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15 Robotic-Assisted Mesenteric Cyst Resection
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Fig. 15.1 (a & b) Layout of the trocar for robotic-assisted mesenteric cyst resection (ensuring that each point is at least
4 cm apart).
were connected with a vertical line, making
small incisions at 4 cm from the umbilicus,
about 8 mm in size. An auxiliary hole can be
located at the right clavicular midline and
infrahepatic intersection, depending on intraoperative conditions (Fig. 15.1).
mmHg). Alternatively, the rst 8 mm sleeve
was inserted directly into the primary mirror.
The second 8mm cannula is inserted into the
left ank to serve as the primary operating
hole for placement of surgical instruments
such as the ultrasonic scalpel, bipolar electrocoagulation, electrocoagulation hook or needle holder. To ensure a suitable operating
15.5 Surgical Steps
distance, the cannula was positioned high or
low based on the cyst site and size. The third
• The position and docking are the same as
before
• Routine disinfection and napkins
• Establish pneumoperitoneum and place
TORCA: After making an 8 mm longitudinal
incision at the center of the umbilical ring, the
pneumoperitoneum was established by puncturing the peritoneal cavity with a pneumoperitoneum needle (pressure 6 mmHg-12
8 mm sleeve was placed on the upper right
abdomen for the insertion of an attractor or
operating pliers.
• Abdominal cavity exploration: After entering
the abdominal cavity, a thorough exploration
was performed to examine the location and
size of the cyst in detail, as well as its relation
to the attachment and blood supply of the
intestinal canal (Fig 15.2).
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Z. Gao and D. Hu
Fig. 15.2
mesenteric cyst; (i) Removing the cyst by retrieval bag; (j–k) Closing the mesentery hiatus
Surgical procedures. (a) Abdominal cavity exploration; (b–g) Peeling off the cyst; (h) Surgical excision of
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J
K
LMN
Fig. 15.2 (continued)
• Excision of the cyst: To remove the cyst, the
area near the cyst was carefully cut using an
ultrasonic knife or an electrocoagulation hook
to detach any adherent mesangium, after
which the cyst was peeled off with great care.
If the cyst was too large, it was punctured and
aspirated rst to reduce its volume before
removing it. If the cyst was closely adhered to
the intestinal tube and could not be separated,
pletely stripped. Any mesangial defect was then
sutured using 4-0 barbed thread (Fig. 15.2).
The abdominal cavity was then washed out
carefully, with particular attention given to the
presence of chylous leakage or active bleeding. If necessary, a drainage tube was inserted
before the mirror was removed. Finally, the
gas was exhausted, and the incision was
closed.
the bursal wall was opened rst with careful
excision. The remaining bursal wall was then
peeled off from the adherent intestinal wall.
15.6 Technical Points andSkills
• To remove the cyst, it was placed in a pickup
bag and then carefully extracted through the
umbilical incision. If necessary, the umbilical
incision was expanded to facilitate the removal
process.
• Explore the abdominal cavity and drainage:
After the cyst was removed, the abdominal
cavity was thoroughly examined to ensure that
the submucosal layer of the base was com-
• It is recommended to maintain a distance of at
least 3 cm but no more than 8 cm between the
umbilical cord and the puncture operation
hole to prevent any mechanical arm movement restrictions during the procedure.
However, if the cyst’s location dictates, the
position of the puncture operation hole may
need to be altered accordingly.
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Z. Gao and D. Hu
• Compared to adults, children have smaller,
lighter, and softer organs in the abdominal
cavity. To minimize the use of auxiliary
devices during surgery, suture traction and
lifting and suspension through the abdominal
wall can be employed to help expose the surgical eld.
• The surgical approach chosen should be based
on the specic case at hand. During intraoperative exploration, the surgeon should assess
factors such as the cyst’s proximity to surrounding organs and blood vessels, as well as
the color and characteristics of the cyst uid.
