The peritoneal cavity is entered through an upper midline or a bilateral subcostal incision. The round ligament is divided at the liver and the portion between the liver and the umbilicus is excised. A fixed abdominal wall retractor system of the surgeon’s choice is engaged after a wound protector is placed. Especially in the cases where a malignancy must be ruled out, the liver, the omentum, and the peritoneal surfaces are inspected and palpated. Any suspicious lesions are biopsied and submitted for frozen-section analysis.

Operative assessment begins with a wide Kocher maneuver and mobilization of the duodenum and the head of the pancreas from the underlying inferior vena cava and aorta. When the duodenum and head of the pancreas have been mobilized sufficiently, a hand is placed under the duodenum and the head of the pancreas to palpate the local anatomy. The lesser sac is then opened widely by incising the lesser omentum and by removing the entire greater omentum off the transverse colon. Every attempt is made to preserve the greater omentum. The hepatic flexure of the colon is also mobilized and retracted downward out of the operative field early in the operative procedure.

Our preference is to dissect the SMV and portal vein as an initial step. The inflammatory response associated with chronic pancreatitis can be considerable making this dissection somewhat tedious, therefore early control is important if bleeding is encountered at any point in the case. Identification of the portal vein is greatly simplified if the common hepatic duct is divided early in the dissection. Once the hepatic duct has been divided, the anterior surface of the portal vein is easily and quickly identified. The lymph node tissue lateral to the hepatic duct and the portal vein should be dissected off the structures to be included in the surgical specimen. This is somewhat less important in cases of chronic pancreatitis where a malignancy is not the primary concern. It must be remembered that important variations in the hepatic arterial anatomy, including a replaced right hepatic artery, may be encountered during this dissection. If the appropriate plane is found along the anterior surface of the portal vein, it is often possible to pass the index finger of the left hand on top of the vessel posterior to the first portion of the duodenum and the neck of the pancreas (because usually there are no veins joining the anterior surface of the portal vein). If this maneuver proves difficult, which is not uncommon in cases of chronic pancreatitis because of adherence of the fibrotic pancreas gland to the SMV and portal vein, the gastroduodenal artery should be identified where it originates from the common hepatic artery. Once adequate dissection has been carried out, the artery should first be clamped with a nonoccluding vascular clamp, then, if the hepatic artery pulse is preserved, divided and ligated with 2-0 silk ties. (The initial clamping of the gastroduodenal artery with a vascular clamp confirms that the arterial supply to the liver will not be interrupted should either variations in hepatic arterial anatomy or important collateral circulation be present in the face of celiac artery stenosis.) After the artery has been divided and ligated, an additional ligature of 3-0 polypropylene should be placed on the proximal stump. Division of the gastroduodenal artery unroofs part of the tunnel through which the index finger is slipped, thereby greatly facilitating the separation of the portal vein from the posterior aspect of
the first portion of the duodenum and the neck of the pancreas.

Once the anterior surface of the portal vein has been dissected posterior to the neck of the pancreas, the next step is to identify the SMV and dissect its anterior surface. This is most easily accomplished by extending the Kocher maneuver past the second portion of the duodenum to include the third and fourth portions. During this extensive kocherization, the first structure encountered anterior to the third portion of the duodenum is the SMV. The anterior surface of the vein can then be cleaned and dissected under direct vision by retracting the neck of the pancreas anteriorly. This dissection is continued until it connects to the portal vein dissection from above.

In a PPPD, the duodenum is first mobilized and divided <2 cm distal to the pylorus with a gastrointestinal anastomosis (GIA) stapler. The posterior surface of the proximal first portion of the duodenum is dissected until the lesser sac is entered. At this point, the soft tissue attachments from the inferior border of the duodenum to the inferior border of the pancreas are divided. The right gastroepiploic vessels, which can be sizable, are clamped, divided, and ligated. In a similar fashion, the soft tissue areolar attachments found superiorly are divided with the electrocautery. The right gastric artery, which originates from the common hepatic artery, is also ligated.

In a classic Whipple procedure, an antrectomy is performed. The right gastroepiploic arcade and the right gastric vessels are divided to permit mobilization of the antrum. The stomach is then divided with a GIA stapler, usually at the level of the incisura. At this point, if the gastroduodenal artery was not divided earlier, it is identified, divided, and ligated as described (see above). During this step, particular care must be taken to ensure that the lumen of the common hepatic artery is not encroached on by one of the proximal ties.

The neck of the pancreas is then divided with the electrocautery, with care taken not to injure the underlying SMV and portal vein. The head of the gland is then reflected to the right and head and the uncinate process of the pancreas is dissected away from the portal vein and SMV. In the patients with chronic pancreatitis, this dissection can again be difficult because of adherence between the fibrotic gland and the SMV. Great caution must be taken for all dissection around the SMV and portal vein to prevent a major vascular injury and subsequent hemorrhage. If a replaced right hepatic artery is present, its origin from the superior mesenteric artery (SMA) will be encountered at this point and must be preserved. The uncinate process can then be divided between clamps flush with the SMA, then ligated with 2-0 silk ties; alternatively, either an energy-based vessel-sealing system or ultrasonic shears may be used. The SMA is completely exposed during this dissection, which proceeds from cephalad to caudad, as shown in Figure 2. Unlike PPPD for cancer, the extent of this dissection, and therefore the inclusion of the lymphatic tissue adjacent to the SMA, is less critical in the patients with chronic pancreatitis. As a rule, there are two large veins joining the SMV inferiorly that must be dissected free, doubly ligated, and divided.

Once the uncinate process has been completely divided, the specimen is attached only by the third portion of the duodenum. At this point, the upper abdomen is copiously irrigated with an antibiotic solution and packed. The transverse colon, along with the greater omentum, is reflected cephalad. The proximal jejunum and the ligament of Treitz, along with the fourth portion of the duodenum, are dissected free, and the dissection is continued until it meets the right-side upper abdominal dissection. At a convenient point where there is a wide vascular arcade, the proximal jejunum is divided with a GIA stapler <10 to 12 cm distal to the ligament of Treitz. The proximal jejunum is then grasped with a Babcock clamp and retracted cephalad. The mesentery to the proximal jejunum is divided between clamps and ligated with 2-0 silk suture (or divided with a vessel-sealing energy device). Alternatively, dividing the jejunum early, before dividing the uncinate process, can help with retraction and exposure especially in the face of local inflammation.