This document discusses different techniques for gross examination of Whipple resection specimens. It describes the components and key steps of the procedure, including orientation of the specimen and identification of structures. Two main dissection methods are covered - axial slicing and bi-valving. Axial slicing is recommended as it allows standardized visualization and accurate margin assessment. Margin status, site of origin, and lymph node examination are important prognostic factors that require assessment.

1. Whipple’s procedure
By- Dr. Annu Khokhar
Guide- Dr. Milind Kesarkhane

4. Types of specimens
 Pancreatoduodenectomy (Whipple resection)
 Median pancreatectomy
 Distal pancreatectomy
 Total pancreatectomy
 Enucleation (excisional biopsy)

5. Pancreatoduodenectomy
(Whipple resection)
 For intra or peri-
ampullary
carcinomas
 Head of pancreas
tumour
 Distal common bile
duct tumours

7. Median pancreatectomy
 Also called central
pancreatectomy
 For body of pancreas
tumours

8. Distal pancreatectomy
 For distal body and tail of
pancreas tumours
 Including neuroendocrine
tumours

9. Total pancreatectomy
 Very rare

10. Enucleation (excisional biopsy)
 For small tumours <2 cm usually
 Benign or isolated tumours

11. Components of Whipple Specimen
• Essential components:
– Duodenum + Head of Pancreas + Common Bile duct
• Additional components:
– Distal stomach, Jejunum and Gall bladder

49. Grossing of Whipple resection – pre requisites
 Check patient details, number of specimens
 Clinical and radiological correlation – site of
primary
 Stenting procedure done earlier
 Neoadjuvant therapy
 Type of surgery done

50. Grossing of Whipple resection
 Orient the specimen
 Identify various structures, resection margins and the pancreatic
surfaces
 Record the dimensions of stomach (greater and lesser curvature),
duodenum, pancreatic head (all three dimensions) and gall
bladder
 Examine outer surface for any abnormality.
 Identify the surfaces and ink them with differential inks.
 Open stomach along greater curvature, pylorus anterior wall and
outer curvature of duodenum

51. • Prognostic factors :-
1. Tumor origin
2. Tumor size
3. Degree of differentiation
4. Lymph node status
5. Resection margin status
• Different guidelines diverge on diagnostic criteria for evaluating the
completeness of resection
• The macroscopic assessment of the site of origin in periampullary
tumors and cystic lesions is influenced by the grossing method

52. Pancreatic ductal adenocarcinoma (red), ampullary carcinoma
(blue), and distal common bile duct carcinoma (green) all
arise within close proximity to one another.
By The University of
Chicago

54. Stomach
Neck margin
Retroperitoneal margin
Duodenum
Anterio
r
surface

55. Stomach
Neck margin
Retroperitoneal margin
Duodenum
CBD margin
Medial
surface
SMV groove

56. Assess for :-
1. Status of surgical margins:
Positive surgical margin is associated with very poor
prognosis and may be given adjuvant CTRT
Median survival rate of patients with positive margin
is the same or worse than that of patients with
unresectable tumors
2. Site of origin and extent of tumour
3. Status of lymph nodes:
One of the most important independent prognostic
factors of survival.
Guidelines recommend examination of at least 12

57. • Margin assessment :-
R0 resection :- > 1 mm margin clearance
R1 resection :-
1. UICC – microscopic residual disease without further
specifying the type of margin
2. Europe and Japan – Tumor cells within 1 mm of
resection margin
3. USA – Tumor cells are present on margin

58. Remove surgical margins :
Essential margins:
1. Common bile duct
2. Pancreatic resection/neck margin
3. Retroperitoneal/uncinate
4. Stomach/duodenum margin
All shaved margins. Retroperitoneal margin should
preferentially be taken radially.

59. Grossing of Whipple resection
 Transection margins taken
before fixation :
 Gastric resection margin
 Duodenal resection margin
 CBD resection margin
 Pancreatic neck resection
margin

60. Pancreatic dissection methods
1. Axial dissection
2. Bi-valving the specimen
3. Bread loafing
4. Slicing perpendicular that follows curvature of
pancreatic head

61. Axial Method :- Slice the specimen perpendicular to
longitudinal axis of duodenum
• Technically easy to perform
• No need for probing or longitudinal opening of the
pancreatic and/or common bile duct
• Pancreatic surface remains intact, facilitating margin
assessment

62. • Applicable to all pancreatoduodenectomy specimens,
irrespective of the pathology encountered
• Fully standardized visualization of the pancreas and related
structures, facilitating identification of anatomic variation and
pathologic change
• Allowing accurate margin assessment along the entire
craniocaudal length of the pancreatic head
• Visualization of the pancreatic head and related anatomy in the
same (axial) plane as on computed tomography imaging,
facilitating pathological-radiological correlation

63. https://www.rcpa.edu.au/Manuals/Macroscopic-Cut-Up-
Manual/Gastrointestinal/Pancreas/Pancreas-resection
Axial dissection

66. Bi-valving Method :- requires probing of main pancreatic
duct and common bile duct
• Beneficial for evaluation for Intraductal lesion
• Provides better yield of lymph nodes
• Difficult to perform
• R1 resection reportedly lower in this specimen
(inadequate sampling of margins and free surfaces )

67. Bi-valving the specimen

68. Bi-valving the specimen

69. Methods of lymph node dissection :-
1. Verbeke :- Extensive perpendicular sampling of pancreas
with surrounding soft tissue
2. Orange peel method :- shaving of all peri-pancreatic soft
tissue after multi colour inking

70. Sections to be submitted
 Tumour – minimum 4
sections:
• with ampulla,
• with CBD,
• with duodenum,
• with pancreatic head

71. Sections to be submitted
1. Transection margins :
• Stomach, duodenum, CBD margin
• Pancreatic neck
2. Circumferential margins :
• Anterior, posterior pancreatic surface
• Retroperitoneal surface and SMV groove
3. Adjacent duodenum, stomach, pancreas
4. Gall bladder sections – cystic duct, wall

72. THANK YOU