Whenever possible, complete removal of the
cyst is ideal. For larger cysts, the surgeon may
puncture the cyst and extract the uid while
carefully separating it along the cyst wall to
avoid damage to the mesangial vessels. If the
cyst is tightly connected to the intestinal tube
and its supply vessels, removing the adjacent
section of the intestinal canal and performing
an intestinal anastomosis may be necessary. In
cases where the cyst extends to the mesenteric
root and is adhered closely to vital blood vessels, partial removal may be necessary, followed by opening and electrocauterizing the
endothelial cells of the smaller residual cysts
to reduce the likelihood of recurrence.
15.7 Postoperative Complications
Da Vinci robot auxiliary intestinal cyst resection
and laparoscopic surgery are almost the same.
• Infection of the abdominal cavity: Due to a
large cyst, large wound during peeling or secondary infection, of the cyst prior to surgery,
the cyst may rupture during the operation. In
such cases, pus can be absorbed into the
abdominal cavity, leading to residual infection
after the operation. To address this, the
abdominal cavity should be thoroughly rinsed
with a large amount of normal saline, a drainage tube should be inserted, and antibiotics
should be administered after the operation.
• Recurrence of cyst: improper treatment of the
residual cyst wall or incomplete removal of
cyst attachment can result in small cysts being
left behind, leading to recurrence.
Conrmation can be performed through ultrasound or CT examination. In such cases, secondary resection or cyst resection may be
necessary. Therefore, during the operation, it
is important to remove as much of the cyst
wall as possible and explore the abdominal
cavity carefully to avoid missing multiple
cysts.
• Adhesive intestinal obstruction is a common
complication after traditional abdominal surgery. It can present with symptoms such as
abdominal pain, distension, nausea, vomiting,
and cessation of bowel movements.
Conservative treatment, including fasting,
uid therapy, and antibiotics, is typically
attempted rst in patients with intestinal
obstruction. However, if symptoms persist or
worsen, reoperation may be necessary to
decompose the adhesion and remove the
obstruction to prevent serious complications
such as intestinal strangulation or necrosis.
During surgery, it is essential to conduct a
careful operation to minimize the risk of postoperative adhesions. The use of antiadhesion
products can also be considered for
prevention.
• Intestinal necrosis: When the mesenteric
attachment of a cyst is removed, it can cause
damage to the mesenteric blood vessels,
which can lead to necrosis of the intestine due
to loss of blood supply. This condition is characterized by postoperative peritonitis or the
presence of bloody uid upon abdominal
puncture. Surgical exploration should be performed promptly after diagnosis to prevent
serious complications.
• Chyle leak: When the mesenteric root is
treated, the chyle (lymphatic uid) duct can be
damaged, leading to milky white postoperative drainage uid. In cases where there is signicant drainage uid, parenteral nutrition
support can be used to accommodate fasting.
• Intestinal leakage: The condition is characterized by fever, abdominal pain, and abdominal
distension. It may result from loose sutures
and an infection in the anastomotic stoma
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during anastomosis, or from injury to the
intestinal canal during surgery. For children
who may have an intestinal stula and whose
abdominal symptoms are limited, conservative treatment is recommended, including
anti-infection measures, fasting, dehydration,
etc. Their disease progression should be
closely monitored. In cases where there are
obvious symptoms throughout the body and
abdomen, and with diffuse peritonitis, immediate surgical exploration is necessary.
15.8 Comparisons
withConventional
Laparoscopic Surgery
While da Vinci robotic surgery can be used to
treat most mesenteric cysts, different cysts will
require different skills and procedures. Possible
disadvantages of robotic surgery include preoperative diagnosis uncertainty and uncertainty
regarding the position of the cyst, leading to discomfort in the puncture site, and the possibility
of requiring auxiliary holes during the operation.
The most signicant technical aw of Da Vinci’s
robot system lies in its haptic feedback system.
Although 3D visual information can partially
compensate for this drawback, there is still a risk
of broken stitches or intestinal wall damage during knotting and pulling. Additionally, the cost of
hospitalization per patient for Da Vinci robot surgery is considerably more expensive than traditional laparoscopy, representing the most
signicant barrier to the routine clinical development of Leonardo da Vinci robot surgery.
Consequently, traditional laparoscopy remains
the most cost-effective option.
Complete surgical resection is considered the
most effective treatment for mesenteric cysts.
