By Patricio Polanco, M.D.
In surgery circles, the Whipple procedure is widely regarded as one of the most complex abdominal operations. It requires deft skill and extensive training to successfully remove the head of the pancreas, duodenum, gallbladder, nearby lymph nodes, and part of the stomach, if necessary, and then reattach the remainder of the pancreas, bile duct, and stomach to the small intestine.
Traditionally performed through a large incision, at UT Southwestern our pancreatic cancer surgeons have specialized in robotic-assisted Whipple surgery, a more precise approach through smaller incisions that has been proven to benefit patients with faster recovery times, less pain, less use of pain medication, and prompter return to work. It has also been shown to have comparable cancer treatment results with lower rates of complications and transfusions than the open surgery.
Besides the Whipple procedure, several other robotic pancreatic surgeries are routinely performed at UT Southwestern, including distal pancreatectomies, tumor enucleations, cystogastrostomies, ampullectomies, and bypass procedures for chronic pancreatitis, among others.
Initially led by robotic pancreas surgery pioneer Herbert Zeh III, M.D., Chair of the Department of Surgery at UT Southwestern, our gastrointestinal surgery program has become one of the few international centers of excellence for this approach. We care for patients from all over the U.S. who have complex pancreatic tumors that other centers are not equipped to treat surgically.
Also, surgeons from around the world travel to our main campus in Dallas to train with our team and at our state-of-the-art Simulation Center.
In recent years, we have hosted surgeons from Slovenia, Mexico, Peru, Japan, Costa Rica, Egypt, and Israel, all of whom have been able to immerse themselves in hands-on training rather than just observing procedures and techniques. UT Southwestern surgeons have also visited some of those surgeons’ hospitals to provide additional guidance and skill refinement in robotic-assisted techniques.
The Whipple procedure is the only treatment with curative potential for patients with early-stage pancreatic head cancer when combined with systemic perioperative chemotherapy. As early adopters and developers of robotic-assisted pancreatic surgery, UT Southwestern considers it part of our mission to share knowledge and increase access to this cutting-edge technique.
Benefits of robotic-assisted Whipple procedure
Both traditional and robotic-assisted Whipple surgeries require a tight-knit team of surgeons, physician assistants, and OR nurses.
The da Vinci robot systems in our operating room and Simulation Center are equipped with state-of-the-art, miniaturized surgical tools and a lighted camera, which are attached to a series of robotic arms. Real-time, 3D-HD images are displayed throughout the operating room, as well as within the computer console pod in the OR. The robotic arms provide a wider range of motion and more steadiness than human hands alone.
One surgeon is seated at the robot console and an assistant surgeon is positioned at the bedside; they stay in constant communication throughout the procedure.
- After the patient is put under, we insufflate the abdomen and make a series of small incisions, most of which are less than half an inch long.
- Surgical instruments and a camera are inserted into the incisions and are controlled by the console surgeon.
- We carefully remove the head of the pancreas and parts of the small intestine, gallbladder, nearby lymph nodes, and stomach, if necessary.
- The remainder of the pancreas, bile duct, and stomach are anastomosed to the small intestine using delicate and precise suturing techniques. Some of these structures, such as the pancreatic duct, can be one-tenth of an inch.
Depending on the type of tumor, some patients may need adjuvant chemotherapy or radiotherapy after surgery to decrease the chances of tumor recurrence.
The robotic-assisted Whipple procedure can take four hours or longer to perform. Yet, due to the small size of incisions and limited amount of pain, most patients are ambulating the same evening of the day of surgery.
Our research team has shown that minimally invasive, robotic-assisted Whipple surgery is not only safe and feasible but reduces wound infections, transfusions, and length of hospital stay. Additionally, we have shown that in high-volume centers, robotic-assisted pancreatoduodenectomy outcomes are equivalent to those of patients who had laparoscopic surgery but with a lower rate of conversions to open surgery.
Academic excellence in robotic-assisted surgery
At UT Southwestern’s Simulation Center – one of the largest facilities in the nation at 49,000 square feet – our trainees and visitors can hone their skills on virtual reality training platforms, sharpen procedural maneuvers using biosynthetic material that simulates human tissue, and use the Sim Center robot system on demand, 24/7. As the Director of Robotic Surgical Training for the Department of Surgery, I led a team of surgical educators and researchers that has developed a comprehensive robotic training curricula for residents and surgeons. Our work validating this training model has also been published in recognized surgical journals.
One recent example of our international collaborations was the visit of Miha Petric, M.D., a pancreas surgeon from the University of Ljubljana, Slovenia, in fall 2022. Dr. Petric spent five weeks at UTSW, observing robotic pancreas and liver surgeries in real time and practicing techniques with our Sim Center robot. After training with our team, he took the techniques home and began offering lower-complexity robotic-assisted pancreas surgeries.
A few months later, I traveled to Slovenia to proctor Dr. Petric and his team in robotic-assisted Whipple procedures, the first ones in the Balkans region of eastern Europe. To date, the Slovenian surgeons we trained have performed several robotic-assisted Whipple procedures at their hospital with excellent results. Our teams remain in touch, consulting on cases and discussing options together as part of a tele-mentoring process.
As a leader in the field of robotic surgery, UT Southwestern embraces the opportunity to share knowledge, surgical techniques, and research surrounding pancreas surgery, and we are dedicated to pursuing advanced treatments in the fight against pancreatic cancer.