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18 Robot-Assisted Gastrectomy
205
Fig. 18.17 Clipping and cutting of the posterior gastric artery
1. Posterior gastric artery
2. Upper pole artery of the spleen
1
Fig. 18.18 Completed lymphadenectomy along the splenic vessels
(lymph node station 10/11)
1. Pancreas
2. Spleen
3. Diaphragm
4. Gerota’s fascia
5. Left diaphragmatic crus
Fig. 18.19 Separation of the gastric meso from the colonic meso
1. Stomach
2. Meso of the transverse colon
3. Omentum
4. Pancreas
Fig. 18.20 Mobilization of the hepatic exure
1. Hepatic exure of the colon
206
A. Billeter et al.
Fig. 18.21 Dissection of the hepatocolic ligament with visualization
of the anterior part of the duodenum
1. Duodenum
2. Pancreas
1
Fig. 18.22 Lymphadenectomy along the right gastroepiploic vessels
(lymph node station 6)
1. Gastroepiploic pedicle
Fig. 18.23 Division of the right gastroepiploic vein
1. Right gastroepiploic vein
Fig. 18.24 Division of the right gastroepiploic artery
18 Robot-Assisted Gastrectomy
Lymphadenectomy Along theRight Gastric
Artery andoftheHepatoduodenal Ligament
andTransection oftheDuodenum (Lymph
Node Stations 5 and12) (Figs. 18.25, 18.26,
18.27, 18.28, 18.29, and 18.30)
Lymphadenectomy Along theCommon
Hepatic Artery andCoeliac Axis (Lymph Node
Station 8 and9), Transsection of the
Esophagus (Figs.18.31, 18.32, 18.33, 18.34, 18.35,
and 18.36)
Retrieval oftheStomach (Figs. 18.37 and 18.38)
207
Esophagojejunostomy withRoux-En-Y
Reconstruction (Figs.18.39, 18.40, 18.41, 18.42,
18.43, 18.44, 18.45, 18.46, 18.47, and 18.48)
Fig. 18.25 Lymphadenectomy of the hepatoduodenal ligament (lymph
node station 12)
1. Gallbladder
2. Right hepatic artery
3. Right gastric artery
Fig. 18.26 Preparation of the right gastric artery (lymph node station 5)
1. Right gastric artery
Fig. 18.27 Division of the right gastric artery
208
A. Billeter et al.
1
Fig. 18.28 Lymphadenectomy down to the left side of the portal vein
1. Portal vein
2. Proper liver artery
Fig. 18.29 Dissection of the pylorus and the duodenum
1. Pylorus
2. Duodenum
3. Clipped and transected right epiploic vessels
4. Pancreas
Fig. 18.30 Transection of the duodenum
1. Pylorus
2. Duodenum
Fig. 18.31 Lymphadenectomy along the common hepatic artery (the
lesser omentum is held upwards with the fourth arm)
1. Coronary vein
2. Pancreas
3. Lymph nodes surrounding the common hepatic artery
18 Robot-Assisted Gastrectomy
209
1
Fig. 18.32 Division of the coronary vein
2
Fig. 18.34 Division of left gastric artery
1. Left gastric artery
2. Common hepatic artery
3. Splenic artery
3
Fig. 18.33 Dissection of the left gastric artery (lymph node station 9)
1. Left gastric artery
Fig. 18.35 Mobilization of the esophagus after completed
lymphadenectomy
1. Left crus of diaphragm
2. Right crus of diaphragm
3. Esophagus
4. Paracardial lymph nodes (1/2)
210
A. Billeter et al.
Fig. 18.36 Transection of the distal esophagus (rst cut the vagal
nerves separately!)
1. Esophagus
2. Stomach (cardia)
Fig. 18.37 Pfannenstiel incision
Fig. 18.39 Insertion of a 42 French calibration tube into the
esophagus
1. Esophagus with calibration tube inside
Fig. 18.40 Incision of the esophageal staple line (use cold scissors!)
