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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_541_Библиотеки_им_академика_М_И_Перельмана.pdf
15 Robotic Transcervical andTranshiatal Esophagectomy (RACE Procedure)
165
Fig. 15.29 Complete lymphadenectomy of the subcarinal and of the
left and right main bronchus lymph nodes can be performed during this
phase. Extreme care should be taken to avoid thermic injuries to the
airways during the dissection
Fig. 15.30 Once the lymphadenectomy is completed, the carina and
the two main bronchi are clearly visible. The dissection can be extended
cranially to separate the esophagus from the pars membranacea of the
trachea (arrow)
Fig. 15.31 The transhiatal dissection is normally concluded once the
azygos vein is reached. The vein can be clipped and transected provided
that adequate control of the vessel is acquired; however, since a bleeding
would be difcult to control during the transhiatal or the transcervical
phase, we normally prefer to dissect the vessel from the anterior aspect
of the esophagus without attempting at clipping and transecting it
Fig. 15.32 The gastric conduit is then nalized by completely dividing
the gastric fundus from the specimen
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P. P. Grimminger et al.
Fig. 15.33 The anterior surface of the gastric conduit is marked to
assure its correct position during the cervical phase and to prevent
twisting of the conduit during the cervical transposition
Fig. 15.34 While during RAMIE (transabdominal and transthoracic
fully robotic esophagectomy) the gastric conduit is left attached to the
specimen during the abdominal phase to facilitate the thoracic transposition, during RACE the conduit is completely separated from the specimen and approximated in an end-to-end fashion at its most apical point
to the specimen’s staple line using two or more interrupted cross stiches.
This is done to reduce the bulkiness of the specimen and the gastric
conduit to ease the cervical transposition
Fig. 15.35 The nal appearance of the gastric conduit attached to the
specimen is depicted in the gure. We meticulously check the apex of
the conduit to evaluate the appearance of any ischemic demarcation
zone
Fig. 15.36 For the transcervical phase, the patient’s head is slightly
stretched and turned to the right. A thick gastric intraluminal tube is
placed, to facilitate the identication of the cervical esophagus. About
two ngers above the left clavicle, a 3cm skin incision was made at the
anterior border of the sternocleidomastoid muscle
15 Robotic Transcervical andTranshiatal Esophagectomy (RACE Procedure)
Fig. 15.37 The cervical esophagus is dissected and encircled using a
silicon drain to retract the esophagus during the upper mediastinal preparation, as normally performed during a conventional open transcervical procedure. A blunt dissection is initially performed toward the
thoracic inlet to facilitate the subsequent robotic dissection
Fig. 15.39 The robotic dissection phase is initiated at the thoracic
inlet. The left aspect of the esophagus was already prepared and dissected from the left common carotid artery and the left sternocleidomastoid muscle during the open transcervical phase
167
Fig. 15.38 The sternocleidomastoid muscle is lateralized, and an
x-small Alexis Wound Retractor (Applied Medical, Rancho Santa
Margarita, California, United States) is inserted. A GelPOINT Mini
(Applied Medical, Rancho Santa Margarita, California, United States)
is placed and a pressure of 5mm Hg is applied. The da Vinci Xi surgical
system is approaching the patient from the right side. The robotic arms
are reaching over to the left and are docked in a cranial to caudal direction. The initial setting includes three 8mm robotic trocars positioned
as to form a triangle, with the central camera trocar as the apex. An
energy dissection device (SynchroSeal or Vessel Sealer Extend) is
placed on the right and a bipolar forceps on the left. A 5mm assistant
trocar is placed below to assist in the retraction and for suction
Fig. 15.40 The left side of the trachea is identied and gently pulled to
the right to identify the left recurrent laryngeal nerve. The upper mediastinal esophagus with surrounding lymph nodes along the left recurrent nerve is dissected
168
P. P. Grimminger et al.
Fig. 15.41 Proceeding medially, the esophagus is dissected from the
tracheal pars membranacea using the energy device and blunt
dissection
Fig. 15.42 After complete detachment of the anterior aspect of the
esophagus from the pars membranacea, the right lateral plane is dissected. The right subclavian artery can be identied on the right side
and should be carefully dissected from the right lateral aspect of the
esophagus
Fig. 15.43 After completing the dissection on the anterolateral aspect
of the esophagus, the subclavian artery and the mediastinal pleura
underneath are visible on both sides, the pars membranacea is completely freed from the anterior esophageal wall. The transcervical and
the transabdominal dissection planes are connected. On the right side,
the azygos vein is identied
Fig. 15.44 The azygos vein is dissected laterally and preserved, thus
connecting the transcervical and the transhiatal dissection planes
15 Robotic Transcervical andTranshiatal Esophagectomy (RACE Procedure)
169
Fig. 15.45 The esophagus is then divided through the cervical incision. The head of the circular stapler is placed at the proximal esophageal stump using a purse-string suture. We normally use a 25 mm
circular stapler (CEEA™, Covidien, Manseld, MA, USA)
Fig. 15.46 The specimen and the attached gastric conduit are then
pulled to the neck and exteriorized through the cervical incision. The
connecting suture is removed, and the specimen is extracted
Fig. 15.48 The 25mm circular stapler (CEEA™, Covidien, Manseld,
MA, USA) is inserted through the incision and connected to the head at
the proximal esophageal stump to create an end-to-side circular stapled
cervical anastomosis
Fig. 15.49 The circular stapler entry site is closed using a linear stapler (Endo GIA™, Covidien, Manseld, MA, USA)
Fig. 15.47 The proximal portion of the gastric conduit is once again
meticulously checked to evaluate the appearance of any ischemic
demarcation zone. The conduit is opened proximally at the staple line
Fig. 15.50 The linear staple line is checked for bleeding. We normally
avoid oversewing the linear stapler line to prevent narrowing of the
proximal conduit
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P. P. Grimminger et al.
