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12 Robotic-Assisted Congenital Choledochal Cyst Radical Surgery
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roscopic treatment. Surg Laparosc Endosc. 1995;5:354–8.
6. Li L, Yu QZ, Liu G, et al. Laparoscopic total cyst exci­sion with Roux-Y hepatoenterostomy for choledochal cyst. Chin J Gen Surg. 2002;17:473–5 (in Chinese).
7. Wong KY, Lan CL, Liu XL, et al. Da Vinci robotic system for pediatric surgery: report of rst 20 cases. Chin J Min Inv Surg. 2013;13:4–8 (in Chinese).
8. Meehan JJ, Elliott S, Sandler A. The robotic approach to complex hepatobiliary anomalies in children: pre­liminary report. J Pediatr Surg. 2007;42:2110–4.
9. Jin Y, Chen Q, Zhang Y, et al. Robot-assisted resec­tion of choledochal cysts in children weighing less than 6 kg. Br J Surg. 2023;110:267–8.
10. Chang Z, Hao JW, Zhang AM. Comparison of lapa­roscopic nephron sparing surgery with and without robotic assistance. Guoji Mi Niao Xi Tong Za Zhi. 2017;37:745–7 (in Chinese).
11. Ener K, Canda AE, Altinova S, et al. Robotic par­tial nephrectomy for clinical stage T1 tumors: Experience in 42 cases. Kaohsiung J Med Sci. 2016;32:16–21.
Robotic-Assisted Splenectomy
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ZhigangGao andYuebinZhang
13
13.1 Introduction
Review the history of minimally invasive sple­nectomy [1, 2]. In 1991, Delaitre et al. reported the rst laparoscopic splenectomy (LS). In 1993, Tulman et al. applied LS to the eld of pediatric surgery. In 2003, Talamini et al reported 7 robotic splenectomy (RS) operations. In 2013, Ruan Hu, Jiang Zhiwei et al [3] reported 5 cases of RS sur­gery in China. In the eld of pediatric surgery, Mbaka et al. summarized and reported 32 cases of robotic splenectomy in children in 2017.
Minimally invasive surgery is the development trend of surgery. With its advanced technical advantages, the robotic surgical system has brought many changes compared with the tradi­tional laparoscopic technique for the minimally invasive operation of splenectomy [4]. At present, robot surgery for children in China is still in its infancy [3, 5], and it is necessary to continuously explore and summarize the experiences and indi­cations of robots in splenectomy. Based on the RS operation experience of the author’s unit and pre­vious LS operation experience, this chapter pro-
vides a reference for the surgical route, which is not the only optimal plan at present. Specic sur­gical decisions should be made according to the specic conditions of children with personalized surgical plans, and exible adjustment should be made according to the intraoperative conditions.
13.2 Indications andContraindications
With the continuous improvement of minimally invasive technology and the application of advanced equipment and instruments, the tradi­tional surgical indications of open splenectomy can be applied to RS surgery [6]. By means of intraoperative suspension and assisted exposure, the robot-assisted surgical system can provide a better visual eld than the traditional laparo­scope. The focus of the operation is on ne ana­tomical operation during the operation to avoid or reduce the conversion to open surgery caused by massive bleeding.
Supplementary Information The online version con­tains supplementary material available at https://doi.org/
10.1007/978- 981- 19- 9693- 1_13.
Z. Gao (*) · Y. Zhang Department of General Surgery, Children’s Hospital of Zhejiang University School of Medicine, Hangzhou, China e-mail: ebwk@zju.edu.cn; pwzyb@zju.edu.cn
© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2023 Q. Shu (ed.), Pediatric Robotic Surgery, https://doi.org/10.1007/978-981-19-9693-1_13
13.2.1 Indications
1. Diseases of the spleen itself: spleen trauma,
migratory spleen, splenic cyst, splenic abscess, and splenic tumor [7].
2. Diseases of the blood system:
(1) Hereditary spherocytosis (HS); (2) Idiopathic thrombocytopenic purpura;
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(3) Autoimmune hemolysis and aplastic ane-
mia with obvious hypersplenism or inef­fective medical treatment can relieve the symptoms but cannot remove the cause.
