Whipple operation – a pancreaticoduodenectomy is an advanced surgical procedure which requires a lot of technical expertise and is associated with a lot of morbidity and mortality. This is usually performed by open surgical approach, with a long wound which is painful . Currently minimally invasive surgery (MIS) is used worldwide with improved wound cosmesis and to minimize pain in most abdominal procedures, but minimally invasive pancreaticoduodenectomy is not very well established for complex pancreaticoduodenectomy due to its technical complexity. Robotic surgery which has been recently introduced can help overcome most of the limitations associated with the laparoscopic approach. It provides high-definition three-dimensional vision, ten times high optical magnification, 7 degrees of freedom with endo wristed instruments, which in turn lead to increased precision of suturing , eliminating surgeon tremor and increased control. Robotic surgery helps to perform more complex procedures requiring wide ranging dissection with fine articulate suturing such as pancreaticoduodenectomy. Though it takes longer operative room times, robotic pancreaticoduodenectomy offers the important advantages like reduced gastric emptying times, minimal bleeding, quicker post operative recovery, less hospital stay, and reduced surgical site infections, vis a vis open pancreaticoduodenectomy. Robotic Whipples is also technically possible compromising the survival – both disease free and overall for pancreatic head and ampullary adenocarcinomas. Robotic pancreaticoduodenectomy should thus be offered to patients on the basis of all these factors – surgical feasibility, surgical outcomes, and patient satisfaction.
Robotic Surgical Systems enables us to perform radical and at the same time delicate procedures like a pancreaticoduodenectomy which involves comprehensive dissection and careful delicate restoration of continuity of the digestive tract. Robotic pancreaticoduodenectomy benefits from reduced bleeding, reduced gastric emptying times, quicker of postoperative recovery, and lower surgical site infection, but prolonged OR time, when compared worldwide with open pancreaticoduodenectomy.
Whipple operation – a pancreaticoduodenectomy is an advanced surgical procedure which requires a lot of technical expertise and is associated with a lot of morbidity and mortality. This is usually performed by open surgical approach, with a long wound which is painful. Currently minimally invasive surgery (MIS) is used worldwide with improved wound cosmesis and to minimize pain in most abdominal procedures but minimally invasive pancreaticoduodenectomy is not very well-established for complex pancreaticoduodenectomy due to its technical complexity. Robotic surgery which has been recently introduced can help overcome most of the limitations associated with the laparoscopic approach.
First case of Robotic Whipples resection was reported by Giulianotti et al in 2003, and now multiple centres have reported this procedure. Studies have also reported the oncologic safety of this procedure with reduced morbidity vis a vis open Pancreaticoduodenectomy. Robotic surgery which has been recently introduced can help overcome most of the limitations associated with the laparoscopic approach. It provides high-definition three-dimensional vision, ten times high optical magnification, 7 degrees of freedom with endo wristed instruments, which in turn lead to increased precision of suturing, eliminating surgeon tremor and increased control. Robotic surgery helps to perform more complex procedures requiring wide ranging dissection with fine articulate suturing such as pancreaticoduodenectomy. Though it takes longer operative room times, robotic pancreaticoduodenectomy offers the important advantages like reduced gastric emptying times, minimal bleeding, quicker post operative recovery, less hospital stay, and reduced surgical site infections, vis a vis open pancreaticoduodenectomy. Robotic Whipples is also technically possible compromising the survival – both disease free and overall for pancreatic head and ampullary adenocarcinomas. Robotic pancreaticoduodenectomy should thus be offered to patients on the basis of all these factors – surgical feasibility, surgical outcomes, and patient satisfaction. Various reviews and studies have found equivalence of robotic pancreaticoduodenectomy with open pancreaticoduodenectomy with better post operative outcomes. Short term outcomes are well documented. But long term results are still scarce owing to the rarity of this procedure.
