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19 Robot-Assisted Distal Gastrectomy
Fig. 19.5 The omentectomy is continued to the distal side of the stomach. Posterior side attachments to the pancreas need to be cut, and then the
fusion plane of infrapyloric pedicle and transverse mesocolon is exposed. The plane is gently divided by blunt and sharp dissection
215
Fig. 19.6 The omentectomy is followed to the duodenum. The gallbladder can be a structure guiding the direction
Fig. 19.7 The infrapyloric pedicle is dissected at its roots, and caution
has to be taken to the pancreas
Fig. 19.8 The duodenum is cleared, so the whole lymph node station 6
is brought to the specimen’s side, when the duodenum is transected
216
Fig. 19.9 The right gastroepiploic artery and vein are clipped and cut separately
H.-K. Yang and F. Berlth
Fig. 19.10 On the duodenum’s posterior side, the gastroduodenal artery is dissected, and small branches to the duodenum are cut with very small
bites of the energy device in order to provide enough distal margin length and duodenal stump when reconstructing with Billroth I
Fig. 19.11 The antrum is retracted to the patient’s ventral side so dissection of the suprapancreatic area over common hepatic artery, lymph node
station 8 can be partly performed. In this step lymph node station 5 and lymph node station 8 can be divided
19 Robot-Assisted Distal Gastrectomy
Fig. 19.12 Gauze is put in the bursa and dissection continues on the anterior side. The gauze pumps up the lesser sac and protects the common
hepatic artery and the pancreas when approaching from anterior
217
Fig. 19.13 The pylorus and proximal duodenum are dissected on the
lesser curvature side, and then dissection follows common hepatic
artery to the roots of the right gastric vessels, which are clipped and cut.
Fig. 19.14 The stomach is retracted in caudal direction in order to expose the suprapancreatic area. The dissection along the common hepatic
artery is completed in direction to the celiac trunk. The left gastric vein is clipped and cut
Following that direction, the proper hepatic artery can be dissected. In
this way, lymph node station 12a is connected to lymph node station 5
and is brought to the specimen’s side
218
Fig. 19.15 Depending on the desired level of radicality, the splenic vessels can be followed close to the splenic hilum if complete lymph node
station 11 dissection is necessary
H.-K. Yang and F. Berlth
Fig. 19.16 The right crus and right side of the esophagogastric junction is dissected, and then the lesser curvature is cleared to the desired
location of proximal transection. This way, lymph node station 1 and
lymph node station 3 are brought to the specimen’s side. The Lymph
Fig. 19.17 After Billroth I reconstruction with circular stapler
node dissection is completed, and transection and reconstruction can be
performed. In case of Billroth I with circular stapler, both can be performed simultaneously through upper abdominal mini-laparotomy
References
1. Han DS, Suh YS, Ahn HS, Kong SH, Lee HJ, Kim WH, et al.
Comparison of surgical outcomes of robot-assisted and laparoscopyassisted pylorus-preserving gastrectomy for gastric cancer: a propensity score matching analysis. Ann Surg Oncol. 2015;22(7):2323–8.
https://doi.org/10.1245/s10434- 014- 4204- 6.
2. Yang HK, Berlth F. Gastric cancer surgery: the importance of
technique and not only the extent of lymph node dissection.
Lancet Oncol. 2019;20(3):329–31. https://doi.org/10.1016/
S1470- 2045(19)30073- 7.
Robotic Partial Gastrectomy forGIST
Tumors
MatthiasBiebl, ChristianDenecke, TomaszDziodzio,
RobertÖllinger, andJohannPratschke
20
Introduction
Gastrointestinal stromal tumors are mesenchymal tumors of
the gastrointestinal tract that potentially can be malignant.
