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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_536_Библиотеки_им_академика_М_И_Перельмана.pdf
Fig. 36.8 No. 6 lymph
node is separated from the
upper margin of the anterior
superior pancreaticoduodenal
vein (ASPDV)
Fig. 36.9 After identifying
and ligating the right
gastroepiploic vein branching
from proximal of ASPDV and
right accessory colic vein
28936 Robotic Distal Gastrectomy for Gastric Cancer
Fig. 36.10 Ligate the right
gastroepiploic artery from the
posterior right gastroepiploic
vein
290 Y.-W. Kim and W. H. Han
Fig. 36.11 Infrapyloric
vessels should be ligated
because hemostasis is not
easy by ultrasonic device
Fig. 36.12 Then
supraduodenal vessels are
exposed
Fig. 36.13 Common hepatic
artery, proper hepatic artery,
and right gastric artery should
be identified and then ligated
the origin of right gastric
artery with No. 5 lymph node
dissection simultaneously
Fig. 36.14 Duodenal
resection is performed by
stapler through assistant port
29136 Robotic Distal Gastrectomy for Gastric Cancer
7. Suprapancreatic lymph node dissection
To expose surgical plane between pancreatic upper border and
suprapancreatic lymph node, operator lifts the left gastric vessel vertically. Articulated movement of robotic arm can prevent the assistant from compressing the pancreas to damage it
(Fig. 36.15). After dissection along the common hepatic artery
(Fig. 36.16), left gastric vein is ligated (Fig. 36.17).
Around celiac trunk, the origin of the common hepatic
artery on the left side and the origin of the splenic artery on
the right side should be identified, then left gastric artery is
divided and ligated (Fig. 36.18).
No. 12a lymph node dissection requires exposure of the
anterior side of the proper hepatic artery and portal vein. It
is easy to expose portal vein by retracing the adjacent tissue
of common hepatic artery (Fig. 36.19).
In No. 11p lymph node dissection, operator lifts No. 11p
lymph node vertically and tilts left side slightly. Assistant
retracts the pancreas to the caudal side to expose splenic
vein (Fig. 36.20).
8. Abdominal esophagus and No. 1, 3 lymph node
dissection.
The anterior and posterior sides of the abdominal esophagus are dissected to divide the surrounding tissue. After
Left and right vagus nerve ligation, stomach is freed to dissect No. 1, 3 lymph node dissection (Fig. 36.21). Assistant
retracts soft tissues including No. 1, 3 lymph nodes to
straighten the lesser curvature (Fig. 36.22).
9. Billroth I anastomosis
The two ends of the duodenal and gastric stump are placed
facing each other (Fig. 36.23).
Opening of the duodenal stump (Fig. 36.24).
Opening of the gastric stump (Fig. 36.25).
Traction stitch from the gastric opening to outside
(Fig. 36.26).
Linear stapler in the gastric side (far from the staple line)
(Fig. 36.27).
The other part is placed on the duodenal side
(Fig. 36.28).
GastroduodenalBillroth I anastomosis is performed
(Fig. 36.29).
Closure of the opening by linear stapler (Fig. 36.30).
Aspect of the anastomosis (Fig. 36.31).
292 Y.-W. Kim and W. H. Han
Fig. 36.15 Articulated
movement of robotic arm can
prevent the assistant from
compressing the pancreas to
damage it
Fig. 36.16 After dissection
along the common hepatic
artery
Fig. 36.17 Left gastric vein
is ligated
Fig. 36.18 Left gastric
artery is divided and ligated
Fig. 36.19 It is easy
to expose portal vein by
retracing the adjacent tissue
of common hepatic artery
29336 Robotic Distal Gastrectomy for Gastric Cancer
Fig. 36.20 Assistant retracts
the pancreas to the caudal
side to expose splenic vein
294 Y.-W. Kim and W. H. Han
Fig. 36.21 After Left and
right vagus nerve ligation,
stomach is freed to dissect
No. 1, 3 lymph node
dissection
Fig. 36.22 Assistant retracts
soft tissues including No. 1, 3
lymph nodes to straighten the
lesser curvature
Fig. 36.23 After resection,
the two ends (duodenal and
gastric stump) are placed in
front of each other. Close (a)
and schematic view (b)
Fig. 36.24 Duodenal
stump is open. Close (a) and
schematic view (b)
29536 Robotic Distal Gastrectomy for Gastric Cancer
Fig. 36.25 Gastric stump is open. Close (a, b) and schematic view (c)
Fig. 36.26 Traction stitch at the gastric opening and put through trocar outside. Close (a–c) and schematic view (d)
296 Y.-W. Kim and W. H. Han
Fig. 36.27 Linear stapler
(anvil side) is placed in the
gastric side. Close (a) and
schematic view (b)
Fig. 36.28 Linear stapler
(cartridge side) is placed in
duodenal side (a, b)
Fig. 36.29 GastroduodenalBillroth I anastomosis. Close (a–d) and schematic view (e, f)
Fig. 36.30 Closure of the opening by linear stapler
29736 Robotic Distal Gastrectomy for Gastric Cancer
Fig. 36.31 Final aspect of the Billroth I anastomosis
References
1. Kim HI, Han SU, Yang HK, et al. Multicenter prospective comparative study of robotic versus laparoscopic gastrectomy for gastric
adenocarcinoma. Ann Surg. 2016;263(1):103–9.
