Where is the Pancreas?

By Marty Makary M.D., M.P.H.

Located directly behind the stomach, the pancreas lies deep in the center of the abdomen. Its position corresponds to an area 3-6 inches above the “belly button”, straight back on the back wall of the abdominal cavity. In fact, the bones of the spine are just a few inches behind the pancreas. And the major vessels of the abdomen (the portal vein, mesenteric vessels, aorta, and vena cava) all course through or next to the pancreas, making it a treacherous area for a surgeon inexperienced in pancreas surgery.

diagram showing physical location of pancreas

The pancreas is an integral part of the digestive system. The flow of the digestive system is often altered during the surgical treatment of pancreatic cancer. Therefore it is helpful to understand the normal flow of food before reading about surgical treatment. Food is carried from the mouth to the stomach by the esophagus. This tube descends from the mouth and through an opening in the diaphragm. (The diaphragm is a dome shaped muscle that separates the lungs and heart from the abdomen and assists in breathing.)

Immediately after passing through the diaphragm’s opening, the esophagus empties into the stomach where acids that break down the food are produced. From the stomach, the food flows directly into the first part of the small intestine, called the duodenum. It is here in the duodenum that bile and pancreatic fluids enter the digestive system.

At the time of surgery, exposing the pancreas requires retracting the liver, stomach, omentum, small bowel, and colon. The liver, stomach, and omentum are retracted up towards the head and the small bowel and transverse colon is retracted down towards the feet. The kidneys do not need to be retracted because the pancreas sits between the 2 kidneys. The center of the back wall of the abdominal cavity, or the retroperitoneum, is pancreas bed, a space the pancreas shares with the first part of the small intestine (a.k.a. the duodenum). In fact, the head of the pancreas is intimately in contact with most of the duodenum.

The Whipple operation for tumors of the pancreas head removes both the pancreas head and duodenum as a unit due to their close proximity and shared blood supply. In addition, the Whipple operation removes part of the bile duct (which carries bile from the liver to the duodenum) because the bile duct courses through pancreas head. Thus after the pancreas tumor is removed in a Whipple operation, the intestine, bile duct, and remnant pancreas are meticulously reconstructed, making the operation long and tedious.

Conversely, tumors of the pancreas body or tail may not require removal of a segment of intestine and these tumors can sometimes be removed laparoscopically, even sparing the spleen in select cases. These minimally-invasive options are determined by the location of the tumor, the tumor size, the proximity to the portal vein, and the surgeon’s experience with laparoscopy.

The deep and central location of the pancreas in the abdomen, coupled with its “wet sponge” texture, make it a unique organ for surgeons to conquer. Adding to the complexity of pancreas surgery, the pancreas lacks a capsule, or covering, and is thus prone to bleed or leak juices with even a small degree of rough handling. For these reasons, we recommend that pancreas surgery be performed by a specialist who is familiar with standard tissue handling techniques for the pancreas.

When performed open, pancreas surgery often involves an incision directly over the organ. This incision begins at the lower aspect of the central sternal bone (the xyphoid), and extends to a point a few inches below the “belly button”. Laparoscopic pancreas surgery usually involves 3-4 one-inch incisions for instrumentation and a camera.

Every week, newly diagnosed patients call to ask if a their CAT scan findings indicate that surgery open, or laparoscopic, is feasible. For most patients, a quick assessment of the CAT scan findings can yield a rough estimate of surgical candidacy, and allow for planning for the next steps in assessment leading to the appropriate care in a rapid and timely fashion.

Marty Makary M.D., M.P.H.
Pancreas and Advanced Laparoscopic Surgery
Johns Hopkins Hospital

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13 Responses to “Where is the Pancreas?”

  1. Kevin Brown Says:

    Dr. Makary,

    I had a distal pancreatomy performed laparoscopically by you on 9-5-2008.

    It was a pleasure working with you and the entire staff at Johns Hopkins.

    I am feeling great and recovery has been a snap. I was pleased that I was a candidate do have this procedure done laparoscopically. On a scale of 1-10, my pain level never went above 1.5 and I didn’t take any pain medication after I was disconnected from the pain pump a few days after the surgery and before I was discharged from the hospital. I had no discomfort after a week. There is something to be said about minimally invasive surgery.

    Its always unfortunate that a person has to undergo surgery but I can tell you one thing, more patients should consider having it done laparoscopically if they are a candidate.

    Best Regards,

    Kevin

  2. Hap Says:

    How do you determine if one is a candidate? I was dx 12/07- stage 3 inoperable. Gemzar/oxaliplatin shrunk tumor over 6 mos. enough to make me a candidate for cyberknife performed at Sinai-August 08.

    Post procedure PET/CT scans will be done in Nov.

    Thank you.

  3. mmakary1 Says:

    Kevin–You hit a home run and I’m so glad you are cured. It was awsome you had practically no pain with laparoscopic surgery!

    Keep smiling. my staff and I are always here for you.

