What Are the Six Steps of the Whipple Procedure?

The Whipple procedure, or pancreaticoduodenectomy, can be understood in six main stages: checking whether the disease can be safely removed, exposing the pancreas and nearby structures, removing the affected organs, and then making three important connections to rebuild the digestive tract.

In a simplified patient-friendly sequence, the six steps are:

1. Explore the abdomen and confirm the disease is removable
2. Expose the pancreas, bile duct and major blood vessels
3. Remove the pancreatic head and other affected structures
4. Reconnect the remaining pancreas to the small intestine
5. Reconnect the bile duct to the small intestine
6. Reconnect the stomach or remaining duodenum and complete the operation

This six-step description is a useful way to understand the operation, but it is not one universal surgical checklist. Surgeons may perform individual parts in a different order depending on the tumour, anatomy and surgical technique.

For a broader explanation of why the surgery is performed and who may be suitable for it, see our main guide to the Whipple procedure.

The Whipple Procedure Has Two Main Phases

Although the operation involves many technical manoeuvres, it can first be divided into two major phases:

Resection: The surgeon removes the diseased part of the pancreas along with closely connected organs and tissues.

Reconstruction: The remaining pancreas, bile duct and stomach or duodenum are connected to the small intestine so digestion can continue.

The first three steps below mainly involve removal. The final three focus on reconstruction.

Step 1: The Surgeon Checks Whether the Disease Can Be Removed

After general anaesthesia is given, the surgeon examines the abdomen before committing to the full operation. This is particularly important when the Whipple procedure is being performed for cancer. The surgical team checks for evidence that the tumour has spread to areas such as the:

• Liver
• Abdominal lining
• Nearby organs
• Major blood vessels around the pancreas

Preoperative CT or MRI provides much of this information, but surgery can occasionally reveal disease that was not visible on imaging. Some patients undergo a staging laparoscopy before the full abdominal operation so the surgeon can look for small areas of metastatic disease. If the disease cannot be safely and completely removed, the planned Whipple operation may need to be changed or stopped.

Step 2: The Pancreas and Nearby Structures Are Carefully Exposed

The head of the pancreas lies in a crowded area surrounded by the duodenum, bile duct and major blood vessels. The surgeon therefore needs to carefully mobilise these structures before removing anything. 

One important manoeuvre involves freeing the duodenum and pancreatic head from the tissues behind them. This allows the surgeon to inspect the relationship between the tumour and nearby vessels. During this stage, the surgeon also identifies important structures such as the:

• Common bile duct
• Hepatic artery
• Gastroduodenal artery
• Portal vein
• Superior mesenteric vein
• Superior mesenteric artery

This vascular assessment is crucial because the pancreas sits directly beside some of the largest blood vessels supplying the abdominal organs.

Step 3: The Pancreatic Head and Other Affected Organs Are Removed

This is the main removal phase of the operation. In a typical Whipple procedure, the surgeon removes:

• The head of the pancreas
• The duodenum
• The gallbladder
• Part of the bile duct
• Nearby lymph nodes

What Happens to the Stomach?

This depends on the type of Whipple procedure. In a standard Whipple procedure, part of the lower stomach may be removed. In a pylorus-preserving pancreaticoduodenectomy, the stomach and pylorus—the muscular outlet at the bottom of the stomach—are preserved. 

The surgeon then divides the pancreas so that the diseased head can be separated from the remaining body and tail. The pancreatic head and uncinate process must be carefully dissected away from the major veins and artery located behind them. Once all necessary structures have been divided, the specimen is removed and sent for pathological examination.

Step 4: The Remaining Pancreas Is Reconnected to the Small Intestine

After the diseased tissue has been removed, the surgeon begins rebuilding the digestive tract. The first major connection is usually between the remaining pancreas and the jejunum. This connection is called a pancreaticojejunostomy. Its purpose is to allow pancreatic digestive enzymes to flow into the small intestine again.

