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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_541_Библиотеки_им_академика_М_И_Перельмана.pdf
Robot-Assisted Total Gastrectomy
andRoux-en-Y Reconstruction
Han-KwangYang andFelixBerlth
Introduction
Minimally invasive gastrectomy is on the rise since several prospective randomized trials provided evidence that
it is oncologically safe compared to traditional open surgery, not only for early but also for locally advanced gastric cancer [1].
The large randomized trials were performed for distal
gastrectomy and laparoscopic surgery; however it has been
assumed that for the robot-assisted procedure, similar results
could be achieved. This assumption was proved in a Korean
multicenter comparative trial, which compared laparoscopic
and robot-assisted procedures in terms of surgical radicality
and postoperative morbidity [2]. For the subgroup of patients
receiving a full D2 lymphadenectomy, a signicantly lower
blood loss could be shown in the robot-assisted gastrectomy
group [3]. The benets of robotic procedures, the angulating
instruments, the magnied vision, and precise maneuvers,
are illustrated in this chapter. Further technological progress
and instrument development is supposed to signicantly
improve the robot-assisted gastrectomy procedure in the
future.
Fenestrated bipolar
Assistant trocar
Liver retraction
Energy device
17
Double fenestrated
grasper
Robot-Assisted Total Gastrectomy
Preparation (Figs.17.1 and17.2)
Fig. 17.1 The camera trocar is located infraumbilical; the other trocars
are positioned in a slightly round shape. The 12mm assistant trocar is
put on the right side of the patient. The robotic instruments that are used
for this procedure are: fenestrated bipolar on the left hand and energy
device as well as double fenestrated grasper on the right hand
H.-K. Yang
Department of Surgery, Seoul National University College of
Medicine, Seoul, South Korea
F. Berlth (
Department of General, Visceral and Transplant Surgery,
University Medical Center of the Johannes Gutenberg University,
Mainz, Germany
e-mail: felix.berlth@unimedizin-mainz.de
© 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_17
*)
185
186
H.-K. Yang and F. Berlth
Colon
Bursa entry
Fig. 17.2 Liver retraction is performed by monol threat, which is
anchored to soft tissue at the right crus with a clip. The threat is tied
externally, the liver is gently retracted. Another threat can be used to
retract the ligamentum teres hepatis in order to provide good exposure
at the pyloric region
Omentectomy (Figs.17.3, 17.4, and17.5)
Left Gastroepiploic Vessels (Figs.17.6 and17.7)
Infrapyloric Area (Figs.17.8, 17.9, 17.10, 17.11,
17.12, and17.13)
Common Hepatic Artery (Figs.17.14, 17.15,
and17.16)
Right Gastric Artery andHepatoduodenal
Ligament (Figs.17.17, 17.18, 17.19, 17.20, 17.21,
and17.22)
Fig. 17.3 The dissection begins with the omentectomy, and access to
the bursa omentalis is achieved. In case of advanced gastric cancer, a
total omentectomy is performed close to the transverse colon; in case of
early gastric cancer, a partial omentectomy is indicated. In both cases,
lymph node station 4sb remains at the specimen side
Stomach
Colon
Fig. 17.4 The omentectomy is rstly directed toward the spleen and
the left gastroepiploic vessels
17 Robot-Assisted Total Gastrectomy andRoux-en-Y Reconstruction
Stomach
Colon
Assistant
187
Fig. 17.5 The assistant can gently give countertraction by pushing the
colon aside. This way, the dissection can follow the transverse colon
toward the lower border of the spleen
Left gastroepiploic
vessels
Spleen
Fig. 17.6 The left gastroepiploic vessels are dissected and can be
clipped. If access is not easy, the completion of the fundus region
including lymph node station 4sa can be performed after complete
mobilization of the stomach
Fig. 17.7 Clipped left gastroepiploic vessels
Antrum
Right gastroepiploic
vein
Gallbladder
Fig. 17.8 The omentectomy is completed to the distal side, leaving
lymph node station 4d at the specimen’s side. Right after, the infrapyloric region is identied and dissected. The gallbladder is an important
anatomical landmark to guide the dissection in direction of the postpyloric duodenum
188
Gallbladder
H.-K. Yang and F. Berlth
Antrum
Right gastroepiploic vessels
Pancreas
Fig. 17.9 The antrum can be lifted by the third robotic arm in order to
separate the posterior pyloric region from the pancreas, until the gastroduodenal artery appears
Right gastroepiploic artery
Gallbladder
Pancreas
Right gastroepiploic vein
Fig. 17.10 The right gastroepiploic vessels are dissected, and lymph
node station 6 remains with the specimen. Attention has to be paid not
to injure the pancreas
