Robotic Whipple Procedure for Pancreatic Cancer

Pancreatic cancer is the fourth leading cancer killer in the U.S. and the treatment can be brutal. However, doctors say advancements in robotic surgery can lessen the pain, speed up your recovery, and possibly improve your chances of survival. We show you why in this medical breakthrough.

Bob Dies never skips the chance to dance with his wife. Earlier this year, Bob was diagnosed with pancreatic cancer and thought his dancing days might be over.

"It's the worst type of cancer," Bob Dies told Ivanhoe.

Bob underwent a complex surgery called the Robotic Whipple procedure. His gallbladder and large portions of his stomach, pancreas, and small intestine were removed and the remaining pancreas and digestive organs were rebuilt and reconnected.

"That's why the operation is so complicated," Mokenge P. Malafa, MD, a Surgical Oncologist at the Moffitt Cancer Center, told Ivanhoe.

That's also why these two surgeons use this robot to get it done.

Dr. Malafa claims that, "This technology actually allows us to sometimes see better, to sew better, and to cut better with less trauma to the tissue."

They also make several small incisions instead of one big one.

"There were four spots essentially where the arms of the robot went into my body," Dies said.

These doctors say it leads to less pain, shorter hospital stays, faster recoveries, and "the wound infection rate is very low from this," Kenneth Meredith, MD, FACS, Assistant Member Surgery and Oncology at the Moffitt Cancer Center, told Ivanhoe.

Bob says he was walking the day after surgery and is optimistic about a full recovery.

There are still side-effects to the surgery, including infection, bleeding, and trouble with the stomach emptying itself after meals. Not everyone is a candidate for this procedure, especially those who are obese and have had abdominal surgery before. Since this is a risky operation, the American Cancer Society says it's critical that you have the procedure done at a specialized institution and with doctors who have the most experience.


BACKGROUND: The American Cancer Society estimates that there will be about 45,220 new cases of pancreatic cancer and about 38,460 deaths from pancreatic cancer in the United States in 2013.  The lifetime risk of having pancreatic cancer is about one in 78.  The pancreas contains two different kinds of glands.  The exocrine glands make pancreatic "juice," which have enzymes that break down fats and proteins in food.  Most of the cells in the pancreas are part of the exocrine system.  A smaller number of cells are endocrine cells.  These cells are arranged by clusters called islets.  They make hormones like insulin that help balance the amount of sugar in the blood.  Both types of cells of the pancreas can form tumors, but tumors that are formed by the exocrine cells are more common.  It is important to know if a tumor is from the exocrine or endocrine part of the pancreas.  Each tumor has its own symptoms, is found using different tests, treated in different ways, and has a different outlook for prognosis.  (Source:  http://www.cancer.org)


RISKS FACTORS:  Doctors are still unsure of what exactly causes pancreatic cancer, but there are some risk factors that have been linked to the disease.  Recent research has proved that some of risk factors affect the DNA of cells in the pancreas, which can lead to abnormal cell growth and can cause tumors to form.  Some risk factors include:

  • Age:  The risk of this cancer goes up as people age.  The average age at the time pancreatic cancer is found is 71.
  • Race:  African Americans have an increased risk to have pancreatic cancer than Caucasians.
  • Gender:  Men are 30 percent more likely to get this cancer than women.
  • Smoking:  The risk is at least twice as high in smokers compared to those who never smoked.
  • Diabetes:  Pancreatic cancer is more common in people with diabetes.  Most of the risk is in people with type 2 diabetes. (Source:

    http://www.cancer.org )


