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Virtual Whipple: Preoperative Surgical Planning with Volume-Rendered MDCT Images to Identify Arterial Variants Relevant to the Whipple Procedure

¹ Department of Radiology, Beth Israel Deaconess Medical Center, 1 Deaconess Rd., Boston, MA 02215.
² Department of Surgery, Beth Israel Deaconess Medical Center, Boston, MA.

View larger version (137K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 1A —44-year-old man with pancreatic adenocarcinoma. Images show sequential steps in performance of virtual Whipple procedure. Initially, margins of gallbladder are defined on sequential axial images (A) using freeform region of interest tool. Electronic sculpt function allows for subsequent electronic removal (B). Note that patient has had prior ERCP with stent placement. After electronically simulating cholecystectomy, pancreaticoduodenectomy is simulated using similar function. Reference to sagittal (C), coronal (D), and axial (E) multiplanar reformat images and volume-rendered projections (F) allow for real-time monitoring of progress and prevent inadvertent inclusion of vital structures such as mesenteric vessels. Pancreatic head, uncinate process, regional lymph nodes, and transverse mesocolon, if involved, are included and then removed electronically (G).

View larger version (143K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 1B —44-year-old man with pancreatic adenocarcinoma. Images show sequential steps in performance of virtual Whipple procedure. Initially, margins of gallbladder are defined on sequential axial images (A) using freeform region of interest tool. Electronic sculpt function allows for subsequent electronic removal (B). Note that patient has had prior ERCP with stent placement. After electronically simulating cholecystectomy, pancreaticoduodenectomy is simulated using similar function. Reference to sagittal (C), coronal (D), and axial (E) multiplanar reformat images and volume-rendered projections (F) allow for real-time monitoring of progress and prevent inadvertent inclusion of vital structures such as mesenteric vessels. Pancreatic head, uncinate process, regional lymph nodes, and transverse mesocolon, if involved, are included and then removed electronically (G).

View larger version (103K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 1C —44-year-old man with pancreatic adenocarcinoma. Images show sequential steps in performance of virtual Whipple procedure. Initially, margins of gallbladder are defined on sequential axial images (A) using freeform region of interest tool. Electronic sculpt function allows for subsequent electronic removal (B). Note that patient has had prior ERCP with stent placement. After electronically simulating cholecystectomy, pancreaticoduodenectomy is simulated using similar function. Reference to sagittal (C), coronal (D), and axial (E) multiplanar reformat images and volume-rendered projections (F) allow for real-time monitoring of progress and prevent inadvertent inclusion of vital structures such as mesenteric vessels. Pancreatic head, uncinate process, regional lymph nodes, and transverse mesocolon, if involved, are included and then removed electronically (G).

View larger version (98K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 1D —44-year-old man with pancreatic adenocarcinoma. Images show sequential steps in performance of virtual Whipple procedure. Initially, margins of gallbladder are defined on sequential axial images (A) using freeform region of interest tool. Electronic sculpt function allows for subsequent electronic removal (B). Note that patient has had prior ERCP with stent placement. After electronically simulating cholecystectomy, pancreaticoduodenectomy is simulated using similar function. Reference to sagittal (C), coronal (D), and axial (E) multiplanar reformat images and volume-rendered projections (F) allow for real-time monitoring of progress and prevent inadvertent inclusion of vital structures such as mesenteric vessels. Pancreatic head, uncinate process, regional lymph nodes, and transverse mesocolon, if involved, are included and then removed electronically (G).

View larger version (81K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 1E —44-year-old man with pancreatic adenocarcinoma. Images show sequential steps in performance of virtual Whipple procedure. Initially, margins of gallbladder are defined on sequential axial images (A) using freeform region of interest tool. Electronic sculpt function allows for subsequent electronic removal (B). Note that patient has had prior ERCP with stent placement. After electronically simulating cholecystectomy, pancreaticoduodenectomy is simulated using similar function. Reference to sagittal (C), coronal (D), and axial (E) multiplanar reformat images and volume-rendered projections (F) allow for real-time monitoring of progress and prevent inadvertent inclusion of vital structures such as mesenteric vessels. Pancreatic head, uncinate process, regional lymph nodes, and transverse mesocolon, if involved, are included and then removed electronically (G).

View larger version (106K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 1F —44-year-old man with pancreatic adenocarcinoma. Images show sequential steps in performance of virtual Whipple procedure. Initially, margins of gallbladder are defined on sequential axial images (A) using freeform region of interest tool. Electronic sculpt function allows for subsequent electronic removal (B). Note that patient has had prior ERCP with stent placement. After electronically simulating cholecystectomy, pancreaticoduodenectomy is simulated using similar function. Reference to sagittal (C), coronal (D), and axial (E) multiplanar reformat images and volume-rendered projections (F) allow for real-time monitoring of progress and prevent inadvertent inclusion of vital structures such as mesenteric vessels. Pancreatic head, uncinate process, regional lymph nodes, and transverse mesocolon, if involved, are included and then removed electronically (G).

View larger version (125K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 1G —44-year-old man with pancreatic adenocarcinoma. Images show sequential steps in performance of virtual Whipple procedure. Initially, margins of gallbladder are defined on sequential axial images (A) using freeform region of interest tool. Electronic sculpt function allows for subsequent electronic removal (B). Note that patient has had prior ERCP with stent placement. After electronically simulating cholecystectomy, pancreaticoduodenectomy is simulated using similar function. Reference to sagittal (C), coronal (D), and axial (E) multiplanar reformat images and volume-rendered projections (F) allow for real-time monitoring of progress and prevent inadvertent inclusion of vital structures such as mesenteric vessels. Pancreatic head, uncinate process, regional lymph nodes, and transverse mesocolon, if involved, are included and then removed electronically (G).

View larger version (120K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 2A —73-year-old woman with pancreatic adenocarcinoma. Volume renderings of arterial dominant phase of imaging show accessory hepatic artery (arrowhead) arising from superior mesenteric artery. Artery is not color encoded because it does not cross through surgical plane, although documenting its presence for surgeon is important. A superior pancreaticoduodenal artery has aberrant origin from this vessel, and its long course is in surgical plane (arrows). Because it crosses surgical plane, this aberrant superior pancreaticoduodenal artery is removed during workstation simulation of Whipple procedure and is color encoded in volume-rendered CT angiogram. Biliary stent (asterik, B) is in place and is also color encoded as it crosses surgical plane.

View larger version (111K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 2B —73-year-old woman with pancreatic adenocarcinoma. Volume renderings of arterial dominant phase of imaging show accessory hepatic artery (arrowhead) arising from superior mesenteric artery. Artery is not color encoded because it does not cross through surgical plane, although documenting its presence for surgeon is important. A superior pancreaticoduodenal artery has aberrant origin from this vessel, and its long course is in surgical plane (arrows). Because it crosses surgical plane, this aberrant superior pancreaticoduodenal artery is removed during workstation simulation of Whipple procedure and is color encoded in volume-rendered CT angiogram. Biliary stent (asterik, B) is in place and is also color encoded as it crosses surgical plane.

View larger version (153K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 3A —80-year-old man with small ampullary adenocarcinoma. Volume-rendered image shows large ileal artery from superior mesenteric artery feeding retrogradely to anastomose with gastroduodenal artery and in so doing crossing surgical plane (arrowhead). Biliary stent (asterisk) is in place. Also shown are two complete pancreaticoduodenal arcades.

View larger version (112K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 3B —80-year-old man with small ampullary adenocarcinoma. MDCT scan shows presence of retrograde feeding artery (arrowhead) in oblique thick slab.

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