Dr. Ihab Samy
Lecturer of Surgical Oncology
National Cancer Institute
• The pancreas was first mentioned in the
writings of Eristratos (310-250 bc) and given
its name by Rufus of Ephesus (circa 100 ad).
• The name pancreas (Greek pan, all; kreas,
flesh or meat) was used because the organ
contains neither cartilage nor bone.
Location And Gross Description
• The pancreas lies transversely in the retroperitonium
across the posterior wall of the abdomen, at the back of
the epigastric and left hypochondrial region , between the
duodenum on the right and the spleen on the left.
• It is related to the omental bursa above, the transverse
mesocolon anteriorly, and the greater sac below. For all
practical purposes, the pancreas is a fixed organ.
• It is long and irregularly prismatic in shape. Its length varies
from 12.5 to 15 cm., and its weight from 60 to 100 gm
Parts Of The Pancreas And Their Relations
• Traditionally, the pancreas has 4 parts.
• The right extremity, being broad, is called the
head, and is connected to the main portion of
the organ, or body, by a slight constriction, the
neck; while its left extremity gradually tapers
to form the tail.
• The posterior surface may be related to the
third part of the common bile duct (CBD) in a
variety of ways:
• The bile duct is partially covered by a tongue
of pancreatic tissue (44 %).
• The bile duct is completely covered (30 %).
• The duct is uncovered in (16.5 %) of cases .
• The (CBD) is covered by two tongues of
pancreatic tissue (9%) of cases.
• Is a hook-like extension of the head of the
pancreas and is highly variable in size and shape.
• It passes downward and slightly to the left from
the principal part of the head.
• It further continues behind the superior
mesenteric vessels and in front of the aorta and
inferior vena cava, with the left renal vein above
and the 3rd part of duodenum below.
Pancreatic Ductal Anatomy
• The main pancreatic and accessory ducts lie in
an anterior plane to the major pancreatic
• The main pancreatic duct (Wirsung) arises in
the tail of the pancreas and lies between the
superior and inferior borders, slightly closer to
the superior border, and lies in a more
posterior than an anterior plane.
• There are 15 - 20 short tributaries that enter the
duct at right angles.
• In addition, the main duct may receive a tributary
draining the uncinate process. In some
individuals, the accessory pancreatic duct
empties into the main duct.
• After entering the head of the pancreas, it turns
inferiorly and posteriorly. In the lower part of the
head of pancreas, it joins the distal end of (CBD)
forming the hepatopancreatic ampulla (Vater),
which enters the descending part of the
duodenum at the major duodenal papilla.
• Its length varies from 175 to 275 mm.The diameter is
greatest in the pancreatic head at 3 to 4 mm and
decreases to 1 to 2 mm in the tail.
• The accessory pancreatic duct (Santorini) (absent in
15%-30% of individuals) empties into the duodenum
just above the major duodenal papilla at the minor
• In 11% of cases the main duct is suppressed and loses
its connection to the accessory duct (pancreas
• The pancreatic duct and (CBD) may open separately in
Ampulla of Vater
The ampulla is a dilatation of the common
pancreatico-biliary channel adjacent to the
major duodenal papilla and below the junction
of the two ducts.
According to Michels’ Classification there are 3
• Type 1: The pancreatic duct opens into the CBD
at a variable distance from the opening in the
major duodenal papilla. The common channel
may or may not be dilated (85 %).
• Type 2: The pancreatic and bile ducts open near
one another, but separately, on the major
duodenal papilla (5%).
• Type 3: The pancreatic and bile ducts open into
the duodenum at separate points (9%)
• The major duodenal papilla: is a nipple-like projection of the
duodenal mucosa through which the distal end of the ampulla of
Vater passes into the duodenum.
It lies on the posteromedial wall of the second portion
of the duodenum, 7 to 10 cm from the pylorus.
• The minor duodenal papilla: lies about 2 cm cranial and slightly
anterior to the major papilla. It is smaller and its site lacks the
characteristic mucosal folds that mark the site of the major papilla.
Its opening is guarded by muscular and elastic fibers (sphincter of
Helly), which is not a typical anatomical sphinter
Sphincter of Oddi
It is the sphincter of the pancreatico-biliary channel which is a
circular smooth muscle complex largely within the duodenal
wall. It is made up of four different sphincters:
1. The sphincter pancreaticus encircling the pancreatic duct
2.3.The superior and inferior choledochal sphincters around
the bile duct
4. the sphincter ampullae around the ampulla.
Pancreatic Vascular Anatomy
• the body and tail are supplied by branches of
the splenic artery.
• Whereas the head and uncinate process
receive their supply through arcades
originating from the gastro-duodenal artery
(GDA) of hepatic artery of the celiac trunk and
from the inferior pancreatico –duodenal artery
, the first branch of the superior mesenteric
The Anterior Pancreatic Arcade
• On the anterior surface of the head ,supplying
it together with the concave surface of the
• It is formed by the anastomosing branches of
two main arteries: The (GDA) and the anterior
inferior pancreatico-duodenal (AIPD) artery.
