Laparoscopic Whipple Procedure

Guideline for Open and Laparoscopic Whipple Procedure


Overall information for laparoscopic Whipple procedure

Whipple operation is perhaps one of the most technically challenging operations in the abdomen. The overall perioperative mortality rate is about 2 % to 5% and with operative morbidity of about 25 % to 45%

Many published series and leap frog group had suggested that the outcome of Whipple operation is directly related to surgeon’s volume. Just like any complicated surgical procedure, the more you do, the better you get and the outcome is more optimal. This is no different for Whipple procedure


Who should perform Open Whipple procedure?

Most data would suggest any surgeon who has annual volume of 3 successful Whipple is qualify to do a Whipple operation. Please refer to Leap frog data, NSQIP and Hospital volume data (pub med). Please note, there are no national guideline on who should performed such on operation. Outcome data from the above source strongly suggest a minimal annual volume of 3. Therefore it is strongly suggested that surgeon who does less than 3 Whipple procedures annually should not offer patient a Whipple procedure. These patients are best referring to a more qualified surgeon who has done more than 3 successful Whipple procedures a year.

For surgeon that has not done enough Whipple procedure, the intra-operative bleeding risk is higher; the oncologic clearance of surgical margin especially on the uncinate process tends to be lower. Most surgeons are not familiar with periadventitial superior mesenteric artery dissection. More importantly, most low volume surgeon also has a higher incident of unable to complete the whole operation. They can then tell the family that the intra-operative finding precludes the Whipple procedure to be completed but in fact it can be due to their technical deficiency. The perioperative complications from such surgeon, both short and long terms are higher.


Why would some surgeon still want to do Whipple procedure?

Despite the fact that they have not done an adequate number of Whipple operation, some surgeon still wants to Whipple. Personally, I do not know why.

This can be due to two main reasons: Pride and Price.

Pride: Most surgeons have some internal pride. They have this attitude that “ I can do it” They may have done several whipple procedures over the years or even worse while during the residency… which can be 5,10 years or even more years ago !!!! Boy….. If the patient is their own mom or dad…. I do not think they will like such surgeon to do a Whipple procedure on the patient…. But they are willing to do it for YOU!!!! For me… This does not make sense….

Price: Ya.. Perhaps… the financial reimbursement is better than other surgical cases…. But this SHOULD not be the reason to offer patient such a major operation… A Whipple procedure!


Who should perform laparoscopic Whipple operation?

Laparoscopic Whipple is perhaps the last frontier in advanced laparoscopic surgery in the abdomen. Since there are no guideline on who should performed such operation. Most experts would suggest the following guideline for any surgeon to perform a laparoscopic Whipple procedure. Surgeon must fulfill all these criteria
1. A fellowship trained laparoscopic surgeon
2. A surgeon with interest in pancreatic surgery
3. A surgeon who had performed at least 3 open Whipple procedures annually.
4. A surgeon that can suture intracorporeally either free hand or via robotic.


Patient’s selection for laparoscopic Whipple procedure

Contraindication for Laparoscopic Whipple procedure
1. Multiple previous operations especially in the upper abdomen.
In patients who had previous abdomen operation, any laparoscopic surgery may be more challenging due to scar tissue ( adhesion), therefore laparoscopic pancreatic surgery, including laparoscopic whipple operation may be a bit more difficult but not impossible.


Indications for Laparoscopic Whipple procedure

Pancreatic Head Tumor:
1. Pancreatic adenocarcinoma (tumor not involve the Portal Vein or Superior Mesenteric Vein)
2. Intraductal papillary mucinous neoplasm (IPMN)
3. Pancreatic Neuroendocrine tumor
4. Pancreatic cystic tumor (mucinous)
5. Chronic pancreatitis


Preoperative Patients counseling for laparoscopic Whipple Procedure:

1. Most patients are seen on more than one clinical visit to ensure patient fully comprehended the discussions between surgeon and patients

2. Most patients are requested to bring their family member to one of the clinic visit to ensure both the patient and the family member understood the disease process, the risk, the benefit and options of the treatment options.