NEW TECHNOLOGY:  Based on the stage and type of pancreatic cancer, patients may need more than one type of treatment.  Treatment options include surgery, radiation therapy, chemotherapy and other drugs, and ablative techniques.  Pain control is an important part of the treatment process for many patients.  Statistics show a six percent chance of living five years once a patient develops the disease.  Now, doctors are using robotic procedure to increase the survival rate to 25 percent.  The Moffitt Cancer Center on the USF Tampa campus is the first hospital in Florida to conduct a robotic Whipple surgery and have now performed 16 total.  The Whipple surgery involves gaining entrance through the abdomen with the goal of removing the head of the pancreas, with some later reconstruction of the intestines.  Robotic surgeries offer less cosmetic scarring, faster recovery times, and less pain.  "It's kind of like playing a videogame. After the small incisions are made for the robot equipment to enter the patient's abdomen, I go into another room and perform the surgery through viewing an HD camera. I insert my hands into a controller and perform the operation remotely. I am always in control," Mokenge Malafa, MD, Chair of the Department of Gastrointestinal Oncology at Moffitt Cancer Center, was quoted as saying. The robotic Whipple surgery uses the da Vinci Surgical System, which is a system that allows doctors to view the procedure with an HD camera and a robotic hand that is capable of more motion than a human hand. Dr. Malafa said the da Vinci System was previously used for simpler surgeries, like gall bladder removal.  "The bottom line is we are still in the early days of this technology.  As people get more used to it, we should start to see a rapid expansion of at least partially robotic surgeries," John D. Petrila, Professor in the Department of Health Policy and Management at USF, Tampa, was quoted as saying.  (Source:  http://www.usforacle.com/moffitt-performs-fully-robotic-whipple-surgery-1.2804356)



Mokenge P. Malafa, MD, Department Chair for Gastrointestinal Oncology, and head of the section of Hepatopancreatobiliary Oncology at Moffitt Cancer Center, and Kenneth Meredith, MD, Assistant Member Surgery and Oncology at Moffitt Cancer Center, talk about a new robotic procedure for people with pancreatic cancer.

Can you tell us about the Whipple procedure?

Dr. Meredith:  Basically, the Whipple procedure involves removing the distal part of the stomach, the head of the pancreas and duodenum, bile duct, and gallbladder. It involves a very complicated reconstruction. Usually there's an anastomosis or connection between the stomach and the small intestine. Then there's a connection between the small intestine and the pancreas, and finally the small intestine to the bile duct. So, then basically the whole plumbing for the foregut is in a new position. This operation can vary in length, anywhere from four to eleven hours, depending on how complicated the operation gets. This operation is not for patients that have vein involvement or arterial involvement because the one disadvantage of the robot is that it lacks haptic feedback or the tactile sensation of manipulation of tissue. As you get further on in your robotic experience, and this is going sound very kind of futuristic, you begin to feel with your eyes. I started doing robotic procedures in 2009 in the GI tract. So, I have over time now developed a sensation where I can tell exactly how hard I'm pulling on tissue just based upon my sensory feedback from my eyes. People starting out in robotics really shouldn't be doing very complicated procedures like this and this is very much a team approach. We both do different parts of this operation and to become proficient at the entire operation we flip on which part we do of the operation. For instance there's an ablative phase then a reconstruction phase. At one area one surgeon will be doing the ablative phase and then the other surgeon does the reconstructive phase. Then we flip and the surgeon that did the ablative phase before will then do the reconstructive phase. This allows you to become proficient at the entire operation. The other thing is surgeon fatigue; this is a very long operation. Once you've reached that learning curve, then your times go down but also your length of hospitalization and everything related to a prolonged operation actually decreases as well.

So, who is an ideal candidate for this procedure?

Dr. Malafa: Non-obese patients, whom we define as having BMI's less than 30, those are the ideal. Patients that have dilated bile duct and pancreatic duct make it easier to sew through these structures when they've been blocked. So, it's kind of an advantage to have those. Also, not having previous radiation or chemotherapy makes for a good candidate; for example, patients that have what we call borderline resectable tumors that are involved in the vein and the artery like we talked about. So, if those patients have been treated previously sometimes the tissues around the blood vessels are very sticky and you need that tactile response to really get an advantage of what you're doing and to do it safely. So safety is kind of the primary concern in this operation and so selecting these patients carefully is a very, very important way for us to accomplish that goal of safety.

Can you explain to us the traditional Whipple procedure? What is that like and why is that so complex?

Dr. Malafa: Because the procedure is very precise and very standardized, there's a potential to have excellent clinical outcomes for just controlling the cancer, meaning the precision of removing the whole tissue. The next question comes is a quicker return or recovery from the procedure. For example, they're able to eat earlier in the hospital. Normally, most patients are not ready to eat for about a week or so after the surgery, but with the robotic procedure sometimes just a few days afterwards they're hungry already and they're ready to eat in sometimes as early as three or four days after the surgery. That can also translate to what we call a shorter hospital stay. The typical stay for a patient that has an open procedure can be anywhere from a week to two weeks. The average length, and a lot of people report this, is approximately ten to twelve days in the hospital. However, what we've seen in our experience is an average of about eight days in the hospital. So there's just a little bit quicker discharge from the hospital.