Gastro-duodenal artery (GDA)
• One of the two terminal branches of the common hepatic
artery branch of the celiac trunk .
• It may give off supra-duodenal and retro-duodenal arteries
before descending posterior to the superior part of the
• Reaching the lower border of the superior part of the
duodenum, the (GDA) divides into its terminal branches,
the right gastro-omental artery and the superior
pancreatico-duodenal artery which further divides into
anterior superior pancreatico-duodenal (ASPD) artery and
posterior superior pancreatico-duodenal (PSPD) artery.
The posterior Pancreatic Arcade
• It lies on the posterior surface of the head
supplying it together with the anterior and
posterior surface of the 2nd part of the
duodenum. It passes posterior to the intra-
pancreatic portion of the CBD.
• It is formed by anastomosis of (PSPD) artery and
the posterior inferior pancreatico-duodenal
• The largest branch of the celiac trunk.
• Gives off numerous small branches to supply the
neck, body, and tail of the pancreas.
• The dorsal pancreatic (DP) artery : is the first
major branch of splenic artery usually joins one
of the postero-superior arcades after giving off
the inferior (transverse) pancreatic artery to the
• The inferior (transverse) pancreatic artery: is a
collateral vessel runs within the pancreas and usually is
formed by the left branch of the artery for the neck
and/or the (DP) artery.
• The great pancreatic artery of Von Haller (pancreatica
magna): arises from the splenic artery near the
junction of the body and tail. It may anastomoses with
the inferior pancreatic artery.
• The caudal pancreatic artery : arises from the distal
segment of the splenic artery. It anastomoses with
branches of the great pancreatic and other pancreatic
Major arterial supply to
• The large artery for
• The medium-sized
artery for the body
• The smaller arteries
for the tail all
from splenic artery
with the transverse
• The venous drainage of the head of the
pancreas and duodenum: is via an anterior
and a posterior arcade termed the (ASPD) and
(AIPD) veins and the (PSPD) and (PIPD) veins.
• The (PSPD) vein commonly drains directly into
the portal vein near the superior border of the
pancreas after crossing anterior to the bile
• The (ASPD) vein drains directly into the gastro-colic trunk
which is formed by the confluence of the right gastro-
epiploic vein and middle colic vein.
• The gastro-colic trunk then joins the superior mesenteric
vein (SMV) just below the neck of the pancreas.
• The veins of the neck, body, and tail of the pancreas: form
two large venous channels, the splenic vein above and the
transverse (inferior) pancreatic vein below.
• The splenic vein receives from 3 to 13 short pancreatic
tributaries. The inferior pancreatic vein may enter the left
side of the (SMV), the inferior mesenteric vein (IMV) , or
occasionally the splenic or the gastro-colic veins.
The standard regional lymph nodes draining the
head and neck of the pancreas include:
• Along the (CBD)
• Common hepatic artery
• Portal vein
• Posterior and anterior pancreatico-duodenal
• Along the superior mesenteric vein
• Along right lateral wall of the superior mesenteric
• Those draining the body and tail lie along the
common hepatic artery, celiac axis, splenic
artery, and splenic hilum.
• According to their relation to the pancreas ,
regional lymph nodes are described in five
1. Superior nodes
2. Inferior nodes
3. Anterior nodes
4. Posterior nodes
5. Splenic nodes
Classic Pancreaticoduodenectomy (PD)
• In 1898 ,Halsted performed the first local excision
of carcinoma of ampulla of Vater.
• In 1909, the first successful regional resection of
a periampullary tumor was performed by Kausch.
• He performed the operation as a 2-stage
procedure in which a cholecystojejunostomy was
performed 6 weeks before the second operation.
• Resection of periampullary tumor was
popularized in a 1935 article by Whipple and
• Their 2-stage pancreatoduodenectomy consisted
of posterior gastroenterostomy, ligation and
division of the common bile duct and
cholecystogastrostomy in the first stage, followed
by resection of the duodenum and pancreatic
head in the second stage.
• The pancreatic stump was closed with sutures,
without a pancreaticoenteric anastomosis.
• Whipple later completed the whole procedure
in a single stage in 1940, and the
reconstruction was modified in 1942 to
include pancreaticojejunostomy, as he found a
high rate of pancreatic fistula after closure of
(A) Resectable neoplasms of the head and uncinate process as well as peri
ampullary cancers have the following CT characteristics:
1-Normal fat plane between the low-density tumor and the superior
mesenteric artery and superior mesenteric vein (SMV).
2-Absence of extrapancreatic disease.
3-Patent Superior mesenteric-Portal vein (SMPV) confluence (assumes ability
of the surgeon to resect and reconstruct isolated segments of the SMV or
4-No direct tumor extension to the celiac axis or SMA.
