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PANCREAS AND ADJACENT STRUCTURES: WHIPPLE PROCEDURE SPECIMEN FOR BENIGN AND MALIGNANT DISEASE OF THE HEAD OF THE PANCREAS, DISTAL COMMON BILE DUCT, AMPULLA OF VATER, AND DUODENUM. DISTAL PANCREATECTOMY SPECIMEN FOR LESIONS IN THE BODY AND TAIL OF THE PANCREAS
Procedure: Ask staff for help if this is the first such specimen you have encountered. For subsequent specimens, ask the staff for help whenever you are uncertain how to handle it. (see diagram on next page)
The Whipple specimen usually will include distal stomach, duodenum with attached pancreas (at least the head, possibly more) and the proximal jejunum.
The distal pancreatectomy specimen will almost always include the spleen.
For Whipple resections, the surgeon is supposed to mark with purple ink the uncinate (retroperitoneal margin), the groove of pancreatic tissue that lies against the Superior Mesenteric Vein and Artery.
Open the stomach, duodenum, and proximal jejunum on the side opposite the head of the pancreas. This will extend from the lesser gastric curvature onto the lateral duodenal wall.
Pin the specimen on a styrofoam board, trying to preserve the anatomic relationships. The duodenum should be flattened if possible. Flattening is less important for the distal stomach and proximal jejunum.
It may be necessary to get the cooperation of the surgeon to orient the specimen.
Place the material into a large container, cover with formalin, and fix overnight.
Paint with India ink the common bile duct surgical margin, as well as the pancreatic surgical margin, unless frozen sections were already performed on these margins. Look for the retroperitoneal pancreatic margin.
Cut off the gastric part of this specimen, and usually the first part of the duodenum as well, right close to the pancreas, unless the stomach or duodenum is invaded by the tumor.
Cut off the distal duodenum and proximal jejunum also close to the pancreas.
Do not probe the ampulla and the distal common duct, since such manipulation may alter any intraluminal growth. If a stent is in the common duct, carefully remove it.
See diagram about "cutting a Whipple". Make serial (bread loaf) sections through the duodenum and head of the pancreas, from proximal to distal, observing the location and status of the common bile duct, the ampulla, and head of the pancreas as the sections progress.
Take photographs of the important serial sections. Often, it will be beneficial to mark the common bile duct with paper arrows on the cross sections prior to photographing. Photograph all cystic lesions. Gross photographs of cystic lesions may help to differentiate one type of cystic lesion from the others.
Organs present in the specimen and their dimensions (pancreas, distal stomach, duodenum, spleen, common bile duct).
Tumor characteristics: involvement of ampulla, duodenal mucosa, stomach, bile duct, pancreatic duct, pancreas, and any combination; size, shape (papillary? flat? cystic?, ulcerated?, mixed), color and consistency.
If the lesion is a cystic lesion, is it a single cyst or multilocular. State this in the dictation.
Common bile duct and main pancreatic duct: dilated? stones? tumor? stent?
Location, number, and appearance of regional lymph nodes.
Sections for Histology
Where possible, localize and number each serial section, preferably from proximal to distal using the duodenum as the reference point.
Tumor: as many sections as are needed to identify origin and extent.
Distal line of resection of the pancreas, unless prior frozen section was done.
Common bile duct surgical margin, unless prior frozen section was done.
For Whipple resections: Uncinate (Retroperitoneal) pancreatic margin, as marked by the surgeon.
For distal pancreatectomy specimens, sample the retroperitoneal margin, which will be posterior.
Stomach if abnormal, or if you cannot stand seeing so much stomach and not taking a section from it.
Jejunum: no sections unless there is a gross abnormality.
Spleen: no section if grossly normal. Otherwise sample any abnormality. Sample hilar nodes.