These enzymes are needed to digest:

• Fat
• Protein
• Carbohydrates

This is one of the most technically delicate parts of the reconstruction. The surgeon carefully stitches the pancreatic tissue and pancreatic duct to the intestine while trying to create a secure, well-supplied connection. A small pancreatic duct or very soft pancreatic tissue can make this connection more challenging and can increase the risk of postoperative pancreatic leakage.

Step 5: The Bile Duct Is Reconnected

The next connection allows bile from the liver to flow back into the digestive tract. The remaining bile duct is joined to another part of the jejunum. This is known as a hepaticojejunostomy. Bile plays an important role in digesting and absorbing fat.

Before surgery, bile normally travels from the liver through the bile duct into the duodenum. Because the duodenum and lower bile duct have been removed, a new route has to be created. The new connection allows bile to enter the small intestine and mix with food again.

Step 6: The Stomach or Remaining Duodenum Is Reconnected

The final major digestive connection allows food to pass from the stomach into the intestine. The exact reconstruction depends on which type of Whipple procedure was performed.

After a Standard Whipple Procedure

The remaining stomach is commonly connected to the jejunum in a procedure called a gastrojejunostomy.

After a Pylorus-Preserving Whipple Procedure

The remaining duodenum may instead be connected to the jejunum, creating a duodenojejunostomy. Once the reconstruction is completed, food, pancreatic enzymes and bile can once again enter the small intestine through their new pathways.

What Happens Before the Operation Is Finished?

The surgeon carefully checks all reconstructed areas before closing the abdomen. This includes checking for:

• Bleeding
• Secure surgical connections
• Adequate blood supply to the reconstructed organs
• Unexpected injury to surrounding structures

Why Are Three New Connections Needed?

The unusual complexity of the Whipple procedure becomes easier to understand when you consider the anatomy. The structures being removed normally bring together three different components of digestion:

• Food from the stomach
• Digestive enzymes from the pancreas
• Bile from the liver

Removing the pancreatic head and duodenum interrupts all three pathways. The surgeon therefore needs to create a new route for each one. After successful reconstruction:

The pancreas → small intestine connection delivers pancreatic enzymes.

The bile duct → small intestine connection delivers bile.

The stomach or duodenum → small intestine connection allows food to continue through the digestive tract.

How Long Do These Six Steps Take?

A Whipple procedure commonly takes several hours and may take approximately 4 to 12 hours depending on the complexity of the case and the surgical approach. Surgery may take longer when:

• The tumour is close to major blood vessels
• Vascular reconstruction is required
• There is difficult anatomy or significant scar tissue
• Minimally invasive robotic or laparoscopic techniques are used in complex cases

The length of the operation alone does not determine whether the procedure has gone well. Careful removal and reconstruction are more important than completing the surgery quickly.

Are the Steps Different in Robotic or Laparoscopic Whipple Surgery?

The overall goals remain essentially the same. Whether the procedure is performed through a traditional open incision, laparoscopically or with robotic assistance, the surgeon still needs to:

• Assess the disease
• Remove the affected organs and tissues
• Preserve important blood vessels whenever possible
• Reconnect the pancreas
• Reconnect the bile duct
• Restore the passage of food through the digestive tract

What changes is mainly the way the surgeon accesses and handles the tissues.

The Bottom Line

The Whipple procedure can be understood as six major stages: assessing the disease, exposing the pancreatic region, removing the affected organs, reconnecting the pancreas, reconnecting the bile duct and finally reconnecting the stomach or remaining duodenum to the small intestine.

The operation is essentially divided into two parts—removal and reconstruction. The surgeon first removes the pancreatic head, duodenum, gallbladder, part of the bile duct and sometimes part of the stomach, along with nearby lymph nodes when appropriate.

Three new digestive connections are then created so pancreatic enzymes, bile and food can once again reach the small intestine. Although describing the operation in six steps makes it easier to understand, the exact surgical sequence can vary according to the tumour, anatomy and surgeon's technique.