3. Patient or family members are encourage to take note and write down any questions they may have so that all can be answered either during the pre-operative clinic visit or subsequent telephone conversation.

4. All relevant imaging study will be shown to the patient and the family. A printed picture of the pancreas, the parts of the pancreas, gastric-duodenum-proximal jejunum, bile duct and gallbladder that will be removed during a whipple operation will also shown to them.

5. Emphasis on possible surgical risks including perioperative mortality of less than 5% and perioperative morbidity of 30%to 40% will be use as a guideline. The mean hospital stays of 7 to 10 days are mentioned. Most experts would stress heavily to patients and the family that, Whipple operation is one of the most Major abdomen operations.

6. In patients who are suitable candidate for laparoscopic Whipple, Not only surgeon should mention all the above in formations, they should also tell them that the laparoscopic way of approach a Whipple operation has not been widely applicable in United States. But here in SHMC, one surgeon has done three of totally laparoscopic operations within the last several months. The durations of the operations, the perioperative complications should be mentioned to them. Surgeon need to emphasize to them that, the goal of the laparoscopic Whipple operation is safety. If during any stage of the surgery, if the surgeon do not feel comfortable regarding the safety, the operation will be converted to open approach immediately.

7. The potential advantages of laparoscopic Whipple operation are the following but our series are too small to confirm them. Hopefully the Mayo Clinic series will be published soon.
Laparoscopic Whipple operations utilized several small incisions. Therefore, the advantages of laparoscopic Whipple operation will be:

1. Less perioperative pain
2. Early ambulation
3. Better return of full pulmonary functions
4. Less chances of developing DVT and pneumonia
5. Early return of bowel functions (less narcotic use, early ambulation)
6. Lower incidence of incisional hernia

8. Only with informed consent and the above discussions, laparoscopic Whipple operation will be offer to the patients.

Intraoperatively monitoring for laparoscopic Whipple procedure

The laparoscopic Whipple Procedure is current done with assistant of a team in the operating room that is familiar with advanced laparoscopic hepatobilliary surgery. It is vital to keep such variable constant for laparoscopic Whipple procedure.

5 to 10 minutes preoperative briefing is always conducted to ensure all the necessary surgical instructments are available. Only the familiar scrub nurse and circulating nurse are involved in laparoscopic Whipple operation. Open procedure surgical instructment set is always in the operating room in case of immediate need of conversion to open approach.

The operative time for laparoscopic Whipple procedure can be long. To avoid early atelectasis and causing early post operative fever, discussion with the anesthesia colleagues is made pre-operatively and intraoperatively. The goal is to use larger volume ventilation (to encourage full lung expansion) in the as much as possible. During portal vein and superior mesentery artery dissection, pancreaticojejunostomy, choledochojejunostomy and gastrojejunostomy reconstruction, small tidal volume will be use to avoid to much intra-abdominal movement.


Postoperative care for laparoscopic Whipple procedure

All patient spend at least the first day to two in the ICU. These due to the fact that duration of the operation can be longer than the open approach. The operating time is longer in part due to extra carefulness during this advanced laparoscopic Whipple operation. (The very first laparoscopic Whipple in New York took 16 hours !)

The rest of the postoperative care is standard as in open Whipple procedure.


Patients monitoring after Laparoscopic Whipple Procedure

All patients who had laparoscopic Whipple procedure are seen in the clinic by me the week after their hospital dismissal. They will be seen on at least 2 other follow visits. The initiate few visits are to ensure patient continues recovery and the subsequent visit is to make sure advises on their disease process when the pathology is available. Any patient with malignant disease will be referring to medical and/or radiation Oncologic colleagues.

Patient who had a laparoscopic Whipple procedure should also be tracked in a prospective database.


Are you a patient who needs a Whipple procedure…. ?

Are you a patient who may benefit from a laparoscopic Whipple Procedure…

Find out and ask around !!!!