Choosing Between Open Surgery and Da Vinci Surgery for Pancreatic Tumors

Choice between Open Surgery and Da Vinci Surgery

Hello, Doctor.
My mother is 65 years old and has been diagnosed with a malignant tumor in the ampulla.
She will need to undergo resection and reconstruction of some nearby organs early next year.
We are currently struggling with the decision between Da Vinci robotic surgery and traditional open surgery.
I would like to ask:
1.
Is the blood loss during Da Vinci surgery less than that of open surgery?
2.
Is the only difference between the two methods the size of the skin incision?
3.
Given the complexity of the organ resections, is Da Vinci surgery suitable?
4.
Traditional surgery takes about 4 hours, while Da Vinci surgery takes about 5-6 hours.
Does the duration of the surgery have other implications for the patient?
5.
Since there are multiple organs to be removed, will they be fragmented inside the body before extraction?
6.
Is Da Vinci surgery truly a better option?
The surgical procedure involves the resection of the ampulla, head of the pancreas (one-third of the pancreas), complete removal of the gallbladder, complete removal of the duodenum, one-third of the stomach, and connecting the bile duct to the small intestine, pancreas, and stomach.
The doctor initially asked if we had a health insurance plan that covers out-of-pocket expenses, and after we replied no, he recommended open surgery.
However, after researching online, we made another appointment to inquire about Da Vinci surgery in detail.
The doctor has reserved the robotic system for us, but he mentioned that we could switch to open surgery while hospitalized (the earlier we notify them of the change, the better).

Due to cost concerns (which may exceed NT$350,000), my mother leans towards open surgery.
My sister and I are considering the benefits of allowing the body to heal its internal organs, which may reduce the need for skin wound healing, and we are also worried about potential infections from improper care of the skin incision (better to avoid complications).
However, after our inquiries, we found a lot of online information mostly related to single-site surgeries, and we are uncertain if such extensive organ adjustments are suitable.
Additionally, the difference in surgery time is over an hour, and the doctor recommended open surgery (though we are unsure how much the cost influenced his recommendation).

While the cost is indeed high for us, it is not to the extent that it would leave us without food.
Therefore, we are quite hesitant about convincing our mother to opt for Da Vinci surgery.
My mother had stage 0 breast cancer around the age of 40, and during her recent follow-up appointment, abnormal blood results led to the discovery of her current condition.
She is also struggling psychologically; my sister had already informed her about the possible organ removals based on online research, which caused her to lose sleep.
After hearing the diagnosis from the doctor, her mood has been very low.
We initially thought about seeking a second opinion at another hospital, but she is reluctant to spend the money, so we decided to consult here for other doctors' advice.

The abnormality in the ampulla was confirmed through endoscopy and ultrasound at another clinic, so we trust this diagnosis.
The surgeon is also known for minimally invasive procedures, and he is currently the attending physician, so we are inclined not to switch hospitals.
Thank you for your assistance, Doctor.

Mimi Xiaojie, 30~39 year old female. Ask Date: 2022/12/21

Dr. Chen Ronghong reply Surgery

Hello, let me clarify that my expertise is not in pancreatic surgery, and I have not participated in Da Vinci pancreatic cancer surgeries.
Therefore, the following responses are based on my understanding.

