Open Whipple

The Whipple operation (pancreatoduodenectomy) is one of the most complex and technically challenging surgical procedures. It is most commonly performed for the surgical resection of lesions involving the head of the pancreas, ampulla, distal common bile duct, or duodenum. Initially associated with a high patient mortality, advancements made by surgeon pioneers such as Dr. Allen Whipple himself as well as the regionalization of pancreatic surgery to high-volume centers have dramatically reduced the mortality rate after pancreatoduodenectomy. However, even in experienced hands, the post-operative morbidity rate remains high, and complications can be devastating. Thorough preoperative planning, including deliberate selection of imaging modalities prior to surgery as well as careful patient selection, and careful perioperative management are necessary to optimize patient outcomes after surgery. Intraoperatively, meticulous dissection and precise surgical technique are paramount for a successful operation. The procedure requires a thorough understanding of vascular, gastrointestinal, and hepatopancreatobiliary anatomy, as well as mastery of good surgical principles such as atraumatic tissue handling and the achievement of tension- and obstruction-free anastomoses. In this chapter, we describe the key steps of the pancreatoduodenectomy, including modifications such as vascular reconstruction or pylorus preservation that should be performed depending on the indications for surgery and patient-specific factors, as well as common anastomotic techniques for reconstruction.