What is more impressive for these patients is that they actually come back to see us in the clinic two to three weeks afterwards, compared to the patients we do on open operation. These patients that we do in the minimally invasive or robotic operation really are stronger. They feel like getting back to their normal activity; they want to drive. They want to get back to their sporting activity and because their incisions are so small we are able to allow them to return to those activities sooner. Now it's important that in addition to the benefit for the patient there's actually potential benefit for the surgeon. This technology actually allows us to sometimes see the dexterity of the instruments and the textbook technology actually has a potential to increase our ability to do the operation better, to sew better, and to cut better. Then, it allows us to basically do the tying of the knots and the suturing with fewer traumas to the tissue. So, we're not traumatizing the tissues. Because of the way the surgeon sits in the console and is able to  manipulate the instrument, there's less fatigue compared to when we do minimally invasive; for example, using the laparoscopic technique where we only have a two dimensional ability to see. This translates to the surgeon and to the patient that there's less blood loss in the operation and obviously a quicker recovery. So, less chance that you start doing the minimal invasive and you have to open the patient up. That's what we mean by conversion.

Does that happen quite often?

Dr. Malafa: We're doing the same exact operation we do in the open, meaning we're removing the head of the pancreas in the case of the Whipple procedure, which is the most complex pancreatic surgery. When you remove that head of the pancreas you have to remove the intestine that's next to the stomach called the duodenum and you have to remove the bile duct that goes in to the head of the pancreas. Well, what that leaves you with is that you have to reconstruct those three things. You have to reconstruct the pancreas by bringing a piece of bowel and reconstructing the connection of the pancreas to the gut. You have to reconstruct the connection of the bile duct to the gut because now you have to remove the part of the bile duct. Then you also have to reconstruct the intestine to the stomach again so that the things will flow. So that's why the operation is so complicated because you are removing a tumor, which is in the head of the pancreas that's attached to these three different areas of the intestine. Then you're finishing up by doing this reconstruction. So you do the same thing you do in the open. The only difference is in the open the way we do it is we make an incision in the upper abdomen, a big incision, and then we physically do all the steps of the operation. In the robotic setting, what we do is that we're able to use smaller incisions where we put these instruments that are called the robotic instruments.

So the patient is in a room and you're somewhere else?

Dr. Malafa: Well, there are two surgeons. So one surgeon is on the side of the patient and he is the one directing the instruments in the patient in terms of exchanging the instrument. Then, the other surgeon is in the consol. One person focuses on what we call the ablative phase of the operation. They are in the console; so they are actually removing the head of the pancreas, removing the intestine, the gallbladder, and the bile duct. That's one phase of the operation. After the tumor is out of the organs, then another surgeon goes to the console and that surgeon does the reconstruction or the reconnection. When one surgeon is at the console, the other surgeon is actually at the patient and we're communicating, passing instruments, talking, and controlling.

Is this mostly what you guys do?

Dr. Malafa: Yes. As you can imagine, it is intense.

Is this being used here and in other areas?

Dr. Malafa: Yes it is.

Do you think this can treat other conditions?

Dr. Malafa:  Yes. There are other diseases of the pancreas that are relevant in the area around the pancreas that you can also treat. For example, there is a large entity we call pancreatic neuroendocrine tumor. That's the kind of tumor that Mr. Steve Jobs died of, metastatic neuroendocrine tumor of the pancreas. We have duodenal cancers that you can treat like this. We have bile duct cancers that you can treat like that and we have also an area called periampullary cancers that can be treated like that. There's a lot of benign type of tumors in the head of the pancreas that are sometimes ideal for this treatment because these lesions are not cancer yet, but they have a potential to grow in to cancer. So, there are multiple types of cysts that can turn in to cancer that would be ideal to treat, or polyps or tumors that are in this area that has not turned to cancer, but could eventually. 




Patty Kim

Moffitt Cancer Center

(813) 745-7322