatic duct (Wirsung) runs from tail, merges with CBD at ampulla of Vater. Accessory duct (Santorini) drains via minor papilla.

Most common indication: PDAC. Whipple is the sole curative option for most pancreatic head malignancies.

Also: NET, periampullary cancers (ampullary, distal CBD, duodenal), IPMN with high-risk features (mural nodules, main-duct dilation >5mm).

Less common: duodenal GIST (vs. local resection), chronic pancreatitis with intractable symptoms (Frey or Beger may be alternatives), severe trauma.

Benign indications require careful risk-benefit analysis given 40-60% morbidity.

This case: distal CBD adenocarcinoma confirmed on intraoperative frozen section.

NCCN criteria for resectability based on vascular involvement.

Resectable: clear planes, no vascular distortion. Proceed directly to surgery.

Borderline: some vascular contact but reconstructable. Often neoadjuvant chemo/RT first to downstage.

Unresectable: encasement >180° of SMA, celiac abutment, distant mets. Not surgical candidates — palliative chemo.

Key imaging: triple-phase CT with thin cuts. Arterial phase for arterial anatomy, portal venous phase for portal vein (PV)/SMV involvement.

Vascular resection: if SMV/PV involved, <2cm = primary anastomosis; >2cm = graft interposition (autologous vein, cadaveric, prosthetic).

This case: resectable on preop imaging. No vascular resection needed.

Classic Whipple: includes distal gastrectomy. Pylorus-preserving: retains stomach, divides proximal duodenum instead.

Cochrane review: PP similar outcomes, shorter OR time, less blood loss, but lower-quality evidence.

All peripancreatic LN stations included en bloc. Standard lymphadenectomy = stations 5, 6, 8a, 12b1, 12b2, 12c, 13, 14, 17.

Preop checklist: confirm resectability on imaging, optimize nutrition, decompress biliary if jaundiced, plan analgesia with anesthesia.

This patient: biliary stent placed (NSQIP variable), erector spinae block preop day prior, Zosyn for abx, SQ heparin 5000u for DVT prophylaxis.

Nutrition: pancreatic cancer patients often cachectic. Enteral preferred over parenteral when possible.

Prehabilitation: emerging evidence for reducing postop complications in frail patients.

Imaging: triple-phase CT with thin cuts. Arterial phase for arterial anatomy, portal venous phase for PV/SMV involvement.

Available grafts and vascular instruments should be on hand if vascular resection is anticipated.

Staging lap: 2-3 5mm ports. Systematic inspection of all surfaces.

Attending note: Veress technique, solitary LUQ peritoneal lesion biopsied, frozen negative.

Proceeded to open: upper midline between xiphoid extending around umbilicus, Thompson retractor.

Took down round ligament/falciform — saved round ligament for gastroduodenal artery (GDA) stump coverage later.

Erector spinae block placed preop day prior. Abx: Zosyn. SQ heparin 5000u.

Step 1 from attending note: mobilized omentum off transverse mesocolon, entered lesser sac. Right colon mobilized, plane found between colon and duodenum.

Identified SMV and gastrocolic trunk. Ligated RGEV and MCV.

Saved round ligament for GDA coverage — important detail, prevents pseudoaneurysm.

Step 2 from attending note: extended Kocher mobilizing duodenum and pancreatic head off inferior vena cava (IVC) including retroperitoneal lymphadenectomy.

All peripancreatic and lower portal LN reflected downward with specimen.

Key landmarks: IVC, left renal vein. If needed, gonadal vein can be ligated.

Step 3 from attending note: most complex step.

Hepatic artery (HA) lymph node dissection → GDA identified, 2 silk + 4-0 Prolene, divided after confirming HA pulse.

Developed superior pancreatic tunnel (artery off PV).

Top-down cholecystectomy from cystic plate.

Reflected periportal lymph nodes downward.

Common hepatic duct (CHD) transected proximal to cystic duct, Bovie 30. Mild pus = preop cholangitis. Plastic bulldog placed.

Proximal margin frozen: negative. Distal CBD frozen: POSITIVE for adenocarcinoma → committed to complete Whipple.

Step 4 from attending note: energy device to take omentum. Echelon 60 blue ×2 for Hofmeister shelf.

Pulled back NGT before firing — important to avoid stapling the tube.

Hofmeister shelf = angled gastric transection leaving greater curvature longer than lesser curvature.

Step 5 from attending note: jejunal division ~15 cm distal to Treitz in a nice loose area.

Energy device for mesentery. Flipped duodenum to right.

Critical: the limb must reach the pancreatic remnant WITHOUT tension.

Retrocolic tunnel created for the Roux limb.

Step 6 from attending note: PV-SMV tunnel developed. Bovie at 50 to cross pancreas.

