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17 Robot-Assisted Total Gastrectomy andRoux-en-Y Reconstruction
Esophagus (Fig.17.37)
Anvil andProximal Transection (Figs.17.38,
17.39, 17.40, 17.41, 17.42, 17.43, 17.44, 17.45,
and17.46)
Reconstruction (Figs.17.47, 17.48, 17.49,
and17.50)
Esophagus
195
Fig. 17.39 Anterior esophagotomy is performed. The esophagus can
be retracted by a sling cord that is pulled by the assistant
Fig. 17.37 The esophagus is cleared of tissue; the vagus nerves are cut
which gives some extra length for reconstruction. This is the last step of
the resection, and the robotic system is undocked afterward
Needle
Spike
Fig. 17.38 The anvil is used with spike, which is connected to a 2-0
monol threat with needle. The anvil is put intraabdominally through
midline minilaparotomy, which will be used to also retrieve the specimen as well as perform the esophagojejunostomy later on
Fig. 17.40 The anvil is put into the esophagus. A 25mm anvil is used
196
H.-K. Yang and F. Berlth
Fig. 17.41 The anvil needs to be pushed gently to the right direction
Esophagus
Needle
Fig. 17.42 After the anvil is pushed into the esophagus’ lumen, the
needle is stitched inside out to the right lateral esophagus wall above the
level of esophagotomy
Fig. 17.43 The anvil is pulled through partly
Fig. 17.44 The proximal transection can be performed, covering the
esophagotomy. The esophagus is retracted again using the sling cord
surrounding the cardia region
17 Robot-Assisted Total Gastrectomy andRoux-en-Y Reconstruction
Spike
197
Staplerspike
Anvil
Jejunum
Fig. 17.45 The anvil is now pulled through and the spike is removed
Fig. 17.46 The specimen is retrieved in a bag
Fig. 17.47 After performing the jejunojejunostomy extracorporeally,
the jejunum is xed on the stapler with a vessel loop. The desired location of anastomosis is marked with a pen. For stapler entering, the minilaparotomy at the location of former camera trocar is used
Fig. 17.48 After both ends are connected, the esophagus and jejunum
are approximated
198
Fig. 17.49 The anastomosis is performed
H.-K. Yang and F. Berlth
References
1. Hyung WJ, Yang HK, Park YK, et al. Long-term outcomes of
laparoscopic distal gastrectomy for locally advanced gastric cancer: the KLASS-02-RCT randomized clinical trial. J Clin Oncol.
2020;38(28):3304–13. https://doi.org/10.1200/JCO.20.01210.
Epub 2020 Aug 20.
2. Kim HI, Han SU, Yang HK, etal. Multicenter prospective comparative study of robotic versus laparoscopic gastrectomy for gastric adenocarcinoma. Ann Surg. 2016;263(1):103–9. https://doi.
org/10.1097/SLA.0000000000001249.
3. Park JM, Kim HI, Han SU. Who may benet from robotic gastrectomy?: a subgroup analysis of multicenter prospective comparative study data on robotic versus laparoscopic gastrectomy.
Eur J Surg Oncol. 2016;42(12):1944–9. https://doi.org/10.1016/j.
ejso.2016.07.012. Epub 2016 Jul 29.
Fig. 17.50 The jejunum is closed by linear stapler. The total gastrectomy is nished
Robot-Assisted Gastrectomy
AdrianBilleter, MartinWagner, ManuelaCapek,
andBeatPeterMüller-Stich
18
Introduction
Gastrectomy remains the only curative treatment for gastric
cancer. Minimally invasive surgery has convincingly shown
to achieve similar oncologic outcomes as open surgery while
reducing morbidity and length of hospital stay. While laparoscopic assisted gastrectomy has been widely established in
recent years, robotic surgery may offer some additional benets such as better visualization and better means for manipulating the tissue as well as the ability to perform complex
reconstructions. Furthermore, the robotic platform may
allow for a more complete lymphadenectomy compared to
open or laparoscopic gastrectomy.
When performing robot-assisted gastrectomy, we suggest
performing the resection in a clockwise fashion. We start
with the dissection of the lesser omentum followed by dissection of the hiatus. This part is completed by the dissection
of the gastrophrenic ligament followed by the dissection of
the short gastric vessels until the splenic artery in the splenic
hilum has been reached. Then, the greater omentum is dissected from the transvers colon. This step is completed by
the lymphadenectomy above and around the splenic artery
(lymph nodes of stations 10 and 11). The greater omentum is
then completely dissected from the colon and hepatic exure
until the anterior duodenum can be seen. After this step, the
lymphatic pedicle of the right epiploic vessels is dissected at
the origin. After that, the duodenum is transected, and the
lymphadenectomy around the common hepatic artery and
hepatoduodenal ligament is performed until the portal vein is
reached (lymph nodes of station 12).
During these steps, the right gastric artery is also cut at the
base including the lymphatic vessels. Lastly, the lymphadenectomy is completed toward the coeliac axis with transection of the left gastric vessels including the coronary vein
and left gastric artery (lymph nodes of station 12). This step
is nalized by the lymphadenectomy toward the dorsal conjunction of the diaphragmatic crura. Next the esophagus is
mobilized and transected. The reconstruction is performed
by using a linear stapled side-to-side Roux-en-Y reconstruction as commonly used during bariatric surgery. The biliopancreatic limb is anastomosed using a linear stapler
anastomosis with the esophagus followed by the jejunojejunostomy. Both anastomoses are performed about 50cm from
the duodenojejunal exure and the esophagojejunostomy,
respectively.
