OT notes · General Surgery

Pancreaticoduodenectomy (Whipple's)

Usual anaesthesia
General anaesthesia with endotracheal intubation, central venous and arterial lines
Position
Supine with both arms out
Setting
elective

Operative note template for pancreaticoduodenectomy (classic or pylorus-preserving), with a filled example for a classic Whipple done for a periampullary carcinoma with a biliary stent in place.

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Blank template

Follow this order in the case sheet. Tick the options that apply and fill the blanks.

Patient and case

  1. Name / Age / Sex
  2. UHID / IP no. / Ward-Bed
  3. Date of surgery / OT no.
  4. CaseElectiveEmergency (non-elective)if emergency, state urgency and reason
  5. Timesin OT ___ anaesthesia start ___ incision ___ closure ___ out of OT ___

Team

  1. Operating surgeonname, designation
  2. Assistant(s)
  3. Supervising consultantpresent in OT / available / not applicable
  4. Steps done by the residentwhole procedure / named steps, under whose supervision
  5. Anaesthetist
  6. Scrub nurse / circulating nurse

Diagnosis and procedure

  1. Pre-operative diagnosis
  2. Post-operative diagnosis
  3. Procedure planned
  4. Procedure performedif different from plan, state why
  5. Extra procedure done and reason'none' if none. Only to save life or health if not consented

Consent and safety checks

  1. Informed consentGeneralProcedure-specificHigh-riskAnaesthesiain a language the patient understands: language ___ witness ___
  2. Site / side markedYesNot applicable
  3. WHO Surgical Safety ChecklistSign inTime outSign out
  4. Antibiotic prophylaxisdrug, dose, route, time given before incision
  5. VTE prophylaxisMechanicalPharmacologicalNot indicated

Risks to explain in the consent for this operation

  • pancreatic leak or fistula
  • delayed gastric emptying and prolonged nasogastric tube
  • bile leak
  • bleeding, including late bleeding from the gastroduodenal artery stump
  • intra-abdominal collection or abscess needing drainage
  • injury to the portal vein, superior mesenteric vessels or hepatic artery
  • tumour found unresectable at operation, so only biopsy or bypass is done
  • wound infection
  • death after major pancreatic surgery

Pre-operative details for this operation

  1. Diagnosis and tissue diagnosissite (pancreatic head, ampulla, distal bile duct, duodenum), biopsy / EUS-FNA result if done
  2. Resectability on pancreatic protocol CTResectableBorderline resectablerelation to SMV/PV, SMA, hepatic artery, coeliac axis; distant disease
  3. Hepatic arterial anatomy on CTConventionalReplaced / accessory right hepatic artery from SMAOther variant
  4. Biliary stentNonePlastic stent (date)Metal stent (date)
  5. Bilirubin, INR, albumin, CA 19-9values and dates; vitamin K given if INR prolonged
  6. Performance status and cardiopulmonary assessmentECOG / Karnofsky, physician clearance
  7. Tumour board discussiondate and plan (upfront surgery or after neoadjuvant therapy)
  8. Blood reservedgroup and units cross-matched

Anaesthesia and position

  1. AnaesthesiaGeneral
  2. Linescentral venous line (side; head turned right for left internal jugular), arterial line, urinary catheter, nasogastric tube
  3. PositionSupine, both arms out
  4. Staging laparoscopy before laparotomyNot doneDone: findings
  5. RetractorBookwalterThompsonOmniOther

Operative findings

  1. Liver, peritoneum, omentum, ascitesany metastasis; frozen section of any suspicious deposit and its result
  2. Tumoursite, size, consistency of pancreatic head
  3. Relation to SMV / portal vein and SMAFreeAbutting veinAdherent to vein: vascular control takenInvolving SMA: unresectable
  4. Hepatic artery anatomy seenreplaced right hepatic artery present or absent
  5. Gastroduodenal artery test clampStrong hepatic pulse maintainedHepatic pulse lost (do not divide)
  6. Lymph nodescoeliac, hepatic artery, aortocaval; enlarged or not
  7. Pancreas texture and ductSoft, small ductFirm, dilated ductduct diameter in mm
  8. Bile ductdiameter, bile colour, bile sent for culture
  9. DecisionResectable: proceededUnresectable: resection abandoned (state reason and what was done)

Procedure (steps)

