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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_541_Библиотеки_им_академика_М_И_Перельмана.pdf
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Fig. 21.1 Patient is placed supine, arms out at 90 degrees, foot board placed for steep reverse Trendelenburg
H. Takla and A. Gleason
Fig. 21.2 Preparation and draping of the abdomen with robot trocar placement. Robot will be docked on the right side of the patient
21 Robotic Vertical Sleeve Gastrectomy
227
Fig. 21.3 Four robotic trocars are placed in linear fashion supraumbilical across the abdomen. We prefer to use two 12mm ports for stapling and two 8mm ports
Fig. 21.4 A Nathanson liver retractor can be placed in the subxiphoid
position. Intracorporeal liver retraction using a suspension barbed
suture will be demonstrated as well
228
Fig. 21.5 The robot is
docked from the right side.
Arm 1 (far right): fenestrated
bipolar. Arm 2 (right medial):
30 degree camera. Arm 3 (left
medial): Vessel sealer or
needle driver. Arm 4 (far left):
fenestrated grasper
H. Takla and A. Gleason
21 Robotic Vertical Sleeve Gastrectomy
Fig. 21.6 Demonstrating
appropriate spacing of the
trocars and robotics arms
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230
H. Takla and A. Gleason
Fig. 21.7 Initial insufation and inspection reveals the stomach mostly
concealed by the liver and omentum. The omentum is swept laterally,
and the liver is retracted anterior and cephalad. This case will demonstrate the use of a temporary suspension suture for liver retraction
Fig. 21.8 Liver retraction is performed using a 2–0 barbed suture
which will create a temporary sling to keep the liver edge out of the
operative eld and provide excellent hiatal exposure
Fig. 21.9 Optimizing liver retraction and exposure
Fig. 21.10 The operative eld is now exposed demonstrating the gas-
trohepatic ligament, stomach, and spleen. The omentum is further
swept laterally and caudad
21 Robotic Vertical Sleeve Gastrectomy
231
Fig. 21.11 Attention is turned to the distal stomach. The pylorus and
incisura angularis are identied. A 6cm silk tie is used to aid in measuring the distance from the pylorus as a guide for dissection and avoid
excessive narrowing at the incisura
Fig. 21.12 The dissection of the gastrocolic ligament along the greater
curvature begins using the vessel sealer
Fig. 21.13 The lesser sac is exposed, and retraction of the stomach
anteriorly provides a good view of the dissection plane along the greater
curvature
Fig. 21.14 Three-arm coordination provides good exposure and
allows for easy dissection of the gastrocolic ligament while remaining
close to the greater curvature
232
H. Takla and A. Gleason
Fig. 21.15 Dissection continues along the greater curvature cephalad
toward the fundus. Short gastric arteries are identied and ligated close
to the stomach using the vessel sealer
Fig. 21.16 The stomach is retracted anteriorly and inferiorly to expose
the posterior wall. The gastrolienal and splenic attachments are dissected off the stomach
Fig. 21.17 Further splenic attachments are taken down. This exposure
is enhanced by three-arm coordination, and an easy dissection plane is
identied with good retraction on the stomach
Fig. 21.18 The greater curvature and fundus are now nearly completely mobilized. The posterior stomach is further exposed to allow for
dissection of the posterior attachments. Visualization of the left crus of
the diaphragm is a good landmark for completed mobilization of the
fundus
21 Robotic Vertical Sleeve Gastrectomy
233
Fig. 21.19 Stomach mobilization continues with dissection of posterior stomach attachments. The dissection plan on the right side of the
photo shows the now dissected gastrocolic ligament previously attached
to the greater curvature
Fig. 21.20 Camera mobility and wrist articulation allows for easy dissection of the nal posterior stomach attachments
Fig. 21.21 Complete mobilization of the greater curvature and fundus.
The posterior stomach is free for stapling
Fig. 21.22 The distal portion of the gastrocolic attachments are taken
down to nish stomach mobilization
234
H. Takla and A. Gleason
Fig. 21.23 Complete dissection of the distal gastrocolic ligament prior
to stapling
Fig. 21.24 Prior to stapling, attention is turned to the hiatus. The distal
esophagus, diaphragmatic crura, and hiatal hernia are dissected and
identied
Fig. 21.25 Hiatal hernia repair is completed using a 0 Ethibond suture
Fig. 21.26 A 38Fr bougie is placed intraluminal. Bougie positioning is
adjusted to create the appropriate size and orientation for the gastric
sleeve
21 Robotic Vertical Sleeve Gastrectomy
235
Fig. 21.27 Final positioning of the bougie prior to creation of sleeve
gastrectomy. It is recommended to leave 3–5mm of space adjacent to
the bougie for optimal stapling and avoid excessive tension on the staple line
Fig. 21.28 With the bougie in appropriate positioning, the Robotic stapler is placed through the 1 port. Using a black load stapler for the rst
re, division of the greater curvature begins at approximately 6cm from
the pylorus
Fig. 21.29 The rst staple re is completed. After the rst re, it is
appropriate to transition to the next staple height either green or blue
load if the thickness of the tissue permits
Fig. 21.30 The rst staple line is inspected. Setup for the remaining
staple res is planned. The stapler is reloaded. Appropriate tension is
kept on the gastric sleeve and gastric resection in order to keep the
stomach at and allow for a straight staple line