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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_536_Библиотеки_им_академика_М_И_Перельмана.pdf
332 J. S. Azagra et al.
Fig. 40.18 Anterior layer is
sutured (a). Schematic view
of esophagojejunostomy
anastomosis (b)
References
1. Arru L, Azagra JS, Facy O, et al. Totally laparoscopic 95% gastrec-
tomy for cancer: technical considerations. Langenbecks Arch Surg.
2015;400(3):387–93.
2. Sarriugarte A, Arru L, Makai-Popa S, et al. Short-term results
of near-total (95%) laparoscopic gastrectomy. Cir Esp.
2018;96(10):634–9.
3. Parisi A, Nguyen NT, Reim D, et al. Current status of minimally
invasive surgery for gastric cancer: A literature review to highlight
studies limits. Int J Surg. 2015;17:34–40.
4. Desiderio J, Jiang ZW, Nguyen NT, et al. Robotic, laparoscopic
and open surgery for gastric cancer compared on surgical, clinical and oncological outcomes: a multi-institutional chart review.
A study protocol of the International study group on Minimally
Invasive surgery for GASTRIc Cancer-IMIGASTRIC. BMJ Open.
2015;19;5(10):e008198.
Fig. 40.19 Final aspect of the intrathoracic anastomosis
Robot-Assisted Total Gastrectomy for Gastric Cancer
Felix Berlth and Han-Kwang Yang
41
41.1 Description of the Surgical Procedure (See Video 41.1)
The key steps to perform a Robot-assisted Total
Gastrectomy are
1. Preparation. Position of patient. Trocar placement.
Start with laparoscopy
Patient is put into straight supine position. The trocar positioning is similar for all different extend of gastric cancer
resection. Camera trocar is placed in supraumbilical position.
Overall, four other trocars are placed, one assistant 12 mm
trocar on the patient’s right side and one 8 mm robotic trocar
at least 8 cm away from the camera trocar and some centimeters above. Two 8 mm trocars are placed most laterally and
above and are placed under careful vision in order to provide
the highest range of motion for the instruments [1]. In contrary to the laparoscopic gastrectomy setting (sharp V-angle),
the trocars in robot-assisted gastrectomy are more placed in a
round (smiling) shape position with more caudal location of
the lateral trocars in order to avoid external robotic arm collision. The right 12 mm trocar is used for the assistant to bring
in and out gauze, use suction or retrieve small pieces of tissue, and to insert stapler, if desired (Fig. 41.1) [2].
The liver can be retracted by the use of two sutures that
are pierced through the middle upper abdomen and tied on
Electronic supplementary material The online version of this
chapter (https://doi.org/10.1007/978-3-030-55176-6_41) contains
supplementary material, which is available to authorized users.
F. Berlth · H.-K. Yang (*)
Department of Surgery, Division of Gastrointestinal Surgery,
Seoul National University Hospital, Seoul, Republic of Korea
e-mail: hkyang@snu.ac.kr
F. Berlth
Department of General, Visceral and Cancer Surgery, University
Hospital of Cologne, Cologne, Germany
a gauze. The first suture is catching the ligamentum teres
hepatis and exposes the area of pylorus and hepatoduodenal
ligament. The second suture is clipped on the hiatal arch in
order to lift up the left liver and expose the esophagogastric
junction and lesser curvature (Fig. 41.2a, b).
Robotic system is docked, and instruments are to be
brought in (Figs. 41.3a, b and 41.4). One good option is to
use an energy device in the left 8 mm trocar as right hand of
the surgeon. Fenestrated bipolar forceps are used as the operator’s left hand through the right lateral 8 mm trocars. Third
instrument (fenestrated, e.g., Cadiere forceps) is inserted
through the left patient’s side to provide traction. As haptic
feedback is lacking in robotic surgery so far, it has to be mentioned that these instruments are feasible to use under visual
control to provide gentle tissue handling (Fig. 41.5a, b).
2. Omentectomy and greater curvature
The resection begins with the omentectomy. In case of cT3
or cT4, total omentectomy is performed; in case of cT1 and
cT2, partial omentectomy including 3 cm distance from the
arcade represents an appropriate extend. Before finding the
correct plane, the stomach can be lifted up to invite air into
the lesser sac in order to separate the omentum from the
underlying structures. Omentectomy starts along the stomach’s lower body and is proceeded in direction to the spleen
and the left gastroepiploic vessels which are clipped and cut
(Fig. 41.6a, b, c).
The short gastric vessels can be safely clipped as well. If
bleeding occurs or the exposure is difficult, further mobilization and dissection of the stomach can be carried out first.
