By Omar Llaguna, MD
Patients with pancreatic cancer have few options. While surgery to remove the disease can provide some of the best outcomes, only a few patients are surgical candidates. The national five-year survival rate is 11% and, without surgical intervention, the cure rate is zero.
Within this small subset of patients is an even smaller group who qualify for a “pancreaticoduodenectomy” or Whipple procedure. One of the most complex surgeries, it involves removing the head of the pancreas, the duodenum, a portion of the bile duct, the gallbladder, and associated lymph nodes. The liver, small intestine, and stomach all need to be reconnected with hair-like sutures in soft tissue, all while being bathed in digestive enzymes that can eat away at the area being connected.
Despite the challenging setup and complexity, it’s critically important that we continue to perform the Whipple procedure, since it’s often the patient’s best chance for long-term survival. And, like any surgery, if it can be done in a minimally invasive way, patients lose less blood, endure less pain, and recover quicker than with a traditional, open procedure.
By the Numbers
There were less than 18,000 Whipple procedures completed from 2004-2017 in the U.S., according to the National Cancer Database. Of those, only 12% were minimally invasive (done laparoscopically or with robotic technology), with less than 400 robot-assisted procedures in the total. A high-volume surgical center might see 10-20 Whipple-appropriate cases in a year.
Memorial Healthcare System is one of the few hospital systems in Florida performing the Whipple surgery robotically.
In addition to the minimally invasive approach being better for the patient, robotic surgery offers considerable advantages to surgeons trained in the technology. While seated at a computer console near the operating table, we control a robotic arm with a camera attached that provides a high-definition, magnified, 3D view of the area being worked on. With three other arms holding robotically-controlled surgical instruments and the improved visuals, we’re able to perform the maneuvers required to complete the Whipple procedure more precisely. Interestingly, even in cases where the patient’s cancer and anatomy require a conversion to open surgery, some of the benefits of the robotic approach remain, including an increased number of lymph nodes that can be obtained.
Choosing to Adapt
Despite its advantages, there hasn’t been a widespread adoption of robotic surgery as the standard of minimally invasive surgical care for pancreatic cancer. It takes a changed mindset to pivot from the more commonly-performed open approach, especially given the few candidates that qualify for the Whipple procedure, the special training required to operate robotically, and the steep learning curve associated with a surgery as delicate as this one. My own comfort performing the procedure was aided by connecting with others that have successfully completed it, observing their surgeries, and working in simulated situations on non-human subjects.
None of this is meant to minimize the value of open surgery, which is still very much required, given that not all patients are candidates for a robotic approach. However, when clinically indicated, Memorial believes the benefits to the patient of the robot-assisted Whipple procedure makes it a better option moving forward. We’ve had success combining the newer technology with preoperative chemotherapy regimens and an overall approach that focuses on whole person care. This includes not only the clinical approaches to fighting the disease, but also tactics that address the physical, mental, and emotional aspects of an individual and family’s battle against cancer. All of this enhances recovery time and leads to better outcomes.
As importantly, the robotic Whipple procedure provides pancreatic cancer patients hope while battling a disease most often viewed as a death sentence. If for no other reason, that makes it a worthwhile undertaking.
Dr. Omar Llaguna is a surgical oncologist with Memorial Healthcare System who treats patients with gastrointestinal cancers (including of the pancreas, gallbladder, liver, appendix, etc.), melanoma, soft tissue sarcomas, and peritoneal malignancies. He also assists with the system’s surgical oncology curriculum, is an active researcher, and assistant professor of surgery at Florida International University’s Wertheim College of Medicine.
