“Robotic Whipple Procedure for Pancreatic
Cancer ”
Mokenge Malafa, MD
Kenneth Meredith, MD
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 t here’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. P eople 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 par t 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. O nce 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 hav ing 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. F or 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: W e’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 neuroe ndocrine 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 ca lled 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.
This information is intended for additional research purposes only. It is not to be used as a prescription or advice from Ivanhoe Broadcast News, Inc. or any medical professional interviewed. Ivanhoe Broadcast News, Inc. assumes no responsibility for the depth or accuracy of physician statements. Procedures or medicines apply to different people and medical factors; always consult your physician on medical matters.
If you would like more information, please contact:
Patty Kim
Moffitt Cancer Center
(813) 745-7322
Patricia.Kim@moffitt.org
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