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 !!!!

Laparoscopic Central Pancreatic Resection or Laparoscopic Median Pancreatectomy

http://www.peacehealth.org/Oregon/WhoWeAreSHMC.htmhttp:

Laparoscopic Central Pancreatic Resection or Laparoscopic Median Pancreatectomy

Laparoscopic central pancreatic resection or laparoscopic median pancreatectomy

Overall facts about laparoscopic central pancreatectomy or laparoscopic median pancreatectomy
1.This is a highly controversy procedure
2. It can be done via an open approach or via laparoscopic central pancreatectomy or so call laparoscopic median pancreatectomy

Indication for laparoscopic central pancreatectomy or laparoscopic median pancreatectomy
1. Benign but symptomatic tumor of the pancreas located at the pancreatic neck or proximal body.
2. Pre-malignant cystic pancreatic tumor ( ie: mucinous cystic lesion) located at the pancreatic neck

Contraindication for laparoscopic central pancreatectomy or laparoscopic median pancreatectomy
1. Malignant pancreatic tumor

Advantages of laparoscopic central pancreatectomy or laparoscopic median pancreatectomy
1. Preservation of pancreatic body and tail. Therefore, lower the risk of subsequent development of diabetes mellitus

Disadvantages of laparoscopic central pancreatectomy or laparoscopic median pancreatectomy
1. Removed minimal tissue, therefore, may not be as oncologic as one think.
2. No lymph node clearance
3. Two cut pancreatic surfaces, therefore a high risk of pancreatic leaks post operatively

Surgery
1. Open central pancreatectomy or median pancreatectomy
2. Laparoscopic central pancreatectomy or laparoscopic median pancreatectomy


Which one to go for if you need central pancreatectomy ?
One can always consider Laparoscopic central pancreatectomy or laparoscopic median pancreatectomy rather than open central pancreatectomy. The advantages of laparoscopic central pancreatectomy or laparoscopic median pancreatectomy are small incisions, less pain, quicker return of bowel activity, earlier resuming of oral intake, earlier ambulation, lower risk of DVT and pneumonia.

Therefore in selected patient and in an experience surgical hands, Laparoscopic central pancreatectomy or laparoscopic median pancreatectomy should be the operation of choice


Where to recieve laparoscopic central pancreatectomy or laparoscopic median pancreatectomy
Here at Kaiser Permanente, South San Francisco experienced laparoscopic surgeons we had performed a very successful laparoscopic central pancreatic resection or laparoscopic median pancreatectomy about 1 year ago. Patient did very well and was able to play golf at St Andrews ( Scotland) several week after surgery. No postoperative diabetes Mellitus.

Kaiser Permanente, South San Francisco experienced laparoscopic surgeons currently do not perform laparoscopic central pancreatectomy or laparoscopic median pancreatectomy for pancreatic adenocarcinoma

Contact about laparoscopic central pancreatectomy or laparoscopic median pancreatectomy

Laparoscopic pancreatic surgery

Pancreatic Surgery

In patients with malignant pancreatic tumor, aggressive pancreatic surgery is the only chances of long term survival. Most of these patient will also be treated with multimodality therapy either pre-operatively or postoperatively. Pancreatic surgery also offer patient a cure when the pancreatic tumor in benign or pre-malignant. In patients with chronic pancreatitis, pancreatic surgery can effectively palliate their symptoms of abdomen pain.

The type of pancreatic surgery

The type of pancreatic surgery is largely depends on the location of the tumor at the pancreas.

The anatomical location of the pancreas is divided into pancreatic head, uncinate process, pancreatic neck, pancreatic body and pancreatic tail.

For a pancreatic tumor at the head or uncinate process, Whipple operation is the operation of choice. For a pancreatic tumor at the body and tail of the pancreas, distal pancreatic resection is the operation of choice. For tumor in the pancreatic neck, the choice of surgery is slightly more controversy. If the tumor is benign (but symptomatic) or pre-malignant, then our choice is central pancreatic resection ( median pancreatectomy). However, if the tumor is deems malignant, then then choice of operation is either an extended distal pancreatic resection of whipple operation.

At Sacred Heart Medical Center, Eugene, OR, specialised surgeons can now offer all the pancreatic surgery mentioned to be done laparoscopically or in an open fashion. They have done laparoscopic whipple operation, laparoscopic central pancreatic resection, laparoscopic distal pancreatic resection with spleenic preservation or with spleenectomy. Laparoscopic enucleation is the standard of care for isolated pancreatic insulinoma.

These are the procedures offer in Sacred Heart Medical Center, Eugene, OR.