3. Metabolic system diseases: Gaucher disease, Niemann-Pick disease, etc.
4. Hypersplenism: portal hypertension, splenic vein thrombosis and other secondary hyper­splenism cannot control the primary disease.
5. When the spleen is involved in surgery for pancreatic or gastric malignancies [8].
13.2.2 Contraindications
Some contraindications for RS will gradually become relative contraindications or indications with the improvement of technology, the accu­mulation of experience, and the upgradation of equipment, but there are still some cases that are not suitable for RS surgery.
1. Poor general condition, poor function of the heart and lung and other important organs, intolerance to pneumoperitoneum.
2. Splenomegaly caused by infection.
3. Hematopoietic function of bone marrow decreases, anemia is difcult to correct, coag­ulation dysfunction occurs, and the spleen has compensatory function.
4. A history of severe abdominal trauma or sur­gery with severe adhesion in the surgical area.
Severe splenic trauma or splenic laceration, with a large amount of blood loss and unstable vital signs.
13.3 Preoperative Preparation
RS in children is a difcult and high-risk opera­tion, and adequate preoperative preparation is particularly important for the smooth implemen­tation of the whole operation process and postop­erative recovery. Spleen liver, and pancreas is the one and only organ in the human body, the func­tion of the spleen has not been fully elucidated, no replacement therapy after splenectomy, espe-
cially after splenectomy explosive infection com­plications after splenectomy valued gradually, so needs when making operation scheme in combi­nation with the actual situation of children, if there is a part of the conditions of the spleen resection or postoperative spleen transplantation.
1. Selection of surgical age: due to the risk of infection outbreak after surgery, the overall incidence rate is low (3.2%) but the mortality rate is very high (40%–50%). Therefore, total splenectomy is recommended after sixyears of age.
2. Perfect preoperative imaging examinations: Doppler ultrasound and enhanced CT exami­nations were performed to understand the size of the spleen, the course of splenic hilum ves­sels and the relationship between them and the pancreas. Individual surgical plans were formulated, possible risks were fully evalu­ated, and emergency treatment measures were taken.
3. Preoperative nutritional support to correct malnutrition. Severe anemia can be corrected by blood transfusion before surgery.
4. Preoperative medication adjustment: most children with blood diseases need to be treated with hormone or immunosuppressive drugs for maintenance treatment. The dose should be adjusted or stopped according to the condi­tion before and after surgery, and the prophy­lactic application of broad-spectrum antibiotics is recommended 24 hours before surgery to reduce the risk of postoperative infection.
5. Vaccination: children who underwent elec­tive total splenectomy can receive prophy­lactic multivaccine vaccination two weeks before surgery, including pneumonia vac­cine, inuenza vaccine, and meningitis vac­cine. Children undergoing emergency surgery can also be vaccinated 30days after surgery.
6. Routine preoperative preparation: included fasting semiuid for 6hours before surgery, water forbination for 2hours before surgery, skin preparation, gastrointestinal decompres­sion, catheterization, preoperative steriliza-
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tion, blood preparation, and correction of severe anemia and water and electrolyte disorders.
7. Surgical instruments: select matching operat­ing instruments according to the size of the child, and routinely equip them with ultra­sonic knives or Ligasure. Due to the risk of massive intraoperative bleeding, an autolo­gous blood transfusion device is recom­mended in qualied units.
13.4 Position andDocking
1. Surgical position
In the supine position, the head is tilted 30° high and the feet are tilted 30°–45° to the right side to facilitate the exposure of the operative eld.
