GROSSING OF WHIPPLE'S SPECIMEN/ PANCREATICODUODENECTOMY SPECIMEN

1. GROSSING OFWHIPPLE’S
SPECIMEN
PRESENTOR: DR. POOJA DWIVEDI
M.B.B.S., M.D.(PATHOLOGY)
(FIRSTYEAR JUNIOR RESIDENT)
DEPTT. OF PATHOLOGY K.G.M.U. LUCKNOW

2. INTRODUCTION
Whipple’s procedure-Pancreaticoduodenectomy
•It’s a radical surgery for operable neoplasms of –
a) Periampullary region
b) Head of pancreas
c) Common bile duct
d) Ampulla of vater
e) Duodenum

3. BASIC APPROACH FOR GROSSING OF
WHIPPLE’S SPECIMEN
• A pathologist must master these few basic things for grossing of
whipple’s specimen:
a. Types of specimens
b. Components of whipple’s specimen
c. Surgical anatomy
d. Orientation of specimen
e. Surgeon’s preference and requirement of sections
f. Proper Grossing and Dissection
g. Sampling

4. TYPES OF SPECIMENS
•Two types of surgical specimens commonly received
for tumours in ampulla, CBD or head of pancreas:
1. Standard Kausch-Whipple’s
pancreaticoduodenectomy specimen
2.Pylorus preserving pancreaticoduodenectomy
(PPPD)

5. WHIPPLE’S SPECIMEN : COMPONENTS

6. SURGICAL ANATOMY
•C-Loop: Head of pancreas
cradled by C – loop of
duodenum.
•Proximal end: formed by
stomach (or without stomach in
pylorus preserving
pancreaticoduodenectomy).
•Distal end: formed by
duodenum/ jejunum.

7. Surgical anatomy contd…
A.Relationship of pancreatic head and superior
mesenteric vessels
B.Pancreatic head surfaces
1. Anterior pancreatic surface
2. Posterior pancreatic surface
3. Pancreatic neck cut end / surface
4. SMV surface (Medial margin)
5. SMA surface (Retroperitoneal margin / uncinate margin)

8. RELATIONSHIP OF PANCREATIC HEAD AND
SUPERIOR MESENTRICVESSELS

9. Contd…
•Important criteria for tumor resectability-
Absence of invasion of these blood vessels
by the pancreatic head tumor.
•‘SMV GROOVE’
•Course of SMA
•Retroperitoneal margin/ uncinate margin/ SMA surface
formed by sharp dissection

10. SMA And SMV Relationship to Uncinate Process

11. PANCREATIC HEAD SURFACES
1.Anterior Pancreatic Surface: peritoneum-lined
surface.
2.Posterior Pancreatic Surface: fibrous surface,
formed due to peeling off the pancreas from
aortocaval groove per-operatively.
• Anterior surface is buldging & posterior surface is
flat and smooth.
•Anterior and posterior surfaces are anatomic
surfaces, not true resection margins.

12. Contd…
3.Pancreatic Neck Cut End/ Surface:
•On medial aspect.
•Between anterior and posterior
pancreatic surfaces.
•Sharp plane created when
pancreatic head is divided from
pancreatic body.
•Identified by presence of pancreatic
duct within it.

13. Contd…
4.SMV Surface (Medial Margin):
•A shallow curvilinear groove which reflect tract of SMV.
•Between anterior and posterior surface of pancreatic
head.
•Beneath pancreatic neck cut margin.
5.SMA Surface (Retroperitoneal Margin/ Uncinate
Margin):
•Triangular area of rougher texture that in vivo faces SMA.

14. PANCREATIC HEAD SURFACES

15. How to orient theWhipple’s specimen?

16. ORIENTATION OF SPECIMEN
Duodenal C-loop.
Two features of duodenum can be used to identify its
proximal and distal end-
i. Free proximal end is always shorter than free distal
segment of resected duodenum.
ii. A small part of the stomach is occasionally attached to
proximal end.
Identify the Bile Duct: recognised by its greenish colour and
tubular appearance.
Remaining component of pancreas can be identified using
duodenum and bile duct as guide.