References
1. Fujiwara H, Shiozaki A, Konishi H, etal. Single-port mediastinoscopic lymphadenectomy along the left recurrent laryngeal nerve.
Ann Thorac Surg. 2015;100:1115–7.
2. Grimminger PP, van der Sluis PC, Stein H, Lang H, van Hillegersberg
R, Egberts JH.Feasibility of transcervical robotic-assisted esophagectomy (TC-RAMIE) in a Cadaver study—a future outlook for an
extrapleural approach. Appl Sci (Basel). 2019;9:3572.
3. van der Sluis P, Egberts JH, Stein H, Sallum R, van Hillegersberg
R, Grimminger PP. Transcervical (SP) and transhiatal DaVinci
robotic esophagectomy: a cadaveric study. Thorac Cardiovasc Surg.
2021;69(3):198–203. https://doi.org/10.1055/s- 0040- 1716323.
Epub 2020 Sep 8. PMID: 32898893.
4. Nakauchi M, Uyama I, Suda K, et al. Robot-assisted mediastinoscopic esophagectomy for esophageal cancer: the rst clinical
series. Esophagus. 2019;16(01):85–92.
Fig. 15.51 The specimen is dissected at the back-table. The collected
lymph node stations have been mentioned during the previous
description
Robotic-Assisted Proximal Gastrectomy
withDouble Tract Reconstruction
PeterP.Grimminger, GiovanniCapovilla, andFelixBerlth
16
Introduction
The incidence of cancer of the upper third of the stomach
(proximal gastric cancer) and particularly of proximal early
gastric cancer has increased worldwide in the recent years,
probably as a consequence of the improvement of the endoscopic screening. Total gastrectomy is the most frequently
performed surgical procedure for the treatment of proximal
EGC, when endoscopic resection is not feasible. However,
this technique shows considerable disadvantages, in that it
may severely affect patients’ feeding capacity and nutritional status. Proximal gastrectomy has been proposed as an
alternative to total gastrectomy for the surgical treatment of
proximally located EGC, with the potential advantage of
improving the long-term functional outcome. However, the
use of such technique was limited by its technical demand,
the lack of standardization and the considerable incidence
of postoperative esophagitis and stenosis of the gastrojejunal anastomosis [1]. In this context, proximal gastrectomy
with “double tract” reconstruction has been proved to overcome the complications related to the other reconstructive
techniques for proximal gastric resection [2]. Finally, a
recent meta-analysis comparing laparoscopic proximal gastrectomy and laparoscopic total gastrectomy demonstrated
the superiority of proximal gastrectomy in preventing vitamin B12 deciency, with no increased risk of anastomotic
stricture and reux esophagitis and comparable clinical
effect [3].
We present here our technique for Robotic-Assisted prox-
imal gastrectomy with “double tract” reconstruction using
P. P. Grimminger (*) · G. Capovilla
Department of General-, Visceral- and Transplant Surgery,
University Medical Center Mainz, Mainz, Germany
e-mail: peter.grimminger@unimedizin-mainz.de
F. Berlth
Department of General, Visceral and Transplant Surgery,
University Medical Center of the Johannes Gutenberg University,
Mainz, Germany
the da Vinci Xi® Surgical System (Intuitive Surgical,
Sunnyvale, CA, USA). Briey, the proximal stomach is
resected, leaving an adequate residual antral portion. The circular stapler anvil is trans-orally inserted and exteriorized
through the distal esophageal stump using a dedicated device
(OrVil™; Covidien, Manseld, MA, USA). The specimen is
then retrieved through a median mini-laparotomy. A proximal jejunal loop, at circa 30cm from the Treitz ligament, is
exteriorized through the mini-laparotomy and divided using
a linear stapler (Endo GIA™, Covidien, Manseld, MA,
USA). An end-to-side hand-sewn single-layer anastomosis is
performed at 50cm from the proximal end of the distal jejunal loop. A circular stapler (CEEA™, Covidien, Manseld,
MA, USA) is introduced through the proximal end of the
distal jejunal loop. Upon restoration of the pneumoperitoneum, the distal jejunal loop is transposed cranially in an
antecolic position, after connection with the anvil the CEEA
is red, thus conguring an end-to-side esophago-jejunal
anastomosis. A side-to-side gastrojejunal anastomosis is
nally intracorporeally hand-sewn on the same bowel loop,
thus leaving a 15-cm-long jejunal segment between the
esophago-jejunal and the gastrojejunal anastomoses.