Lastly, the two anastomoses are divided by transection of
the jejunum between the esophagojejunostomy and the jejunojejunostomy. Thereby, the candy cane is formed. The
mesenteric defects of the jejunojejunostomy and the
Peterson defect are closed to prevent internal hernias.
Usually, we also remove the gallbladder although this step is
not performed by all surgeons. The patency of the esophagojejunostomy can be tested by a large gastric calibration
tube (42 French), and the esophagojejunostomy can be
tested using a methylene blue leak test. The resected stomach is removed through a small Pfannenstiel incision for
cosmetic reasons and to reduce postoperative pain and risk
of incisional hernias. Frozen sections of the resection margins are performed before reconstruction.
A. Billeter · M. Wagner · M. Capek · B. P. Müller-Stich (*)
Department for General, Visceral and Transplantation Surgery,
Division for Minimally Invasive and Robot-Assisted Surgery,
Division for Upper Gastrointestinal Surgery, Heidelberg University
Hospital, Heidelberg, Germany
e-mail: beat.mueller@med.uni-heidelberg.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_18
199
200
Procedure
Positioning ofTrocars andDiagnostic
Laparoscopy (Fig.18.1)
A. Billeter et al.
22 cm
Fig. 18.1 Trocar positioning
1. 12mm robotic trocar
2–4. 8mm robotic trocar
5. 5mm assistant trocar for the liver retractor
3
8 cm
4
10 cm
5
1
6
6. 12mm assistant trocar
Distance between trocar 1 and 2 is 8–10cm. Distance between trocars
2–4 is 7–8cm. The line at the bottom marks the Pfannenstiel incision
line
8 cm
2
Pfannenstiel
incision 8 cm
18 Robot-Assisted Gastrectomy
Dissection oftheLesser Omentum, Hiatus, and
Gastrophrenic Ligament (Figs.18.2, 18.3, 18.4,
18.5, 18.6, 18.7, 18.8, and 18.9)
Fig. 18.2 Overview
1. Stomach
201
Fig. 18.4 Dissection of the lesser omentum close to the liver.
Additional left hepatic artery running through the lesser omentum can
be cut if it is not an aberrant left gastric artery (check in the arterial
phase of a CT scan). Dissection of the lesser omentum to the right crus
of the diaphragm (lymph node station 3)
1. Hepatoduodenal ligament
2. Liver
3. Additional left hepatic artery
Fig. 18.3 Overview
1. Pancreas
2. Lesser omentum
3. Duodenum
4. Gastric cardia
5. Liver
6. Additional left hepatic artery
Fig. 18.5 Dissection of the additional hepatic artery using the vessel
sealer. In patients with an aberrant left hepatic artery, the vessel must be
preserved and the lymph nodes must be dissected from the left gastric
artery and coeliac axis
1. Additional left hepatic artery
202
A. Billeter et al.
Fig. 18.6 Circular incision of the peritoneum around the hiatus and
mobilization of the distal esophagus (lymph node station 1/2)
1. Right crus of the diaphragm
2. Esophagus
Fig. 18.7 Circular incision of the peritoneum around the hiatus and
mobilization of the distal esophagus. The abdominal esophagus can be
seen
1. Gastric fundus
2. Right diaphragmatic crus
3. Esophagus
Fig. 18.8 Dissection of the gastrophrenic ligament and mobilization of
the gastric fundus. Dissection of the short gastric vessels with the vessel
sealer close to the spleen until the splenic artery and vein in splenic
hilum
1. Left diaphragm
2. Partially dissected gastrophrenic ligament
3. Upper pole of the spleen
4. Left crus of the diaphragm
5. Gastric cardia
Fig. 18.9 Gastrophrenic ligament
1. Gastrophrenic ligament
2. Completely mobilized gastric fundus
18 Robot-Assisted Gastrectomy
Dissection oftheGastrocolic Ligament (Lymph
Node Station 4d) (Figs.18.10, 18.11, 18.12, 18.13,
and 18.14)
Lymphadenectomy Along theSplenic Artery
(Lymph Node Station 10/11) (Figs. 18.15, 18.16,
18.17, and 18.18)
Complete Dissection oftheGreater Omentum
andMobilization oftheHepatic Flexure
(Figs.18.19, 18.20, and 18.21)
Lymphadenectomy oftheRight Gastroepiploic
Arcade (Lymph Node Station 6) (Figs.18.22,
18.23, and 18.24)
203
1
Fig. 18.11 Dissection of the gastrocolic ligament along the transverse
colon (Lymph node station 4d)
1. Gastrocolic ligament
2. Transverse colon
Fig. 18.10 The greater omentum is completely placed on top of the
stomach
1. Transverse colon
2. Greater omentum
Fig. 18.12 Opening of the lesser sac (bursa omentalis)
1. Back wall of the stomach
2. Pancreas
3. Transverse colon
204
A. Billeter et al.
1
Fig. 18.13 Dissection of the left gastroepiploic vessels, which arise
from the splenic vessels
1. Splenic vessels
2. Left gastroepiploic vessels
Fig. 18.14 Dissection of the remaining short gastric vessels from the
spleen upward to the gastric fundus
1. Short gastric vessels
Fig. 18.15 Lymphadenectomy along the splenic vessels (lymph node
station 10/11)
1. Splenic vessels
2. Lymph node station 10/11
Fig. 18.16 Lymphadenectomy along the splenic vessels (lymph node
station 10/11)
1. Pancreas
2. Lymph nodes