May or may not include pylorus, depending on whether it was pylorus-sparing procedure
Anatomic Orientation
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Duodenum
Free proximal end usually shorter than free distal segment
Small portion of stomach usually attached to proximal end
Distal end may be either duodenum or jejunum
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Common bile duct
Sometimes green in color
Posterior and superior to pancreas
May be easier to identify from ampulla than from transected end
If gallbladder is present, can identify insertion of cystic duct and follow to common bile duct
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Ampulla of Vater
Usually obvious within duodenum, unless obscured by tumor
Some patients have accessory ampulla that drains accessory duct of Santorini
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Pancreas
General anatomic features
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Retroperitoneal organ located in C-groove of 2nd part of duodenum
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Anterior to pancreas is free space (omental bursa/lesser sac), and then posterior aspect of stomach
Anatomic divisions of pancreas
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Head: To right of superior mesenteric vein/portal vein confluence; includes uncinate process
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Neck: Constricted region to left of head
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Body: Between superior mesenteric vein/portal vein confluence and aorta
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Tail: Between aorta and splenic hilum
Pancreatic duct
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Usually main pancreatic duct drains bulk of gland into duodenum at major duodenal papilla (ampulla) along with common bile duct
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Normal diameter is < 1 cm
Specimen Handling
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Identify proximal end of duodenum
Usually shorter than distal end
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Head of pancreas sits in duodenal C-loop
Neck margin can be identified as oval-shaped transected pancreatic surface with central duct
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Determine anterior vs. posterior pancreatic surface
Anterior pancreatic surface bulges
Posterior pancreatic surface is flat
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Common bile duct is superior to pancreas near 1st part of duodenum
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Adsay trapezoid method of orientation
Useful method to identify essential margins/surfaces
Place proximal intestinal margin to left, distal intestinal margin to right, and medial aspect of pancreas facing toward you
Visualize trapezoid
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Left nonparallel side represents pancreatic neck margin
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Right nonparallel side is uncinate margin
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Space between sides is vascular groove
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Anterior surface is base, and posterior surface is parallel opposite side
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Hand method of orientation
Curled left hand resembles pancreas enveloping superior mesenteric artery and portal vein
Thumb is uncinate process; flat fingers are neck, body, tail
Surgical Margins
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Common bile duct (shave margin)
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Pancreatic resection (shave margin to include duct)
CAP calls this distal margin
AJCC calls this pancreatic neck margin
