A 63-year-old male patient came to American Hospital Dubai with symptoms of jaundice, passing of dark urine and itching. After performing several diagnostic tests, including endoscopic ultrasound, CT scan and MRI, his condition was diagnosed as a pancreatic tumuor – a tumour of the ampulla of Vater, to be precise. The ampulla of Vater is the point where the head of the pancreas attaches to the duodenum (the first portion of the small intestine). It is also where the bile and pancreatic ducts come together to empty into the small intestine. A complex location with a high activity level of different organs, this area can develop tumours of these various structures called periampullary tumours, meaning tumours around the ampulla.
The patient met Dr Ahmed Kemmou, Consultant General Surgery at American Hospital Dubai, who advised him to undergo a pancreaticoduodenectomy, the preferred option since his tumour was deemed removable by surgery.
A pancreaticoduodenectomy, also known as a Whipple procedure, involves removing the head of the pancreas, the duodenum or the first part of the small intestine, the gallbladder and the bile duct. The term Whipple procedure comes from Dr Allen Oldfather Whipple, a surgeon at Columbia Presbyterian Hospital in the US, who brought his success at pancreaticoduodenectomy into the limelight in 1935.
First robotic Whipple procedure in Dubai
American Hospital Dubai’s pancreaticoduodenectomy for the 63-year-old patient is of particular significance as it is Dubai's first robot-assisted Whipple procedure. “We have done other types of robotic pancreatic surgery, removing tumours from the centre and the tail of the pancreas with excellent outcomes and an average hospital stay of two to three days,” said Dr Kemmou. “But due to the complexity of Pylorus Preserving Pancreaticoduodenectomy and robotic expertise required, it is not unusual for most surgeons to perform Whipple non-robotically. However, we proudly offer this technique and technology at the American Hospital Dubai.”
What makes Whipple so challenging? The pancreas’ location - it is tucked behind the stomach, making it hard to get to. Making matters more complicated is that the head of the pancreas is closely connected to many organs in the abdomen, for example, the bile duct and the small intestine, rendering it the perfect complex anatomical landscape for surgical navigation.
Dr Kemmou emphasised the significance of a surgeon’s experience and quality of skill in ensuring a successful outcome. “Complex surgical procedures involve many difficult steps and can carry significant risks. A surgeon's experience is crucial. A higher volume of cases and experience correlates with improved patient outcomes,” he said.
Apart from the skill a Whipple procedure requires, its scope is also challenging. “For any cancerous tumour, surgical removal usually involves a clear margin,” explained Dr Kemmou. “It means we need to remove some normal tissue beyond where the tumour ends to ensure no malignant tissue is left behind, thus reducing the risk of local recurrence. In pancreatic tumours, because the structures intimately attach to the head of the pancreas, the latter cannot be separated from the duodenum or bile duct without disrupting these organs. Therefore, some organs/tissues are removed to achieve a clear margin. Finally, the lymph nodes are removed to ensure the absence of spread and remove any nodes that may been affected.”
PPPD or Pylorus Preserving Pancreaticoduodenectomy
In the 63-year-old male patient’s case, it was decided to perform a modified Whipple procedure, the PPPD or Pylorus Preserving Pancreaticoduodenectomy. As the name suggests, the operation preserves the pylorus or the stomach valve, which regulates the emptying of stomach contents into the duodenum and prevents their re-entry into the stomach. “When the pylorus is left intact, the patient's ability to eat early after surgery improves, decreasing the risks of regurgitation or vomiting,” explained Dr Kemmou.
The Whipple procedure is done in two stages: removing the affected pancreatic tissue and surrounding structures and then restructuring the gastrointestinal tract by attaching the small intestine to the pancreas, bile duct and stomach. “In pylorus-preserving surgery, where the duodenum is divided just beyond the pylorus, the jejunum is attached to the first portion of the duodenum, which is only about 2cm left in place,” he said.
He elaborated on the complexities a surgeon must master to ensure a successful PPPD. “Anytime we attach structures, there are challenges,” he explained. “These involve meticulous preparation of the organs to be attached, including ensuring adequate blood supply and no tension on the organ. Additionally, suturing has to be accurate to achieve an adequate approximation of the organs.” Therefore, the surgical skill for anastomosis (connecting two different structures) cannot be overstated. Any error carries the risk of an anastomotic leak or disruption of the attached areas, which is a significant complication, Dr Kemmou said.
A bright future for robotic Whipple in Dubai
The advent of robotic surgery has dramatically enhanced the outcomes of the Whipple procedure: it allows the surgeon to perform all the surgical steps of the traditional open approach using smaller incisions (usually around 1cm or less), 3D visualisation and accurate use of instruments. But ultimately, its driving force is surgeon-centric. “Doing this reattachment with minimally invasive surgery is challenging since the surgeon is not working directly with their hands,” explained Dr Kemmou. “Though it simulates the feel of open surgery, it can only be done if the surgeon's robotic surgery skills are highly advanced.
“I believe that it will take some time for this procedure to become standard in the UAE and for other robotic and pancreatic surgeons to adopt this treatment method,” said Dr Kemmou.
Speedy recovery for the patient
The PPPD went without complications or the need for blood transfusion and feeding tubes. Most importantly, it took no longer than a typical open Whipple procedure, and the removed specimen was equivalent to what is performed using open Whipple. “As we perform more of these procedures, we expect our patients' experience to be excellent, with major improvement over traditional open surgery,” said Dr Kemmou.
The patient recovered faster than patients who had open surgery. He could eat regular food on the third day after surgery. “He had less pain and a quick return to mobility compared to patients who underwent open surgery,” added Dr Kemmou. “He is at home recovering well with minimal pain medication requirement. He eats a regular diet, walks normally and is preparing to return to his routine.”