  1. IncisionUpper midline, xiphoid to umbilicusBilateral subcostal (chevron)
  2. Exploration for metastasisfour-quadrant exploration, bimanual palpation of liver, small bowel run
  3. Kocher manoeuvre and mobilisation of hepatic flexureKocher onlyExtended Kocher with Cattell-BraaschIVC and left renal vein exposed
  4. Lesser sac opened, infrapancreatic SMV exposedgastroepiploic vein ligated and divided; middle colic vein preserved or divided (reason)
  5. Porta hepatis dissected, cholecystectomycommon hepatic artery, GDA, proper hepatic artery identified; right gastric artery ligated
  6. Gastroduodenal arterytest clamped, then ligated, suture ligated or clipped; stump left
  7. Tunnel between pancreatic neck and portal vein / SMVblunt clamp, vessel loop or tape placed
  8. Division of stomach or duodenumAntrum divided (classic)Duodenum divided 1.5 to 2 cm beyond pylorus (PPPD)Just proximal to pyloric ringstapler and load
  9. Bile duct dividedlevel (common hepatic / common bile duct), bulldog on proximal duct, stent removed, frozen section of margin
  10. Jejunum divided beyond ligament of Treitzdistance, stapler; mesentery taken close to bowel; jejunum passed behind the superior mesenteric vessels
  11. Pancreatic neck dividedstay sutures on upper and lower borders, scalpel or cautery, duct identified, frozen section of neck margin
  12. Uncinate process and retroperitoneal (SMA) marginvenous branches to SMV/PV ligated, first jejunal vein handled, inferior pancreaticoduodenal artery ligated, ties or energy device
  13. Specimen oriented and margins markedsutures on bile duct, pancreatic neck and SMA margin
  14. PancreaticojejunostomyDuct-to-mucosa (Blumgart)InvaginationPancreaticogastrostomysuture materials and sizes; stent internal / external / none
  15. Hepaticojejunostomyend-to-side, distal to the pancreatic anastomosis; suture material, size, interrupted or continuous
  16. Gastrojejunostomy or duodenojejunostomyposition (antecolic), distance from biliary anastomosis, layers or stapled

Closure, drains and dressing

  1. Mesocolic window and mesenteric defectsjejunum fixed to mesocolon with interrupted sutures; defects checked and closed
  2. GDA stump coverFalciform ligament placed over stumpNot done
  3. Irrigationespecially if a stent was in place or tumour was entered
  4. DrainsNoneOne closed drainTwo closed drainstype, size, position (near pancreatic and biliary anastomoses)
  5. Nasogastric tube position confirmed
  6. Fascia and skinsuture material and technique

Specimens and implants

  1. Main specimen for HPEpancreatic head, duodenum, distal bile duct, antrum (if classic), gallbladder; margins marked with sutures
  2. Frozen sections sentbile duct margin, pancreatic neck margin, any vein resected; results
  3. Bile for cultureSentNot sent
  4. Biliary stent removedsent with specimen, noted on requisition
  5. Pancreatic duct stent left inNoneInternal (size)External (size)
  6. Fiducial markersNot placedPlaced at SMA margin (number)

End of procedure

  1. Estimated blood lossml
  2. IV fluids and blood / products givenfluids (ml); blood: type, units, bag nos.
  3. Swab, needle and instrument countCorrectIncorrect: action taken
  4. Intra-operative complications / difficultieswhat happened and what was done; 'none' if none
  5. Implant stickersNo implantAffixed in case sheet, OT register and for discharge summary
  6. Condition at end of surgery / shifted toPACUWardICU/HDU

Post-operative orders

  1. Shift to ICU / HDUhaemodynamics, urine output, drain character
  2. Drain fluid amylaseon POD 1 and POD 3; remove on POD 3 if no pancreatic or bile leak
  3. Drain watchbile-stained or blood-stained output to be reported at once
  4. Warning signstachycardia, rising WBC: inform surgeon, consider CT; a small bleed from drain or vomit may herald a pseudoaneurysm: urgent angiography
  5. Nasogastric tubefree drainage, record output; removal when gastric emptying is adequate
  6. Antibioticsprophylaxis to finish within 24 h; if bile culture positive, culture-directed course
  7. Blood sugar monitoringfrequency and sliding scale as per protocol
  8. InvestigationsHb, LFT, creatinine, electrolytes on POD 1
  9. Oral intakewrite the day and what to start
  10. Follow up HPE and margin statustumour board after report

Signature

  1. Name and designation of person writing note
  2. Medical Council registration no.
  3. Signature / date / time of writingwrite before the patient leaves recovery

Worked example

Fictional case: Mr. R.K., 58 years, with painless obstructive jaundice from a 2.2 cm periampullary carcinoma, biopsy-proven on endoscopy, plastic biliary stent placed 3 weeks earlier, resectable on pancreatic protocol CT.

Case details

Date: 14/07/2026. Elective pancreaticoduodenectomy (classic Whipple). OT 1.

In OT 08:10. Incision 09:05. Specimen out 12:50. Closure completed 15:10.

