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In a borderline pancreatic cancer the tumour sits against the great veins and arteries behind the pancreas. After chemotherapy, how freely it comes off them decides whether the operation is robotic or open. Apollo Hospital, Bhat, Gandhinagar · Gota OPD, Ahmedabad.
Last updated: 6 October 2026
Shah’s Gastro, Cancer & Robotic Surgery Centre. Super-specialty training in surgical gastroenterology, two higher degrees in it, and 18 years of experience in GI and cancer surgery. Every borderline pancreatic cancer is discussed at the tumour board before chemotherapy and again at re-staging, before the operation and its approach are named.
A pancreatic head cancer is called borderline resectable when it touches the main vein behind the pancreas or, to a limited degree, a main artery. It is treated with chemotherapy first, and the operation — a Whipple’s pancreatoduodenectomy — follows if re-staging allows.
After chemotherapy, scar tissue and remaining tumour around the vessels look alike on the scan, so the surgeon does not know in advance how easily the tumour will come away. That uncertainty, more than anything else, chooses the approach.
When the tumour has drawn back from the vessels and no vein repair is expected, Dr Harsh Shah may offer a robotic Whipple. When a length of vein is expected to need removal and rebuilding, the operation is open. Either way the aim is the same: a complete removal with a clear margin.
In a resectable tumour the plane between the cancer and the great vessels is clear before the operation starts. In a borderline tumour it is not: the cancer touches the portal or superior mesenteric vein, or lies against an artery, and chemotherapy has left scar tissue that the scan cannot tell apart from tumour.
The CT after chemotherapy often looks little changed even when the treatment has worked, which is why a patient whose CA 19-9 has fallen and who is well may still be explored. It also means that the hardest part of the operation — freeing the tumour from the vein and from the right side of the superior mesenteric artery — can only be judged with the vessels in view.
An approach is therefore chosen for the tissue the surgeon expects to meet, and with a plan ready for the tissue he actually meets. That is the decision this page explains. Whether to operate at all after chemotherapy, and how borderline disease is diagnosed and staged, are covered on the robotic pancreatic cancer surgery page; they are not repeated here.
The robot is offered selectively: when the tumour has drawn back from the vessels, no vein reconstruction is expected, the anatomy is clear and the patient is fit for a long operation. Open surgery remains the default when the vein is expected to need removal and rebuilding, when the head tumour is bulky, or when earlier operations have left the abdomen scarred.
| After chemotherapy | Usual approach | Why |
|---|---|---|
| Tumour drawn back from the vessels; no vein reconstruction expected | Robotic may be offered | The wristed instruments and magnified view help the artery-first dissection and the pancreas join |
| A length of portal or superior mesenteric vein expected to need removal and rebuilding | Open | A vein reconstruction is done with full exposure and control |
| Artery encased beyond limited contact | Operation not usually offered | Removing and rebuilding the main artery is not standard practice |
| Bulky head tumour, several earlier operations, a very heavy patient | Open | Exposure and safety come before the size of the incision |
| An unusual artery to the liver arising from the superior mesenteric artery | Robotic with fluorescence imaging, or open | The artery must be seen and protected throughout |
The choice is made at the tumour board after the re-staging CT, with the radiologist’s reading of each vessel. It is not made because a patient asks for small cuts, and it is not withheld because the robot costs more. When the robot is chosen, the consent always includes the possibility of continuing open.
Four things: an artery-first dissection along the right side of the superior mesenteric artery under a steady, magnified, three-dimensional view; wristed instruments that sew the pancreas to the bowel almost as an open surgeon would; fluorescence imaging that shows arteries, bile ducts and blood supply; and gentle control of the small, fragile veins that drain the pancreatic head.
The margin that most often decides whether a Whipple is complete lies along the right side of the superior mesenteric artery. The robot’s third arm holds the duodenum and turns the pancreatic head away from the vessels, laying that margin open; the dissection then follows the artery closely with fine instruments, and the specimen is freed only once the artery side is clear.
The join between the pancreas and the bowel is the step that decides most complications after a Whipple. Keyhole instruments find it hardest; the robot’s wristed instruments restore near-open movement for a duct-to-mucosa join. Small vein branches from the pancreatic head tear easily; under magnification they are clipped and divided one by one.