Pancreatic Tumor

Whipple operation
i. Laparoscopic Whipple operation
ii. Open Whipple operation

Central pancreatic resection (Median pancreatectomy)

Distal pancreatic resection
i. Laparoscopic distal pancreatectomy
1. Laparoscopic distal pancreatectomy with splenic preservation
2. Laparoscopic distal pancreatectomy with spleenectomy
ii. Open distal pancreatectomy

Pancreatic enucleation
i. Laparoscopic pancreatic tumor enucleation
ii. Open pancreatic tumor enucleation

Chronic pancreatitis

Pseudocyst drainage procedure
i. Laparoscopic cytogastrostomy
ii. Laparoscopic cystoduodenostomy
iii. Laparoscopic cystojejunostomy

Peustow’s operation ( pancreaticojejunostomy)
i. Laparoscopic Peustow’s Operation
ii. Open Peustow’s operation

Berger operation
i. Laparoscopic Berger operation
ii. Open Berger operation

Frey operation
i. Laparoscopic Frey operation
ii. Open Frey operation

Resection
i. Whipple operation ( laparoscopic whipple or open)Distal pancreatic resection

Laparoscopic Whipple operation

Video of laparoscopic whipple operation to come

Laparoscopic Whipple Operation

Who should perform laparoscopic Whipple operation ?

The quick answer is: Those who have the skills as laparoscopic Whipple operation is technically VERY challenging...

These are the surgeons not only has done lots of pancreatic surgery but also need to be fully trained in advanced laparoscopic surgery. Since laparoscopic fellowship training has only been around for about 5 years, therefore most of these surgeons are rather young.

Therefore, if you surgeons is an old surgeons, make sure you do not let him/her talk you into letting him/her do the laparoscopic Whipple operation.


In USA: There are only a few surgeons who has the skill set to complete laparoscopic Whipple operation.

Kaiser Permanente, South San Francisco experienced laparoscopic surgeons

Laparoscopic Whipple Operation

Variety of laparoscopic Whipple operation

1. Totally laparoscopic Whipple operation

In this approach, all the incisions are small, all the dissection and anastomosis are done by laparoscopic means.

This is a technically much more challenging operations and therefore only a few trained advanced laparoscopic surgeons can complete these a totally laparoscopic Whipple operation


2. Hand assisted laparoscopic Whipple operation

In this approach, all the dissections are done laparoscopically. When it come to performing the anastomosis, the surgeon make a large open incisions ( much bigger than the totally laparoscopic Whipple operation, but smaller than the classic open whipple operation)


Kaiser Permanente, South San Francisco experienced laparoscopic surgeons

Laparoscopic Whipple Operation

Potential advantage of laparoscopic Whipple operation.

Laparoscopic Whipple operations utilised 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



Kaiser Permanente, South San Francisco experienced laparoscopic surgeons

Laparoscopic Whipple Operation

Controversy with laparoscopic Whipple operation.

Whipple operation is one of the most major abdomen operation. Whipple operation is associated with significantly high perioperative complications. Since Dr Whipple described this operation, this surgery has been done with a LARGE incision. Often time extend from the right side of the abdomen to the left side ( almost to the very edge). The complication rate of Whipple operation is approximately 30 to 40 %. The perioperative mortality rate range from 0 % to 10%, average about 5%.

The controversy is what can a laparoscopic whipple operation improved these intrinsic complications.

Nobody can provide patients with an answer yet. As there need to have more data on the outcome of laparoscopic whipple operation.

However, just like most laparoscopic surgery, laparoscopic whipple operation has face many inersia of reluntancy.

However, in selected hand, most advanced laparoscopic pancreatic surgeons suspect that the result of laparoscopic whipple operation is equal and non-inferior to open whipple operation.

Certainly, we smaller incisions, post operative pain will be significantly improved.

Laparoscopic Whipple Operation

Operation for laparoscopic Whipple operation

1. It may take longer... sometime a safe surgery like laparoscopic whipple may takes 6 to 10 hours.
2. Hospital stays may range from 6 to 10 days.
3. Less pain from smaller incision
4. The intrinsic complications of whipple opeartion may not be minimised via laparoscopic Whipple operation



Kaiser Permanente, South San Francisco experienced laparoscopic surgeons

Laparoscopic Whipple Operation

Indication of Laparoscopic Whipple ( Laparoscopic Pancreatic Surgery)

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

Contra-indication:
In patients who had previous abdomen opeartion, 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.


Kaiser Permanente, South San Francisco experienced laparoscopic surgeons

Laparoscopic Whipple Operation

Kaiser Permanente, South San Francisco experienced laparoscopic surgeons

Laparoscopic Whipple Operation

What is new with Laparoscopic Whipple Operation

Whipple operation is perhaps one of the most technically challenging operation in the abdomen. Now, we can do a total laparoscopic Whipple operation ! Amazing !!!