Surgeon: Dr A. (consultant, GI surgery). Assistants: Dr B. (MCh resident), Dr C. (MS 3rd-year resident).

Anaesthetists: Dr D. and Dr E. Scrub nurse: Sr F.

Indication and pre-op

Periampullary adenocarcinoma on biopsy. CT: 2.2 cm mass, fat planes around SMV, SMA and hepatic artery clear, no metastasis. Conventional hepatic arterial anatomy.

Plastic CBD stent placed 23/06/2026. Bilirubin fell from 11.2 to 2.1 mg/dl. INR 1.1. Albumin 3.4 g/dl. CA 19-9 88 U/ml. ECOG 1.

Discussed at tumour board 07/07/2026: upfront surgery.

Consent: general, procedure-specific (including possible abandonment if unresectable, and bypass) and anaesthesia consent taken in Marathi from patient, son present.

Blood group O positive, 2 units cross-matched. WHO checklist sign in and time out done.

Inj cefazolin 2 g IV at 08:45, redosed at 12:45.

Anaesthesia and position

General anaesthesia. Left IJV central line, left radial arterial line, Foley catheter, Ryle's tube.

Supine, both arms out. Parts painted with chlorhexidine-alcohol from nipples to mid thigh and draped.

Findings

No ascites. Liver, peritoneum and omentum free of deposits. No enlarged coeliac or aortocaval nodes.

2.2 cm firm mass at ampulla. Pancreatic head firm. SMV and portal vein free of tumour.

No replaced right hepatic artery. GDA test clamp: strong proper hepatic pulse maintained.

CBD 14 mm with plastic stent. Pancreatic duct 4 mm. Pancreas firm.

Procedure

Upper midline incision, xiphoid to umbilicus. Falciform ligament ligated and kept long. Bookwalter retractor.

Hepatic flexure mobilised. Wide Kocher manoeuvre up to left renal vein. Lesser sac opened through gastrocolic omentum.

Gastroepiploic vein ligated and divided at SMV. Middle colic vein preserved. Anterior surface of SMV exposed below pancreatic neck.

Right gastric artery ligated. Common hepatic artery traced, GDA identified, test clamped, doubly ligated, clipped and divided, stump left.

Portal vein exposed above neck. Tunnel behind pancreatic neck completed with blunt clamp, umbilical tape passed. Cholecystectomy done.

Decision to resect made at this point.

Antrum divided with linear stapler (GIA green load). Lesser curve vessels divided with LigaSure.

Common hepatic duct divided above cystic duct entry with bulldog on proximal duct. Plastic stent removed and passed off field. Bile sent for culture. Distal duct oversewn, ends left long. Proximal duct margin sent for frozen section.

Jejunum divided about 10 cm beyond ligament of Treitz with linear stapler. Mesentery ligated close to bowel. Jejunum passed behind superior mesenteric vessels to the right.

Stay sutures on upper and lower borders of pancreatic neck. Neck divided with scalpel and cautery over the portal vein. Duct identified. Neck margin sent for frozen section.

Uncinate process freed from SMV and PV, small veins ligated. First jejunal vein preserved. Retroperitoneal margin taken along SMA adventitia with ties; inferior pancreaticoduodenal artery ligated.

Specimen oriented: sutures on bile duct, pancreatic neck and SMA margin. Frozen section: bile duct and neck margins free of tumour.

Jejunum brought through transverse mesocolon to the right of middle colic vessels.

Pancreaticojejunostomy, duct to mucosa (Blumgart): transpancreatic interrupted polyglactin 910 (Vicryl) 3-0, duct to mucosa with polydioxanone (PDS) 5-0. No stent.

End-to-side hepaticojejunostomy made downstream of the pancreaticojejunostomy, without tension.

Antecolic gastrojejunostomy 40 cm beyond the biliary anastomosis, two layers.

Closure

Jejunum fixed to mesocolic window with interrupted Vicryl. Mesenteric defects checked and closed. Falciform ligament placed over GDA stump.

Peritoneal cavity irrigated with warm saline (stent in place before surgery). Haemostasis checked.

Two drains to gravity drainage: one near the pancreaticojejunostomy, one near the hepaticojejunostomy, brought out through the right flank.

Ryle's tube position confirmed in stomach. Linea alba closed with running nylon No. 2, knots buried. Skin with staples.

Specimens and implants

Whipple specimen (antrum, duodenum, pancreatic head, distal CBD, gallbladder) in formalin for HPE, with margin sutures: short = bile duct, long = pancreatic neck, double = SMA margin. Plastic stent removed, noted on requisition.

Frozen sections: CBD margin and pancreatic neck margin, both negative. Bile sent for culture and sensitivity.

