Robotic Whipple Procedure for an Ampullary Intramucosal Carcinoma

A 76-year-old man presented to the emergency department with fatigue and chest pain. Initial laboratory evaluation revealed significant anemia with a hemoglobin level of 7.4 g/dL. He was transfused one unit of packed red blood cells and discharged with plans for outpatient gastroenterology follow-up. Upper endoscopy performed shortly thereafter demonstrated a tubulovillous adenoma without high-grade dysplasia at the level of the ampulla. Subsequent cross-sectional imaging with CT of the abdomen and pelvis identified an area of mass-like thickening in the descending duodenum as well as two suspicious peripancreatic lymph nodes. Endoscopic ultrasound with biopsy confirmed the presence of a uT3N1 duodenal mass. Histopathologic analysis revealed at least intramucosal adenocarcinoma arising within an adenoma.

The case was reviewed at a multidisciplinary tumor board, where consensus recommendation was for surgical resection. The patient subsequently underwent diagnostic laparoscopy, laparoscopic liver biopsy, robotic pancreaticoduodenectomy (Whipple procedure), and falciform ligament flap. Pathologic examination of the resected specimen revealed an 8.2-cm, grade 2, moderately differentiated invasive adenocarcinoma of intestinal type, arising from a duodenal adenoma. The tumor demonstrated direct invasion into the pancreas, peripancreatic soft tissues, and periduodenal tissue. All surgical resection margins were negative for carcinoma. A total of 22 lymph nodes were examined, of which 6 were positive for metastatic adenocarcinoma, consistent with a final pathologic stage of pT3b pN2 duodenal adenocarcinoma.

This case highlights the diagnostic and therapeutic challenges associated with duodenal adenocarcinoma, a rare and often late-presenting malignancy. It further demonstrates the role of a multidisciplinary approach in guiding management, as well as the feasibility of a minimally invasive robotic pancreaticoduodenectomy in selected patients.

Robotic; pancreaticoduodenectomy; duodenal adenocarcinoma; minimally invasive; adenoma.

Duodenal adenocarcinoma is an uncommon malignancy, accounting for fewer than 1% of all gastrointestinal cancers. Because symptoms are often nonspecific—such as anemia, fatigue, or vague abdominal pain—diagnosis is frequently delayed, and many patients present with advanced disease. Surgical resection remains the cornerstone of curative therapy, with pancreaticoduodenectomy (Whipple procedure) being the operation of choice for tumors located in the second and third portions of the duodenum. Advances in minimally invasive approaches, including robotic surgery, have enabled safe and precise resections with potential benefits in postoperative recovery.
This case highlights the evaluation, multidisciplinary decision-making, and surgical management of a patient with locally advanced duodenal adenocarcinoma. It further illustrates the application of a robotic Whipple procedure to achieve an R0 resection.

The patient is a 75-year-old man with a past medical history notable for heart block, status post permanent pacemaker placement. He had no prior abdominal operations. His body mass index (BMI) was 31 kg/m², and he was classified as American Society of Anesthesiologists (ASA) class III due to his cardiac history.

He initially presented to the emergency department with fatigue and chest discomfort. Laboratory evaluation revealed anemia with hemoglobin of 7.4 g/dL, for which he was transfused one unit of packed red blood cells. He was discharged with outpatient gastroenterology follow-up.

Subsequent upper endoscopy identified a tubulovillous adenoma in the duodenum, located just distal to the ampulla. Biopsies confirmed adenomatous histology without high-grade dysplasia. A CT scan demonstrated a thickened segment of the descending duodenum and two suspicious peripancreatic lymph nodes. Endoscopic ultrasound with fine-needle biopsy was performed, revealing a uT3N1 mass. Pathology demonstrated intramucosal adenocarcinoma arising within an adenoma.

At the time of surgical evaluation, the patient reported ongoing melena and was maintained on oral iron supplementation. He denied weight loss, nausea, vomiting, or abdominal pain, and was tolerating a regular diet with normal bowel and bladder function. His preoperative workup included routine blood tests, which demonstrated stable hemoglobin on iron therapy, normal renal and liver function, and no evidence of coagulopathy.

