This surgery remains every surgeon’s worst nightmare — are robotic hands any helpful?

The growth of cancer in or around pancreas is an unpleasant discovery for all the parties involved — the prime reason being the organ’s anatomically dangerous position with scholars calling it ‘Mount Everest’ of general surgery.

Pancreas is a large, prominent gland which sits right behind one’s stomach, popularly known for its life-saving secretion insulin. Deeply seated inside the abdomen, it does the quiet background work for most but when it makes noise, it can send shivers down the spine for both patients and surgeons alike.

The growth of cancer in or around pancreas is an unpleasant discovery for all the parties involved — the prime reason being the organ’s anatomically dangerous position with many scholars calling it ‘Mount Everest’ of general surgery.

The dreaded cancer form carries a mortality rate as high as 98 percent, said the American Cancer Society, with a poor survival rate of not more than five years.

As per medical experts, the organ is cushioned between other body parts which can make early tumour growth or inflammation go without notice and cause the symptoms to emerge in advanced stages of the disease.

Most patients get diagnosed for the condition when it has already deepened its root in other surrounding structures or spread to other parts of the body.

While in India the risk remained low for pancreatic cancer, recent years are seeing an uphill with nearly 22,980 cases estimated every year.

A silent disease

Situated away from sight, symptoms for pancreatic cancer only show up when the abnormal growth starts to press the nearby bodily structures. 

As per experts, it is mostly found to exist or diagnosed in incidental findings like taking an imaging test for some other health problem. 

Just like other forms of cancer, pancreatic cancer can have stages. 

In its first stage, the growth is not easily traceable and only 15 percent get a timely diagnosis. If detected, it can be removed using a surgical procedure.

As per reports, about 40 percent get a diagnosis when the tumor has attached itself to the surrounding structures. The patient is often administered chemotherapy or radiation therapy prior to a surgical attempt.

Beyond this stage, the disease metastasizes and starts to travel in the body.

Sitting in the center of the abdomen, the pancreas is close to all vital organs — stomach, lungs, liver, spleen and even kidneys.

Remaining hidden for the most part, the disease is known to have an aggressive reach to other parts of the body.

A dangerous geography

A typical surgery for removing cancerous growth from pancreas involves organ removal followed by an anatomical restructuring. 

Clinically called pancreaticoduodenectomy or the Whipple surgery, the procedure is often called a surgeon’s nightmare. 

Research articles haven’t hesitated calling it a complex and technically challenging operation in the realm of abdominal surgery.

The answer is simple — pancreas rest in a hotspot of vital bodily structures circling it from all directions.

Speaking to DH, Dr. Adarsh Pratap Singh, Breast and Endocrine onco-surgeon (MBBS,MS, MCh (AIIMS, New Delhi) said: “The claim is rightfully true. These cases do challenge us as surgeons and are extremely difficult for our patients. The complex anatomy makes it harder to navigate movement during the surgery because of the delicate structure of the organ itself and it being wrapped in arms of major blood vessels.”

Pancreas has a unique shape — a head running towards the right, body crossing over the middle and the tail reaching for the left. This makes it dangerously close to visceral organs in the neighborhood.

“Pancreas is a retroperitoneal organ which means it sits posteriorly in the abdomen. Anterior (front) to it rests the stomach, just behind it runs the abdominal aorta (largest artery carrying blood in the body) and superior mesenteric arteries and veins (offshoot large blood vessels supplying the gastrointestinal tract), on the right its head slips into the second part of the duodenum (first segment of small intestine) and on the left there is spleen, the superior splenic artery and vein, again major blood vessels. To get our hands into this treacherous spot without causing any operative bruises and with utmost precision makes it quite a challenge,” added Dr. Singh. 

The cancerous growth itself is surrounded by a dense, fibrous tissue which makes it immune to conventional treatments like chemotherapy, making it highly aggressive in both self preservation and spread. 

As per the American Cancer Society, cancer removal is just one part of the story as the surgery follows another reconstructive procedure where the remaining bile duct and pancreas are then attached to the small intestine so that bile and digestive enzymes can still go into the small intestine.

Also, the end pieces of the stomach and small intestine are reattached so that the food can flow through the digestive tract.

In short — a temporary, working gastrointestinal tract is recreated using the remains of already excised organs. 

This reconstruction often has major health complications which significantly cuts the survival rates once the surgery is done. 

Some respite with robotic surgery

For the longest, there had been two ways in which the surgeons reached the pancreas — either making a long incision near the stomach (called open surgery) or inserting surgical tools and camera which provided a two dimensional view of the surgical field (called laparoscopy). 

The rise of robotic surgery has given some hope to surgeons as they penetrate the pancreas with robotic arms. However, it hasn't changed the complexity associated with the reconstruction procedure.

Speaking to DH, Dr. Amit Chakraborty, Head and Neck onco-surgeon at the SSO Hospital said: “Head surgeries pose similar challenges as we navigate into the delicate, intricate structures of the brain and spinal cord. However, innovations like the da Vinci Surgical system are changing things for the better. They are providing a three dimensional look into any complex anatomical structure and using its robotic arms, we are able to achieve increased precision and dexterity (freedom to move around). Also, the improvised visualisation is also making us reach into earlier impenetrable tissues.”

As per experts, opting for this surgery has to be a critically thoughtful decision for both the patient and the surgeon.