2. Layout of the operation hole (Fig.13.1)
(1) The observation hole (No. 2 arm) is located
in the umbilical cord. If the giant spleen crosses the mid-umbilical line, the puncture hole can be appropriately moved to the right;
(2) Operating hole 1 (No. 1 arm) between the
midline of the clavicle of the right upper abdomen and the linea albia (adjusted accord­ing to the size of the child and the condition of the spleen);
(3) Operating hole 2 (No. 3 arm) left abdominal
axillary front horizontal;
(4) The auxiliary operation hole (assistant hole)
is located behind the midpoint of the connec­tion between the observation hole and opera­tion hole 2;
(5) The spare operation hole (No. 4 arm) can be
used if the operation is difcult because it is not used routinely. Generally, the spare oper­ation hole can be located under the xiphoid process or at the level of the midline of the left abdominal axillary.
13.5 Surgical Procedures
1. The surgical position was prepared as before. The selection of trocar puncture points should be adjusted according to the position and size of the spleen. In principle, the distance between the operating area and the trocar should be reasonable (4–8 cm), and it is advis­able that each operating instrument should not interfere with each other.
2. Routine disinfection towel laying was per­formed, and a surgical nurse prepared the robot operating arm sterile bag.
3. Establishment of pneumoperitoneum and placement of trocar: the center of the umbili­cal ring was cut 8 mm longitudinally, and pneumoperitoneum was established by needle puncture (pressure 6–12 mmHg) or the rst 8mm trocar was placed through the primary endoscope under direct vision. The second 8mm cannula was placed at the front of the left abdominal axillary line, and its position was positioned according to the lower posi­tion of the spleen. The operation distance was sufcient, and it was used as the main Fig. 13.1 Position of the troca
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operation hole for inserting ultrasonic knife, bipolar electrocoagulation, electrocoagulation hook or needle holder, etc. A third 8mm can­nula was placed in the right middle and upper abdomen and a dissector or operating forceps was inserted. A fourth 5 mm cannula was placed behind the midpoint of the connection between the umbilical primary mirror and the left ventral operating hole to serve as an aux­iliary operating hole for operations such as traction exposure, attraction, ultrasonic knife, hemo-lock, and needle and thread entry and exit.
4. Intraperitoneal exploration: routine explora­tion after entering the abdominal cavity requires the search for the accessory spleen. Once found, whether to remove or retain the accessory spleen should be decided according to the need of the disease. The accessory spleen is usually located in the tissues near the hilum of the spleen and the tail of the pan­creas, the ligaments of the liver and stomach, the ligaments of the spleen and colon, the lig­aments of the stomach and stomach, and the mesentery of the small intestine. First, the spleen-colon ligament was separated with an ultrasonic knife, and then the greater omen­tum was cut open. Then, the greater curvature of the appetizer was turned upward with non­invasive forceps to enter the lesser omentum sac, and the splenic hilum was exposed. At the same time, the presence of an accessory spleen was examined.
5. Splenic treatment: separates the adhesions between the spleen and the colon and the lat­eral abdominal wall. The ligaments of the splenic curvature of the colon were dissected by ultrasound knife or electrocoagulation (Fig.13.2), and the spleen-kidney ligaments from the lower pole of the spleen to the dia­phragm were separated. The ligaments of the spleen and stomach were separated by an ultrasonic scalper (Fig. 13.3), and the short gastric vessels were severed (Fig.13.4). The spleen- stomach, spleen-kidney ligaments, and short gastric vessels can be dissected and
Z. Gao and Y. Zhang
Fig. 13.2 Release of the ligaments of the spleen and colon
Fig. 13.3 Release of the ligaments of the spleen and
stomach
Fig. 13.4 The splenic artery was severed after ligation
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Fig. 13.5 Dissection of short gastric vessels
exposed after dissecting the hilum of the spleen, and further dissecting the ligament tissues around the hilum of the spleen can more clearly reveal the relationship between the splenic vessels and the tail of the pan­creas. For patients with splenomegaly, it is easy to dissect and expose the main splenic artery at the upper edge of the pancreas, and double ligation of the main splenic artery can also be performed after hemo-lock ligation (Fig.13.5). It is convenient to control possi­ble intraoperative hemorrhage and can shrink splenomegaly during the operation. Then, according to the branches of the splenic ped­icle blood vessels, double ligation of the splenic pedicle trunk was used for the con­centrated type and then severed. For the dis­persal type, the vessels of the upper and lower poles of the spleen were separated by separat­ing forceps, and the vessels of the splenic lobes were ligated and severed. After the spleen was reduced, the splenic vein was sev­ered by double ligation of the silk thread or hemo-lock (Fig. 13.6). After the splenic hilum vessels were treated, the residual adhe­sion ligaments of the spleen and surrounding tissues were thoroughly loosened with an ultrasound knife. Irrigation examination con­rmed that there was no active bleeding on the perisplenic anatomical wound, the robot­assisted operation was ended, and the spleen was removed.