1.
Is the blood loss during Da Vinci surgery less than that of open surgery?
Answer: Generally, Da Vinci surgery results in less blood loss because the screen magnifies the surgical area, and the robotic arms provide high stability, reducing the chances of bleeding.
2.
Is the difference between the two methods only in the size of the skin incision?
Answer: There are differences in blood loss, surgical duration, etc.
A smaller incision typically means less pain for the patient, but importantly, how effective is it for cancer treatment (long-term survival rates)? There are variations among hospitals and surgeons.
3.
Is Da Vinci surgery suitable for such complex organ resections?
Answer: It is suitable for surgeons with sufficient experience in minimally invasive surgery.
However, the severity of the disease must also be considered; if pancreatic cancer has severely invaded surrounding organs, Da Vinci surgery may not achieve clear margins.
4.
Traditional surgery takes about 4 hours, while Da Vinci surgery takes about 5-6 hours.
Does the duration of surgery have other impacts on the patient?
Answer: An increase in surgical time also extends anesthesia time, which theoretically may slightly delay the recovery of intestinal motility, but the impact is minimal.
This duration is already quite fast for a pancreaticoduodenectomy.
5.
If there are multiple items to be removed, will they be cut into pieces inside the body before being extracted?
Answer: No, they will not be cut into pieces; they will be removed through a larger incision.
6.
Is Da Vinci surgery really better?
Answer: There is no standard answer to this question; it depends on the surgeon's experience and the severity of the disease.
If your mother is unwilling to consult other doctors, you can request pathology, imaging, and laboratory reports from the original hospital, and take her health insurance card to register at another hospital, choosing a surgeon with expertise in pancreatic surgery for more detailed answers.

Reply Date: 2022/12/21

More Info

Choosing between Da Vinci robotic surgery and traditional open surgery for pancreatic tumors is a significant decision that involves multiple factors, especially considering the complexity of the procedure and the patient's overall health. Here’s a comprehensive overview addressing your concerns:
1. Blood Loss: Generally, Da Vinci robotic surgery tends to result in less blood loss compared to open surgery. The robotic system allows for enhanced precision and control, which can minimize damage to surrounding tissues and blood vessels. This is particularly beneficial in complex surgeries involving the pancreas, where bleeding can be a significant concern.

2. Differences Beyond Incision Size: While the most visible difference between the two approaches is the size of the incisions, there are other important distinctions. Robotic surgery often leads to reduced postoperative pain, shorter hospital stays, and quicker recovery times. However, the effectiveness in terms of cancer control and long-term survival rates can vary based on the surgeon's experience and the specific characteristics of the tumor.

3. Complexity of Organ Removal: The complexity of the surgery you described, involving the removal of multiple organs (the duodenum, gallbladder, part of the pancreas, and stomach), can be performed using the Da Vinci system, provided the surgeon is experienced in such procedures. The robotic approach can be advantageous in navigating the intricate anatomy of the pancreas and surrounding structures, but it’s essential to ensure that the surgical team is well-versed in these types of surgeries.

4. Surgery Duration: The duration of surgery can impact recovery. While Da Vinci surgeries may take longer (5-6 hours compared to 4 hours for open surgery), the difference in time may not significantly affect the overall recovery process. However, longer surgeries can lead to extended anesthesia exposure, which may have implications for recovery, especially in older patients. It’s crucial to discuss these factors with the surgical team.

5. Removal of Tumors: In most cases, tumors are not cut into pieces inside the body for removal. Instead, they are typically extracted whole through the incision. However, if the tumor is large or if there are multiple masses, the surgeon may need to make a larger incision to ensure complete removal.

6. Is Da Vinci Surgery Better?: The question of whether Da Vinci surgery is "better" is subjective and depends on various factors, including the surgeon's expertise, the specific case, and the patient's health status. While many studies suggest that robotic surgery can lead to better outcomes in terms of recovery and complications, the ultimate decision should be based on a thorough discussion with the surgical team regarding the risks and benefits specific to your mother's situation.

Given your mother's previous health history and current diagnosis, it’s essential to weigh the potential benefits of robotic surgery against the financial implications and her emotional well-being. If cost is a significant concern, it may be worth discussing with the healthcare provider about potential financial assistance or payment plans for the Da Vinci surgery.

Ultimately, the decision should involve a collaborative discussion with her healthcare team, considering her preferences, the surgeon's recommendations, and the potential outcomes of each surgical approach. It may also be beneficial to seek a second opinion from another specialist who has experience with both surgical techniques to provide additional insights tailored to your mother's specific case.

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