Whipple Procedure (Pancreaticoduodenectomy)


I. OVERVIEW

Whipple procedure = Pancreaticoduodenectomy
Major surgical resection for tumors involving:

  • Head of pancreas (most common: adenocarcinoma)
  • Distal bile duct
  • Ampulla of Vater
  • Duodenum (esp. periampullary tumors)

🏗️ Procedure involves removal of:

  • Head of pancreas
  • Distal bile duct
  • Gallbladder
  • Duodenum (and possibly part of the stomach)
  • Proximal jejunum

🛠️ Reconstruction:

  • Pancreaticojejunostomy
  • Hepaticojejunostomy
  • Gastrojejunostomy


II. PREOPERATIVE CONSIDERATIONS

1. Thorough Evaluation

Domain

Considerations

Nutritional status

Cachexia, hypoalbuminemia common (due to tumor, anorexia, obstruction)

Jaundice

Obstructive jaundice → coagulopathy, renal/hepatic dysfunction

Diabetes

Common due to pancreatic insufficiency

Cardiopulmonary status

Elderly, malnourished → fragile reserves

Tumor burden

Local invasion (vascular), resectability

Biliary stenting history

May predispose to cholangitis/sepsis



2. Laboratory Investigations

  • CBC, LFTs (bilirubin, PT/INR), renal panel
  • Albumin, coagulation profile
  • Tumor markers (CA 19-9)
  • Blood grouping, crossmatch (major blood loss risk)
  • ABG, electrolytes (especially K⁺, Ca²⁺, Mg²⁺)


3. Imaging Studies

  • Contrast-enhanced CT abdomen: to assess vascular invasion, resectability
  • MRCP / ERCP: to delineate biliary anatomy
  • Cardiac assessment (especially in elderly)


4. Optimization

  • Nutritional support: TPN or enteral feeding preoperatively if albumin <2.5 g/dL
  • Vitamin K or FFP: if PT/INR elevated from obstructive jaundice
  • Correct electrolytes, especially Mg²⁺ and K⁺
  • Treat infections (e.g., cholangitis)
  • Physiotherapy: Incentive spirometry, chest PT
  • Informed consent: includes risk of pancreatic leak, DGE, mortality


III. INTRAOPERATIVE MANAGEMENT

1. Monitoring

  • Standard ASA monitors
  • Invasive arterial line: for BP, ABG, lactate
  • Central venous catheter (CVC): CVP monitoring, fluid therapy, vasoactive drugs
  • Temperature: to prevent hypothermia
  • Urinary catheter: UO as renal perfusion marker
  • Consider TEE in high-risk patients


2. Anesthesia Technique

Component

Consideration

Induction

Rapid, smooth (aspiration risk in obstructive jaundice)

Drugs

Etomidate for unstable, Propofol for fit; Rocuronium/Cisatracurium preferred

Maintenance

Volatile agents + opioids (fentanyl/remifentanil) ± epidural

Ventilation

Lung-protective: TV 6-8 mL/kg, PEEP

Depth

BIS or MAC-guided; avoid awareness in elderly/cachectic



3. Fluid and Hemodynamic Management

  • Goal-directed therapy (GDFT): PPV/SVV/cardiac output-guided
  • Balanced crystalloids (e.g., PlasmaLyte); avoid NS → hyperchloremic acidosis
  • Colloids: for volume replacement
  • Anticipate major fluid shifts & blood loss (average 500–1000 mL)
  • Use vasopressors (norepinephrine) to maintain MAP >65 mmHg


4. Analgesia

  • Thoracic epidural analgesia (TEA) (T7–T10) preferred:
    • Superior pain control
    • ↓ stress response
    • Early ambulation
  • Multimodal analgesia: Paracetamol, NSAIDs (avoid if renal risk)


5. Antibiotics

  • Broad-spectrum coverage (e.g., cefoperazone-sulbactam or piperacillin-tazobactam)
  • Redose after 3–4 h of surgery if prolonged


6. Special Considerations

Risk

Precaution

Pancreatic anastomosis

Gentle handling, minimize edema

Coagulopathy

Due to liver dysfunction or blood loss → FFP, platelets

Air embolism risk

Especially in laparoscopic approaches or exposed veins

Hypothermia

Use warmers, Bair Hugger, fluid warmers



IV. POSTOPERATIVE MANAGEMENT

1. ICU Care

  • Mechanical ventilation: Elective in long surgeries or comorbidities
  • Monitor for:
    • Hemodynamic instability
    • Pulmonary complications (atelectasis, pneumonia)
    • Renal function (due to fluid shifts, hypotension)
    • Coagulopathy


2. Complications to Anticipate

Complication

Details

Pancreatic fistula

Amylase-rich drain output; high morbidity

Delayed gastric emptying (DGE)

NGT for decompression; may need prokinetics

Hemorrhage

From GDA stump, intraabdominal bleeds

Infection

Wound sepsis, intraabdominal abscess, cholangitis

Renal dysfunction

From hypoperfusion, sepsis

Nutritional deficiency

Need enteral feeding (jejunal tube)



3. Drain Monitoring

  • Output quantity and quality
  • Amylase level in drain fluid on POD 3 → detects pancreatic leak


4. Pain Control

  • Continue epidural infusion
  • Multimodal: IV paracetamol, ketorolac (careful in AKI)


5. Nutrition

  • Start enteral feeds via jejunostomy early (within 48–72h)
  • Avoid TPN unless enteral not tolerated
  • Monitor for steatorrhea, enzyme insufficiency


🧠 V. VIVA/MCQ HIGH-YIELD POINTS

  • Whipple = pancreaticoduodenectomy + reconstruction
  • Common indication = pancreatic head adenocarcinoma
  • Complications:
    • Pancreatic fistula > DGE > hemorrhage
  • Epidural analgesia improves outcomes
  • Target MAP: >65 mmHg; UO > 0.5 mL/kg/h
  • Avoid excessive crystalloids: risk of bowel edema → anastomotic failure
  • Drain amylase >3× serum → pancreatic fistula