Fig. 17.11 The gastroepiploic vessels are clipped
Fig. 17.12 The gastroepiploic vessels before being cut
17 Robot-Assisted Total Gastrectomy andRoux-en-Y Reconstruction
189
Gallbladder
Infrapyloric
artery
Pancreas
Fig. 17.13 Attention has to be paid to an infrapyloric artery, which can
arise from the gastroduodenal artery. It often appears behind the right
gastroepiploic artery and should be clipped separately
Lymphatic tissue
Stomach
LN Station 8a
Duodenum
Pancreas
Fig. 17.15 The upper pancreatic border should be surely identied to
safely dissection the lymphatic tissue above the common hepatic artery
Duodenum
Gastroduodenal
artery
Pancreas
Fig. 17.14 The dissected lymph node station 6 is brought to the proximal side in order to receive a good distal transection line. By lifting the
antrum, the dissection of lymph node station 8 can be already
performed
Fig. 17.16 By dissection the tissue in direction to the celiac trunk,
lymph node station 8 (common hepatic artery) and lymph node station
12 (proper hepatic artery) are separated, lymph node station 8 remains
with the celiac trunk tissue, and lymph node station 12 remains with the
right gastric vessel tissue (lymph node station 5). An en bloc resection
should be performed in any case
190
H.-K. Yang and F. Berlth
Right gastric vessels
Gauze
LN Station 12a
Fig. 17.17 By putting gauze in the lesser sac, the perigastric tissue on
the lesser distal curvature side in direction to the hepatoduodenal ligament can be dissected
Right gastric artery
Hepatic
artery
Fig. 17.18 Assof the dissection along the common hepatic artery, the
planes can be identied more easily. Traction and countertraction can
be performed by two robotic arms, while the assistant can triangulate by
gently pushing the pylorus downward
Fig. 17.19 The origin of the right gastric vessels is identied
Proper hepatic artery
Fig. 17.20 Lymph node station 12 is harvested by dissecting the tissue
on the proper hepatic artery
17 Robot-Assisted Total Gastrectomy andRoux-en-Y Reconstruction
Right gastric vessels
Pancreas
Stomach
Fig. 17.21 The roots of the right gastric vessels are dissected at its
roots
191
Distal Transection (Figs.17.23 and17.24)
Fig. 17.23 Now the duodenal transection can be performed safely by
linear stapler
Fig. 17.22 The right gastric vessels are clipped and separated
Gallbladder
Duodenal stump
Pancreas
Fig. 17.24 View after distal transection
192
Common hepatic artery
Celiac Trunk (Figs.17.25, 17.26, 17.27, 17.28,
17.29, and17.30)
Left gastric vein
Segment 1 Liver
LN station 8a
Fig. 17.25 After distal transection, the suprapancreatic lymph node
dissection can be completed. The third robotic arm can hold the vascular pedicle of the left gastric artery and retract the liver at the same time
H.-K. Yang and F. Berlth
Splenic artery
Common hepatic artery
Pancreas
Fig. 17.27 The celiac trunk and splenic artery are identied before
clipping the left gastric artery
Left gastric artery
Pancreas
Gentle traction
by assistant
Fig. 17.26 The dissection is guided by the upper pancreatic border.
The assistant can use a gauze to gently roll the pancreas and deliver
countertraction
Clipped
lymphatic vessel
Common hepatic artery
Splenic artery
Pancreas
Fig. 17.28 If lymphatic vessel appears in the celiac trunk’s region, it
can be clipped as well in order to prohibit lymphatic leak
17 Robot-Assisted Total Gastrectomy andRoux-en-Y Reconstruction
193
Splenic Vessels (Figs.17.31, 17.32, 17.33,
and17.34)
Stomach
Splenic vein
Fig. 17.29 The left gastric artery and the left gastric vain are clipped
separately
Celiac trunk
Splenic artery
Common hepatic artery
Fig. 17.30 View after the left gastric artery is cut
Splenic vein
Pancreas
Splenic artery
Fig. 17.31 The suprapancreatic dissection is completed by dissecting
lymph node station 11 along the splenic vessels. For a radical dissection, the splenic vain is visualized
Pancreas
Fig. 17.32 For this step the countertraction of the assistant is of high
importance in order to safely dissect on the pancreatic border without
injure to the splenic vessels
194
H.-K. Yang and F. Berlth
Fundus (Figs.17.35 and17.36)
Posterior gastric artery
Stomach
Right crus
Celiac trunc
Pancreas
Fig. 17.33 Following the splenic artery on the suprapancreatic border,
a posterior gastric artery can be identied, clipped, and separated. It
appears on the level of hiatus and the border between lymph node stations 11p and 11d
Spleen
Short gastric vessels
Fig. 17.35 Now the remnant short gastric vessels can be safely dissected from the upper side
Fig. 17.34 The suprapancreatic lymph node dissection is completed.
Sight from the celiac trunk in direction to the spleen
Fig. 17.36 The previous complete mobilization of the stomach provides good exposure of the area