R Whipple resection
Whipple resection consists of a pancreatoduodenectomy, pancreatojejunostomy, hepaticojejunostomy, and gastrojejunostomy. On entering the peritoneal cavity, the surgeon determines the resectability of the pancreatic lesion. Contraindications to resection include involvement of mesenteric vessels, infiltration by tumor into the root of the mesentery, extension into the porta hepatis with involvement of the hepatic artery, and liver metastasis. If the tumor is deemed resectable, the head of the pancreas is further mobilized. The common duct is transected above the cystic duct entry, and the gallbladder is removed. When the superior mesenteric vein is freed from the pancreas, the latter is transected with care taken not to injure the splenic vein. The jejunum is transected beyond the ligament of Treitz, and the specimen is removed by severing the vascular connections with the mesenteric vessels. Reconstitution is achieved by anastomosing the distal pancreatic stump, bile duct, and stomach into the jejunum. Drains are placed adjacent to the pancreatic anastomosis. Some surgeons stent the anastomosis until it has healed.
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