The surgical approach used depends on various
factors, including the size and location of the
cyst within the abdominal cavity, as well as the
surgeon’s level of expertise with robotic minimally invasive surgery techniques. In some
cases where the cyst is closely linked to the
intestinal structure or affects blood vessels that
supply the intestinal canal, intestinal resection
may be necessary to completely eradicate the
cyst. Robotic-assisted laparoscopic surgery
offers signicant advantages compared to traditional laparoscopic surgery for the resection of
mesenteric cysts [8]. First, the three-dimensional stereoscopic view and 10 times magnication of the operating eld provides a clearer
view of the surgical area, allowing for precise
identication of the boundary between the cyst
and surrounding tissues. Second, the EndoWrist
surgical instruments with 7 degrees of motion
can mimic the dexterity of human hands, allowing for better control of ne movements during
delicate procedures likesuch as cyst removal
from the bowel or mesenteric vessels. This is
particularly useful in narrow or hard-to-reach
spaces, such as in cases of cysts located in the
lesser sac or small curvature of the stomach.
Robotic-assisted laparoscopic surgery is particularly advantageous for complex mesenteric
cysts that require intestinal resection, as it
allows for better performance of complete
abdominal anastomosis and even complete cyst
removal without the need to remove intestinal
tubes. This type of minimally invasive surgery
can also reduce direct exposure of the intestinal
canal to air, avoid the effects of glove talcum
powder on the abdominal cavity, and limit the
manipulation of the intestinal canal, reducing
the risk of intestinal adhesion and postoperative
obstruction. Additionally, patients may experience reduced postoperative abdominal distension and a quicker recovery of intestinal
function. This can lead to shorter hospitalization
times and lower hospital costs. Although skilled
endoscopic separation, hemostasis, suture and
knot techniques are needed, required, the learning curve with the robotic system is signicantly
lower for difcult surgeries compared to traditional laparoscopic surgery. The duration of the
operation, including the docking procedure in
our group, was not signicantly longer compared to laparoscopic or laparoscopic-assisted
procedures reported in the literature. Physicians
with experience in laparoscopic surgery can
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Z. Gao and D. Hu
quickly adapt to robotic-assisted laparoscopic
surgery techniques.
The application of robotic assistant minimally
invasive surgery has great potential in pediatric
patients, and has opened up new prospects for
robotics in children.
References
1. Huis M, Balija M, Lez C.Mesenteric cysts. Acta Med
Croatica. 2002;56:119–24.
2. Walker AR, Putnam TC. Omental, mesenteric, and
retroperitoneal cysts: a clinical study of 33 new cases.
Ann Surg. 1973;178:13.
3. Kurtz RJ, Heimann TM, Beck AR, etal. Mesenteric
and retroperitoneal cysts. Ann Surg. 1986;203:
109–12.
4. Mackenzie DJ, Shapiro SJ, Gordon LA, et al.
Laparoscopic excision of a mesenteric cyst. J
Laparoendosc Surg. 1993;3:295–9.
5. Wiesen A, Sideridis K, Stark B, etal. Mesenteric chylous cyst. Gastrointest Endosc. 2006;63:502.
6. Ho TP, Bhattacharya V, Wyatt MG.Chylous cyst of
the small bowel mesentery presenting as a contained
rupture of an abdominal aortic aneurysm. Eur J Vasc
Endovasc Surg. 2002;23:82–3.
7. Mattioli G, Pini Prato A, Razore B, et al. Da vinci
robotic surgery in a pediatric hospital. J Laparoendosc
Adv Surg Tech A. 2017;27:539–45.
8. Chen Q, Zhang S, Luo W, et al. Robotic-assisted laparoscopic management of mesenteric cysts in children.
Front Pediatr. 2023;10:1089168.
Robotic System Assisted Soave
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Procedure for Hirschsprung
Disease
QingjiangChen andWenjuanLuo
16
16.1 Introduction
Hirschsprung disease (HSCR) is also called
“congenital megacolon” or “aganglionosis. It is
failure of migration of the neural crest stem cells
from the rostral to the caudal body during
embryogenesis, which results in the absence of
ganglion cells in the myenteric and submucosal
plexuses of the affected bowel [1]. The typical
presentations of Hirschsprung disease are delayed
passage of meconium, chronic severe constipation requiring enema treatment to maintain
defecation, abdominal distention, and growth
retardation. Plain radiographs characteristically
show dilated bowel loops and cut-off signs.