On physical examination, the patient was a well-nourished man in no acute distress. His abdomen was soft, nondistended, and nontender, with no palpable masses or hepatosplenomegaly. No lymphadenopathy was detected. Cardiopulmonary examination was unremarkable aside from the presence of a pacemaker.

Cross-sectional CT imaging of the abdomen and pelvis revealed circumferential thickening of the descending duodenum with two enlarged peripancreatic lymph nodes. No vascular invasion, hepatic lesions, or distant metastases were identified. Endoscopic ultrasound confirmed a mass with invasion through the muscularis propria (uT3) and at least one suspicious regional lymph node (N1).

Duodenal adenocarcinoma is rare but aggressive. Without resection, patients are at risk for progressive local invasion into adjacent structures such as the pancreas, biliary tract, and mesenteric vessels, as well as metastatic spread to regional lymph nodes and the liver. The natural course often includes progressive gastrointestinal bleeding, obstruction, and cachexia. Median survival without resection is poor, and curative-intent surgery is the only potentially definitive treatment.

Treatment options for this patient included:

1. Endoscopic resection: Not feasible given the depth of invasion (T3) and nodal involvement.
2. Nonoperative management with systemic therapy: May provide palliation but is non-curative.
3. Surgical resection (pancreaticoduodenectomy): The only potentially curative option for localized, resectable duodenal adenocarcinoma.
4. Nonoperative management with palliative care: Not appropriate for this patient given his goals of care and eligibility for surgery.

Given the tumor location, depth of invasion, and nodal disease, less invasive local resection was not oncologically sound. Nonoperative management was not appropriate for a fit surgical candidate with localized disease.

The primary goals of treatment were to: achieve complete oncologic resection (R0 margin), provide durable local control of disease, obtain accurate pathologic staging to guide adjuvant therapy, and minimize surgical morbidity by utilizing a minimally invasive robotic approach.

Patients with localized duodenal adenocarcinoma without evidence of distant metastasis benefit most from surgical resection. Minimally invasive approaches, such as robotic pancreaticoduodenectomy, may offer decreased postoperative pain, shorter hospital stay, and quicker return to baseline function compared to open surgery, though these benefits are still being studied in randomized trials.

Contraindications include poor functional status, prohibitive comorbidities, or evidence of metastatic or unresectable disease. Relative contraindications include anatomic considerations such as variant arterial anatomy and/or vascular involvement by the tumor. Careful preoperative staging and multidisciplinary evaluation are therefore critical.

The patient was brought to the operating room and placed under general anesthesia with endotracheal intubation. Sequential compression devices, preoperative antibiotics, and unfractionated heparin were administered. He was positioned supine in split-leg configuration with arms extended.

A left mid-abdominal optical entry port was established, and diagnostic laparoscopy revealed no peritoneal disease. A suspicious liver nodule was biopsied; frozen section confirmed benign tissue, allowing the operation to proceed.

Four robotic ports and a GelPoint access device were placed in standard configuration. The falciform ligament was mobilized, and a round ligament suspension technique was used for liver retraction.

The right colon and duodenum were mobilized through the Kocher maneuver. The ligament of Treitz was divided from the right, and the proximal jejunum was transected and mobilized for reconstruction.

The stomach was divided approximately 3 cm proximal to the pylorus after division of the right gastric and gastroepiploic vessels. The common hepatic artery, portal vein, and gastroduodenal artery were carefully dissected, with the GDA stapled and clipped after confirming adequate hepatic arterial flow.

A cholecystectomy was performed, followed by division of the hepatic bile duct. The pancreas was mobilized off the superior mesenteric vein and transected at the neck. The uncinate process was carefully dissected from the superior mesenteric vessels using a vessel-sealing device, preserving key venous tributaries.

