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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_536_Библиотеки_им_академика_М_И_Перельмана.pdf
352 W. J. Hyung and I. G. Kwon
Fig. 42.12 a, b Dissection
of the retropyloric area (a)
and infrared imaging (b)
showing the gastroduodenal
artery
Fig. 42.13 a, b Duodenal
transection by staplers (a, b)
35342 Laparoscopic Immunofluorescence-Guided Lymphadenectomy …
354 W. J. Hyung and I. G. Kwon
Fig. 42.14 a, b, c After
opening the hepatoduodenal
ligament, hepatic artery, right
gastric artery with lymph
nodes is showed (a). Division
of the right gastric artery by
clips (b). Infrared imaging (c)
Fig. 42.15 a, b
Lymphadenectomy along
portal vein (Stations 8 and
12) (a). Infrared imaging (b)
35542 Laparoscopic Immunofluorescence-Guided Lymphadenectomy …
exposing the splenic hilar area, the tail of pancreas was
retracted to the caudal direction and the dissection of stations 11d and 10 starts from the distal portion of the splenic
vessels to the splenic hilum.
42.4 Robotic Gastrectomy
The trocar placements are somewhat different from laparoscopic gastrectomy except for camera port. Robotic gastrectomy also requires total five trocars; one 12-mm and
three 8-mm ports. Specifically, an 8-mm diameter port for
the third arm of the robot is placed 1 cm below the costal angle of the right abdomen, as far lateral as possible.
Another 8-mm port for the second robotic arm should be
inserted 2–4 cm above along an imaginary line that intersects the middle of the camera port and the right subcostal
port; this step allows easier access to the pancreatic head
and duodenum and achieves a proper angle with the ultrasonic shears, which are not wristed. Another 8-mm port for
the first arm should be inserted 1 cm below the costal angle
of the left abdomen as far lateral as possible. An assistant
port is placed on the left side of the camera port at the midpoint between the camera and the port for the first arm; the
356 W. J. Hyung and I. G. Kwon
Fig. 42.16 a, b, c
Lymphadenectomy of
stations 8 and 9 (a, b).
Infrared imaging (c)
Fig. 42.17 a, b Dissection
and lymphadenectomy along
left gastric vein (a). Infrared
imaging (b)
35742 Laparoscopic Immunofluorescence-Guided Lymphadenectomy …
assistant port should be placed 2 cm below an imaginary line
drawn from the insertion site of the first robotic arm to the
umbilical camera port (Fig. 42.24). The Cadiere grasper is
inserted through the third arm and its main function is traction. Maryland forceps and ultrasonic devices are inserted
through the first and second arms, respectively [14, 15].
Sometimes traction through the assistant port by the assistant
could make a better surgical view.
The overall order of procedure and extent of lymphadenectomy with the robotic system is mostly similar to laparoscopic gastrectomy with lymph node dissection.
358 W. J. Hyung and I. G. Kwon
Fig. 42.18 a, b, c
Lymphadenectomy along left
gastric artery (station 7) and
division of the artery by clips
(a, b, c)
Fig. 42.19 a, b, c
Lymphadenectomy along the
splenic artery (station 11p)
(a, c). Infrared imaging (b)
35942 Laparoscopic Immunofluorescence-Guided Lymphadenectomy …
360 W. J. Hyung and I. G. Kwon
Fig. 42.20 a, b, c
Lymphadenectomy station
stations 1 and 3 along the
small curvature (a, b).
Infrared imaging (c)
Fig. 42.21 a, b Division
of the proximal stomach (a)
guided by infrared (b)
36142 Laparoscopic Immunofluorescence-Guided Lymphadenectomy …