Although GIST tumors have been detected in all age groups,
the predominant number of cases are found in individuals in
their 60s [1], with a prevalence of around 13 per 100,000
and an incidence of 1–1.5 per 100,000 per year [2]. The
stomach seems to be the leading location (around 60%) for
this type of tumor, and often, very small tumors of less than
1 cm are incidental ndings in individuals older than
50years [3]. Surgical R0 resection is the only potentially
curative treatment, which in larger tumors may also include
multivisceral resection. The natural history of small asymptomatic GISTs is largely unknown, but generally, resection
is recommended for symptomatic tumors, tumors with highrisk criteria such as ulceration, irregular borders, internal
heterogeneity, growth during follow-up or enlargement of
regional lymph nodes, as well as any tumor exceeding
2–5cm in diameter [3].
Surgical treatment aims at complete tumor resection, and
care has to be taken to avoid tumor rupture during the procedure. With the evolution of minimally invasive surgery, this
approach has been increasingly advocated, following the
same principles as open resection. Consequently, minimally
invasive resection of gastric GIST tumors has gained popularity and is currently the most commonly used approach,
regardless of tumor location [4, 5]. As dorsally located
tumors especially of the corpus or antrum are often xed to
the retroperitoneal structures and sometimes be located close
to the pylorus, which may preclude from classical wedge
M. Biebl (*) · C. Denecke · T. Dziodzio · R. Öllinger
J. Pratschke
Department of Surgery, Campus Charité Mitte|Campus Virchow
Klinikum, Charité– Universitätsmedizin Berlin, Corporate
Member of Freie Universität Berlin, Humboldt-Universität zu
Berlin, and Berlin Institute of Health, Berlin, Germany
e-mail: matthias.biebl@charite.de
resection and require direct suturing for reconstruction, a
robotic approach has been introduced for such indications as
a safe and feasible way of minimally invasive tumor resection [6, 7].
Case Presentation
We present the case of a 78-year-old male patient with a
biopsy-proven 5cm gastric GIST tumor located at the dorsal
prepyloric antrum (Fig.20.1). The patient had a medical history remarkable for arterial hypertension, type II diabetes
mellitus, hyperlipidemia, and post acute liver failure status
due to paracetamol intoxication 1year ago and suffered from
metastasized prostate cancer under medical treatment. The
gastric tumor itself was asymptomatic and discovered during
CT scan for prostate cancer staging.
Operating Room Setup, Patient Positioning,
andInstruments Used
The patient was placed in supine position with spread legs
and the table tilted upward 30 degrees (Fig.20.2). The standard robotic setup for upper GI procedures was chosen,
using four robotic trocars in a horizontal line about 20cm
below the xiphoid process, and the camera positioned in the
midline. In order to get good view to the gastric antrum from
both above and below, care was taken not to place the trocars
too caudally. Two robotic trocars were located left to the
umbilicus (mid-clavicular line and at the costal margin) and
one at the right costal margin. One 12mm assist trocar was
positioned right to the camera trocar (Fig.20.3).
The da Vinci robot was approximated to the table from the
patient’s left side. The table-side surgeon was positioned
between the patient’s legs. Robotic instruments used included
a tip-up fenestrated forceps introduced from the left lateral
trocar, an articulated bipolar sealing device introduced
© 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_20
219
220
M. Biebl et al.
a
Fig. 20.1 CT scan showing location of the GIST (x) at the dorsal side of the gastric antrum: (a) Sagital view (b) transverse view
b
Fig. 20.2 Patient positioning and trocar setup
through the medial left trocar, and a fenestrated bipolar forceps through the right lateral trocar.
Gastric Mobilization andIdentication
oftheTumor
In order to be able to mobilize the tumor enough to assess
resectability, the gastric antrum was mobilized from above
through the lesser omentum as well as from below through
the gastrocolic ligament. First, the lesser omentum was
divided and the tumor visualized from above. Along the right
gastric artery, several enlarged lymph nodes were noted and
resected for pathological analysis (Fig.20.4).
After mobilization of the accessible parts of the tumor
from above, the approach was switched to from below in
order not to compromise tumor integrity through excessive
manipulation from above (Fig.20.5).
