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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_541_Библиотеки_им_академика_М_И_Перельмана.pdf
14 Robotic McKeown Esophagectomy
145
a
Fig. 14.8 The procedure continues to the superior mediastinum.
Starting at the divided azygos arch, the parietal pleura is incised along
the superior vena cava until the right subclavian vein and artery are
reached. The dissection route is represented by the white line. The
b
robotic arms are most of the time the same as in the inferior mediastinum with the cadiere forceps is in robotic arm 1, the vessel sealer in arm
2, the camera in arm 3, and the cautery hook in arm 4. (a, Created with
BioRender.com)
Fig. 14.9 Now that the parietal pleura at the left side is opened in the
superior mediastinum, the esophagus is mobilized on its dorsal side
towards the left pleura. At this step, it is of importance to include the
meso-esophagus with the resection specimen including the thoracic
duct. Be aware of the aortic arch and subclavian artery that runs at the
level of the trachea to the left. Hereafter, the dissection continues at the
ventral side of the esophagus over the trachea, where the right vagus
nerve should be identied over the right rim of the trachea
146
R. van Hillegersberg et al.
a
Fig. 14.10 After the right vagus nerve is freed, lymph node station 4R
is harvested. Station 4R is located between the superior vena cava and
the right border of the trachea (white line). Important landmarks during
this part are the superior cava vein (lateral), the right subclavian artery
b
and vein at its cross point with the right vagus (cranial), the right lateral
rim of the trachea (medial), and the right azygos arch stump (caudal).
(a, Created with BioRender.com)
Fig. 14.11 Situation after lymph node station 4R is dissected
a
14 Robotic McKeown Esophagectomy
147
b
Fig. 14.12 The esophagus is slightly lifted with the cadiere (arm no. 1)
to dissect it from the membranous part of the trachea and work towards
the left paratracheal groove. Here, the left laryngeal recurrent nerve is
identied at the left lateral rim of the trachea. The esophagus is now
a
Fig. 14.13 The right vagus nerve is divided at the level of the inferior border of the right main bronchus to preserve the pulmonary vagus branches
to the right main bronchus. *Pulmonary branches of the right vagus nerve. **Right main bronchus. (a, Created with BioRender.com)
completely encircled. By lifting the esophagus upwards, the esophagus
is further freed from the trachea towards the carina. *Left laryngeal
recurrent nerve. (a, Created with BioRender.com)
b
148
Fig. 14.14 After the right vagus nerve is divided, the inferior border of
the right and left main bronchus is followed to expose the cranial aspect
of the carinal nodes. A plane between the esophagus and trachea is created. To facilitate this step, the esophagus is lifted with the vessel sealer
in robotic arm 2
R. van Hillegersberg et al.
a
Fig. 14.15 The dissection continues at the level of the azygos vein towards the hiatus. The parietal pleura and lymphatic tissue over the aorta is
dissected, guided by the inferior border of the azygos vein. (a, Created with BioRender.com)
b
14 Robotic McKeown Esophagectomy
Fig. 14.16 The periesophageal lymphatic tissue, including the thoracic duct, is dissected en bloc with the specimen from the aorta to
expose the meso-esophageal plane. At the level of the pericardium, the
dissection continues until the left pleura is reached that should be kept
intact
149
a
Fig. 14.17 At 5–7 centimeters cranial from the hiatus, the thoracic
duct including its fatty sheath and fascia is encircled and divided using
Hem-o-lok clips. The level above the hiatus is chosen to avoid the sepa-
b
rate ductal branches that may cause chylothorax. (a, Created with
BioRender.com)
