Pancreatoduodenectomy Whipple Procedure Sample Report
DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS: Obstructive jaundice secondary to carcinoma of the duodenum, ampulla of Vater.
POSTOPERATIVE DIAGNOSIS: Chronically localized carcinoma of the second portion of the duodenum.
OPERATION PERFORMED:
1. Pancreatoduodenectomy (Whipple procedure).
2. Placement of a 22-French gastroenteric tube.
3. Placement of On-Q pain pump.
SURGEON: John Doe, MD
ASSISTANT: Jane Doe, PA-C
ANESTHESIA: General endotracheal anesthesia.
ESTIMATED BLOOD LOSS: Approximately 1600 mL. The patient did receive one unit of packed red blood cell.
DRAINS: Two 19-French Blake drains.
SPECIMEN: Distal common bile duct, duodenum, and head of pancreas.
OPERATIVE FINDINGS: The patient had a localized carcinoma of the duodenum and ampulla. There was no evidence of any obvious metastatic disease. A standard Whipple procedure was performed with an enterectomy and #22 gastroenteric tube placed for pancreatoduodenectomy.
DESCRIPTION OF OPERATION: With the patient in the main operating room under adequate general endotracheal anesthesia, Kefzol was given at the time of induction for pancreatoduodenectomy. A left subclavian triple-lumen catheter was placed by Dr. (XX), and Foley catheter was placed. The entire abdomen was prepped with iodoform and draped in the usual sterile fashion.
A linear incision was made xiphoid to the umbilicus and carried through the subcutaneous tissue. At this point, the abdominal cavity was entered. Thorough manual exploration was undertaken. The liver was carefully palpated and inspected. Other than cholestatic from the obstructive jaundice, no evidence of any obvious metastatic disease. The gallbladder appeared tense but not inflamed. At this point, the rest of the abdomen was explored, but they did not see any evidence of any metastatic disease or seeding.
Next, Bookwalter retractors were placed. The gastrocolic omentum was opened, exposed in the pancreas as well as to the stomach. At this point, a very generous Kocher maneuver was performed. Elevated the duodenum almost to the area of the inferior vena cava and showed there was no extension of tumor to this area. We could easily palpate this mass at the area of the ampulla.
Next, attention was then directed to the gallbladder. A standard cholecystectomy was performed, and cystic duct was ligated with 2-0 Vicryl. Cystic artery was clipped. The common bile duct was nicely isolated and separated from the portal vein quite nicely and this was then transected. The proximal part was then clamped using bulldog.
Next, attention was directed to the gastroduodenal artery. This was nicely isolated. It could be visualized quite nicely. It came off from the hepatic artery; this was doubly ligated. At this point, we could establish a nice plane along the subportal vein and showed that there was no extension of the tumor within the portal vessels.
Next, performed under generous Kocher maneuver, we were able to identify the inferior mesenteric inferiorly. At this point, we were able to place a finger from both above the portal vein, inferior/superior mesenteric vein, which showed there was no extension of the tumor in this area. It was quite obvious that this was a resectable tumor.
At this point, it was noted that we were able to resect this area. A standard Whipple procedure was performed by doing an antrectomy, taking down the gastroepiploic down to the area of the incisura angularis. At this point, the long lesser curvature was also taken down. A TA-55 was then far along the antrum and the antrum was then left within the area of the duodenum. The proximal stomach was then placed cephalad.
Next, pancreas was transected using the Harmonic scalpel. We were able to identify the duct quite nicely. Also, retroperitoneal structures were also mobilized. At this point, attention was directed to the proximal jejunum just beyond the ligament of Treitz. This is the area to be transected and anastomosed. This was then transected using a GIA. Next, the meso was taken using Harmonic scalpel, and we were able to bring the jejunum in retrograde fashion to the right side of the inferior mesenteric vessels with no difficulty.
Next, attention was directed to the uncinate process of the pancreas. This was then transected using the Harmonic scalpel. The larger vessels were ligated with 3-0 PDS, and the entire specimen was then removed, which included the distal common bile duct. The head of the pancreas and the entire of the duodenum and jejunum were sent to pathology. At this point, hemostasis was adequately obtained. The loop of jejunum was then brought out through the small transverse mesocolon.
Next, an end-to-end pancreaticojejunostomy was then fashioned by excising the staple line. This was then done in double layer fashion along the posterior row by using 2-0 Prolene for the posterior row, 3-0 PDS with internal row. We were able to dunk this quite nicely, and the anterior row was approximated with 3-0 PDS. Next, BioGlue was then placed with pancreatic anastomosis to help with the seal of the anastomosis.
Next, approximately 20 cm beyond this, hepaticojejunostomy was then fashioned by making a small hole within the anterior mesenteric bowel, and using the 3-0 PDS, the hepaticojejunostomy was then fashioned using running 3-0 PDS as open lumen. Next, approximately 30 cm beyond this, a gastrojejunostomy was then fashioned again by making small enterotomies. Before creating anastomoses, a #22 gastroenteric tube was placed, initiated through a small stab wound in the left upper quadrant. The gastric portion was then secured to the abdominal wall using interrupted 3-0 PDS. The jejunostomy port of the gastroenteric tube was then guided down into the jejunum, and this was flushed with no obstruction.
Next, the gastrojejunostomy was fashioned using running 3-0 PDS with a good open lumen and no tension. Both lumens of the gastroenteric tube were checked and found to be nicely intact. At this point, the abdominal cavity was massively irrigated. Hemostasis was found to be nice and intact. Two #19 French Blake drains were placed in the right upper quadrant. One was placed above, the other one below the pancreatic jejunostomy anastomosis in case of any leakage. They were secured to the skin using 2-0 Prolene.
Next, film was placed throughout the entire abdominal cavity. All the laps were subsequently removed. The NG tube was also confirmed to be in good position. Next, the midline was approximated using running #1 PDS. The subcutaneous tissue was irrigated. Two On-Q pain catheters were then placed along the subcutaneous tissue deep along the fascia. They were secured to the skin using Steri-Strips, benzoin, Tegaderm and secured to the On-Q pump, which contained 0.25% plain Marcaine. Next, the skin was approximated using wide staples along with the sterile dressing and abdominal binder. The On-Q pain pump was secured to the On-Q catheter within the pump, which contained 0.25% plain Marcaine.
The estimated blood loss was approximately 1500 mL. The patient did receive one unit of packed red blood cell intraoperatively. Two #19 French drains were placed. Sponge, needle, and instrument counts were correct x3. The patient tolerated the procedure well, including the pancreatoduodenectomy, and he was then returned to the recovery room in very stable condition post the pancreatoduodenectomy and other procedures.