Fig. 13.6 Splenic vein was ligated and severed
Fig. 13.7 The spleen was removed and placed into a
specimen bag
6. Remove spleen through the left abdomen (operation hole 2), remove the umbilical 8mm cannula, improve the 12mm cannula, put into the bag, open the spleen, then close the bag mouth (Fig.13.7), pull out the 12mm cannula, expand the puncture hole, pull out the bag mouth, cut the spleen into pieces with oval forceps or scissors, and then remove the spleen. Attention should be given to avoid leaving the splenic tissue in the abdominal cavity due to damage to the bag.
7. The splenic incision was taken from the umbilical cord by intermittent suture with absorbable thread for drainage, and the pneu­moperitoneum was reconstructed. The splenic bed was rinsed and explored. Special attention
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was given to whether there was active bleed­ing at the splenic pedicle and dissection of the great curvature of the stomach and the short gastric vessels. A routine drainage tube was placed in the splenic fossa, the lens was removed, and the incision was sutured.
13.6 Technical Points andSkills
1. The location of the puncture operation hole should be adjusted according to the size of the spleen. In principle, the location of the opera­tion hole should be more than 2cm from the edge of the spleen and more than 4cm from the operation area to avoid the limitation of the movement of the manipulator arm [8, 9]. The abdominal space of children is small, but after the establishment of pneumoperitoneum, the abdominal wall space will increase, and the puncture part can be selected and marked again. If the integrated operating bed is not equipped, the child’s body position should be adjusted before docking.
2. The Da Vinci system anatomical operating instruments lack force feedback, and the clamping strength of the instruments is large. In the early application of the Da Vinci system, the clamping of tissues and organs such as intestines or blood vessels should be minimized to avoid excessive mechanical bite force and damage to organs and tissues. In the process of suturing and knotting, the risk of suture breakage is greater than that of traditional laparoscopy for the same reasons mentioned above, which will affect the process of surgery and should be considered.
3. During the operation, for patients who need total splenectomy due to hematological dis­eases, the accessory spleen should be rou­tinely explored, especially around the hilum of the spleen. If there is an accessory spleen, accessory splenectomy should be performed. Dissection of the ligaments around the spleen (such as the ligaments of the spleen and colon,
the ligaments of the spleen and stomach, etc.). The short gastric vessels are helpful for the dissection and ligation of the splenic hilum vessels. When surgical exposure is difcult, a traction wire can be used to pull the gastric wall to expose the operating eld. The double ligation of hemo-lock and silk thread is more reliable in the ligation of splenic hilum ves­sels. After the operation, splenic fossa drain­age is helpful to observe postoperative bleeding.
13.7 Postoperative Complications
1. Postoperative bleeding usually occurs within 24hours after surgery [10], and the common reasons are ligation of vascular line knots, coagulation resection of vessel eschar shed­ding and bleeding, or even exfoliation of wound bleeding. When treating the spleen pedicle, loose or unstable ligation and retrac­tion of blood vessels may cause massive bleed­ing. In particular, preoperative blood diseases with coagulation mechanism disorders should be corrected, and intraoperative blood vessels should be carefully handled. The wound should be carefully examined for active bleed­ing before the end of the operation. Attention should be given to keep the spleen bed drain­age tube unblocked, as small blood loss can be observed temporarily, quickly replenishing the blood volume, hemostasis, and uid. If the amount of bleeding is large, rapid surgical exploration should be performed to clear the hemocellosis, and ligation or suturing should be performed at the active bleeding site to stop the bleeding.