In experienced teams, robotic and open Whipples give similar cancer results, with less blood loss and a faster discharge after the robotic approach. The robotic operation takes longer in theatre, and there is no sense of touch through the instruments — one reason it is offered selectively after chemotherapy.
The patient lies on the back with the head slightly raised. A camera port above the navel, four robotic ports across the upper abdomen and one or two assistant ports for staplers and suction are placed; one robotic arm holds the liver up for the whole operation.
Positioning, padding and warming are finished before docking, because the patient cannot be moved once the robot is attached. The first step after docking is a careful look at the lining of the abdomen and the surface of the liver. If deposits are found there, the resection is not performed — a possibility explained before consent, because an operation that cannot remove the cancer brings all of the risk and none of the benefit.
At the end the specimen is placed in a bag and removed through a short cut low on the abdomen, and the drains are brought out through port sites.
The aim is a complete removal with a clear rim of normal tissue at every cut surface. Where the cut edge of the pancreas or the bile duct is close to the tumour, a frozen section is sent to the pathologist during the operation and more is taken if needed.
The standard field of lymph nodes comes out with the specimen and no more; a wider clearance adds complications without adding benefit. The pathologist reports each margin separately — the artery side, the back, the vein groove, the pancreatic cut and the bile duct — and that report is gone through with you at the first follow-up visit.
If, in a robotic operation, the tumour proves more firmly attached to the vein than the scan suggested, and a segment of vein has to be removed and rebuilt, the operation is converted and the vein work is done open. That plan is agreed in advance; the vein is never shaved to keep the operation robotic.
Changing to open surgery during a robotic Whipple is a clinical judgement made in the patient’s interest. It is planned for, consented beforehand and done early rather than late.
The usual reasons are bleeding from one of the great veins, a margin along the artery that needs more exposure, tumour stuck to the vein beyond what was planned, a pancreatic neck so scarred that no clear plane can be found, and an operation that has stopped progressing over many hours. A team that never converts is choosing its patients too narrowly or continuing when it should not.
Severe heart or lung disease may also make a long operation with the abdomen inflated unwise; that is weighed with the anaesthetist before the approach is chosen.
All three aim at the same specimen: the pancreatic head, duodenum, bile duct and the standard lymph nodes, with clear margins. They differ in how the artery side and the vein are handled, how the pancreas join is sewn, and how quickly a patient recovers.
| Open | Keyhole (laparoscopic) | Robotic | |
|---|---|---|---|
| Incision | A long cut across or down the upper abdomen | Ports and a short extraction cut | Ports and a short extraction cut |
| Artery-side dissection | By hand and eye | Straight instruments; demanding | Wristed instruments under a magnified view, with a third arm turning the pancreatic head |
| Removing and rebuilding a length of vein | The standard setting | Not suited | Converted to open when it is needed |
| Sewing the pancreas to the bowel | Direct | The hardest single keyhole step | Near-open movement with wristed instruments |
| Blood loss | Higher | Lower | Lower |
| Lymph nodes removed | The standard field | The same | The same |
| Hospital stay | Longest | Shorter in experienced teams | Shorter in experienced teams |
| Starting chemotherapy afterwards | Can be delayed by the wound | Rarely delayed by the wound | Rarely delayed by the wound |
| Time in theatre | Shortest | Long | Longest |
| Cost | Lowest | Moderate | Highest |
| Suited to, after chemotherapy | Vein reconstruction, bulky tumour, hostile abdomen | Rarely chosen for borderline disease | Tumour drawn back from the vessels, no vein reconstruction expected |
The table describes the approaches in general. For your own operation, Dr Harsh Shah explains which column you fall in, and why, after reading your re-staging scan.
Recovery follows an enhanced-recovery pathway. The stomach tube comes out at the end of the operation, the patient sits out of bed the same day, and fluids start early. The drain fluid is tested on the first morning; when the result is low, the drains come out within a few days.
Slow emptying of the stomach is common after a Whipple and usually settles with time; it is not a failed operation. Pancreatic enzyme capsules are taken with every meal and snack — with the food, not before or after — and the dose is checked at each visit. Blood sugar is watched, and anyone who becomes diabetic leaves with a written plan. Clot-prevention injections continue for four weeks after discharge.