Contrast enema of patients with HSCR frequently
demonstrated an obvious stenotic distal bowel
and dilated proximal bowel, and retention of the
contrast beyond 24 hours after enema examination. The diagnosis of HSCR is mainly based on
Supplementary Information The online version contains supplementary material available at https://doi.org/
10.1007/978- 981- 19- 9693- 1_16.
rectal biopsy, through suctional mucosal biopsy
or full-thickness biopsy. Anorectal manometry is
another useful screening technique.
The principles of surgical management for
HSCR are to remove the aganglionic and the signicantly dilated and hypertrophic proximal
bowel and reconstruct the intestinal tract by pulling the normally innervated bowel through the
rectum to the anus to obtain normal defecation
function.
Swenson, Duhamel and Soave procedures are
the most commonly performed operations in
clinical practice by means of laparotomy, laparoscopy or transanal pull-through.
The Soave procedure, reported by Franco
Soave in the 1960s, is the rst endorectal pullthrough (ERPT) for the management of
Hirschsprung disease and is now the most commonly adopted endorectal dissection technique
in the radical treatment of this disease. The
Soave procedure performed a submucosal
endorectal dissection and pulled the normal
innervated bowel down to the anus within a
“cuff” consisting of aganglionic muscle, signicantly avoiding the risks of injury to pelvic
structures and thus preserving both fecal and uri-
Q. Chen (*) · W. Luo
Department of General Surgery, Children’s Hospital
of Zhejiang University School of Medicine,
Hangzhou, China
e-mail: chengqj0157@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_16
Currently, most cases of HSCR are treated by
one-stage pull-through procedures using minimally invasive techniques. The rst laparoscopic
surgery for HSCR was introduced by Georgeson
111
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Q. Chen and W. Luo
in 1995, and has also been applied to the
Duhamel and Swenson procedures. Laparoscopic
surgery in children has progressively gained
popularity, with the advantages of cosmetic
effects, fewer abdominal complications and a
quick postoperative recovery. With the rapid
development of robotic surgery and its increasing application in pediatric surgery during the
last decade, most laparoscopic surgeries are feasible with robotic approaches, as with HSCR
[2–4]. Compared with the laparoscopic approach,
robotic surgery offers more advantages of highquality vision, intuitive hand-eye coordination,
and improved exibility and precision of movement, making it more conducive in performing
pelvic dissection.
16.2 Indications
andContraindications
Theoretically, the indications of traditional
laparoscopic-assisted Soave surgery can be
applied to robotic surgery as well and bear the
advantages of more convenience in splenic exure mobilization and pelvic dissection.
However, for long- segment HD, re-docking is
usually necessary, and is regarded as a relative
contraindication for robotic assisted
procedures.
1. Indications:
(a) Common megacolon
(b) Short segment Hirschsprung’s disease
2. Contraindications
(a) Poor general condition, severe abdominal
distention, complicated with enterocolitis
or severe congenital malformation.
(b) Serious abdominal distention due to
abdominal trauma, operation, or intraabdominal infection.
(c) Long-segment HD, massive rectal disten-
sion, and giant fecalith impaction.
16.3 Preoperative Preparation
1. Antegrade colonic irrigation should be performed at least oneweek before surgery.
2. Mechanical antibiotic bowel preparation
(gentamicin and metronidazole) is given
3days prior to the operation.
3. Clear liquids are given orally for 24 hours
preoperatively.
4. Perioperative antibiotics should be administered.
5. A nasogastric tube is placed.
6. Wrap the lower limbs so that his/ her legs can
be maneuvered up and down.
7. Place a urine catheter after draping.
8. Special equipment: bipolar grasper, robotic
monopolar hook/scissors, harmonic scalpels, and/or LigaSure are needed.