Using the tip-up fenestrated forceps, the ventral side of
the stomach was lifted ventrally, and the gastroomental
arcade was safely identied. Next, the gastroomental ligament was broadly divided with the vessel sealer and the
20 Robotic Partial Gastrectomy forGIST Tumors
221
Fig. 20.3 Instrument placement and view at the beginning of the
procedure
Fig. 20.4 Resection of lymph nodes along the right gastric artery
Fig. 20.6 Visualization of the gastroomental arcade for safe access to
the omental bursa
Fig. 20.7 Access of the bursa omentalis through the gastrocolic ligament using the articulated bipolar Vessel Sealer
Fig. 20.5 Identication of the tumor from above. Note that without
excessive mobilization, the tumor could not be further mobilized, and,
therefore, the approach was switched to from below
tumor identied from below. Some dorsal adhesions of the
tumor with the retroperitoneum were identied and taken
down (Figs.20.6, 20.7, and 20.8).
Following complete mobilization of the gastric antrum,
the resection strategy was evaluated. In this situation, a dorsal
rotation of the antrum was possible and the basis of the tumor
Fig. 20.8 Identication of the tumor and completion of the mobilization from above
completely visualized from above. Therefore, a transverse
wedge resection of the tumor using an endoscopic stapler
without compromise of the antral passage seems feasible and
was therefore aimed at. Resection was performed using two
60-mm-thick (green) linear endoscopic stapler loads. In order
to ensure a constant safe resection margin, it is not advisable
222
to staple as much as possible with one load, but rather to use
several small bites under direct vision (Figs.20.9 and 20.10).
The tumor was positioned in a retrieval bag and meticulous hemostasis along the staple line obtained. At the end of
the procedure, the specimen was retrieved and the trocars
removed and a silicone drain placed next to the staple line for
24h (Figs.20.11 and 20.12).
Fig. 20.9 The tumor (blue) is rotated from dorsal to cranial. Note the
sharp line of the tumor and the healthy stomach. Atypical wedge resection using endoscopic linear stapler seems meaningful
M. Biebl et al.
Fig. 20.12 Macroscopic view of specimen
Fig. 20.10 First staple line in a transverse way from ventral to dorsal
Fig. 20.11 Completion of stapler resection under direct visualization
of the cranial resection margin
Fig. 20.13 Situs and trocar position after robotic resection
Total procedure time was 42min, and the patient was discharged after an uneventful postoperative course on postoperative day 6. Figure 20.13 depicts the postoperative situs
and the positioning of the incisions after wound closure.
Tumor histology revealed a 49 mm pT2pN0(0/3)
R0L0V0Pn0 GIST with an intermediate risk with a mitosis
rate of 7/50 HPF.
20 Robotic Partial Gastrectomy forGIST Tumors
223
References
1. Ma GL, Murphy JD, Martinez ME, Sicklick JK.Epidemiology of
gastrointestinal stromal tumors in the era of histology codes: results
of a population-based study. Cancer Epidemiol Biomark Prev.
2015;24:298–302.
2. Nilsson B, Bümming P, Meis-Kindblom JM, Odén A, Dortok A,
Gustavsson B, etal. Gastrointestinalstromal tumors: the incidence,
prevalence, clinical course, and prognostication in the preimatinib mesylate era—a population-based study in western Sweden.
Cancer. 2005;103:821–9.
3. Nishida T, Blay J-Y, Hirota Y, Kang Y-K. The standard diagnosis,
treatment, and follow-up of gastrointestinal stromal tumors based
on guidelines. Gastric Cancer. 2016;19:3–14.
4. Hagerty BL, Torres MB, Drake J, Hernandez JM, Mullinax JE,
Blakely AM, et al. Trends and predictors of failure of mini-
mally invasive surgery for gastric GIST. J Gastrointest Surg.
2021;25:1319–22.