150
R. van Hillegersberg et al.
a
Fig. 14.18 The esophagus is encircled and lifted with the vessel sealer. The dissection continues cranially, to the carina over the plane between
the pericardium and the esophagus. The suction device provides contra-traction towards the pericardium. (a, Created with BioRender.com)
b
Fig. 14.19 The subcarinal lymph nodes (station 7) are surrounded by
an enveloping fascia which is demonstrated in this photo. This surrounding fascia is incised to allow the subcarinal nodes to be lifted
away from the superior pulmonary vein using the attachment to the
esophagus that is lifted up. The carinal nodes are dissected from caudal
to cranial and from the right towards the left bronchus
14 Robotic McKeown Esophagectomy
151
a
Fig. 14.20 The enveloping fascia around station 7 is dissected in Panel (a) so the lymph nodes could be collected. The feeding artery at the apex
of the carina is sealed with the vessel sealer. In Panel (b) the result after lymph node station 7 is removed is shown
b
Fig. 14.21 Now that station 7 is resected en bloc with the esophagus,
the left main bronchus is optimally exposed. At this point, the next step
is to dissect the attachments between the dorsal side of the esophagus
and the left main bronchus at the level of the aortic arch with the vessel
sealer. The esophagus remains lifted to facilitate the dissection
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R. van Hillegersberg et al.
a
Fig. 14.22 The lymph node dissection in the mediastinum is completed when the aortopulmonary nodes of station 5 are retrieved. The nodes are
located between the trachea/left main bronchus and the aortic arch along the left recurrent laryngeal nerve. (a, Created with BioRender.com)
a
b
b
Fig. 14.23 The last step of the thoracic phase is the lymph node dissection around the left recurrent laryngeal nerve taking advantage of the maximal lifting of the esophagus, which is now possible after complete mobilization. (a, Created with BioRender.com)
14 Robotic McKeown Esophagectomy
153
Fig. 14.26 The right crus is visualized and dissected until the hiatus is
reached
Fig. 14.24 For the abdominal phase, the patient is placed in supine
position after which six incisions are made for the surgical instruments.
Four incisions are for the robotic ports (4 × 8mm); one incision is for
the Nathanson to retract the liver (5mm) and one incision for the assistant port (12mm). (a, Created with BioRender.com)
Fig. 14.25 The liver retractor is placed under the left liver lobe. The
cadiere is placed in robotic arm 1, the vessel sealer in arm 2, the camera
in arm 3, and the cautery hook in arm 4. The abdominal phase starts
with opening the hepatogastric ligament which creates access to the
omental bursa. The stomach is retracted caudally by the robotic arm.
The dissection follows the white line in the photo and continues to the
crus to mobilize the right side of the stomach. Grasping of the stomach
should be avoided during the entire procedure to avoid damage of the
future gastric tube
Fig. 14.27 The procedure continues to the greater curve of the stomach. The gastrocolic ligament is opened above the transverse colon.
Caution should be taken to keep the right gastroepiploic artery undamaged as it provides the vascularization of the gastric conduit. The stomach is lifted with the cardiere, and the dissection is performed with the
hook and vessel sealer
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R. van Hillegersberg et al.
Fig. 14.28 The dissection of the greater curvature continues to the left
upper quadrant. The table surgeon retracts the tissue laterally to the left,
protecting the colon and enabling the formation of a tunnel between
spleen and stomach. The short gastric arteries between the fundus and
the spleen are then ligated with the vessel sealer. This part of the procedure ends by releasing the stomach from the left side of the crus
Fig. 14.30 The stomach should be fully mobilized to make sure that
the gastric conduit will be long enough for the creation of a tension-free
anastomosis in the neck. In order to create enough length, the rst part
of the duodenum is mobilized, and the omentum between the stomach
and the right colon is dissected (white line) dissecting the hepatic exure. The stomach is lifted upwards to facilitate this and to avoid damage
to the mesocolon, which is often attached closely to the omentum
Fig. 14.29 The dissection continues to the posterior and distal side of
the stomach. The greater curve of the stomach is mobilized towards the
gall bladder as the main landmark. The stomach is lifted and dissected
free from the pancreas towards the pylorus until the gastroduodenal
artery is reached. The hepatic exure is mobilized free from the duodenum (Kocher maneuver) to facilitate the mobilization of the future gastric tube. One of the robotic instruments is used to lift the stomach
upwards
Fig. 14.31 Care should be taken to follow the plain over the mesogastrium, containing the gastroepiploic artery and vein. During this phase,
the stomach is also lifted