Woo

Innovations in GI/Endocrine Surgery

by Columbia Surgery on June 7, 2014

Surgeons expand the use of the surgical robot to benefit patients undergoing complex pancreatic and gastric operations.

Yanghee Woo, MD

Yanghee Woo, MD

Readers may have heard about surgical robots, which surgeons are using in increasing numbers across the country. At NewYork-Presbyterian/ Columbia, surgeons now use the surgical robot to perform gynecologic, urologic, colorectal, and a number of abdominal procedures. According to Yanghee Woo, MD, Assistant Professor of Clinical Surgery and Director, Global Center of Excellence in Gastric Cancer Care, it provides “phenomenal advantages” during operations to remove abdom­inal cancers, allowing surgeons to perform highly precise dissections, to retrieve lymph nodes without blood loss, and promoting faster recovery. She now performs almost all gastric (stomach) cancer operations with the surgical robot.

Based on Dr. Woo’s extensive training and clinical experience with the surgical robot, as well as careful observation of published data, the Division of Gastrointestinal (GI)/Endocrine surgery is now expanding its use of the robot to a broader range of pancreatic and abdominal operations. Together with John A. Chabot, MD, FACS, Chief, Division of GI/Endocrine Surgery and Executive Director, Pancreas Center, Dr. Woo performed the first robotic Whipple procedures at NYP/Columbia this year.

Methodical approach to adopting new technology

Dr. Chabot explains how the Division of GI/Endocrine Surgery has approached the prospect of incorporating the surgical robot into its toolbox.

“We have taken a very methodical approach in evaluating the surgical robot’s benefits in gastrointestinal and endocrine operations,” says Dr. Chabot. “Dr. Woo gained extensive experience during training with the world’s foremost experts in Korea. Following this, other surgeons in our division went through extensive, rigorous training. Once we had a well-trained team assembled, we then began choosing our cases very carefully in order to use the new technology in the safest way possible.” During this process of training and evaluation, some surgeons determined that using the robot did not offer sufficient benefits. James A. Lee, MD, Chief, Endocrine Surgery, found that it did not improve upon other methods of performing thyroid surgery. Dr. Woo found that using the robot to remove the gallbladder through a single incision was possible, but not worth the larger incision it required, especially to perform a surgery that is already so highly successful and low in risk. “There is no proven benefit in this instance, and the cost is significantly higher,” she says.

Benefits for complex abdominal surgery

However, the team has found the robot to be of great benefit for other types of procedures, including many colorectal, liver, and gastric operations. During complex operations, the robot is equipped with four arms that are inserted through small ports into the patient’s abdomen. The arm with surgical instrumentation is wristed, meaning that it can articulate in all directions. Another arm is equipped with three-dimensional, magnified camera technology that provides far better visualization than the two-dimensional visualization that is available during laparoscopic surgery. “These advances give us far more freedom of movement as well as precision” explains Dr. Chabot. Dr. Woo says that because of these capabilities, she is confident that she is able to do complex gastric operations better with the robot than without, even though studies have not yet confirmed her experience.

Initially, the GI/Endocrine division has used the surgical robot in patients with less advanced cancers or premalignant conditions. Patients could not have had any previous upper abdominal surgery, and their tumors could not be attached to major blood vessels that would require blood vessel reconstruction.

Although studies have not yet directly compared robotic and traditional abdominal operations, Dr. Chabot and Dr. Woo believe that the robot offers important advantages to patients by reducing surgical trauma overall. “We are seeing patients have shorter hospital stays and shorter recovery time overall. For patients with pancreatic cancer, one of the most important aspects is that this quicker recovery may allow them to start chemotherapy sooner than they otherwise would.”

On the horizon: improved visualization and surgical outcomes

“We have developed confidence in ourselves to do more advanced cases,” says Dr. Chabot. “Our primary goal has been to maintain safety by being prudent with this new technology.” With that foundation, the team anticipates that the surgical robot will facilitate important innovations in pancreatic surgery, particularly as it allows new forms of surgical visualization. New technologies under development include the use of various wavelengths of light and injected substances that allow surgeons to better detect the boundaries of tumors or to find disease that is not visible using natural light. These innovations may allow surgeons to perform cancer operations more effectively in the future, but they­ will require laparoscopic or robotic access. “The new tools coming down the line won’t be available through traditional incisions,” explains Dr. Chabot.

To learn more about pancreatic and GI/endocrine surgery, visit pancreasmd.org

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pancreas, WhippleOn March 4, 2014, the first robotic Whipple procedure was performed by Dr. John Chabot, Executive Director of The Pancreas Center, and Dr. Yanghee Woo at NewYork-Presbyterian/Columbia University Medical Center.

This is exemplary of The Pancreas Center’s mission to continually advance the quality of pancreatic care.

What is a Whipple Procedure?

For those who may not know, the Whipple procedure is an operation in which surgeons remove the head of the pancreas, which constitutes almost forty percent of the pancreas, as well as the duodenum, the first section of the small intestine. This piece of the intestine is closely attached to the head of the pancreas, so they must be removed together as a unit. A portion of the stomach, as well as the gallbladder and a portion of the bile duct, may be removed as well.

Typically, the Whipple procedure is performed most commonly to treat pancreatic cancer, but also cancer of the duodenum and pancreatic ducts, and occasionally, chronic pancreatitis. Also known by its technical name, pancreaticoduodenectomy, the Whipple procedure received its more familiar name after its founder, Dr. Allen Whipple, who was Chairman of the Department of Surgery at NewYork-Presbyterian/Columbia for twenty-five years.

The robotic Whipple procedure is significant for a few of its advantages, notably that it improves cosmetic outcomes and reduces post-operative pain when compared to the traditional approach. Another potential advantage, currently under evaluation, includes shortening patients’ recovery time before starting chemotherapy. “If we can enhance patients’ recovery, they can begin their post-operative chemotherapy sooner,” explains Dr. Chabot. Currently, it’s common for patients to wait eight to ten weeks after surgery before starting chemotherapy. “We would much prefer if we started at five to six weeks,” says Dr. Chabot.

The Pancreas Center prepared for the procedure with a lot of work and effort, to ensure the right team was in place with a strong background in both robotics and the Whipple procedure itself. “Dr. Woo is one of the world’s leading experts in upper abdominal robotic surgery, having performed over two hundred robotic operations for gastric cancer. I have extensive experience in pancreatic surgery, especially with the Whipple procedure,” explained Dr. Chabot. Dr. Woo and Dr. Chabot also recruited a dedicated operating room staff with expertise in robotic surgery, spanning numerous departments. “Together, we performed a multitude of simpler pancreatic operations until we developed a sufficient comfort level to complete this more complex surgery.”

At the Pancreas Center, the first robotic Whipple procedure was a big step forward but there’s still work to be done according to Dr. Chabot, “We’re not going to start doing every Whipple procedure robotically. I believe in three to four years, however, we might be doing half of our Whipple procedures robotically.” Dr. Chabot concluded, “We must always assess the patients’ needs and perform the treatment best for the patient.”

For more information about The Pancreas Center, please visit our website at pancreasmd.org or call our new patient coordinator at 212-305-9467.

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