2. Pancreatic stula: the literature has reported that the incidence of pancreatic stula after splenectomy is 3%–5% [11]. The amylase test can be used to identify the drainage uid. The cause of postoperative pancreatic stula is closely related to the spleen, and the pancre­atic tail is injured during the intraoperative treatment of the splenic pedicle or the applica-
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tion of the straight-cut closure device, result­ing in postoperative pancreatic stula. It is very important to maintain smooth drainage for the management of postoperative pancre­atic stula. In addition, inhibition of trypsin secretion, anti-inammation, maintenance of water and electrolyte balance, and systemic nutritional support can mostly be conserva­tively improved. If there is no improvement or deterioration of the condition, surgery can be performed. The prevention measures of pan­creatic stula should be a gentle operation during the operation, familiarity with the anatomy, avoidance of large ligation at the tail of the pancreas, and adoption of the treatment method of secondary splenic pedicle to reduce injury to the tail of the pancreas.
3. Residual abdominal infection of the left sub­phrenic abscess is the most common, mainly in subphrenic blood and uid secondary infection, improper treatment of pancreatic tail injury, gastric or colon collateral injury pollution, patients with low immunity, etc. Postoperative persistent high fever and symp­toms of diaphragmatic stimulation should be taken into account, and further X-ray exami­nation should be conducted to show left dia­phragmatic elevation and movement limitation. Ultrasound or CT could nd sub­diaphragmatic uid inclusion. After diagno­sis, active anti-infection and supportive treatment should be performed. If the conser­vative effect is not good, puncture or incision drainage should be performed in time. It is very important to maintain the patency of postoperative drainage by careful operation, avoiding contamination and placing sub­phrenic drainage tubes after operation.
4. Portal vein thrombosis (PVT) is a potentially life-threatening complication that can occur days to months after surgery. Postoperative portal vein thrombosis may be related to mul­tiple factors such as vascular endothelial injury, local eddy current formed by slow por­tal vein blood ow velocity, and platelet increase. The clinical manifestations of PVT
are usually atypical and may include diffuse abdominal pain, fever, nausea, diarrhea, loss of appetite, or other symptoms. In patients with nonspecic abdominal symptoms, PVT must be considered and examined early. PVT should be treated with intravenous low molec­ular weight heparin and later oral warfarin as soon as diagnosed. The current standard of warfarin treatment aims to maintain the inter­nationally standardized rate of 3–6 months (INR between 1.5 and 2.0).
5. Incisional hernias usually occur at umbilical incisions, and the size of the umbilical inci­sions is usually 15–25 mm due to the pro­longed removal of the spleen from the umbilical incision. In general, the puncture site is larger than 5mm, and the whole suture process is recommended to close the abdomi­nal wall defect to reduce the risk of incision dehiscence or incisional hernia.
6. After any abdominal surgery, there is a risk of adhesive ileus. Accurate operation of the sur­gical process to reduce side injuries is crucial to reduce the incidence of postoperative adhe­sions. Anti- adhesion products can also be used prophylactically. Finally, during the pro­cess of closing the peritoneal membrane, acci­dental suturing of the omentum or intestinal canal causing iatrogenic adhesive intestinal obstruction should be avoided.
13.8 Comparisons
withConventional Laparoscopic Surgery
Robotic splenectomy (RS) is essentially laparo­scopic splenectomy (LS) with upgraded instru­ments and equipment. The application principle is similar to LS, but there are some differences in the application process.
1. Compared with the traditional laparoscope, the three-dimensional magnied eld of vision of the robot system is clearer and has higher resolution [9, 12]. It can maintain lens
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clarity for a long time without being affected by smoke, which guarantees a smooth surgi­cal process.
2. Robot system: the highly exible robotic arm system can complete difcult operations such as grasping, holding, walking, hemostasis, suturing, and ligation in a narrow space, which cannot be achieved by laparoscopic instruments and human hands. Moreover, the robot system can lter the shaking of human hands, reduce the fatigue of surgeons, and reduce misoperation.