The greater curvature is mobilized up to the left crus of diaphragm, where the esophagus is mobilized from left side. If
the exposure is good, the suprapancreatic lymph node dissection can be started from the left pancreas upper border
along the splenic vessels (Fig. 41.7).
Then, the omentectomy is completed to the right side
and finished by dividing the plane toward the gallbladder.
Then, the infrapyloric region is exposed.
© 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_41
333
334
Fig. 41.1 Patient’s position
in supine and trocar’s
placement. Real (a) and
schematic view (b)
Fig. 41.2. Liver retraction
by a stitch (right needle) (a)
around the falciform ligament
(b)
F. Berlth and H.-K. Yang
Fig. 41.3 Robot system is
docked (a, b)
3. Infrapyloric node dissection
For the infrapyloric dissection, the stomach is gently
grasped at the posterior side of antrum by the third arm and
lifted above and to the left side of the patient. The right gastroepiploic vessels should be in orthogonal position with
good exposure of the avascular fusion plane of infrapyloric
tissue and mesocolon (Fig. 41.8).
For better mobilization, the pylorus and duodenum first
portion (posterior) is dissected from the pancreas. The
desired extend of duodenal resection can be decided; the
gastroduodenal artery can be exposed usually (Fig. 41.9).
The fusion plane of infrapyloric tissue and mesocolon
is then carefully divided first anterior, then in direction of
gallbladder, and finally the anterior side of the duodenum is
exposed (Fig. 41.10).
The infrapyloric tissue is dissected along the pancreas,
and the gastroepiploic vein, artery, and infrapyloric artery
are clipped and cut. Now, the stomach is prepared on the
33541 Robot-Assisted Total Gastrectomy for Gastric Cancer
Now, a retroduodenal window is dissected between right gastric artery and first portion of duodenum (Fig. 41.12a–d).
Then, the dissection is continued toward the hepatoduodenal ligament, dissecting lymph node station #12a over the
proper hepatic artery. The right gastric vessels are exposed
at its roots, clipped, and cut (Fig. 41.13a–c).
Now, the duodenum is transected with the linear stapler (Fig. 41.14a, b). Duodenal stump is resutured
(Fig. 41.15a, b).
After transection of the duodenum, lymph node dissection completion in the suprapancreatic area can be easier.
5. Suprapancreatic lymph node dissection
Fig. 41.4 Robot port placement. Ⓐ: assistant port, Ⓒ: camera port
greater curvature and posterior side for transection of the
duodenum (Fig. 41.11a–c).
4. Right gastric vessels and hepatoduodenal ligament
One gauze is put behind right gastric artery under the stomach
in the lesser sac. This gauze will act as a cushion to protect
injury of underlying structures such as common hepatic artery,
and it also lifts up the right gastric artery for better dissection.
Fig. 41.5 Instrument setting.
Triangulation for retraction
of the tissue. Assistant’s
instrument (Ⓐ) counter-tracts
against the main retracting
device, Cadiere forceps at the
third robot arm (a, b)
The suprapancreatic lymph node dissection can be started
when the antrum is lifted for infrapyloric dissection. But
after transection of the duodenum, the exposure might be
easier.
Lymph node station #8a is carefully dissected on the
upper pancreatic border along the common hepatic artery
up to the roots of left gastric artery. Normally, the left gastric vein appears on the way and is cut after clipping. A
good way of retraction is to hold up the left gastric artery
toward the ventral side with the third arm. Putting a gauze
between the third arm’s joint and the liver can provide additional liver retraction if necessary (Fig. 41.16a, b).
Fig. 41.6 Omentectomy to the left (a), short gastric and left gastroepiploic vessels are clipped and divided (b, c)
336
Fig. 41.7 Omentectomy to the right
F. Berlth and H.-K. Yang
Fig. 41.9 Duodenum is dissected from the pancreas
Fig. 41.8 Exposure of the right gastroepiploic lymph nodes
Fig. 41.10 Fusion plane between the mesocolon and infrapyloric tis-
sue is divided
Fig. 41.11 Right
gastroepiploic vessels are
clipped and divided. Close (a,
b) and schematic view (c)
Fig. 41.12 A gauze is place in the retroduodenal area and retrieved in front (a, b, c). A retroduodenal window is done (d)
33741 Robot-Assisted Total Gastrectomy for Gastric Cancer
Fig. 41.13 Hepatoduodenal ligament is opened (a). Right gastric artery is dissected (b) clipped and cut (c)
Fig. 41.14 Duodenum is
divided by stapler (a, b)
338
Fig. 41.15 Duodenum
stump is resutured (a, b)
F. Berlth and H.-K. Yang
Fig. 41.16 Lymphadenectomy of Lymph nodes 8a (a, b)
Fig. 41.17 Retraction of the tissue by the second and third arm. The
Cadiere forceps at the third arm hold up the pedicle of the left gastric
artery, and lift up the left liver by articulating wrist at the same time.