The specimen, including the duodenum, head of the pancreas, gallbladder, and distal bile duct, was placed in a retrieval bag and removed through the GelPoint incision. Frozen section analysis of the pancreatic and biliary margins was negative for carcinoma.

Three anastomoses were performed:

• Pancreaticojejunostomy: A modified Blumgart technique with duct-to-mucosa sutures and internal stent.
• Hepaticojejunostomy: End-to-side interrupted sutures with excellent bile flow.
• Gastrojejunostomy: Antecolic, isoperistaltic, side-to-side stapled reconstruction.

A falciform ligament flap was placed over the gastroduodenal artery stump to reduce risk of erosion. A 19-Fr Blake drain was positioned adjacent to the anastomoses. Bilateral TAP blocks were performed for analgesia.

The patient tolerated the procedure well with an estimated blood loss of 100 mL. He was extubated in the operating room and transferred to recovery in stable condition.

This case highlights a 75-year-old man with duodenal adenocarcinoma who successfully underwent a fully robotic pancreaticoduodenectomy (Whipple procedure) with minimal blood loss and an accelerated recovery, being discharged on postoperative day four. One year after surgery, he remains recurrence-free despite declining adjuvant chemotherapy. This outcome illustrates that a robotic approach can safely achieve high-quality oncologic resection while promoting enhanced recovery, even in elderly patients.

Pancreaticoduodenectomy remains one of the most technically challenging operations in abdominal surgery. The robotic platform offers three-dimensional visualization, articulated wristed instruments, tremor filtration, and improved ergonomics, providing distinct advantages in the confined retroperitoneal workspace where delicate vascular and biliary structures must be dissected and reconstructed. These advantages have translated into meaningful perioperative outcomes without compromising oncologic principles.

Accumulating evidence supports the safety and efficacy of robotic pancreaticoduodenectomy (RPD) compared with open pancreaticoduodenectomy (OPD). Multiple large database analyses and meta-analyses have shown that RPD results in lower blood loss, fewer wound complications, shorter hospitalization, and equivalent oncologic outcomes, including lymph node yield and margin status.^1-4 In a systematic review of randomized controlled trials, no significant differences were found in morbidity, mortality, or oncologic parameters between open, laparoscopic, and robotic approaches, though both minimally invasive techniques were associated with less intraoperative blood loss.² The EUROPA phase 2b randomized trial further demonstrated that overall postoperative complication burden, as measured by the Comprehensive Complication Index, was comparable between RPD and OPD, confirming the safety and feasibility of the robotic approach in experienced hands.³ Propensity score–matched analyses from national databases reinforce these findings, showing that RPD is associated with fewer overall and surgical complications, including a significantly reduced risk of clinically relevant postoperative pancreatic fistula.^5,6 Other matched studies similarly found equivalent morbidity and mortality once the learning curve was overcome, emphasizing the role of institutional experience in optimizing outcomes.⁷ These collective data indicate that RPD can reproduce the outcomes of open surgery while offering potential perioperative advantages.

Successful implementation of RPD depends on structured training and standardization. The steep learning curve historically associated with robotic Whipple procedures has been mitigated through formalized curricula, proctorship, and simulation-based education.⁸ As adoption expands, structured mentorship and outcome tracking will remain essential to ensure patient safety and maintain quality benchmarks.

From an oncologic standpoint, duodenal adenocarcinoma is rare and typically managed with pancreaticoduodenectomy when located near the ampulla. Complete (R0) resection with adequate lymphadenectomy remains the primary determinant of survival, and this case achieved both. The patient’s durable recovery and recurrence-free interval further support the ability of robotic resection to maintain oncologic adequacy while reducing physiologic stress. Although the role of adjuvant therapy in duodenal adenocarcinoma is less well defined than in pancreatic cancer, retrospective data suggest a potential benefit in node-positive disease.^9,10 Ongoing collaborative research will help clarify the optimal use of systemic therapy and the long-term oncologic equivalence of minimally invasive approaches.

Nothing to disclose.

The patient referred to in this video article has given their informed consent to be filmed and is aware that information and images will be published online.