Specimen Handling, Whipple

 May or may not include pylorus, depending on whether it was pylorus-sparing procedure

• Ampulla of Vater

• Common bile duct

• Pancreas

Anatomic Orientation

• Duodenum
image Free proximal end usually shorter than free distal segment

image Small portion of stomach usually attached to proximal end

image Distal end may be either duodenum or jejunum

• Common bile duct
image Sometimes green in color

image Posterior and superior to pancreas

image May be easier to identify from ampulla than from transected end

image If gallbladder is present, can identify insertion of cystic duct and follow to common bile duct

• Ampulla of Vater
image Usually obvious within duodenum, unless obscured by tumor

image Some patients have accessory ampulla that drains accessory duct of Santorini

• Pancreas
image General anatomic features
– Retroperitoneal organ located in C-groove of 2nd part of duodenum

– Anterior to pancreas is free space (omental bursa/lesser sac), and then posterior aspect of stomach

image Anatomic divisions of pancreas
– Head: To right of superior mesenteric vein/portal vein confluence; includes uncinate process

– Neck: Constricted region to left of head

– Body: Between superior mesenteric vein/portal vein confluence and aorta

– Tail: Between aorta and splenic hilum

image Pancreatic duct
– Usually main pancreatic duct drains bulk of gland into duodenum at major duodenal papilla (ampulla) along with common bile duct

– Normal diameter is < 1 cm

Specimen Handling

• Identify proximal end of duodenum
image Usually shorter than distal end

• Head of pancreas sits in duodenal C-loop
image Neck margin can be identified as oval-shaped transected pancreatic surface with central duct

• Determine anterior vs. posterior pancreatic surface
image Anterior pancreatic surface bulges

image Posterior pancreatic surface is flat
– Common bile duct is superior to pancreas near 1st part of duodenum

• Adsay trapezoid method of orientation
image Useful method to identify essential margins/surfaces

image Place proximal intestinal margin to left, distal intestinal margin to right, and medial aspect of pancreas facing toward you

image Visualize trapezoid
– Left nonparallel side represents pancreatic neck margin

– Right nonparallel side is uncinate margin

– Space between sides is vascular groove

– Anterior surface is base, and posterior surface is parallel opposite side

• Hand method of orientation
image Curled left hand resembles pancreas enveloping superior mesenteric artery and portal vein

image Thumb is uncinate process; flat fingers are neck, body, tail

Surgical Margins

• Common bile duct (shave margin)
• Pancreatic resection (shave margin to include duct)

image CAP calls this distal margin

image AJCC calls this pancreatic neck margin

• Uncinate/retroperitoneal (perpendicular margin)
image CAP: Uncinate

image AJCC: Retroperitoneal

image Should be inked, sectioned perpendicularly, and entire area submitted

image Additional lymph nodes often found if this method is used

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Apr 20, 2017 | Posted by in PATHOLOGY & LABORATORY MEDICINE | Comments Off on Specimen Handling, Whipple

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