17. WHIPPLE’S SPECIMEN: AnteriorView

18. WHIPPLES SPECIMEN: Posterior view

19. Look for common bile duct…

20. Probing of Common Bile Duct…

21. GROSSING AND DISSECTION
STEPS IN GROSSING:
1.State the type of specimen
2.Identification and orientation
3.Record the dimensions of -
• Stomach along greater and lesser curvature.
• Duodenum.
• Pancreatic head in all three dimensions.
• CBD (length, diameter and wall thickness of the stump).
• Gall bladder.

22. Contd…
4.Document presence and absence of stent or a named
vessel (e.g. portal vein, SMV) if any.
5.Examine external surface of specimen for any
abnormality.
6.Remove all staples.
7. INKING OF SPECIMEN:
Ink the different external surfaces of the
pancreas using multicolour inking.

23. MULTICOLOUR INKING OF PANCREATIC
SURFACES
•Orange: Anterior
Surface
•Green: Medial/ SMV
Surface
•Black:
Retroperitoneal/ SMA
Surface
•Blue: Posterior Surface

25. DISSECTION
8. Open the stomach along the
greater curvature of stomach
Continuing along the anterior
Wall of pylorus and outer
curvature of duodenum.
9. Look for and document
macroscopic appearance
and dimensions of any-
• Duodenal masses
• Duodenal ulcers
• Area of puckering of duodenal mucosa

26. 10.Examine the ampullary region and adjacent
duodenum for presence of any tumour/ lesion.
11. Before fixation transection margins are taken.
12. Make serial cuts in the pancreatic head in an axial
plane, perpendicular to long axis of duodenum, to
allow fixation of pancreatic head.
13. Fix the specimen in formalin for 24 to 48 hrs.

27. SERIALLY BREAD LOAFINGTHE PANCREAS

28. 14. Serially slice or
bread loaf the
pancreatic head in an
axial plane from
superior to inferior
surface along the cuts
made previously for
fixation.
Slices should be of equal
thickness, each slice
measuring 3-5mm.

29. 15. Identify the epicentre of the tumour (ampulla,
CBD or head of pancreas).
16. Note tumour size, appearance, extent and
relation to anatomic sites and distance from the
resection margins and surfaces.
17. In case of pancreatic carcinoma determine-
Whether tumour arise in an intraductal papillary
mucinous neoplasm Or in a cystic neoplasm.

30. INTRADUCTAL PAPILLARY MUCINOUS
NEOPLASM V/S CYSTIC NEOPLASM
•Intraductal papillary
mucinous neoplasms
involve the larger duct
system-Pancreatic Duct
and Common Bile Duct
•Involve head of pancreas
more often than tail.
•CYSTIC NEOPLASMS:
2Types
A) Serous cystic neoplasms:
generally benign
B) Mucinous cystic
neoplasms: predominantly
malignant

31. CYSTIC NEOPLASMS
For cystic neoplasms-
1) Describe the character of cyst contents:
*Is the fluid clear or cloudy?
*Is it serous, mucinous, necrotic or bloody?
2) Document whether the cyst is unilocular or multilocular?
*How large are the cysts, and are there any mural nodules?
3) Is the cyst lined by mucinous epithelium?
*If yes, then submit the entire cyst for histologic diagnosis.
4) Document the relationship of the cyst to the pancreatic ducts.

32. 18. Describe the adjacent pancreatic parenchyma,
duodenum and pancreatic duct and CBD.
19. Dissect the surrounding soft tissue for lymph
nodes and record their location.
20. In case if Gall bladder submitted separately,
record their dimension and examine for
abnormality.

