Whipple (Pancreaticoduodenectomy)
Updated On: July 22, 2026
Anesthetic Approaches
Full preoperative workup essential — ECG, CBC, CMP, coagulation studies, type and screen (crossmatch 2–4 units PRBCs)
Assess for obstructive jaundice — may cause coagulopathy, renal impairment, and altered drug metabolism (reduced hepatic clearance)
Baseline glucose — ~80% of pancreatic cancer patients have DM or impaired glucose tolerance
VTE risk — typically very high (cancer-related hypercoagulability); confirm anticoagulation status before neuraxial placement
Arterial line (radial preferred) — mandatory for continuous hemodynamic monitoring and serial blood sampling
Two large-bore IVs — recommended; central line with CVP less commonly used but consider in high-risk patients
Epidural — typically placed at T6–T11 for optimal upper abdominal coverage. Confirm anticoagulation status before neuraxial placement. If placed, it is very likely to be continued post-operatively.
NG/OG tube — placed after intubation for gastric decompression; avoid nitrous oxide (bowel distension risk)
Fluids — Goal-directed fluid therapy; significant intraoperative fluid shifts are expected
Active Warming — Fluid warmers and forced-air warming — hypothermia risk due to case duration and potential open abdomen
Regular BGs — Intraoperative glucose monitoring every 1–2 hours; target 140–180 mg/dL
Pulmonary recruitment maneuvers — recommended before emergence to reduce postoperative atelectasis
Awake extubation preferred — especially in elderly patients, prolonged cases, or those who received large fluid volumes
Have blood products available — transfusion triggers should be defined preoperatively
Vasopressors - Very likely needed (due to fluid shifts and epidural-induced sympathectomy
Tucked Arms (general considerations): Consider a second IV – once the procedure has started, it's going to be VERY difficult to handle IV issues – especially if your only IV has problems. Ensure the IV is running and monitors are still functioning after tucking the patient's arms.
High Blood Loss (general considerations): Type and cross, CBC, and CMP should be done prior to the procedure. Consider having an A-line, blood tubing, and extra push-lines. Depending on the fragility of the patient, you may want to have blood in the room and available.
Trendelenburg Position (general considerations): Take precautions for upper airway obstruction or stridor. Avoid excessive fluid administration. OG tube is a good consideration to empty the contents of the stomach. Regurgitation of stomach contents can ulcerate the airway and/or damage the eyes. Consider throat packs and/or eye lubrication to further protect the patient. Brachial nerve injury is also a strong possibility. Be very careful with head and shoulder brace positioning. Peroneal nerve injury is a strong possibility if the patient is also in the lithotomy position. Make sure pressure points are padded. If there's peroneal nerve damage, it will manifest as foot drop. Increased IOP. Take precaution with patients that have glaucoma. Conjunctival swelling will sometimes be irritating to the patient post-operatively. Keep reminding the patient not to rub their eyes. Increased ICP. Cerebral perfusion pressure = MAP-ICP. Make sure you keep the MAP up.
Long procedure (general considerations): Procedures anticipated to last longer than 2 hours generally require a urinary catheter. Also, consider checking lines and positioning regularly as the risks of infiltration and nerve damage are increased with procedure time. Consider an IV fluid warmer and a forced air warmer to keep the patient euthermic.
High post-operative pain (general considerations): Plan ahead to treat pain in the postoperative period. If not contraindicated, consider hydromorphone or other long-acting analgesics along with adjuncts such as Ofirmev and/or toradol. Where possible, give during the operative period to limit pain in the postoperative period. Where applicable, consider peripheral nerve blocks and/or epidural interventions.
Fluoroscopy / Xray (general considerations): Have lead aprons and thyroid shields available. Alternatively, distancing yourself 3 to 6 feet will reduce scatter radiation to 0.1% to 0.025% respectively. Occupational maximum exposure to radiation should be limited to a maximum average of 20 Sv (joules per kilogram - otherwise known as the Sievert/Sv) per year over a 5 year period. Limits should never exceed 50 Sv in a single year.
Arterial line (general considerations): Preoperatively check pulses to gauge the best side to attempt the A-line. Perform an Allen test to ensure adequate blood flow. Have the A-line equipment set up and ready in the room.
High Blood Loss RISK (general considerations): Though most of these cases don't result in a high blood loss, there is a high blood loss RISK. Type and cross, CBC, and CMP should be done prior to the procedure. Consider having an A-line, blood tubing, and extra IV push-lines. Depending on the fragility of the patient, you may want to have blood in the room and available.
Bispectral Index Scale (BIS) monitor (general considerations): The recommended values under general anesthesia are 40-65. Values of 65-85 are recommended for sedation.
The Whipple procedure is performed most commonly for pancreatic ductal adenocarcinoma (PDAC) arising in the head of the pancreas, but may also be indicated for periampullary tumors (ampullary carcinoma, distal cholangiocarcinoma, duodenal carcinoma), and select benign conditions including chronic pancreatitis, cystic neoplasms, or islet cell tumors.
The Whipple procedure involves the surgical resection of the head of the pancreas along with adjacent structures and subsequent reconstruction of the gastrointestinal tract to restore digestive continuity.