The surgeon and the instrument nurse stand on the right side of the patient. The first assistant is on the left side of the patient.

• Intravenous antibiotics should be given prior to skin incision. 
• Octreotide administration depends on surgeon preference.
• Colonic bowel preparation is not necessary unless colonic resection is planned.
• Vascular surgeons should be consulted earlier and alerted in case of potential vascular resection and reconstruction.

Pancreaticoduodenectomy (PD) is performed using vertical midline incision or with a bilateral subcostal incision. A self-retaining retractor is applied. The first step of pancreaticoduodenectomy is a thorough assessment of the extent of disease to determine the resectability. Staging laparoscopy is currently widely used to determine the resectability, and it either could be done as a separate procedure or performed together with PD. The entire liver is assessed and palpated for the possible presence of metastases. Any suspicious findings on the liver but indeterminate on palpation could be evaluated by intraoperative ultrasound. The parietal and visceral peritoneal surfaces, the ligament of Treitz, the omentum, and the entire small and large intestine are examined for the presence of metastasis. The celiac axis is inspected for lymph node involvement. Any suspicious looking lymph nodes outside the planned field of dissection are sent for frozen section. PD is not performed if the biopsy is positive for metastatic cancer. The porta hepatis is inspected by mobilizing the gallbladder and dissecting the cystic duct down to the junction of the common hepatic and common bile duct. The proper hepatic artery and common hepatic artery are assessed for any presence of tumor tissue.

Kocher maneuver is performed by elevating the duodenum and head of the pancreas out of the retroperitoneum. Cattell-Braasch maneuver (extensive mobilization of the entire right colon and small bowel mesentery) is usually not necessary except for mobilization and resection of SMV or if the tumor extends into the 4th part of duodenum.[23]

The gallbladder dissected from the liver, and the distal common hepatic duct is divided close to the level of the cystic duct entry site. The proximal bile duct is left without a clamp to avoid crush injury, and the distal bile duct is clamped or sutured to prevent the spillage of the bile and tumor cells. The bile duct is retracted caudally, and portal dissection continued at the anterior aspect of the portal vein. During these maneuvers, the portal structures should be assessed for a replaced right hepatic artery and should be protected. If the patient appears to have an accessory right hepatic artery and a significant native right hepatic artery, the accessory vessel can often be taken without consequence. The gastroduodenal artery is ligated to minimize the chance of erosion and bleeding. The division of the gastroduodenal artery also helps to expose the anterior surface of the portal vein and facilitates the dissection of the portal vein behind the pancreatic neck. The surgeon identifies the portal vein above the neck of the pancreas and SMV inferior to the neck of the pancreas. Blunt dissection downwards along the portal vein is aimed to create a plane in front of the portal vein and behind the neck of the pancreas. This plane is crucial in the surgery, and if one is unable to create a clear plane between the portal vein and the neck of the pancreas, the surgery should be aborted.

Extensive Kocher maneuver should reveal the SMV inferior to the neck of the pancreas. The superior mesenteric vein runs anterior to the third part of the duodenum and surrounded by adipose tissue as it receives tributaries from the uncinate process and neck of the pancreas, the greater curve of the stomach, and from the transverse mesocolon. Two ways of identifying the superior mesenteric vein are by following the middle colic veins to their juncture with the superior mesenteric vein or by tracing the course of the right gastroepiploic vein to the point at which it meets the superior mesenteric vein immediately below the inferior border of the pancreas. The plane anterior to the superior mesenteric vein is created under direct vision, and the splenic vein is preserved. The junction between the PV and SMV should be clearly visualized.

The vascular resection is performed if necessary. The segmental resection of the portal vein or superior mesenteric vein is usually done with the help of vascular surgeons. The vascular defect can be closed with primary repair, patch closure, or using an autologous graft (internal jugular vein, left renal vein, splenic vein, or greater saphenous vein) or with a synthetic graft (PTFE). The reconstructed portal vein should be followed up regularly postoperative for the risk of portal vein thrombosis. 

For the Whipple procedure, antrectomy is performed by dividing the right gastric and right gastroepiploic arteries and dividing the antrum with a linear stapler. The pylorus is preserved in a pylorus-preserving pancreaticoduodenectomy in which the proximal GI tract is divided 2 to 3 cm distal to the pylorus with a linear stapling device. The jejunum is divided between 15 to 20 cm distal to the ligament of Treitz and brought in dorsal to the superior mesenteric vessels from the left to the right side. A Penrose drain is looped under the neck of the pancreas in the created tunnel to elevate the neck of the pancreas and protect the underlying portal vein. The pancreatic neck is then divided using electrocautery after confirming a free plane anterior to the portal and superior mesenteric veins. Stay sutures are placed superiorly and inferiorly on the pancreatic remnant to reduce bleeding from the segmental pancreatic arteries running in those locations.

