Whipple
1. Creation of a plane between the superior mesenteric vein (SMV) and
pancreas as the SMV enters the portal vein. This step is typically done
with a clamp instrument and is done only to ensure that, during the
subsequent steps of the procedure, lifting the specimen off of the
portal vein and SMV will be able to be done safely
2. Entry into the lesser sac to mobilize the root of the small bowel
mesentery
3. The Cattell maneuver, which allows visualization of the SMV/superior
mesenteric artery (SMA) as they emerge from the base of the
pancreatic neck
4. The Kocher maneuver, which permits visualization of the portal triad
proximal to their insertion into the pancreas
5. Division of the right gastric and gastroduodenal arteries
6. Division of the common hepatic duct, during which the posterior
surface of the duct is typically palpated to investigate whether a
replaced right hepatic artery off the superior mesenteric artery is
present
7. Antrectomy (or duodenectomy of D1, if the procedure is pylorussparing)
8. Division of the pancreatic head at the level of the portal vein
9. Medial retraction of the specimen off of the SMV-portal vein
confluence. This step must be done carefully, with the individual
branches of the inferior pancreaticoduodenal arteries each being
identified and divided. If performed too quickly, arterial avulsion can
ensue. Occasionally, the first jejunal tributaries of the middle colic vein
may be encountered during this step, and if so, they too should be
divided
10.
Creation of the pancreaticojejunostomy
11.
Creation of the hepaticojejunostomy
12.
Creation of the gastrojejunostomy (or duodenojejunostomy, if
the pylorus is spared)