BED SIDE TEACHING

WHIPPLE’S PROCEDURE

Submitted to-Sarita Nadiya madam

Submitted by-Ms.Manisha
ABOUT THE PATIENT
My patient ,pooran Singh,41 yrs,male,presented to OPD with the complaints of
Jaundice(S.Bil-25) from 2 months,c/o dyspepsia,Itching,loss of appetite,loss of
weight(10-15 kg), from 2 months, he is chronic alcoholic and smoker,all the lab
investigations done,amd biopsy confirmed the diagnosis PERIAMPULLARY
CARCINOMA,then surgery(WHIPPLE’S PROCEDURE) is done on 21
aug,and patient shifted to the ward on next day.

What Is a Whipple Procedure?

This is sometimes called a pancreaticoduodenectomy.

The operation consists of removing the gallbladder, part of the bile duct, the duodenum, the
head of the pancreas and sometimes the lower portion of the stomach. Following the removal of
these organs, the remaining portions must be reattached for proper digestion. The surgery
generally takes 4 - 6 hours. The Whipple Procedure is considered, by any standard, a major
surgical procedure.
 Indications for a Whipple Procedure

The most common indications include:

 Cancer of the head of the pancreas
 Cancer of the duodenum

 Cholangiocarcinoma (cancer of the bile duct)

 Cancer of the ampulla – an area where the bile and pancreatic duct enter into
the duodenum.
 The whipple operation may also sometimes be performed for patients with
benign (non-cancerous) disorders such as chronic pancreatitis and benign
tumors of the head of the pancreas.

Preoperative nursing Management-

 A thorough history and physical should be obtained.
 Discuss about diagnosis ,If being treated for a cancer, patient will also be referred to an
oncologist.
 Keep up with your regular activities, exercise and eat a balanced diet.
 You want to be as strong as you can before you have the surgery.
 Arrange for someone to help you around the house and do errands for you when you
come home after surgery.
 Follow the pre-op checklist and medication instructions that were given to you during your
pre-op visit.

o Blood tests to be done before surgery-

1.Blood Tests
Full blood count, Kidney and Liver function tests.
2.Tumour markers (Ca19.9): it is important to remember, blood tests for cancer are not helpful in some
people. They can be normal in 30% of patients. They are used only as a guide and not for diagnosis.
These tests can be elevated in anyone with jaundice even if they don’t have cancer.
2. CT scan of the chest and abdomen
Scan performed to look for cancer outside the pancreas or bile ducts i.e. distant spread to the lungs or
liver. It also gives vital planning information about the arteries and veins around the pancreas and their
relationship or involvement with the tumour. In order to perform successful, curative surgery, there
must be no cancer present distant to the pancreas.
 3. Endoscopic Ultrasound – EUS
This is done under a light anaesthetic by a skilled gastroenterologist. A flexible telescope with an
ultrasound mounted in the head is inserted via the mouth into the stomach. Because the pancreas is
behind the stomach an excellent view of the pancreas can be obtained. A fine needle can be inserted
into the area of concerns and a biopsy can be taken. This is the most common way to get a biopsy of
the pancreas. If the diagnosis is obvious from the CT scan however, this test may not be performed.

4. ERCP – Endoscopic Retrograde Cholangiopancreatography

ERCP gives an X-ray picture of the bile duct. It is also used to place a plastic tube in the bile duct to
relieve jaundice. This is done under a light anaesthetic by a skilled gastroenterologist. A flexible
telescope is inserted via the mouth into the stomach. It is not performed in every patient and has some
serious risks including pancreatitis, perforation of the bowel and bleeding.

5. Heart and lung tests

Performed to assess your fitness for major surgery. This will depend on your age and other health
problems. The tests may be an ultrasound of the heart (Echocardiogram), lung function tests and
exercise tests.

6. MRI If there is some doubt about the diagnosis an MRI can sometimes be of benefit.

Postoperative Nursing Management

Most patients go to the surgical intensive care unit initially after surgery for close observation.
When you are stable you will transfer to a regular hospital room. The length of hospital stay varies
but most patients are hospitalized for 1-2 weeks after their surgery. They may have several tubes
in place after the surgery including:

Nasogastric Tube (NG):

After he go to sleep in the operating room a plastic tube is inserted through his nose and down your
throat into your stomach. It suctions secretions out of your stomach until his stomach and bowel
begin to function again. The NG tube usually stays in 1-2 days. He cannot eat or drink anything with
this tube in place, but you may be allowed some ice chips.