    Marty Makary

  4. mmakary1 Says:

    Send your CAT to my office and I’ll call you with an opinion regarding operability and approach (laparoscopic/open surgery). We have removed many tumors in patients who were deemed inoperable by good surgeons prior to coming to Hopkins. Tumors which DO NOT “encase” the superior mesenteric vein or artery on CAT scan are usually candidates for surgical removal. Another common CAT scan finding for which we do not recommend surgery is pancreas adenocarcinoma in the liver. Marty Makary

  5. Kalexand Says:

    My mom (age 65) was diagnosed in May 08 with a malignant mass near her ampula of vater. She was deemed a candidate for the Whipple Procedure, however after some time in surgery the dr came out to tell us that she had pancreatitus and he was unable to get to the tumor for removal, however he did remove part of her stomach, gall bladder, and I believe some of her intestines. He did this in hope that he would be able to finihs the surgery once the pancreatitus resolved. After 3 mos of gemzar, her second CT scan did not indicate pancreatitus, so the second surgery was done in an attempt to remove the tumor and complete the resectioning. Again, once she was opened up she still had pancreatitus. It was no better than the first time, and basically the surgeon told us there was nothing he could do. I could not accept that there was nothing that could be done, and I pressed him to do something. He did a prestow (Not sure about the spelling) so the fluid would hopefully drain better and the pancreatitus would resolve faster, or minimally, she would be more comfortable. It has been 3 mos since the second surgery, and she is due for her next CT scan. So much of this doesn’t make sense to me…for instance:
    If the last CT scan did not show the pancreatitus that she had, why are they doing it again this time?
    We were told that the gemzar would not really have typical side effects, yet she is tired and becomes sick to her stomach after treatments.
    She has a family history (4 generations deep) of breast cancer, and is herself a survivor of two different breast cancers (radical masc). Her mom died in her 30’s as did her sister…mom’s first breast cancer was in her 30’s and then the second was in her early 40’s). How can this cancer be unrelated? I can’t help but believe that there is a genetic adnormality, and I would like to be proactive in my own health as well as my daughter’s and my niece’s.
    Does the pancreatitus totally elimiate the possiblility of surgery, or are there some surgeons who would be able to get in there and get the mass out?
    How long does it take pancreatitus to resolve. They feel that the scans done during the diagnosis period caused the pancreatitus. She was jaundice and tired prior to the diagnosis, and also had blood in her stool (something the drs have also dismissed as unrelated). The blood has since resolved, but who knows why.
    I am my mom’s health care proxy. I need to know where to go from here. Is this a case, and is this the time for a second opinion? She spoke about getting a second opinion if after her next CT scan they suggested not operated a third time, but I am almost more nervous about going in a third time and finding the pancreatitus again…then what???? How many times can they open her up??? Please make any suggestions. I just want to advocate for what is right for my mom, much the way she has done for me all of my life. Thank you.

  6. Kalexand Says:

    Additional information: My mom does not call her cancer pancreatic, however it is listed as such, and the pathology report indicated that pancreatic cells were involved.
    I left that out…..sorry!

  7. mmakary1 Says:

    Thanks for your message. I recommend that she have a high-resolution pancreas CAT scan here at Johns Hopkins so we can view the pancreas in 3-D and determine with the highest degree of certainty the likelyhood of resectability at this point. You can schedule it through the pancreas website or by calling my office.

  8. janet farrell Says:

    My Son has Pancratic Cancer , he has lost weight, and still losing , can’t eat , mouth sores…..weak…….pain, nauseau, vomit…what can we do.\
    thank you
    janet farrell

  9. mmakary1 Says:

    Dear Ms. Farrell,

    Sorry to hear about your son. I’m sure this is a tough time for both of you.

    The surgical treatment of pancreas cancer is based on the CAT scan. In general if there is no spread to the liver, and no invasion of the SMV/portal vein/SMA vessels, then select patients can be candidates for a surgical removal. If this is the case, send me/us his CAT scan and we can give an opinion over the phone regarding surgical candidacy.

    The non-surgical treatment is managed by a medical and/or radiation oncologist and is based on treatment to try to get added months or years of life and treatment/medications to focus on comfort and quality of life.

  10. Marlene Says:

    My husband was diagnosed in late Aug. of 2008. He went in to have the whipple early Sept. by a surgeon in San Diego , CA who specializes in the whipple. The original tumor was in the bile duct. When they got in, they found another tumor on the backside of the pancreas. It was inoperable because it was in the tissues and blood vessels. They worked 5 and 1/2 hours on him and were able to do a bypass to relieve the jaundice. The surgeon said it was a very difficult operation because it was like sewing wet kleenex to wet kleenex. He just finished his first round of a 24/7 chemp pump with 5fu and radiation 5x a week for 28 treatments. We now have to wait 4 to 6 weeks to have a pet scan to see the results of his treatment. They’re planning a systemic chemo for 4 months starting mid Jan.of Gemzar and cisplatin. He’s in stage 3. I’m just wondering if it sounds like he could be cured or is it going to be a life of chemo for him? I would like to know so I can be a support and encouragement for him. He’s really struggling with fatigue and nausea. I wonder if the side effects will be worse with the gemzar and cisplatin. Thanks for answering my question.
    Marlene

  11. Pat Woernle Says:

    Hello,
    My Mother has recently been diagnosed with several pre-cancerous cysts on the tail of her pancreas. The pathology showed high level of CEA in the Cystic fluid and her blood level was 15, she is a smoker, age 68, history of Asthma and Chronic Pancreatitis for many years and had a Bill Roth II about 20 years ago for sever ulcer disease.
    What type of surgery might she be a candidate for, removal of the tail alone or the entire pancreas making her a Type 1 diabetic?
    I am also wondering about screening of myself and my sister. Is there screening available and is it recommended? I think you can tell I am a nurse and sometimes knowledge is a very bad thing. I know this is quite brief but please let me know your gut response to the information I have presented. Thank you very much!

  12. mmakary1 Says:

    Hi Pat, I would recommend she send me her CT or, even better, get a high-resolution 3D CT here at Johns Hopkins. Based on the CT findings I can make a recommendation.

    Marty Makary

  13. mmakary1 Says:

    Dear Marlene,

    I would recommend a repeat CT 6 weeks after the completion of chemo to re-assess. We can arrange for this CT to be done here at Hopkins if you wish.

    Marty Makary