Specimen Handling, Whipple



Specimen Handling, Whipple


Laura Webb Lamps, MD

Grace E. Kim, MD








This illustration shows the Whipple (pancreaticoduodenectomy) procedure. Note the common bile duct margin image, the pancreatic margin image, and the intestinal margins image.






This graphic depicts the reanastomoses after a Whipple procedure, including the anastomoses between the small bowel and the stomach image, the pancreas image, and the bile duct image.


WHIPPLE (PANCREATICODUODENECTOMY)


Major Components



  • Duodenum



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


  • Ampulla of Vater


  • Common bile duct


  • Pancreas


Anatomic Orientation



  • 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


  • Common bile duct



    • Sometimes greenish 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


  • Ampulla of Vater



    • Usually obvious within duodenum if not obscured by tumor


    • Some patients have an accessory ampulla that drains accessory duct of Santorini


  • Pancreas



    • 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


    • 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


    • 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 Handing



  • Identify proximal end of intestines



    • Usually shorter than distal end


  • Head of pancreas sits in duodenal C-loop



    • Neck margin can be identified as oval-cut pancreatic surface with central duct


  • Determine anterior vs. posterior pancreatic surface



    • Anterior pancreatic surface bulges


    • Posterior pancreatic surface is flat



      • Common bile duct is superior to pancreas near 1st part of duodenum


  • 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 a 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



    • Curled left hand resembles pancreas enveloping superior mesenteric artery and portal vein


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



Surgical Margins

Jul 7, 2016 | Posted by in PATHOLOGY & LABORATORY MEDICINE | Comments Off on Specimen Handling, Whipple
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