In the late 1990s and early 2000s, there were two main options for the surgical treatment of diseases of the head of the pancreas: the open pancreatoduodenectomy or Whipple procedure and the laparoscopic Whipple.
The open procedure required a large incision, a six- to seven-hour operation and a lengthy hospitalization and recovery. The laparoscopic surgery allowed for smaller incisions and held promise for quicker recovery times but had its own shortcomings. It only allowed for two-dimensional vision, did not have “wristed” instruments to enable easy suturing, and provided limited ergonomics. Ultimately, the laparoscopic Whipple proved difficult to perform for most surgeons and was not readily adopted.
A Better Way to Whipple
In 2003, another minimally invasive “keyhole” surgical approach to the Whipple was developed—the robotic-assisted pancreatoduodenectomy. Benefits of the robotic platform over its laparoscopic counterpart were clear. It provided:
- Better magnification
- Three-dimensional vision
- Elimination of surgeon tremor
- Precision and dexterity through the use of wristed instruments that mimic human hand movements.
By about 2009, a handful of programs had begun to perform the minimally invasive robotic-assisted Whipple procedure, which offered the benefits of the laparoscopic version with better surgical precision. The leading program in the country was UPMC Hillman Cancer Center.
Since then, UPMC Hillman surgeons have performed more than 500 robotic-assisted Whipple procedures and trained many other surgeons nationally and internationally to perform them. That has helped expand the availability of the surgery worldwide. Robotic-assisted Whipples currently are being performed at an increasing number of hospitals in the U.S. and around the globe. In fact, recent data from the American College of Surgeons Surgical Quality Program (NSQIP) suggest that more surgeons nationally are doing the Whipple robotically than laparoscopically. The data implies that surgeons are finding this approach easier to adopt.
That’s good news for people with pancreatic cancer because more than 2/3 of them now can be considered candidates for the robotic-assisted Whipple.
“At first, only the fittest of patients were considered for the surgery at UPMC because it was so new,” says Amer H. Zureikat, MD, a surgical oncologist and co-director of the UPMC Pancreatic Cancer Center, who was one of the surgeons trained at UPMC Hillman. “Now that the learning curve has been identified and surpassed, most patients with localized pancreatic cancer have become candidates for the Whipple as long as they are healthy enough to sustain an operation.”
Unfortunately, many people with pancreatic cancer don’t seek treatment because their impression is that nothing can be done—that it is always fatal. “Robotic Whipple surgery is a potential game changer because it reduces recovery time and may restore health quicker so that other treatments needed to improve survival after surgery—like chemotherapy and radiation therapy—don’t seem as daunting and are better tolerated,” Dr. Zureikat adds. “We recently performed a multi-institutional comparison of open and robotic Whipples at eight large hospitals within the U.S., including UPMC, and found the robotic Whipple to be associated with fewer complications compared to the open approach.”
Better Chemotherapy Drugs
The chemotherapy drugs used in conjunction with the Whipple have improved over the last few years, as well, which has led to better survival rates. “Five years ago, there was only one main chemotherapy drug used to treat pancreatic cancer—gemcitabine, marketed under the brand name Gemzar®,” says Dr. Zureikat. Two new chemotherapy regimens composed of multiple drugs were recently FDA-approved for the treatment of pancreatic cancer—FOLFIRNOX and Gemcitabine-Abraxane.
“These regimens have been shown to shrink tumors more effectively and improve survival rates,” he adds. “Our pancreas team has been at the forefront of using these novel regimens for pancreatic cancer. In combination with less invasive surgery like the robotic Whipple, we are making pancreatic cancer a disease we can battle.”
Even the robotic daVinci® Surgical System used to perform the Whipple has been improved. Like the older model, the new model requires two surgeons to operate three tiny hands, which rotate and bend more nimbly than the human hand.
A miniature camera provides a magnified, three-dimensional high-definition view. The increased vision, combined with the dexterity of the robotic hands, allows for precise movement and placement of sutures in the organs, which are accessed through small incisions in the abdomen.
And although the surgery is referred to as “robotic,” the term can be misleading to patients and families. A robot does not do the surgery—it is merely a tool used by the surgeon. The surgeon controls the robot’s movements and is in full control of all aspects of the operation.
The Whipple Explained
In a standard Whipple procedure, the surgeon removes the head of the pancreas, where tumors often start; the gallbladder; the duodenum, which is the upper part of the small intestine; a part of the stomach called the pylorus; part of the bile duct; and the lymph nodes near the head of the pancreas. The surgeon then reconnects the remaining part of the pancreas and digestive organs so that pancreatic digestive enzymes, bile, and stomach contents will flow into the small intestine during digestion.
In a similar procedure known as the pylorus-preserving Whipple, the pylorus is not removed. The pylorus plays an important role in digestion, acting as a valve that controls the flow of partially digested food from the stomach to the small intestine, so it is preserved if there is no sign of disease.
Although people who have either Whipple procedure can have digestion problems afterward, those who have surgery tend to have better long-term survival rates than those who do not have surgery.
“The robotic-assisted Whipple procedure also can be used for other diseases of the pancreas,” Dr. Zureikat adds. “Of all Whipples performed, only about 1/3 are done to treat pancreatic cancer. The other 1/3 are for benign conditions, like cysts or chronic pancreatitis, and the remaining 1/3 are for other cancers of the duodenum and bile duct.”