The warning signs after a Whipple are fixed: fever, a fast pulse, new abdominal pain, drain fluid turning dark, cloudy or bloody, and above all any small bleed from a drain, the stomach tube or the wound. A small bleed that stops on its own can be the warning of a major one — it is an emergency even if the patient looks well.
The histology report is gone through at about two weeks. Chemotherapy after the operation is planned to start within two to three months, once recovery allows, and follow-up continues with CA 19-9, scans and a review of weight, enzymes and sugar at every visit.
Watch Dr Harsh Shah’s video: how pancreatic cancer is treated (YouTube, Hindi).
A robotic Whipple costs more than an open one, because of the robotic instruments used in each case and the longer theatre time. A conversion to open, an intensive-care stay or a longer admission changes the total. The office prepares a written estimate before admission, once the approach is decided.
Cashless admission is arranged at Apollo Hospital, Bhat where your policy allows it, and the pre-authorisation paperwork is prepared by the office. Ask whether your policy covers robotic surgery and up to what limit, and how it treats chemotherapy given before and after the operation. Bring the policy documents, photo identity, all reports with the CT scans on disc, and a list of current medicines including the enzyme dose.
★★★★★
“We are very thankful to Dr. Harsh Shah for successfully performing the Whipple’s procedure. From the beginning, he explained everything clearly and gave us great confidence throughout the treatment. Today, we are happy to share that we received the discharge and are going home with a positive feeling. Thank you, Dr. Harsh Shah, for your expertise, care, and support. Highly recommended for GI surgery. — Desai Sonal, Google review, Apollo Hospital, Bhat listing”
★★★★★
“My patient was having tumour in abdomen. Dr Harsh Shah did an operation called whipple’s operation. Today after 7 days of operation, we are being discharged from the hospital. We are happy with the services provided by Dr Harsh Shah & Apollo Hospital. — piyush aanjna, Google review, Gota clinic listing”
★★★★★
“Met with Dr. Harsh Shah for the consultation of one of my relative. Dr. Harsh Shah is an exceptional surgical oncologist in Ahmedabad. His expertise in treating complex GI cancers like liver, pancreas, and colon cancers is truly remarkable. He explains everything clearly and gives patients full confidence in their treatment. Highly recommended for anyone looking for a skilled and compassionate cancer specialist. — Nagesh Patidar, Google review, Gota clinic listing”
Real Google reviews from Dr Harsh Shah’s listings, reproduced exactly as written.
Sometimes. After chemotherapy, if the tumour has drawn back from the vessels and no vein reconstruction is expected, a robotic Whipple may be offered. If a length of vein is expected to need removal and rebuilding, the operation is done open.
It should not be. The same organs and lymph nodes are removed, margins are checked by frozen section where they are close, and if the tumour is stuck to the vein the operation is converted to open rather than shaving the vein.
The operation continues open, the segment of vein is removed with the tumour and rebuilt. This possibility is part of the consent before surgery.
Because chemotherapy changes the tissue around the vessels, and the approach must suit what the surgeon expects to find after it. The decision is made at the tumour board on the re-staging scan.
It depends on how the pancreas join behaves and how soon the stomach empties. Drains come out early when the first-morning drain test is low; slow stomach emptying can lengthen the stay and usually settles.
Usually yes. It is planned to start within two to three months, once recovery allows, and is decided with the medical oncologist after the histology report.
Shah’s Gastro, Cancer & Robotic Surgery Centre — Gota, Ahmedabad
Consultation, review of scans and pathology reports, second opinions, follow-up and surveillance.
Google: 4.9 · 53 reviews
Apollo Hospital — Bhat, Gandhinagar
Admission, robotic and open surgery, and inpatient care.
Google: 5.0 · 25 reviews
Patients travel for pancreatic cancer surgery from across Gujarat, southern Rajasthan and western Madhya Pradesh.
More on robotic surgery for pancreatic cancer at this centre: Robotic pancreatic cancer surgery in Ahmedabad · HPB cancer surgery at this centre · Robotic cancer surgery at this centre · Pancreatic cancer explained
Send the pancreatic-protocol CT reports from before and after chemotherapy, the CA 19-9 results and the biopsy report ahead of your appointment, so the consultation starts with them already read. Whether to operate, and by which approach, is decided at the consultation after examination and at the tumour board. Call +91-63590-11009 WhatsApp the office
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