33. Sections to be submitted
A.Transection margins
B.Tumor sections
C.Circumferential margins
D.Adjacent duodenum
E.Adjacent pancreas
F.Adjacent CBD
G.Gall Bladder
H.Lymph nodes

34. Sections to be submitted: In detail
A. Transection Margins:
I. Distal duodenum/ jejunal resection margin
II. Proximal duodenum/ Stomach resection
margin
III. Pancreatic neck resection margin
IV. Common bile duct resection margin

35. TRANSECTION MARGINS

36. V. If Portal/ Superior mesenteric vein is removed
en-bloc with whipple’s;
Submit proximal and distal ends of this vessels as
transection margins.
•If a lateral sleeve resection of the vein is included in the
specimen;
then submit the entire edge of vessel.

37. SECTIONSTO BE SUBMITTED

38. Five questions to answer after exposing
various components-
1)Is neoplasm present?
2)If tumour is present, where is it located and what is its possible site
of origin (pancreas, bile duct, ampulla of vater, or duodenum)?
3)What is the size of tumour?
4)What is the gross appearance of neoplasm (solid or cystic)?
5)How many lymph nodes are present and are lymph nodes grossly
abnormal?
Answers to each of these 5 questions will help identify and stage the
neoplasm and document each answer in gross description.

39. B. Tumour:
Minimum of 4 sections which should
include:
•Tumour with ampulla
•Tumour with CBD
•Tumour with duodenum
•Tumour with pancreatic head

40. SINGLE SECTIONTECHNIQUE: A section that we
find particularly helpful is-
Single section parallel to the long axis of bile duct
that includes all in one-
•Duodenum
•Ampulla of vater
•Bile duct
•Pancreas

41. SINGLE SECTION

42. C. Circumferential margins/ surfaces:
I. Anterior pancreatic surface
II. Posterior pancreatic surface
III. SMV surface (Medial margin)
IV. SMA surface (Retroperitoneal/ uncinate margin)
The slices showing tumour closest to inked circumferential
margins/ surface should be chosen for sampling.

43. If no tumour identified- As in post-chemotherapy
specimen, multiple sections should be taken from
areas showing firm to hard areas.
D. Adjacent duodenum
E. Adjacent pancreas
F. Adjacent CBD
G. Gall bladder

44. H. Lymph nodes dissection:
•Infra-pyloric
•Anterior
pancreaticoduodenal
•Posterior
pancreaticoduodenal
•Uncinate
•Anterior
•Posterior
•Inferior
•Superior
•Peri-choledochal
nodes

45. LYMPH NODES DISSECTION

46. WHIPPLE’S GROSSING: Summary

47. AMPULLECTOMY
•Ampulla of vater formed by the confluence of Pancreatic
Duct and Distal Common Bile Duct as they pass through
wall of duodenum and open into duodenal lumen.
•In ampullectomy specimen usually consists of a small
disk of duodenal tissue.
•The underside of disk is composed of transected sections
of the pancreatic and bile ducts.
•Disk itself is traversed by the ducts, and the upper
surface is lined by duodenal mucosa, in the centre of
which is the papilla of vater.

48. •Identify the bile and pancreatic ducts and submit a shave
section of each duct margin.
•Ink the edges of the disc (the duodenal margins).
•Simply bread-loaf the specimen in 2 mm slices along the
axis that best demonstrates the relationship between the
tumour and the duodenal margin it most closely
approaches.
•Document the gross appearance, size, and location of
any masses; then submit the entire specimen for
histologic evaluation.

49. REFERENCES
•Grossing of surgical oncology specimens,TMH, Pg 101-108.
•Adsay et al.Whipple Made Simple For Surgical
Pathologists. AmJ Surg Pathol. 2014 April;38(4): 480–493.
•Sternberg's Diagnostic Surgical Pathology, 6th ed. 2015,
Pg 1770- 1846.
•KimuraW, Futakawa N,Yamagata S,WadaY, Kuroda A,
MutoT, et al. Different clinicopathologic findings in two
histologic types of carcinoma of papilla ofVater.Jpn J
Cancer Res. 1994;85:161–66.

50. Thank You!