The specimen remains only connected by the uncinate process of the pancreas. It is separated from the portal vein, superior mesenteric vein, and superior mesenteric artery. This is performed by serially clamping, dividing, and tying the smaller branches off the portal and superior mesenteric vessels. The specimen is removed en-bloc with the pancreatic neck margin, uncinate margin, and common hepatic duct margins are marked for the pathologists. The common hepatic duct margin and the pancreatic neck margin are essential and may be sent earlier for frozen section analysis to determine the extent of further resection. After the removal of the specimen, metal clips are placed at the margins of the resection field to target postoperative radiation therapy. There are various methods available for reconstruction after pancreaticoduodenectomy. Standard reconstruction involves the pancreatic anastomosis (PA) first, followed by the bile duct, and finally, the duodenum to establish the GI continuity.

PA is the most critical step in pancreaticoduodenectomy and meticulous care given during this procedure to reduce morbidity. Either jejunum or stomach can be used for the reconstruction of the pancreatic anastomosis. There are two ways of constructing PA: duct to mucosa anastomosis or invagination technique. For the pancreaticojejunostomy, the duct to mucosa anastomosis is constructed between the end of the pancreatic duct remnant and side of jejunum in a retrocolic fashion. For the invagination technique, the pancreatic duct is junked into the jejunum. The techniques of pancreaticojejunostomy are diverse such as modified Blumgart, modified Kakita, binding pancreaticojejunostomy anastomosis, and so one. The variety of these techniques help to improve the rate of pancreatic fistula formation, but there is no single superior technique.[24] The reconstruction is then followed by end-to-side hepaticojejunostomy, which is performed 10 to 15 cm distal to pancreaticojejunostomy with interrupted single layer synthetic absorbable suture. The third anastomosis performed is the gastrojejunostomy in patients who have undergone classic pancreaticoduodenectomy with distal gastrectomy or duodenojejunostomy in cases of pylorus preservation. This anastomosis is typically performed 10 to 15 cm downstream from the hepaticojejunostomy, proximal to the jejunum traversing the defect in the mesocolon.

After the reconstruction is completed, closed suction drains are placed at Morrison pouch and in the vicinity of the pancreatic and biliary anastomosis. A feeding jejunostomy is usually not needed and depends on the surgeon’s preference. The postoperative management includes keeping the patient with nothing by mouth for day 1 and advancing with clear liquids and then gradually to a low-fat diet in frequent small feeds. The stomach is decompressed overnight after surgery with a nasogastric tube, which is usually removed the next morning if there is no high output. The drains are removed gradually once the output is minimal, there is no evidence of pancreatic fistula, and the patient is tolerating a normal diet.

• Delayed gastric emptying, defined as the inability to discontinue nasogastric tube and inability to tolerate a solid diet after the surgery[25]
• Pancreatic fistula, defined as drain output on postoperative day 3 or beyond with an amylase content that is more than three times the upper limit of serum amylase.[26]
• Postpancreatectomy hemorrhage[27]
• Wound infection[27][28]
• Intra-abdominal abscess[29]

Pancreatic cancer is the fourth common cause of cancer death, and its 5-year survival rate is only about 12 percent despite the advancement in medical care, chemotherapy, radiotherapy, and molecular biology.[30][31] The pancreaticoduodenectomy is the only curative treatment. The late diagnosis of cancer because of the lack of concrete symptoms makes this cancer as one of lethal cancer. There is an urgent need to find diagnostic markers to detect pancreatic cancer in the early stage.

The morbidity and mortality associated with pancreaticoduodenectomy and its complications are high. Due to the high morbidity associated with this procedure, a more vigilant postoperative care becomes imperative. High suspicion and early detection of the postoperative complication is the critical factor in the care of the patient. Physicians, nurses, and the entire team should be adequately educated, and the organized team approach for patient care must be implemented. 

The involvement of an interprofessional team in the management of cancer patients is of the essence, and pancreatic cancer is no exception. The success of pancreaticoduodenectomy depends on a meticulous selection of surgical patients for resectability using a CT of the abdomen with the pancreas protocol. The nurses, physiotherapists, counselors, oncologists play a crucial role in delivering optimum care to the cancer patient.

Dietary assessment and artificial enzyme replacement therapy should be the standard of care in surgical patients. If left untreated exocrine insufficiency results in severe nutritional deficit. Whenever possible, enteral nutrition is preferred over parenteral. Patients should be monitored to assess pancreatic insufficiency, either endocrine or exocrine. Fecal elastase-1 is a rapid test to detect exocrine insufficiency but it has a low sensitivity and specificity.[32] 

Nurse care is directed to the proper assessment of weight, general pain, and symptoms, vital signs. The patient must be monitored for weight loss, liquid balance, nausea, fecal, and urine color. Due to the forced loss of pancreatic enzymes, it is crucial to evaluate the presence of fatty stools to ensure proper adjustment of lipidic intake together. A medical-nursing team should ensure a proper evaluation of dietary balance before and after surgical treatment.[33][34]