Fig. 18.38 Retrieval of the stomach
18 Robot-Assisted Gastrectomy
211
Fig. 18.41 Incision of the jejunum 50 cm from the duodenojejunal
exure
1. Jejunum
Fig. 18.42 Creation of a linear stapler side-to-side esophagojejunal
anastomosis
1. Esophagus
2. Jejunum
Fig. 18.43 Closure of the enterotomy with a modied double row
technique
Fig. 18.44 Incision of the jejunum 50 cm from the
esophagojejunostomy
212
A. Billeter et al.
Fig. 18.45 Creation of a side-to-side jejunojejunostomy Fig. 18.47 Closure of the mesenteric defects with Endohernia clips
Fig. 18.46 Closure of the enterotomy with a modied double row
technique
1. Mesenteric defect
2. Jejunum
Fig. 18.48 Transection of the jejunum between the anastomoses
Suggested Reading
Aiol A, Lombardo F, Matsushima K, Sozzi A, Cavalli M, Panizzo V,
etal. Systematic review and updated network meta-analysis of randomized controlled trials comparing open, laparoscopic-assisted,
and robotic distal gastrectomy for early and locally advanced gastric cancer. Surgery. 2021;S0039–6060(21)00339–1.; https://doi.
org/10.1016/j.surg.2021.04.014.
Choi S, Song JH, Lee S, Cho M, Kim YM, Hyung WJ, etal. Surgical
merits of open, laparoscopic, and robotic gastrectomy techniques
with D2 lymphadenectomy in obese patients with gastric cancer. Ann
Surg Oncol. 2021; https://doi.org/10.1245/s10434- 021- 09952- 6.
Kinoshita T, Sato R, Akimoto E, Tanaka Y, Okayama T, Habu
T.Reduction in postoperative complications by robotic surgery: a
case-control study of robotic versus conventional laparoscopic sur-
gery for gastric cancer. Surg Endosc. 2021; https://doi.org/10.1007/
s00464- 021- 08483- 1.
Marano L, Fusario D, Savelli V, Marrelli D, Roviello F.Robotic versus
laparoscopic gastrectomy for gastric cancer: an umbrella review of
systematic reviews and meta-analyses. Updat Surg. 2021; https://
doi.org/10.1007/s13304- 021- 01059- 7.
Terashima M.The 140 years' journey of gastric cancer surgery: from
the two hands of Billroth to the multiple hands of the robot. Ann
Gastroenterol Surg. 2021;5(3):270–7. https://doi.org/10.1002/
ags3.12442. eCollection 2021 May.
Robot-Assisted Distal Gastrectomy
Han-KwangYang andFelixBerlth
Introduction
The distal gastrectomy is the prototype of minimally invasive gastrectomy since all prospective randomized trials for
early and advanced gastric cancer investigating the oncological safety and postoperative benets of laparoscopic surgery
were applied for distal gastrectomy.
As the history of robot-assisted procedures is somewhat
younger, large randomized trials for the robot approach are
pending, but since equal safety and radicality in comparison
to the laparoscopic approach has been proven (see “Total
Gastrectomy” chapter), the robotic approach is widely
accepted. Indeed, studies suggest benets of robot-assisted
gastrectomy in terms of surgical precision in case of lymphadenectomy with vessel preservation or a low complication
rate after suprapancreatic lymph node dissection [1]. As in
oncological gastric cancer resection the technique itself
would contribute to the success [2], the robotic approach for
distal gastrectomy is believed to become a standard approach
for distal gastric cancer resection, if a robotic system is in
place (Figs. 19.1, 19.2, 19.3, 19.4, 19.5, 19.6, 19.7, 19.8,
19.9, 19.10, 19.11, 19.12, 19.13, 19.14, 19.15, 19.16, and
19.17).
19
Fig. 19.1 The camera trocar is placed in infraumbilical position. The
assistant trocar I placed on the patient’s right side above the level of
umbilicus, the distance to the camera trocar is 8cm minimum. The trocars are positioned in a slightly round shape
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_19
*)
213
214
Fig. 19.2 The instruments that are used: energy device on right hand,
fenestrated bipolar forceps on left hand, and double fenestrated grasper
on the right lateral hand
H.-K. Yang and F. Berlth
Fig. 19.3 The omentum is divided by energy device in direction to the
splenic lower pole. There the left gastroepiploic vessels are divided
between clips. For early gastric cancer, a partial gastrectomy is per-
Fig. 19.4 The greater curvature is cleared by exposing the proximal
vessel arcade. The lymph nodes of lymph node station 4sb are brought
to the specimen’s side, and the greater curvature is prepared for later
transection
formed; for advanced gastric cancer, a total omentectomy is required.
After having opened the bursa, the third robotic arm can gently grasp
the stomach’s posterior side for good exposure