3. The learning curve of the robot system for dif­cult surgery is signicantly lower than that of traditional laparoscopy, and doctors with certain experience in laparoscopic surgery can quickly adapt to surgical operations.
4. Similar to the traditional laparoscopic system, all operations of the robot system rely on the eld of vision provided by the primary lens. If the eld of vision is polluted or massive bleed­ing cannot expose the operating eld, the robot system cannot replace open surgery [13].
5. The robotic arm of the robot system will occupy a certain space, and the selection and operation space of the assistant auxiliary hole will be more limited than that of the tradi­tional laparoscope.
6. The operation cost of the robot system and the operation cost of the instruments are higher than those traditional laparoscopic instru­ments, and the selection of modied special instruments for splenectomy is not as large as that of traditional laparoscopic instruments [12]. I believe that with the progress of tech­nology, the localization of equipment will fur­ther reduce the use cost, so that more children can benet from it.
7. Finally, the controversial operation time pro­longed problems. The author thinks that, com­pared to the traditional laparoscopic robot system, which does have extra installation time, the skilled operation performer can install time control in 10–15minutes, which
is trivial, and using the RS system can reduce the total operation time.
All in all, domestic children’s robotic surgery is still in the early stage, and the robot splenec­tomy experience and the accumulation of patients are not high. It is believed that through techno­logical advances, equipment will ceaselessly be more and more widely used in the eld of robotic surgery in children, and the robot splenectomy treatment guidelines and suggestions will be con­stantly updated and revised.
References
1. Wilson EB.The evolution of robotic general surgery. Scand J Surg. 2009;98:125–34.
2. Denning NL, Kallis MP, Prince JM.Pediatric robotic surgery. Surg Clin North Am. 2020;100:431–43.
3. Ruan H, Jiang ZW, Zhao K, et al. Robot-assisted sple­nectomy. J Laparosc Surg. 2013;18:899–901.
4. Davide C, Leonardo S, Di PD, etal. Robotic vs laparo­scopic splenectomy for splenomegaly: a retrospective comparative cohort study. Int J Surg. 2018;55:1–4.
5. Bhattacharya P, Phelan L, Fisher S, et al. Robotic vs. laparoscopic splenectomy in management of non­traumatic splenic pathologies: a systematic review and meta-analysis. Am Surg, 2022;88:38–47.
6. Sheth KR, Koh CJ.The future of robotic surgery in pediatric urology: upcoming technology and evolu­tion within the eld. Front Pediatr. 2019;7:259.
7. Meignan P, Ballouhey Q, Lejeune J, etal. Robotic­assisted laparoscopic surgery for pediatric tumors: a bicenter experience. J Robot Surg. 2018;12:501–8.
8. Royall NA, Walsh RM. Robotic distal pancreatec­tomy and splenectomy: rationale and technical con­siderations. J Visual Surg. 2017;3:135.
9. Mbaka MI, Robl E, Camps JI. Laparoscopic ver­sus robotic-assisted splenectomy in the pediatric population: our institutional experience. Am Surg. 2017;83:e358–9.
10. Aziret M, Koyun B, Karaman K, etal. Intraoperative hemorrhage and increased spleen volume are risk factors for conversion to open surgery in patients undergoing elective robotic and laparoscopic splenec­tomy. Turk J Surg. 2020;36:72–81.
11. Manciu S, Nae GA, Diaconu A, et al. Long-term evaluation of the outcomes of subtotal laparoscopic and robotic splenectomy in hereditary spherocytosis. World J Surg. 2020;44:2220–8.
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12. Shelby R, Kulaylat AN, Villella A, etal. A compari­son of robotic-assisted splenectomy and laparoscopic splenectomy for children with hematologic disorders. J Pediatr Surg. 2021;56:1047–50.
13. Ghidini F, Bisoffi S, Gamba P, et al. Robot-assisted versus laparoscopic approach for splenectomy in children: systematic review and meta-analysis. J Laparoendosc Adv Surg Tech A. 2022;32:1203–10.
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