Expanding the Boundaries for Robotic-Assisted Complex, Gastrointestinal Surgery

“Surgical oncologists in the Program for Liver, Pancreas, and Foregut Tumors at Penn State Hershey Cancer Institute, Penn State Hershey Medical Center, are using a robotic-assisted approach to complex gastrointestinal surgeries. The team performed an average of four to five such cases per month during 2013- 2014. “Distal pancreatectomy with splenectomy is the most common procedure in which we use a robotic technique. Compared to laparoscopy, we’re finding that more tumors and cysts are amenable to a robotic approach, with less conversion to an open procedure compared to a laparoscopic approach,” says Niraj Gusani, M.D., director of the Program for Liver, Pancreas, and Foregut Tumors.

Gusani has partnered with Joyce Wong, M.D., director of the Robotic Surgical Oncology Program, to implement a two-attending model for all robotics procedures. Amanda Cooper, M.D., the third member of the team, will also perform robotics procedures. Gusani notes, “Visualization is much better with the robotic platform [see Figure] versus open surgery. This is really key with very complex anatomy. Resections may be more thorough.” Wong further adds, “The robot mimics your hand movements with more precision; there is less internal manipulation. It’s a shift from ‘feeling’ to ‘seeing’.” To date, the team has performed more than thirty complex oncologic cases robotically.

Resection of gastric mass with suture repair of gastrotomy

Intraoperative view from the robotics platform during resection of a gastric mass and suture repair of gastrostomy.

All gastric resections, along with pancreatic body/tail resections, are now performed robotically. The program’s early data from twenty patients¹ shows that for pancreatic adenocarcinoma, a median of thirteen lymph nodes were retrieved; for gastric adenocarcinomas, a median of twenty lymph nodes were retrieved. Pancreatic leak was the most common complication. Average length of stay was four days, and four patients were treated in the intensive care unit. Only three patients were converted to open surgery.

Gusani and Wong are expanding the use of robotic techniques to include major hepatectomy, gastroesophageal junction tumor surgery, and the Whipple procedure, involving the pancreatic head. This area is especially difficult to access, given its location deep in the back of the abdomen. Wong explains, “For the Whipple procedure, we’ve begun by using a stepwise, ‘modular’ strategy, as part of a laparoscopic or minimally-invasive procedure. First, we simply insert the camera to visualize the surgical field. We then mobilize the stomach, bowel, and pancreas. Now, we can do most of the resection laparoscopically.” Gusani adds, “Probably about twenty centers in the United States are beginning to integrate robotics for very complex surgeries. It is the next step in the technical evolution for these procedures.”

Niraj Jaysukh Gusani, M.D.Niraj Jaysukh Gusani, M.D., FACS
Associate Professor of Surgery and Public Health Sciences
Director, Program for Liver, Pancreas, and Foregut Tumors
Penn State Hershey Cancer Institute
Phone: 717-531-5965
E-MAIL: ngusani@hmc.psu.edu
FELLOWSHIP: Surgical Oncology, University of Pittsburgh Medical Center
RESIDENCY: Surgery, General, University of Chicago Medical Center
MEDICAL SCHOOL: University of Pennsylvania School of Medicine

Joyce Wong, M.D.Joyce Wong, M.D.
Director, Robotic Surgical Oncology Program Assistant Professor of Surgery
Program for Liver, Pancreas, and Foregut Tumors
Penn State Hershey Cancer Institute
PHONE: 717-531-5965
E-MAIL: jwong1@hmc.psu.edu
FELLOWSHIP: Surgical Oncology, Moffitt Cancer Center
RESIDENCIES: General Surgery, Georgetown University Hospital and Morristown Memorial Hospital
MEDICAL SCHOOL: Albany Medical College


1. Enomoto LM, Murray A, Cooper AB, Gusani NJ, Wong J. Robotic-assisted complex oncologic surgery at a tertiary medical center: Initial experience. Poster presented at: Keystone Chapter of the American College of Surgeons Meeting, November, 2014.

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