2. Kim MC, Heo GU, Jung GJ. Robotic gastrectomy for gastric
cancer: surgical techniques and clinical merits. Surg Endosc.
2010;24(3):610–5.
3. D’Annibale A, Pende V, Pernazza G, et al. Full robotic gastrectomy with extended (D2) lymphadenectomy for gastric cancer: surgical technique and preliminary results. J Surg Res.
2011;166(2):e113–20.
4. Eom BW, Yoon HM, Ryu KW, et al. Comparison of surgical performance and short-term clinical outcomes between laparoscopic and
robotic surgery in distal gastric cancer. Eur J Surg Oncol: J Eur Soc
Surg Oncol Br Assoc Surg Oncol. 2012;38(1):57–63.
5. Park JY, Jo MJ, Nam BH, et al. Surgical stress after robot-assisted
distal gastrectomy and its economic implications. Br J Surg.
2012;99(11):1554–61.
6. Yoon HM, Kim YW, Lee JH, et al. Robot-assisted total gastrectomy
is comparable with laparoscopically assisted total gastrectomy for
early gastric cancer. Surg Endosc. 2012;26(5):1377–81.
Laparoscopic Total Gastrectomy for Gastric Cancer
Antonio Talvane Torres de Oliveira, Croider Franco Lacerda,
Paulo A. Bertulucci and Miguel A. Cuesta
37
37.1 Introduction
Gastrectomy, total or subtotal, with a proper lymphadenectomy after neoadjuvant therapy, if indicated, is the main
treatment for resectable gastric cancer. Many studies have
shown that Minimally Invasive Surgery (MIS) for other
gastrointestinal malignancies [1, 2], such as colorectal
and esophageal cancer, is oncologically safe and has several important short-term advantages in comparison with
the conventional open surgical techniques. These studies
showed favorable outcomes for MIS such as a less blood
loss, faster patient recovery, and fewer complications with
similar oncological outcomes. Concerning MI gastrectomy
for cancer, important requirement includes the use of neoadjuvant (and adjuvant) therapy [3] in advanced gastric
cancer and to adopt the principles of oncological resection
including a proper lymphadenectomy based on the Japanese
guidelines [4]. Evidence for this MIS for gastric cancer is
based on European (Hulscher, STOMACH, and LOGICA)
and South Korean (KLASS studies) and some meta-analysis [5–11]. They have shown that there are some short-term
advantages for partial gastrectomy whereas for total gastrectomy, it seems they shown similar short-term and oncological outcomes.
37.2 Clinical Staging and Surgical Plan
If gastric cancer is diagnosed, clinical staging should be
done (cTNM) by means of endoscopic ultrasound, CT and
PET-CT scans.
If the tumor seems resectable, depending on the clinical staging and location of the tumor, a surgical plan is
designed, concerning:
– Use of neoadjuvant therapy (stage II or higher).
– Type of resection: local, distal, or total gastrectomy. In
advanced gastric cancer, the margin of resection will be
at least 5 cm.
– The type of lymphadenectomy, D1, D1+ , or D2.
We follow the Japanese Gastric Cancer treatment guidelines
2014 [4] and classify the lymph node stations in the surgical
field according to it.
Figure 37.1 shows the operative field with lymph node
stations.
37.3 Description of the Surgical Technique
(See Video 37.1)
The key steps for a laparoscopic total gastrectomy are:
Electronic supplementary material The online version of this
chapter (https://doi.org/10.1007/978-3-030-55176-6_37) contains
supplementary material, which is available to authorized users.
A. T. T. de Oliveira · C. F. Lacerda · P. A. Bertulucci
Department of Upper GI Surgery, Americas Medical City
Hospital, Rio de Janeiro, Brazil
e-mail: contato@drantoniotalvane.com.br
C. F. Lacerda
e-mail: croider@hotmail.com
M. A. Cuesta (*)
Department of Surgery, Amsterdam UMC, Amsterdam,
The Netherlands
e-mail: ma.cuesta@amsterdamumc.nl
© Springer Nature Switzerland AG 2021
M. Asunción Acosta et al. (eds.), Atlas of Minimally Invasive Techniques in Upper Gastrointestinal Surgery,
https://doi.org/10.1007/978-3-030-55176-6_37
1. Positioning of patient and placement of trocars.
Patient is placed in lithotomy position. Surgeon
stands between the legs of the patient (Fig. 37.2) 5 tro-
cars of 5/12 mm are placed in the upper abdomen.
Assistance incision used is placed on the left side (trocar
site) or Pfannenstiel incision (Fig. 37.3).
2. Omentectomy. Omentectomy will be started from the mid-
dle to the left. Omental bursa is opened. After this, greater
curvature is dissected after division of the left gastroepi-
ploic vessels and short vessels up to left crus (Fig. 37.4),
after this we will proceed the omentectomy to the right
side, up to hepatic flexure and duodenum (Fig. 37.5).
299