Pancreaticoduodenectomy (PD), commonly known as the Whipple procedure, is a complex operation used primarily for diseases involving the head of the pancreas, periampullary region, distal bile duct, and duodenum. The operation consists of two major phases: resection of the pancreatic head and adjacent structures, followed by reconstruction of the gastrointestinal and biliary continuity.
The conventional approach is performed through an open abdominal incision. More recently, robotic pancreaticoduodenectomy (RPD) has been developed as a minimally invasive alternative.
Open Whipple Procedure
The open procedure is performed through an upper midline or bilateral subcostal incision. The gastrocolic ligament is divided, followed by mobilisation of the hepatic flexure and a Kocher manoeuvre to expose the duodenum and pancreatic head. he hepatoduodenal ligament is dissected, with identification and division of the gastroduodenal artery. Cholecystectomy is performed and the common bile duct is divided. Depending on the type of pancreaticoduodenectomy, either the distal stomach is divided (classic Whipple) or the proximal duodenum is divided (pylorus-preserving procedure). The proximal jejunum is divided and mobilised.The pancreatic neck is then dissected from the portal-mesenteric venous axis and divided. The pancreatic head and uncinate process are carefully dissected from the superior mesenteric vein and artery. The specimen, comprising the pancreatic head, duodenum, distal bile duct and gallbladder, with or without the distal stomach, is removed.Reconstruction is usually performed using three anastomoses: pancreatojejunostomy, hepaticojejunostomy, and gastrojejunostomy. In pylorus-preserving procedures, a duodenojejunostomy replaces the gastrojejunostomy.
Robotic Whipple Procedure
Robotic pancreaticoduodenectomy follows the same basic anatomical sequence but is performed through multiple small ports using a robotic surgical platform. After pneumoperitoneum and port placement, diagnostic laparoscopy is performed to exclude metastatic disease.The gastrocolic ligament is divided and the hepatic flexure is mobilised, followed by a robotic Kocher manoeuvre. Hilar and vascular structures are dissected, including identification and division of the gastroduodenal artery. Cholecystectomy and bile duct division are performed, followed by division of the stomach or proximal duodenum and mobilisation of the jejunum. The pancreatic neck is divided after dissection from the portal-mesenteric vessels. The uncinate process is subsequently dissected from the SMV and SMA, completing the resection. The specimen is removed through a small extraction incision.
Reconstruction follows the same principles as the open procedure, with pancreatojejunostomy, hepaticojejunostomy, and gastrojejunostomy or duodenojejunostomy. Robotic articulated instruments allow intracorporeal suturing and provide magnified three-dimensional visualisation.
Comparison
The principal difference between the two techniques is the method of access rather than the anatomical operation itself. Open PD provides wide exposure and direct tactile feedback, whereas robotic PD offers minimally invasive access, magnified three-dimensional vision and wristed instrumentation. Robotic procedures may be associated with reduced blood loss and smaller incisions but often require longer operative times and have a significant learning curve.Thus, both approaches aim to achieve the same oncological resection and reconstruction, with the choice of approach depending on patient factors, tumour characteristics, vascular involvement, surgeon expertise, and institutional experience.