What is removed during Laparoscopic Whipple operation ?

It is amazing that a surgeon can now do whipple operation laparoscopically. This is the operation to remove tumor an the head of the pancreas most of the duodenum, distal common bile duct and some time part of the stomach.

This can be pancreatic adenocarcinoma, pancreatic neuroendocrine tumor and some symptomatic benign pancreatic tumor



Who should perform laparoscopic Whipple operation ?

Laparoscopic Whipple operation can be done safely in selected patients and by only a handful of trained surgeon in the world.

?The quick answer is: Those who have the skills as laparoscopic Whipple operation is technically VERY challenging...These are the surgeons not only has done lots of pancreatic surgery but also need to be fully trained in advanced laparoscopic surgery. Since laparoscopic fellowship training has only been around for about 5 years, therefore most of these surgeons are rather young.Therefore, if your surgeons is an old surgeons, make sure you do not let him/her talk you into letting him/her do the laparoscopic Whipple operation.

Where about in the USA can one get laparoscopic Whipple operation ?

In USA: There are only a few surgeons who has the skill set to complete laparoscopic Whipple operation.In Oregon: The available info that we have is as
follows:

http://www.peacehealth.org/Oregon/WhoWeAreSHMC.htm.





Variety of laparoscopic Whipple operation



1. Totally laparoscopic Whipple operation



In this approach, all the incisions are small, all the dissection and anastomosis are done by laparoscopic means.This is a technically much more challenging operations and therefore only a few trained advanced laparoscopic surgeons can complete these a totally laparoscopic Whipple operation



2. Hand assisted laparoscopic Whipple operation



In this approach, all the dissections are done laparoscopically. When it come to performing the anastomosis, the surgeon make a large open incisions ( much bigger than the totally laparoscopic Whipple operation, but smaller than the classic open whipple operation)




Potential advantage of laparoscopic Whipple operation.






Laparoscopic Whipple operations utilised 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






Potential disadvantages of laparoscopic Whipple operation


1. Longer operating time
2. More and earlier post-operative atelectasis.

Potential disadvantages of laproscopic Whipple operation that is likely not to be true

1. More bleeding
Surgeons that have done several of laparoscopic whipple operations showed that bleeding is not a problem, as they need to address bleeding, even in smaller amount as soon as possible, otherwise, their laparoscopic view will be affected)

2. Pooer oncologist outcome
This outcome of laparoscopic whipple or open whipple operation is likely going to be equal from oncology standpoint. There are minimal handling of the tumor during laparoscopic whipple operation, therefore tumor spread is minimised ( much so compare to open whipple operation)




Again..in experience hand, laparoscopic whipple can be done safely with good oncologic outcome




Controversy with laparoscopic Whipple operation.



Whipple operation is one of the most major abdomen operation. Whipple operation is associated with significantly high perioperative complications. Since Dr Whipple described this operation, this surgery has been done with a LARGE incision. Often time extend from the right side of the abdomen to the left side ( almost to the very edge). The complication rate of Whipple operation is approximately 30 to 40 %. The perioperative mortality rate range from 0 % to 10%, average about 5%.The controversy is what can a laparoscopic whipple operation improved these intrinsic complications.Nobody can provide patients with an answer yet. As there need to have more data on the outcome of laparoscopic whipple operation.However, just like most laparoscopic surgery, laparoscopic whipple operation has face many inersia of reluntancy.However, in selected hand, most advanced laparoscopic pancreatic surgeons suspect that the result of laparoscopic whipple operation is equal and non-inferior to open whipple operation.Certainly, we smaller incisions, post operative pain will be significantly improved.


Indication of Laparoscopic Whipple ( Laparoscopic Pancreatic Surgery)

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





Contra-indication for laparoscopic Whipple operation





In patients who had previous abdomen opeartion, 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





Laparoscopic Whipple operation in Oregon, USA





This is the info for laparoscopic whipple opeartion on Sacred Heart Medical Center web site home page athttp://www.peacehealth.org/Oregon/WhoWeAreSHMC.htm.

Laparoscopic pancreatic surgery, Laparoscopic Whipple

May 13, 2009

SPRINGFIELD, Ore. -- Laparoscopic Whipple Surgery is a technique only a handful of doctors around the world know how to pull of.


One of those surgeons is right here Kaiser Permanente, South San Francisco experienced laparoscopic surgeons Dr. Swee Teh has performed several of these operations


Using the tiniest of incisions, the surgeon is able to remove a portion of the pancreas, eliminating or reducing the size of cancerous tumors.