(B) “Borderline” resectable neoplasms include:
• 1-Short segment occlusion of the SMPV confluence with an adequate
vessel for grafting above and below the site of occlusion (assumes the
technical ability to resect and reconstruct the SMV or SMPV).
• 2- Neoplasms which demonstrate short-segment (usually <1cm) abutment
of the common or proper hepatic artery or the SMA on high-quality CT.
• Extrapancreatic metastatic disease
• Neoplasms encasing the celiac axis or SMA
(anything more than short-segment
Pylorus –Preserving Pancreaticoduodenectomy
• Gastric dumping syndromes, gastritis, and
ulcerations due to bile reflux, led to the
introduction of the pylorus-preserving
modification of the classical PD.
• Introduced by Kenneth Watson in the 1940s, the
(PPPD) was not frequently used until it was
popularized in 1978 by Traverso and Longmire.
• Small periampullary neoplasms (it should not
be performed in patients with bulky
neoplasms of the pancreatic head).
• In cases where tumor involves the first or second
part of duodenum or distal stomach.
• Lesions associated with grossly positive pyloric or
peripyloric lymph nodes.
• Also in cases of peri ampullary lesions associated
with hereditary syndromes like familial polyposis
coli due to the high risk of malignant
transformation within the duodenal remnant due
to genetic field change throughout the
• Some retrospective studies showed benefits with
regard to digestive function (prevention of gastric
dumping and reflux biliary gastritis) and quality of life
for the PPPD.
• No survival disadvantages or advantages were found by
other trials, either retrospective or prospective
• Eventually, many studies showed that there are no
differences in postoperative rates of delayed gastric
emptying (DGE) between PD and PPPD, although DGE
had been cited as a disadvantage of PPPD before.
• The technique for distal pancreas resection
was first outlined by Mayo in 1913.
• Indicated for tumors of the body and tail of
• Tumors of the body and tail, have fewer
clinical symptoms, tend to be diagnosed later.
Forms of Distal Pancreatectomy
-Classic distal pancreatectomy with splenectomy
-DP with splenic preservation.
-DP with multi-organ Resection
• Diabetes mellitus (DM) occurs in 20% of patients
following distal pancreatectomy.
• Higher pancreatic fistula rates than pancreatico-
duodenectomies (usually heal with external drainage)
• Centrally placed benign or low-malignant-
potential lesions specially in the neck of the
• Alternatively known as middle segmental
pancreatic resection, median pancreatectomy,
central pancreatectomy, or intermediate
• Involves removal of the lesion with adequate
margins on either side, the procedure being
guided by intraoperative frozen-section analysis.
Extended pancreatic resections
• En bloc resection of the pancreas and
surrounding organs, along with a retroperitoneal
lymph node dissection.
• Extended resections may include:
1. Total pancreatectomy (TP)
2. Extended lymph node dissection (ELND)
3. Arterial/venous resections with reconstruction
1. Total pancreatectomy (TP)
• Allows for more extensive lymphadenectomy.
• Obviates possible leak from the pancreatic anastomosis
• Decreases the chances of a positive cut margin.
• Obligate diabetes mellitus.
• Decreased immunity because of splenectomy.
• Loss of pancreatic exocrine function.
• worse survival.
2. Extended lymph node dissection (ELND)
• In addition to removal of the pancreaticoduodenal
nodes, removal of lymph nodes along the hepatic artery,
superior mesenteric artery, celiac axis, and between the
aorta and the inferior pancreaticoduodenal artery.
• Furthermore, the anterolateral aspect of the aorta and
the inferior vena cava are also dissected.
• The Japanese demonstrated improved survival rates with
extended surgery. Further studies comparing SL with
ELND showed no survival difference adding to increased
morbidities following ELND.
3. Arterial/venous resections with reconstruction
Vascular resections can be performed based on
• Firstly, to achieve negative resection margins
in case of vessel invasion by the tumor or
adhesion of the vessel to the tumor, making
• Secondly, it can be performed as part of an
extended pancreactectomy with ELND.
• Vein resections include that of the portal vein
(PV), superior mesenteric vein (SMV), or the SMV-
• Venous resections followed by graft
reconstruction can be performed without
increased morbidity and mortality and may be
performed to achieve negative resection margins.
• In contrast, arterial resections of the mesenteric,
celiac, and hepatic arteries are rarely performed
and are considered by most as contraindicated in
PD due to the greatly increased morbidity and
Laparoscopic pancreatic resections
The morbidity of the Whipple's operation is not
related to the length of the abdominal incision but to
the extensive nature of the actual intra-abdominal
At present there is no worthwhile evidence to suggest
that laparoscopic Whipple's is better than open
This procedure may be performed by highly trained
surgeons, in high-volume dedicated centers, and that
too within the context of good clinical trials.
• On the other hand, laparoscopic DP may well
provide a distinct advantage over open
surgery in the near future in highly selected
small tumors of the body and tail.