Robotic surgery is continuing to expand its reach, with widespread interest in the technology for endometrial cancer staging and recent exploration of its viability for complex pancreatic resections and reconstructions.
Gynecologic oncologists and pancreatic surgeons aren’t the only ones vying for time with the da Vinci Surgical System (Intuitive Surgical) – the only such system currently on the market. Their experiences, however, offer perspective on some of the key issues – from operative time and cost effectiveness to training needs – that are being raised as robotic technology is adopted.
Photo credit: University of Pittsburgh Medical Center
Dr. Herbert J. Zeh III (foreground) and Dr. A. James Moser are shown executing a robot-assisted pancreaticoduodenectomy or Whipple procedure.
Pancreatic Surgery
"Robotic-assisted pancreatic resections and reconstructions can be performed safely with postoperative complication rates and fistula formation comparable to results observed with open techniques," according to Dr. Herbert J. Zeh III, and Dr. A. James Moser, codirectors of University of Pittsburgh Medical Center’s pancreatic cancer center, who reported their results with 30 robotic-assisted major pancreatic resections and reconstructions, including 24 pancreaticoduodenectomies (Arch. Surg. 2011:146:256-61).
By now, they said in an interview, they have used a robotic approach for more than 110 major pancreatic resections and reconstructions, including approximately 60 robotic-assisted pancreaticoduodenectomies, or Whipple procedures.
Together with surgeons at the Cleveland Clinic, the Mayo Clinic in Rochester, Minn., and the University of Pisa in Italy, Dr. Moser and Dr. Zeh have pooled outcomes data, and a combined report has been submitted for publication.
"We’ve established comparable safety, and we’re at the point now where our operating times are dropping steadily and we can start to see feasibility and applicability down the road," said Dr. Zeh of the department of surgery at the University of Pittsburgh. "In the next year or two, we’ll start to see whether there are real advantages such as decreased blood loss and better outcomes resulting from a diminished physiologic impact on the patient."
Reductions in postoperative morbidity could make the complex Whipple procedure "less fearsome" for many of the patients with early pancreatic cancer who currently refuse definitive treatment. Robotic surgery might also enable more patients to recover quickly and be well enough to complete chemotherapy, said Dr. Moser of the departments of surgery and cell biology at the university. With the open approach, almost 40%-50% of patients never recover enough to complete their chemotherapy regimens, he said.
Dr. Moser and Dr. Zeh, neither of whom has any financial relationship with Intuitive, began exploring minimally invasive approaches to the Whipple procedure about 2½ years ago. They have been using laparoscopy for distal pancreatectomies since 2001, but were concerned about their ability to take a traditional laparoscopic approach with the Whipple procedure, which involves complex reconstruction.
"The first laparoscopic pancreaticoduodenectomy was described in 1994, and between then and 2010 there were only about 150 cases reported. It didn’t catch on. I think it’s because it takes such a Herculean effort to overcome the limits of the technology [with its two-dimensional imaging and limited range of instrument motion]," said Dr. Zeh.
"We wanted to completely duplicate the open Whipple with a minimally invasive technique without making any compromises or altering any surgical principles because of the limitations of the technology," added Dr. Moser.
Dr. Michael L. Kendrick, who last year published one of the two largest series of totally laparoscopic Whipple procedures, covering 62 patients (Arch. Surg. 2010;145:19-23), maintains that he makes "no alternations or adaptations in surgical principle" with the purely laparoscopic approach, compared with open surgery.
Whether this approach or a robotic-assisted laparoscopic approach is best for patients needing a pancreaticoduodenectomy appears at this time to be "completely the surgeon’s choice" and not driven by any patient characteristics or clinical indications, according to Dr. Kendrick, who chairs the division of gastroenterologic and general surgery at the Mayo Clinic. Proving "any additional clinical advantage of robotic assistance over pure laparoscopy will be very difficult and is unlikely," he said, but "pancreas surgeons may prefer the robotic approach because it is easier to learn and master."
Dr. Kendrick’s experience might be unique. He performed his first laparoscopic Whipple procedure in 2007 and then added the robotic-assisted Whipple to his armamentarium in 2008. To date, he has performed approximately 135 minimally invasive pancreaticoduodenectomies, of which about 30 have been robotically assisted.
The Pittsburgh surgeons, who perform their robotic-assisted Whipple procedures together, place the learning curve for robotic-assisted Whipple at approximately 60 operations – about the same number experts consider necessary with the open approach. While the median operating time in their first reported series of robotic-assisted pancreaticoduodenectomies was almost 9 ½ hours (at least several hours longer than needed for an experienced surgeon to complete an open Whipple), it has steadily dropped to 7-8 hours, they said.