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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_541_Библиотеки_им_академика_М_И_Перельмана.pdf
236
H. Takla and A. Gleason
Fig. 21.31 Stapling continues. The bougie serves as a guide for stapling. Transition from the green load to the blue load is appropriate if
the tissue permits
Fig. 21.32 Using the other arms to maintain adequate tension on the
greater curvature keeps the stomach at and staple line straight. An
adequate posterior stomach dissection is necessary for stapling
Fig. 21.33 Stapling becomes easier as it progresses toward the fundus.
Tension is maintained on the greater curvature
Fig. 21.34 Setting up for the nal staple re at the fundus
21 Robotic Vertical Sleeve Gastrectomy
237
Fig. 21.35 Staple re at the fundus. Complete the last staple re leaving a small cuff of proximal stomach remaining – this should be
approximately 5mm next to the GE junction
Fig. 21.36 Completion of the staple re and creation of the sleeve
gastrectomy
Fig. 21.37 The whole staple line is inspected
Fig. 21.38 The lesser sac, fundus, and splenic hilum are inspected for
bleeding and injury post gastrectomy
238
H. Takla and A. Gleason
Fig. 21.39 Further inspection of the staple line and integrity of the
gastric sleeve
Fig. 21.40 7.5mg of indocyanine green (ICG) is injected followed by
a 10cc ush. The camera lens is toggled which allows for perfusion
visualization. The gastric sleeve perfusion is inspected
Fig. 21.41 Further inspection of the gastric sleeve perfusion. Take
note of the contrast between the well-perfused sleeve and resected
greater curvature
Fig. 21.42 We perform a routine intraoperative endoscopy at the end
of the procedure to assess for any intraluminal bleeding and perform an
air leak test
21 Robotic Vertical Sleeve Gastrectomy
Fig. 21.43 Removal of the sleeve specimen through the right-sided
12mm port with assistance of an Endo Catch bag
239
Fig. 21.44 Sleeve gastrectomy specimen
Fig. 21.45 Fascial layers and skin incisions are closed. Surgical glue
is applied
References
1. Schneider B. Robotic bariatric surgery: a new weapon in the
ght against obesity: digestive: nutrition: UT Southwestern
Medical Center. Digestive|Nutrition|UT Southwestern
Medical Center, 26 Sept. 2019, utswmed.org/medblog/
robotic- bariatric- surgery- new- weapon- ght- against- obesity.
2. Fazl Alizadeh R, Li S, Inaba CS, Dinicu AI, Hinojosa MW, Smith
BR, Stamos MJ, Nguyen NT.Robotic versus laparoscopic sleeve
gastrectomy: a MBSAQIP analysis. Surg Endosc. 2019;33(3):917–
22. https://doi.org/10.1007/s00464- 018- 6387- 6.Epub 2018 Aug 20.
3. Altieri MS, Yang J, Telem DA, Chen H, Talamini M, Pryor
A.Robotic-assisted outcomes are not tied to surgeon volume and
experience. Surg Endosc. 2016;30:2825–33.
Robotic Gastric Bypass
Jan-NiclasKersebaum andJanHenrikBeckmann
22
Introduction
In recent years, surgery has evolved rapidly with the introduction of robotic-assisted systems. In bariatric surgery,
too, robotics must rst hold its own against highly standardized laparoscopy, which has few complications. With
high acquisition, maintenance and material costs, as well as
the lack of proof of cost efciency, robotics is only slowly
making inroads here. The advantages of using robotically
assisted surgery in bariatrics are the decoupling between
the nevertheless pronounced restoring forces of the abdominal wall of the obese patients and the surgeon and the 3D
view combined with the ne preparation possibilities of the
ne instruments in the sometimes exceedingly small surgical site. In international comparison, German patients have
the highest BMI at the time of surgery (34.2kg/m
Korea to 49.1kg/m2 in Germany) [1], which makes the use
2
in South
of robotic systems in this difcult cohort even more reasonable. The rst robotic-assisted gastric bypass was performed in 2001 [2]. Since then, the system has been
implemented internationally in the surgical care of obese
patients [3].
Procedure: Illustrated Steps
Figures 22.1, 22.2, 22.3, 22.4, 22.5, 22.6, 22.7, 22.8, 22.9,
22.10, 22.11, 22.12, 22.13, 22.14, 22.15, 22.16, 22.17, 22.18,
22.19, 22.20, 22.21, 22.22, 22.23, 22.24, 22.25, 22.26, 22.27,
22.28, 22.29, 22.30, 22.31, 22.32, 22.33, 22.34, 22.35, 22.36,
22.37, 22.38, 22.39, 22.40, 22.41, 22.42, 22.43, 22.44, 22.45,
22.46, 22.47, 22.48, 22.49, 22.50, 22.51, 22.52, 22.53, 22.54,
and 22.55 illustrate the technical aspects of robotic Rouxen- Y gastric bypass.
J.-N. Kersebaum · J. H. Beckmann (*)
UKSH Department of General, Visceral-, Thoracic-,
Transplantation-, and Pediatric Surgery, University Medical Center
Schleswig-Holstein, Kiel, Germany
e-mail: jan.beckmann@uksh.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_22
241
242
J.-N. Kersebaum and J. H. Beckmann
Fig. 22.1 The patient is positioned in the “French position” or 20° anti-Trendelenburg position with the legs spread, the left arm supported, and
the right arm extended. In accordance with the in-house standard, all patients receive calf compression pumps. View from the side
Fig. 22.2 View from the top
22 Robotic Gastric Bypass
243
approx. 25 cm
DV1
A1
DV2
DV3
DV4
A2
Fig. 22.3 Trocar placement. DV1 to DV 4 are Da Vinci Trocars; A1
and A2 are 12mm laparoscopic assistance trocars
Fig. 22.5 Division of the greater omentum above the transverse colon
Fig. 22.4 In situ view of the surgical site with the uplifted left liver
lobe
Fig. 22.6 Division of the greater omentum toward the stomach
Fig. 22.7 Visualization of the left hiatus crus
244
J.-N. Kersebaum and J. H. Beckmann
Fig. 22.8 Using the tip-up fenestrated grasper as a measurement tool
Fig. 22.9 Starting from the lesser curvature approximately 6cm below
the gastroesophageal junction, the lesser omentum is opened under
preservation of the left gastric artery
Fig. 22.10 Forming a retrogastric tunnel
Fig. 22.11 Inserting a linear stapler into the prior formed retrogastric
tunnel
22 Robotic Gastric Bypass
245
Fig. 22.12 Before the 40 Charrier Bougie is inserted, gastric adhesions are being severed
Fig. 22.13 Following the cross stapling, a second stapling device is
inserted. The tip should aim toward the left hiatus’ crus
Fig. 22.14 After the bougie is inserted, the stapling device is repositioned toward the bougie to ensure a good pouch sized
Fig. 22.15 View into the omental bursa. It is important to remove lose
stapling brackets
246
J.-N. Kersebaum and J. H. Beckmann
Fig. 22.16 Removal of the dorsal adhesions of the pouch
Fig. 22.17 Continuous removal of dorsal adhesions of the pouch
Fig. 22.18 For safety reasons, the tip-up fenestrated grasper is inserted
in the omental bursa and its branches are opened. The fatty tissue is dissected with the energy device
Fig. 22.19 The fatty tissue is dissected with the energy device