Minimally invasive surgery which includes both laparoscopic and robotic approaches, is today very popular in most surgical fields including oncologic pancreatic surgeries. Laparoscopic pancreaticoduodenectomy though initially introduced early in 1994,15 has not become very popular because of its technical complexity as well as high level of surgical expertise required as well as the unforgiving post operative complications associated with it. Reconstruction after a pancreaticoduodenectomy requires precise suturing together of small lumen ducts and viscera along with intracorporeal knot placement in very soft, friable pancreas. This complicated operative procedure is limited by need for advanced technical laparoscopic skills and a very steep learning curve. With use of da Vinci Robotic Surgical System (Intuitive Surgical, Inc), all these limitations are overcome. It provides high-definition three-dimensional vivid with 10-15 times magnification. With instruments which are articulated in 7 degrees of freedom and endowristing, precision that is needed for suturing these fine structures with elimination of fine tremor, even a procedure as complex as a Whipple procedure can be done confidently though it involves complex and comprehensive resections and reconstructions of the alimentary tract including the pancreatic, biliary and gastrointestinal system. The one major concern with the da Vinci Robotic System is the cost of the robot and the reusable robotic instruments, which is why it is still not widely used as routine procedure in many centers.
We report the case of a 76-year-old lady who presented with pruritus and icterus, diagnosed with a periampullary carcinoma. She was also a diabetic, hypertensive, and on treatment for bipolar mood disorder. She was severely debilitated and bed bound by her illness when diagnosed and a pancreaticoduodenectomy was the treatment of choice as she had localised disease on the PET and MRI.
She was taken up for the surgery and taking into account her physical state a minimally invasive robotic approach was preferred.
da Vinci Robotic Surgical System by (Intuitive Surgical, Inc) was used to perform robotic Whipples resection. Six ports were used – four robotic trocars and two assistant ports (Figure 2) 12-mm trocar to be used as the assistant port is set up via trans umbilical incision, pneumoperitoneum at a pressure level of 12-15 mm Hg is then established. Laparoscopic inspection was performed to check the feasibility and ensure resectability of before docking the da Vinci robotic system. Three 8-mm robotic ports used for working instruments were set up, first one at the right anterior axillary line – the same level pancreatic head, second along the left anterior axillary line – the level pancreatic head, and the third one along the level of left mid-clavicular line slightly below the level of the umbilicus. The 8 Xi camera port was placed at about 3-5 cm to the right of the umbilicus. The robotic camera scope can clearly visualise the relationship of pancreatic head and superior mesenteric vessels during dissection of the pancreatic head. A 5-mm assistant assistant port was placed on the level of right mid-clavicular line below the camera port. Surgery took 13 hours but the patient was hemodynamically stable, with a blood loss of 180 ml. She was extubated immediately after the procedure and remained hemodynamically stable without any inotropic supports.
The patient recovered well after the surgery. She was in the ICU for a day. Was comfortable enough to mobilise on the first post op day. Was started on jejunostomy feeds and could be discharged by 6th post-operative day. She had no wound morbidity. Her post-operative histopathology revealed a periampullary adenocarcinoma grade 1 stage T2N0M0 – with a nodal yield of 12 nodes, comparable to open pancreaticoduodenectomy.
It can be clearly seen that Robotic Pancreaticoduodenectomy has benefits of less delayed gastric emptying, less blood loss, lower surgical site infection rate, and shorter postoperative hospital stay, as compared with Open Pancreaticoduodenectomy, according to studies and literature reports.
The wounds after Robotic and Open Pancreaticoduodenectomy are shown in Figure 4.
Robotic approach allows surgeons to perform more complicated and delicate procedures such as pancreaticoduodenectomy involving extensive dissection and restoration of digestive tract continuity for the pancreas, bile duct, and gastrointestinal tract. Robotic pancreaticoduodenectomy though a longer procedure has been reported as associated with less blood loss, less delayed gastric emptying, shorter length of postoperative stay, and lower wound infection rate, but longer operative time, as compared with the traditional open pancreaticoduodenectomy and may soon become the preferred mode of surgery for patients with ampullary and pancreatic head tumours with constraint of cost being the only barrier.
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Dr. Sujay Susikar Consultant Surgical oncologist Kauvery Hospital, Chennai