5. Xiong Z, Wan W, Zeng X, Wang T, Zhang R, Li C, et al.
Laparoscopic versus open surgery for gastric gastrointestinal
stromal tumors: a propensity score matching analysis. J Gastrointest
Surg. 2020;24:1785–94.
6. Solaini L, Cavaliere D, Fico V, Milone M, De Pascale S, Desiderio
J, etal. Open versus laparoscopic versus robotic gastric gastrointestinal stromal tumour resection: a multicentre cohort study. Int J Med
Robot. 2021;17(2):e2198.
7. Winder A, Strauss DC, Jones RL, Benson C, Messiou C, Chaudry
MA, et al. Robotic surgery for gastric gastrointestinal stromal
tumors: a single center case series. J Surg Oncol. 2020; https://doi.
org/10.1002/jso.26053. Online ahead of print.
Robotic Vertical Sleeve Gastrectomy
HanyTakla andAugustusGleason
21
Introduction
Sleeve gastrectomy has become the most widely performed
bariatric operation in recent years. While the laparoscopic
sleeve gastrectomy (LSG) remains the gold standard, the
increasing accessibility to robotic surgical systems as well as
advances in robotic surgical technology including robotic
stapling and energy devices points to the robotic sleeve gastrectomy (RSG) becoming more of a standard practice in different parts of the world [1]. In our experience the added
benet of better visualization and wristed instruments in
higher BMI patients offer better ergonomics for the operating surgeon which in turn reects on achieving better exposure, better hemostasis, and safer dissection during this
procedure.
Data comparing the laparoscopic sleeve gastrectomy to
the robotic counterpart suggests that the RSG is associated
with longer operating time and a higher rate of postoperative
complications [2]. However, other studies exist that account
for learning curves and involvement of residents/fellows that
do not demonstrate a negative impact on outcomes [3].
Furthermore, it is suggested that having the stapler in the
operating surgeon’s control from the console will mitigate
these differences. Using a standardized approach and steps
and understanding the advantages the robotic platform offers
are the keys to success to implement robotic sleeve gastrectomy in your practice.
The robotic sleeve gastrectomy setup and approach is similar
to that of the laparoscopic version of the operation. It is important
to obtain good exposure of the hiatus, GE junction, and stomach
anatomy before proceeding with your dissection. Identication
of the pylorus and incisura and takedown of the gastrocolic ligament are enhanced with three-arm coordination. Care must be
taken at the dissection of the short gastric arteries and fundus to
ensure appropriate setup for stapling. With proper mobilization
of the stomach and insertion of a bougie tube, stapling can begin.
Vertical stapling along the greater curvature tubularizes the stomach. Again, care must be taken at the fundus and angle of His
with three-arm exposure. This setup ensures good stapling technique and avoidance of retained fundus. We advise using the rey technology liberally to check for the blood supply especially
at the angle of His which is the most common site for staple line
leaks mainly due to poor blood supply.
Procedure: Illustrated Steps
Figures 21.1, 21.2, 21.3, 21.4, 21.5, 21.6, 21.7, 21.8, 21.9,
21.10, 21.11, 21.12, 21.13, 21.14, 21.15, 21.16, 21.17, 21.18,
21.19, 21.20, 21.21, 21.22, 21.23, 21.24, 21.25, 21.26, 21.27,
21.28, 21.29, 21.30, 21.31, 21.32, 21.33, 21.34, 21.34, 21.35,
21.36, 21.37, 21.38, 21.39, 21.40, 21.41, 21.42, 21.43, 21.44,
and 21.45 illustrate a robotic vertical sleeve gastrectomy and
hiatal hernia repair.
H. Takla (*)
Departments of General and Bariatric Surgery, Beth Israel Lahey
Health Winchester Hospital, Winchester, MA, USA
e-mail: hany.m.takla@lahey.org
A. Gleason
Surgical Simulation and Education Research Fellow, Lahey
Hospital and Medical Center Department of Surgery,
Burlington, MA, USA
© 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_21
225