The use of the robotic platform provides undeniable
advantages while performing this technique. The tridimensional stable view offers a clearer visual eld during the
lymphadenectomy. The EndoWrist considerably favors the
far advanced precise dissection in narrower spaces such as
the hiatus and the intracorporeal hand-sewing during the gastrojejunal anastomosis (Figs. 16.1, 16.2, 16.3, 16.4, 16.5,
16.6, 16.7, 16.8, 16.9, 16.10, 16.11, 16.12, 16.13, 16.14,
16.15, 16.16, 16.17, 16.18, 16.19, 16.20, 16.21, 16.22, 16.23,
16.24, 16.25, 16.26, 16.27, 16.28, 16.29, 16.30, 16.31, 16.32,
16.33, 16.34, 16.35, 16.36, 16.37, 16.38, 16.39, 16.40, 16.41,
16.42, 16.43, 16.44, 16.45, 16.46, 16.47, 16.48, 16.49, and
16.50).
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2022
O. Y. Kudsi, P. P. Grimminger (eds.), Atlas of Robotic Upper Gastrointestinal Surgery,
https://doi.org/10.1007/978-3-030-86578-8_16
171
172
Fig. 16.1 Trocar position: the patient is placed in a normal supine
position with a 15° reverse Trendelenburg. Pneumoperitoneum is
applied with a Veress needle in the upper left abdominal quadrant. Upon
removal of the Veress needle, a 12mm trocar is placed to be used for the
energy dissection device (Vessel Sealer Extend or Monopolar-Hook)
and the Stapler. The 8mm midline camera trocar is placed above the
umbilicus; the distance from the umbilicus depends on the location of
the gastric antrum in the computer tomography. An 8mm trocar used
for the Fenestrated Bipolar Forceps is placed in the upper right quadrant. A fenestrated Tip-Up grasper is introduced with the third arm,
through another 8mm trocar placed in the right lateral subcostal area.
Finally, a 12mm assistant trocar is placed in the left lateral subcostal
area and used for retraction, suction, and introduction/removal of any
material during the dissection and for the linear stapler
P. P. Grimminger et al.
Fig. 16.3 The lesser omentum is opened, and the dissection is carried
out toward the right diaphragmatic crus
Fig. 16.2 The initial setting includes the use of the fenestrated bipolar
forceps on the left arm and the Vessel Sealer on the right arm. The third
robotic arm is equipped with a Tip-Up grasper and used to retract the
left liver lobe
Fig. 16.4 The space between the right diaphragmatic crus and the pericardial fat is developed. During this phase the assistant surgeon can
gently retract the pericardial tissue to the left to provide tension and
improve the eld vision
16 Robotic-Assisted Proximal Gastrectomy withDouble Tract Reconstruction
173
Fig. 16.5 The plane is developed deeper into the mediastinum in order
to completely free the lower esophagus on the right side. During this
phase the lymph nodes of station 1 are collected and will be retrieved en
bloc with the specimen
Fig. 16.6 The greater omentum is cranially retracted; the transverse
mesocolon and the gastrocolic ligament are exposed
Fig. 16.7 The gastrocolic ligament is incised at the level of the midtransverse colon. The greater omentum is dissected from the transverse
mesocolon
Fig. 16.8 Further dissection of the greater omentum from the transverse mesocolon gives access to the omental bursa. Visualization of the
posterior gastric wall must be achieved
174
P. P. Grimminger et al.
Fig. 16.9 To achieve complete mobilization of the greater curvature,
the greater omentum and the posterior gastric wall are completely dissected from the anterior surface of the pancreas
Fig. 16.10 The dissection is extended toward the spleen in order to
completely mobilize the gastric fundus
Fig. 16.11 The left gastroepiploic vessels are encountered and divided
to achieve complete mobilization of the gastric fundus. During this
phase the stomach can be gently retracted toward the right using the
third robotic arm (Tip-Up grasper); the assistant can retract the fat pad
toward the left side to provide tension. Lymph nodes of station 4sb and,
above the left gastroepiploic artery, 4sa are retrieved during this phase
and will be extracted en bloc with the specimen
Fig. 16.12 The mobilization of the gastric fundus is completed by
dividing the short gastric vessels. Lymph nodes of station 4sa are
retrieved during this phase and will be extracted en bloc with the
specimen