Stay sutures at superior and inferior borders control bleeding and orient the gland during transection.

Pancreatic duct margin sent for frozen section — positive margin may require further resection.

Dissected head off SMA, PV, SMV. Preserved first jejunal vein (running posterior).

Found adventitia of distal SMA. Marched along SMA toward origin with LigaSure.

Removed small SMV branches. Specimen removed and oriented.

No vascular resection needed in this case. When SMV/PV is involved: <2cm defect = primary anastomosis; >2cm = graft interposition (autologous vein, cadaveric, or prosthetic).

Three anastomoses on one Roux limb, retrocolic.

PJ first (most proximal, highest stakes), HJ 10-15cm downstream, GJ 30-40cm downstream antecolic.

Omentum between PJ and GJ = tissue barrier. Round ligament over GDA stump = pseudoaneurysm prophylaxis.

This ordering is the most common (Child reconstruction). Some surgeons vary the order.

Reconstruction step 1 from attending note.

Duct could NOT be identified (0mm) → can't do duct-to-mucosa → elected dunking.

Posterior 3-0 silk interrupted → enterotomy slightly smaller than cut surface → circumferential 4-0 PDS edge-to-edge → dunk with 4-0 PDS full thickness on pledgets → anterior 3-0 silk.

Soft gland + 0mm duct = HIGH Fistula Risk Score. This is the highest-risk profile for POPF.

Pancreatic stent: may be placed across PJ anastomosis to decompress duct. Not used in this case because duct was not identifiable.

Technique selection varies by institution, duct size, gland texture, and surgeon experience. Duct-to-mucosa is most common when duct is large enough.

Reconstruction step 2 from attending note.

Good blood flow at duct tip confirmed.

Top-row hanging technique: 6 × 4-0 PDS RB-1 placed first to splay the duct.

Enterotomy 10-15cm from PJ. Back row 5 × PDS, knots inside. Top row: remaining hanging sutures.

Single-layer interrupted duct-to-mucosa. No stent.

Reconstruction step 3 (last) from attending note.

Antecolic GJ, 30-40cm from HJ. Measured 4.5cm anastomosis.

Back row 3-0 silk pops. Gastrotomy/enterotomy posterior to staple line.

Inner: 3-0 PDS running on back, Connell on top.

Outer top row: 3-0 silk pops. Two-layer hand-sewn closure.

Antecolic = avoids kinking through mesocolic window, may reduce DGE.

Drain 1: 19Fr Blake, R wall → Morrison's → behind biliary → over PJ → left, under left lateral section of liver.

Drain 2: L wall → behind GJ → inferior to PJ.

Omentum between PJ and GJ. Round ligament over GDA stump.

Counts correct, gloves changed. Fascia: 1-0 Stratafix. SQ irrigated. Skin: staples.

Drain amylase checked POD1 and POD3 for POPF screening.

Standardized postop monitoring per ISGPS guidelines.

Drain amylase: POD1 and POD3. >3× ULN = biochemical leak. Determine POPF grade based on clinical course.

NGT: IPOD trial (JAMA Surg 2020) showed no mandatory NGT use. Remove POD1 if output low.

Drains: early removal (POD3-5) if amylase normal. Prolonged drainage if elevated.

Feeding jejunostomy: not routine, but considered in malnourished patients or anticipated delayed recovery.

Enhanced recovery (ERAS): early mobilization, multimodal analgesia, goal-directed fluid therapy.

NSQIP Pancreatectomy Targeted Module variables.

0mm duct + soft gland = highest POPF risk tier.

Fistula Risk Score (Callery): small duct + soft gland + no pathology in duct + high EBL = high risk.

Pasireotide: somatostatin analog, some evidence for reducing POPF in high-risk glands (PASIREOTIDE trial).

Dunking selected because duct-to-mucosa not possible with non-identifiable duct.

POPF grading (ISGPS 2016): Grade A = biochemical leak, no clinical significance. Grade B = alters management (persistent drain >3wk, abx, percutaneous drain). Grade C = organ failure, reoperation.

DGE: often resolves when underlying POPF managed. Prokinetics: metoclopramide, erythromycin.

GDA pseudoaneurysm: blood in drain = emergency. CTA angiography, interventional radiology embolization/stenting. Surgery = last resort, high failure rate.

Exocrine: Creon/PERT with meals. Endocrine: ~20% new DM, higher if preop glucose intolerance.

Bile leaks: small leaks from HJ usually self-resolve with adequate drainage. Significant leaks presenting early postop may require reoperation.

Biliary strictures: late complication. Can result from narrow anastomosis, ischemia at duct tip, or tumor recurrence. May require endoscopic dilation or surgical revision.