The Whipple Procedure (pancreaticoduodenectomy) is the most technically challenging and demanding abdominal operation for surgeons worldwide. The Whipple Procedure is performed when the tumor is limited to the pancreas and has not yet spread and metastasized. Confirming whether the tumor has impinged adjacent large arteries and veins is a significant criterion for performing pancreatic resection.

The Whipple Procedure is the procedure in which the tumor at the head of the pancreas is removed. Tumors in the tail of the pancreas are removed with “distal pancreatectomy.”

It is well-known that technically and oncologically accurate, safe, and efficient pancreatic surgeries require a highly specialized team with long-standing experience and credentials. Unfortunately, as very few surgeons meet these standards, more than 95% of the tumors mentioned above are described as unresectable. Of course, some of them may be in fact unresectable, but a tumor may be classified as unresectable only when precise and universally acknowledged criteria are met. For example, a large tumor or a tumor invading the duodenum is not necessarily an unresectable tumor. At this point, it is important to highlight a few common instances:

1. Extended lymph node dissection. The radicality of the resection is the most important component of the surgical treatment. This does not only concern the tumor, which must be resected with extensive clear margins, but also adjacent lymph nodes. When the number of resectable lymph nodes is less than 15, the operation is considered oncologically inadequate, i.e., the tumor may recur. In our pancreatic surgeries, the number of lymph nodes removed always exceeds 20-25. Only then can lymph node dissection be considered radical. A clear sign of the quality and the extent of the radicality of this surgery is the so-called “skeletonization” of major vessels around and behind the removed pancreas. In truly radical lymph node dissection, the portal vein, the splenic, and the superior mesenteric vein, as well as the inferior vena cava, must be directly visible and not be surrounded by any other tissue.

2. Portal vein invasion. This is the most common reason why pancreatic tumors are considered unresectable. A tumor is indeed unresectable when there is extensive portal vein and superior mesenteric artery invasion. However, when the invasion involves a part of the portal vein, this part of the vein is removed along with the tumor, and is replaced with a graft. Our team has performed such operations multiple times and has managed to remove pancreatic tumors that were considered “inoperable.”

3. Extensive local spread of a tumor. A tumor is indeed unresectable when there is extensive portal vein and superior mesenteric artery invasion. Radical resection is the only way to ensure therapeutic success. This is why our goal is to make such tumors resectable. This can be done through chemotherapy and radiation therapy. This goal is not always achieved as it greatly depends on each patient and the response of each tumor. We should always do our best to make tumors resectable. 

4. Liver metastasis. Multiple liver metastases are found in patients diagnosed with pancreatic cancer. Such cases must not be surgically treated. However, patients with one or two liver metastases may be advised to undergo pancreatectomy and liver metastases resection. This procedure may be performed only in patients who may undergo regular pancreatectomy (without portal vein resection, etc.), and only if the existing liver metastases can be easily removed. It should be highlighted that such an approach may be recommended to very few selected patients and it can only be performed by surgeons with credentialed knowledge and long-standing experience in pancreatic and hepatic surgery.