No implant.

End of procedure

Duration about 6 hours from incision. Estimated blood loss 650 ml. 1 unit PRBC transfused.

Mop, needle and instrument counts correct at closure, confirmed by scrub nurse.

No intra-operative complications.

Shifted to surgical ICU intubated, pulse 92/min, BP 124/70 mmHg, on no inotropes.

Post-op orders

Hourly vitals, urine output and drain output. Report bile-stained or blood-stained drain fluid at once.

Drain fluid amylase on POD 1 and POD 3.

Ryle's tube on free drainage, record 6-hourly output. Nil by mouth.

Analgesia as per anaesthesia chart.

Capillary blood glucose as per ICU protocol.

Hb, LFT, creatinine and electrolytes on POD 1.

Follow bile culture; antibiotics to be changed as per report.

Signature

Dr B., MCh resident, for Dr A. Reg. no. ________. 14/07/2026, 15:40.

Must document for this operation

  • Findings that decided resectability, and the point at which you committed to resection. If the operation is later questioned, the note must show that metastasis and vascular involvement were looked for before irreversible steps.
  • GDA test clamp result and how the GDA stump was secured. A late bleed after a pancreatic leak often comes from the GDA stump, and the radiologist needs to know what is there before embolisation.
  • Hepatic arterial anatomy, including any replaced right hepatic artery and whether it was preserved. Hepatic ischaemia after surgery will be traced back to this, and the next surgeon or radiologist needs the anatomy.
  • Pancreas texture, duct size and type of pancreaticojejunostomy (with stent or not). These predict pancreatic fistula and guide how the drains and any leak are managed.
  • Margin marking key and frozen section results. The pathologist cannot mark the SMA margin afterwards, and margin status decides adjuvant therapy.
  • Biliary stent removed and bile sent for culture. Stented patients often have infected bile, and a positive culture changes the post-op antibiotics.
  • Order and position of the three anastomoses and drains. Anyone reading a later CT, or placing a drain for a leak, needs to know what lies where.

Common mistakes in these notes

  • Writing 'Whipple done' without saying classic or pylorus-preserving, or how the pancreatic stump was handled.
  • Not recording the GDA test clamp, or the replaced right hepatic artery.
  • Leaving out the margin-marking key on the histopathology (HPE) requisition.
  • Not naming the drains and their positions, so drain charts cannot be matched.
  • When resection is abandoned, not writing why and what was done instead (biopsy, bypass).

Indian practice and paperwork

  • NABH expects the operative note to be written before the patient leaves recovery. For a patient going to ICU intubated, write the note before transfer out of the OT complex. (NABH 5th ed., COP.14(e))
  • If the tumour is found unresectable and a bypass is done instead, the written consent should already cover this. A procedure outside the consent is defensible only if it was needed to save life or health and could not wait (Samira Kohli v. Dr Prabha Manchanda, Supreme Court, 2008). ((2008) 2 SCC 1)
  • Name every anaesthetist in the note. A National Commission case held a hospital negligent when the operation notes left out the name of one of two anaesthetists. (Thomas J. Indian J Urol 2009;25(3):384-8)
  • Discarded formalin from specimen containers is chemical waste in the yellow (f) category. (Bio-Medical Waste Management Rules 2016, CPCB guidelines)

Sources

  • Scott-Conner CEH, ed. Scott-Conner & Dawson: Essential Operative Techniques and Anatomy. 4th ed. Lippincott Williams & Wilkins (Wolters Kluwer); 2014, Ch 84, Pancreatic Resections (Mezhir JJ), pp. 440-451.
  • Mulholland MW (editor-in-chief), Albo D, Dalman RL, Hawn MT, Hughes SJ, Sabel MS, eds. Operative Techniques in Surgery. Wolters Kluwer; 2015, Ch 33, Pancreaticoduodenectomy: Resection (VanBuren G, Fisher WE), pp. 726-738.
  • Bratzler DW, et al. Clinical practice guidelines for antimicrobial prophylaxis in surgery. Am J Health Syst Pharm. 2013;70(3):195-283. Table 1: cefazolin 2 g IV (3 g if 120 kg or more), redose interval 4 h. Table 2: gastroduodenal procedures entering the lumen, including pancreaticoduodenectomy: cefazolin; consider added cover if the biliary tract is infected. Start within 60 min before incision; duration under 24 h. www.ashp.org/-/media/assets/policy-guidelines/docs/therapeutic-guidelines/therapeutic-guidelines-antimicrobial-prophylaxis-surgery.pdf

Educational template for residents. Adapt it to your institution's case-sheet format and your consultant's instructions. Patient details in the example are fictional.

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