A Whipple procedure is usually performed for tumors of the head of the pancreas or of the ampulla of Vater although it may be done for chronic pancreatitis or obstruction. It includes the head of the pancreas, duodenum, distal common bile duct, and may occasionally also include distal stomach and gallbladder.
Identify components of the specimen (the head of the pancreas, distal stomach, duodenum, common bile duct and gallbladder).
Measure each component (stomach, duodenum, common bile duct, gallbladder, and pancreas).
Identify and take the pancreatic and common bile duct margin (cross section).
Dissect lymph nodes while the specimen is unfixed and divide them into the following groups: superior peripancreatic, inferior peripancreatic, anterior pancreaticoduodenal, posterior pancreaticoduodenal, common bile duct and pericystic, lesser curvature, greater curvature.
Ink the distal and posterior retroperitoneal pancreatic margins of resection.
Open the stomach along the greater curvature. Examine for mucosal thickening, ulcers, nodules, hemorrhage, or other abnormalities. Note particularly whether the pancreatic/ampullary tumor invades stomach wall.
Open the duodenum along the lateral border opposite the ampulla of Vater. Examine for ulcers, nodules, and tumors in the wall of the duodenum. If a tumor is present, identify its location, whether it involves either ampulla (primary site, extension from the pancreas, intraampullary, periampullary), and whether it gives rise to obstruction of biliary and/or pancreatic ducts.
Identify the major (Vater) and minor (Santorini) papillae. Probe-open the main pancreatic (Wirsung) duct through the ampulla of Vater. Determine whether these contain any stones or tumor and whether they are dilated.
Bivalve the pancreas into anterior and posterior halves using a sharp knife, going through the pancreatic duct.
Pin the whole specimen to a board, trying to preserve the anatomic relationships. Submerge in formalin and fix for a few hours or overnight if necessary before taking sections.
Serially sectioned the pancreas perpendicularly to the pancreatic duct.
Measure the tumor (three dimensions) and note its relationship to the surrounding ducts, ampullae, duodenum, and other structures and distances from resection margins. Describe the tumor (solid vs. cystic, color, shape, circumscription, ulceration, necrosis).
Examine the uninvolved pancreas for abnormalities (fat necrosis, parenchymal atrophy, fibrosis).
Received without fixative/in formalin, labeled _____ and " _____ " is a Whipple resection specimen including distal stomach, duodenum, head of the pancreas, and common bile duct stump. The stomach is __ cm along the lesser curvature, __ cm along the greater curvature, and __ cm in wall thickness. The duodenum is __ cm in length, __ cm in average circumference, and __ cm in wall thickness. The pancreas is __ cm in length and __ x __ cm in cross-sectional area. The common bile duct stump is __ cm in length and __ cm in diameter at the margin. The posterior pancreatic margin is inked black and the distal pancreatic margin is inked blue. When opened, the gastric and duodenal mucosa shows ____ (e.g. no ulcer, mass, flattening). The ampulla of Vater is identified and the duct is opened to show a ___ cm diameter ampulla (with ____). Serial sectioning of the pancreas reveals a _____ (color, consistency, shape) pancreatic/common bile duct/_____ (peri-) ampullary mass located __ cm from the distal pancreatic/bile duct/duodenal resection margin. The pancreatic duct/bile duct is patent/obstructed by the mass/dilated to __ cm. The mass is __ cm from/infiltrates the ampulla of Vater. The posterior retroperitoneal margin and anterior peritoneal surface are _____ (color, fatty, fibrotic, necrotic), with/without involvement by the mass. The uninvolved pancreas is _____ (color, consistency). Multiple _____ (color, consistency) lymph nodes are identified in the soft tissue around the organs, ranging from __ to __ cm in greatest dimension. Two lymph nodes in the superior peripancreatic soft tissue, __ and __ cm in diameter, respectively, are firm and white-tan. The distal pancreatic, posterior retroperitoneal, common bile duct, gastric, and duodenal margins are inked black. Photographs are taken.