Instrument setting for traction and counter traction
Most important maneuver for a good exposure of the
suprapancreatic area is gentle retraction of the pancreas.
Therefore, a gauze should be placed on the pancreas, and
with an opened assistant’s grasper, the pancreas can be gently rolled downwards to expose the vessels on the upper
border. This maneuver is believed to be safer when performed by the assistant rather than by robotic arm. The ventral traction of the third arm and the countertraction of the
assistant provide best exposure of the suprapancreatic area
(Fig. 41.17).
When clearing the root of left gastric artery, the suprapancreatic dissection goes over to lymph node station #11p.
For a radical dissection, the splenic vein has to be exposed
as well as the artery. Along the splenic vessel dissection, a
posterior gastric vessel might occur. The lymph node station #11d can be dissected by either following the splenic
vessels further or starting from the splenic hilum going
direction towards left gastric artery (Fig. 41.18a, b).
Fig. 41.18 Lymphadenectomy of stations 11p and 11d (a, b)
33941 Robot-Assisted Total Gastrectomy for Gastric Cancer
Fig. 41.19 Dissection of left gastric artery, cleared to all sides and dissect at other level if a important left hepatic artery is observed. Close (a,
b, c) and schematic view (d)
Fig. 41.20 Remnant tissue
around the hiatus is resected.
Close (a) and schematic view
(b)
6. Left gastric artery, celiac trunk, and right dia-
phragmatic crus
Root of the left gastric artery is cleared to all sides, and
the artery is clipped and cut. Now, the exposure of the area
Following the remnant connecting tissue to the right crus
represents lymph node dissection of station #1. The esophagus should be cleared from all sides to have good conditions for transection and reconstruction (Fig. 41.20).
behind, representing lymph node station #9, might be better, so the dissection of this particular station can be completed (Fig. 41.19a–d).
340
Fig. 41.21 Esophagus is
dissected free (a) and a tape
is placed around it (b)
Fig. 41.22 Small assistance
supraumbilical laparotomy is
performed and protected by
Alexis system
of a glove, the insufflation
can be maintained. Anvil with
a stitch is put in the operative
field (b)
®
(a). By means
F. Berlth and H.-K. Yang
Fig. 41.23 Esophagus is open on the anterior side and a 25 anvil
(with a stitch) is put inside. The needle is put through the posterior
wall
7. Reconstruction: Roux-en-Y (laparoscopic)
The esophagus is ligated with a U-tape so that the assistant
can easily retract downwards. It also prevents spillage of
lumen content. Before transection, the esophagus is opened
longitudinal with monopolar device on the anterior side just
below the desired transection line. The circular stapler anvil
(25 mm) is prepared with a 2 cm needle suture connected
to the anvil trocar. The anvil is pushed through the opening into the esophagus completely, but the connected needle is still in reach. The needle is now stitched through the
esophagus on the posterior side above the level of intended
transection. The anvil is pulled through, but not completely.
Now the transection of the esophagus can be performed
with linear stapler. Transection should be performed above
the anterior opening to assure whole circumference is
included. For that, the edges of the opening can be grasped
by the assistant if necessary. The anvil can be pulled
through completely now, and anvil trocar is removed (Figs.
41.21a, b, 41.22a, b, 41.23a, and 41.24a, b). The specimen
is put into a specimen bag and retrieved (Fig. 41.25a, b).
Ligament of Treitz is visualized, and the jejunum is followed 20 cm aboral direction for transection. Orientation
can be given by marking the small bowel with color for
right direction and distance. If the patient’s constitution
allows, the jejunojejunostomy can be performed extracorporeally. Therefore, the supraumbilical port incision can
be extended up to 5 cm. The specimen is retrieved though
this minilaparotomy. Then, the jejunum can be transected
and re-anastomosed 35 cm distal from desired location for
esophagojejunostomy by side-to-side linear stapling. The
stapler opening is closed by 3-0 polyfilament absorbable
continuous suture (Fig. 41.26a, b).
Fig. 41.24 Esophagus is
transected distal of the stitch
(a). View of the prik through
the posterior wall of the
esophagus (b)
Fig. 41.25 Specimen is
introduced in a bag (a) and
retrieved through the small
laparotomy (b)
34141 Robot-Assisted Total Gastrectomy for Gastric Cancer
Fig. 41.26 Jejunum loop
is exteriorized and prepared
for the anastomosis (a).
Jejunojejunostomy is done
(b)
Fig. 41.27 Circular
stapler is introduced into
the jejunum, fixed, and
introduced into the abdomen
through the glove (a, b, c)