16.4 Position andDocking
16.4.1 Patient Position
The patient is placed in a supine position with
arms alongside the trunk and legs abducted, the
operative bed in a Trendelenburg position and a
slight right tilt.
16.4.2 Cannula Placement
The pelvic oor is considered the “target” organ
for the HD procedure. The camera port is placed
on the right edge of the umbilicus (Fig. 16.1).
• R1 is placed in the right iliac fossa for robotic
monopolar hook/scissors, harmonic scalpel,
and/or LigaSure.
• R2 is placed in the left upper abdomen for the
bipolar grasper.
• An assistant port is located at the right lower
abdomen umbilical level when necessary.
E
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D
Fig. 16.1 Cannula placement and targeting. (a, b) The
camera port is placed on the right edge of the umbilicus,
the manipulation ports are arranged in the right iliac fossa
16.5 Surgical Procedure
1. After the ports are placed and docking are nished, gross exploration is performed to evaluate the scope of the stenotic segment,
transitional zone, and dilated segment and to
estimate the level of bowel resection (Fig.
16.2a and b). Full-thickness biopsies or sero-
muscular biopsies are performed with scissors
from the “normal looking” bowel for histological leveling to conrm the presence of
ganglion cells.
2. The mesentery is initially dissected between
the colon and superior rectal vessels using
hook cautery or the ultrasonic scalpel, note to
avoid damaging the surrounding tissues such
as the ureter and iliac vessels (Fig.16.2c).
3. Proximal mesenteric dissection should be performed until the bowel level is removed, and
attention should be given to avoid damaging
the marginal artery (Fig.16.2d), which may
lead to ischemia of the pulled-down colon and
result in complication of stricture, dysfunction, or anastomotic disruption. The pedicled
colon is assessed frequently for its length to
reach the deep pelvis without tension (Fig.
16.2e). Large mesenteric vessels need to be
ligated or clamped by a hemo-lock. Usually,
the lateral peritoneum needs to be opened and
the colonic splenic exure needs to be released.
4. Distal separation should be performed close
to the colon wall, and the mesenteric blood
supply of the rectum should be carefully pre-
F
and in the left upper abdomen respectively; (c) The pelvic
oor is considered as the “target” organ
served. The posterior rectal wall is dissected
along the avascular plane by blunt and sharp
methods to the deep pelvic oor. The anterior
wall of the rectum is dissected about 1–2cm
below the peritoneal reection to avoid damaging the vas deferens and seminal vesicles
(Fig. 16.2f and g). Care must be taken to avoid
extensive lateral dissection to damage the
nervi erigentes.
5. After the anal retractor is installed, a circular
incision of the rectal mucosa at 1cm anterior
and 0.5cm posterior above the dentate line is
made. Stay sutures are placed into the mucosal edges to provide traction to facilitate a
proximal dissection of the submucosal plane
until the colorectum begins to evert or prolapse (Fig. 16.2h).
6. A V-shaped resection was made in the posterior rectal muscular sleeve to the level of 1 cm
above the dentate line, and 3 cm of rectal cuff
was retained in the anterior wall. Then, a short
rectal muscular cuff was left.
7. The dissociated colon and rectum are pulled
through the anus until the proximal ganglionated bowel (Fig. 16.2i). The colon is transected, and a circumferential single layer
anastomosis is created using absorbable
suture.
8. Finally, pneumoperitoneum is re-established
to check for colonic blood supply, colon pedicle twist, and potential internal herniation and
ascertain bleeding and concomitant injuries.
No pelvic drainage is placed routinely.
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H
Fig. 16.2 Surgical procedures. (a, b) Gross exploration
of the colon reveals contracted rectum and signicantly
dilated sigmoid colon, and slightly dilated descending
colon; (c) Transection of sigmoid colon mesocolon with
ultrasonic scalpel; (d) Preservation of mesenteric vascular
arch to avoid colon ischemia and necrosis; (e) The
I
pedicled colon is assessed for its length to reach the deep
pelvis without tension; (f) Keeping close to the colon wall
to separate the distal rectum; (g) Rectal separation completed; (h) Dissecting the rectal mucosa in the submucosal plane; (i) Complete dissection of spastic rectum and
dilated colon
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