Gastrostomy Tube (G-tube):

A G-tube is sometimes used instead of the NG tube. During surgery the surgeon places it into your
stomach through a small opening on the left side of your abdomen. It drains your stomach contents
until your stomach starts to work in about 5 - 7 days after surgery. You will go home with this tube
temporarily in place; however, it is usually clamped so the contents are not draining. It will be
removed in your doctor’s office.

Jejunostomy Tube (J-tube):

A J-tube is a soft, rubber tube that is placed during surgery into a part of your small bowel
(jejunum). It is used to feed you temporarily after surgery while you are not eating. The tube
feedings are started after surgery while hospitalized. Depending on how well you can eat by the
time you are ready to go home you may need to have supplemental tube feedings at home for a few
weeks. Your doctor will remove the tube during one of your postoperative visits.
Foley’s catheter
A tube called a foley catheter in your bladder to drain urine during surgery.
Tubes or drains near your incision area to drain extra fluid that can build up
after surgery.

Pain control while Hospitalized:

Epidural Catheter:
This small catheter or tube is used to give you pain medicine after your operation. Before surgery,
the anesthesiologist will discuss this method for pain relief. Before you go to sleep, the
anesthesiologist will put the tube into the epidural space around your spinal cord. A continuous
infusion of pain medicine is given through this tube. This tube stays in until you can take pain
medicine by mouth.

PCA Pump:

A PCA pump is another device used to give you pain medicine if you cannot have or do not want an
epidural. This pump is connected to your IV. By pressing a button you can regulate when you get your
pain medicine. The pump does not allow too much medicine to be given. A PCA pump is continued
until you are able to take pain medicine by mouth.
Dressing and incision
Your incision is in the upper abdomen (belly) below the rib cage and above yourbelly button. The
incision will be covered by a dressing. The dressing will be removed 2 to 3 days after surgery.The
incision will be closed with dissolvable stiches, or staples which will be taken out in about a week
after your surgery. If the staples are still in when you leave the hospital, they may be taken out by
your family doctor, home care nurse or at your follow-up appointment with your surgeon.

Activity
While in the hospital you will feel tired and unwell. While rest is important, getting up and
walking can help most patients feel better and recover quicker. You will be encouraged to do
deep breathing, coughing and leg exercises after surgery.
Walking and increasing your activities helps to keep your lungs healthy, prevent blood clots
and get your bowels moving.
Move as much as possible while in the hospital:

• Sit up near the edge of the bed and dangle your legs.

• Sit up in a chair for meals.

• Sit up when visiting.

• Walk around the hallway (before doing this, ask for assistance from your
nurse or therapist).

Complications:

Possible complications that patients may experience after this procedure is performed include:
 Biliary and pancreatic leaks may also occur.
 Because the pancreas will not function as effectively, postoperative diabetes and the
occurrence of fatty stool may develop.
 Infection
 Bleeding
 Leaking
 Delayed gastric emptying
 Failure of other organs, such as the heart, kidneys and liver
Call all your surgeon if you notice ANY of these problems:

Fever • Your temperature is 38ºC (100ºF) or higher.

Incision • Pain in your incision that does not get better with medication.
• Your incision is coming open, bleeding, draining or has yellow,
green or smelly discharge.
• The skin around your incision is red or swollen.
• You are concerned about your incision.

Abdomen • You are constipated, or no bowel movement in 3 days.

• You are vomiting or have diarrhea.

• You have pain in your abdomen or feel sick to your stomach.

Skin • You notice that the whites of your eyes or your skin looks yellow.

Other ! You have pain or tenderness in your leg (thigh or calf) with swelling,
redness or warmth.

!
You have trouble breathing, chest pain or cough up blood.

! You have lightheadedness or dizziness that does not go away.

! You have a rapid heart beat (palpitations), facial flushing, sweating.

If you have concerns about your surgery, do not wait for your follow-up
appointment, call your surgeon. If you are unable to reach the surgeon, go to
Emergency.