For pancreatic cancer patients, the robotic technique of the Whipple surgery can mean shaving three weeks off their recuperation. “And the sooner a patient can move on to chemo, the better,” says Stan Hewlett, MD, a gastrointestinal (GI) surgeon with Princeton Surgical Specialists.

Hewlett stands as the only surgeon in Alabama who has performed the robotic version of the surgery. Though called a robot, the da Vinci Surgical System cannot be programmed, but instead uses computer to mimic the surgeon's hand movements in real time from a console near the patient.

A highly complex procedure, the Whipple (pancreaticoduodenectomy) involves removing the wide “head” of the pancreas that lays next to the first part of the small intestine, along with removing the duodenum, a portion of the bile duct, the gallbladder, and sometimes part of the stomach.

After the resection, the surgeon reconstructs the GI tract with three major connections. The biliary, pancreatic and foregut are all reconnected (three anatomoses) to the intestinal stream.

“The Whipple touches a lot of areas of the GI tract,” Hewlett says. He’s been using the da Vinci robot to perform Whipples in Birmingham for the last five years. The next closest surgeons using the da Vinci to carry out the robotic version are in Tampa, New Orleans, or Charlotte, North Carolina.

“There’s not a whole lot of difference in the procedure when you use the robot. It is the same on the inside, but without the laparotomy incision,” Hewlett says. “The actual dissection and resection are the same. But the effect on the patient’s outcome is noticeably different.”

Patients of robotic Whipple surgery come out with only five tiny incisions; four are small enough to be covered with Band-Aids. “So most of my patients can start on chemo in three weeks instead of six, like those who undergo the open procedure,” Hewlett says. The delay for open-surgery patients stems from the large incision needing to heal before starting chemo.

“I don’t think the robot avoids any potential surgery problems, like a leak, but it does result in less blood loss and less IV fluids being administered at the time of surgery and that means less inflammation for the patient,” Hewlett says.

The open abdomen during the four- to six-hour non-robotic Whipple surgery results in about 800 cc per hour of evaporative fluid loss. “With the robot, it’s not zero, but more along the lines of 100 cc,” Hewlett says. More fluids mean more inflammation. “Then there’s swelling, anasarca, and they feel like they’ve been hit by a truck.”

On the robotic version, however, Hewlett’s patients look and feel more like they had a simple laparoscopic cholecystectomy.

“The downside is that the operation does take longer with the robot than with the open and is technically more demanding,” he says. “The patient gets the benefit, not the surgeon.”

Less pain with the smaller incisions also means fewer narcotics and a quicker return to bowel function and mobility. “The hospital stay is the same, though,” Hewlett says, quoting it at about a week. “It’s such a big operation, and we do not want them to have any kind of problem once they’re home.”

Though patients recover far quicker from the robotic surgery, the surgical outcomes seem to remain the same no matter the approach. “Eventually there will be a large enough volume of data from multiple institutions to determine if there’s a difference,” Hewlett says. “But the differences I see now are less blood loss and a quicker recovery, which in and of itself is a good endpoint to shoot for.”

Hewlett also says the robot gives distinct advantages to a surgeon during the procedure. “I feel like I can see and dissect better than any other way,” he says. “Laparoscopy gives a magnified view, but it’s not a 3D picture like you get with the robot. Also with laparoscopy, after a couple of hours, the person holding the camera gets fatigued and the image can get shaky. With the robot system, the image is perfectly still and reliable.”

The steady 3D view adds surety to the numerous delicate dissections during a Whipple procedure. “The uncinate process — the part of the pancreas that wraps around and between an artery and a vein — can be a difficult place in the body to visualize, even with open or laparoscopic surgery,” Hewlett says. “With the robot, I can see so well and feel so confident I know I’m dividing the pancreas away with good margin, no question.”

The robot also grants greater dexterity and range of motion than laparoscopy instruments. “Instead of the ‘chopsticks’, robotic surgery equipment allows for more natural movements, including wrist function,” Hewlett says.

The robot keeps improving as well. In the last five years, da Vinci has added a suction irrigator, vessel sealer and a stapler.

“We’ve gotten faster because of the new instrumentation and refining the procedure,” Hewlett says. Five years ago, it took almost twice as long to complete a Whipple. Over that time, he’s performed around 50 pancreatic robotic surgeries, including seven Whipples so far this year.

“It may take a few hours longer to use the robot for the Whipple, and the surgeon sacrifices for that, but I think it’s worth it, because the patients do better, feel better,” Hewlett. “And that’s what we’re here for—improving patients’ lives.”