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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_541_Библиотеки_им_академика_М_И_Перельмана.pdf
3 Robotic Esophagus Leiomyomectomy
19
Fig. 3.4 The surgeon sits at the console, the table assistant stands ventral to the patient. The table assistant guides the docking of the robot, sucks
and removes the specimen via the assistant’s access. This access also serves as an emergency access in case of intrathoracic bleeding
20
B. Reichert and J.-H. Egberts
Fig. 3.5 The patient lies on the left side in a modied prone position
(∼45°-rotation). To prevent the robot arm 1 from colliding with the
patient, the patient’s right arm is brought to its maximum cranial posi-
tion and only minimally extended outwards (This gure was taken at
the end of the procedure)
3 Robotic Esophagus Leiomyomectomy
21
Fig. 3.8 After incision of the pleura parietalis, the preoperative ink
marking of the tumor is visible (*). As described in the endosonography, the tumor has an extension of ∼ 2cm
Fig. 3.6 The ports are placed as described below. The rst port placed
is P3 to insert the camera. The further placement of the ports is done
under view. P1, laterally, in the 8th or 9th ICR; P2, posterior axillary
line in the 8th ICR; P3, 6th ICR in the mid-axillary line (for camera);
P4, ∼2cm away from the medial edge of the scapula in the 4th ICR; PA,
the assistant port in the mid-axillary line in the 7th ICR
Fig. 3.7 Single-lung ventilation is started, and CO2 insufation of
8mmHg intrathoracic is established. The pleura is inspected for irregularities. If there are none, an esophageal bougie is inserted by the anesthetist. Now the ligamentum pulmonale is mobilized, and
lymphadenectomy of level 9 is performed
Fig. 3.9 The esophagus is mobilized, and the pleura is opened over the
entire distance until the tumor can be exposed cranially and caudally
22
B. Reichert and J.-H. Egberts
Fig. 3.10 Directly above the tumor, the adventitia is opened and carefully preparated onto the muscle layer
Fig. 3.11 The muscle layer is rst carefully coagulated electrically
and then opened in this area
Fig. 3.12 The muscle layer is opened in a semilunar pattern so that the
tumor is visible underneath
Fig. 3.13 Grasping the tumor: protrusion of the tumor, beginning of
transection of the lateral layers with severing of the surrounding muscle
bers
3 Robotic Esophagus Leiomyomectomy
23
Fig. 3.14 The tumor can be carefully dissected and removed from the
surrounding layers
Fig. 3.15 The tumor is held with fenestrated bipolar forceps (→). A
Tip-Up fenestrated grasper (*) tightens the surrounding layers, and with
the use of the electric scissors, the coagulation and following separation
of the layers is performed
Fig. 3.16 When preparing in depth, care should be taken not to injure
the mucosa
Fig. 3.17 The resected tumor is removed in a salvage bag by the table
assistant via the assistant port. The tumor shows clear margins and is
submitted for histological examination
24
B. Reichert and J.-H. Egberts
Fig. 3.18 After removal of the tumor, the mucosal tube is visible in
depth and appears intact
Fig. 3.19 A requirement for direct suturing of the esophagus is that the
esophagus can be mobilized sufciently and that there is no tension on
the suture
Fig. 3.20 The muscle layers can be adapted without tension so that a
direct suture is possible. The muscular defect is then closed in a transverse fashion to avoid postoperative stenosis (>)
Fig. 3.21 The musculature is sutured continuously with STRATAFIX
strength 3.0
3 Robotic Esophagus Leiomyomectomy
25
Fig. 3.22 The suture is xed with a clip and protected from loosening
Fig. 3.23 The esophagus is closed sufciently. The clip secures the
suture. The suture is without tension
Fig. 3.24 The closure of the parietal pleura begins with continuous
with STRATAFIX strength 3.0
Fig. 3.25 The pleura parietalis closure is continued
26
Fig. 3.26 The pleura suture is closed sufciently. The thorax is
inspected for bleeding and injuries to the lungs
B. Reichert and J.-H. Egberts
References
1. van der Sluis PC, van der Horst S, May AM, Schippers C, Brosens
LAA, Joore HCA, etal. Robot-assisted minimally invasive thoracolaparoscopic esophagectomy versus open transthoracic esophagectomy for resectable esophageal cancer: a randomized controlled
trial. Ann Surg. 2019;269(4):621–30.
2. van der Sluis PC, Tagkalos E, Hadzijusufovic E, Babic B, Uzun
E, van Hillegersberg R, et al. Robot-assisted minimally invasive
esophagectomy with intrathoracic anastomosis (Ivor Lewis): promising results in 100 consecutive patients (the European experience).
J Gastrointest Surg. 2021;25(1):1–8.
3. Franke F, Moeller T, Mehdorn A-S, Beckmann JH, Becker T,
Egberts J-H.Ivor-Lewis oesophagectomy: a standardized operative
technique in 11 steps. Int J Med Robot. 2021;17(1):1–10.
Fig. 3.27 A 24-Charriere chest drain is placed via the camera port. The
right lung is ventilated again, the remaining ports removed and the thorax closed. The patient is transferred to the regular ward via the recovery room
Robotic Heller Myotomy withDor
Fundoplication
LauraLorenzon, AlbertoBiondi, PietroSantocchi,
andDomenicoD’Ugo
4
Introduction
Oesophageal achalasia is a motility disorder of unknown
cause, due to the selective loss of inhibitory neurons of the
myenteric plexus. It is characterized by aperistalsis of the
oesophageal body and impaired LES relaxation, and the typical symptoms include dysphagia for solids and liquids,
regurgitation, gradual weight loss, and retrosternal pain.
Specic tests performed to conrm diagnosis are gastroscopy, a barium XR or CT scan swallow (Figs.4.1 and 4.2)
and high-resolution manometry. This latter exam is mandatory to classify the oesophageal motility disorders on the
basis of objective metrics (specically, the integrated relaxation pressure (IRP) and the presence/absence of peristalsis)
using the Chicago Classication (CC). Using these features,
the CC version 3.0 distinguishes achalasia into three forms,
namely, Type I (IRP greater than the upper limit of normal
values and absence of oesophageal contractility), Type II
(IRP greater than the upper limit of normal values and
absence of peristalsis/pan-oesophageal pressurization with
>20% of swallows) and Type III (IRP greater than the upper
limit of normal values and absence of peristalsis/premature
contractions with >20% of swallows) [1]. Although several
endoscopic treatments are currently available [2], the miniinvasive myotomy is recommended for Type I and Type II
achalasia and – when associated with Dor fundoplication – it
has the advantage of resulting in less post-operative reux
symptoms at 2years of follow-up [3].
The robotic approach for achalasia was rst described in
2001 [4], and current experiences report lower rates of intra-
operative oesophageal perforations comparing laparoscopy,
although more powered studies are advocated to conrm this
positive trend [5].
Procedure: Illustrated Steps
Figures 4.1, 4.2, 4.3, 4.4, 4.5, 4.6, 4.7, 4.8, 4.9, 4.10, 4.11,
4.12, 4.13,4.14, 4.15, 4.16, 4.17, 4.18, 4.19, 4.20, 4.21, 4.22,
4.23, and 4.24 illustrate typical imaging, operating room set-
up and the technical aspects of a robotic Heller myotomy
with Dor fundoplication for oesophageal achalasia using XI
Da Vinci system as standardized at our Institution.
L. Lorenzon
General Surgery Unit, Fondazione Policlinico Universitario
A.Gemelli IRCCS, Catholic University of the Sacred Heart,
Rome, Italy
A. Biondi · P. Santocchi · D. D’Ugo (
Fondazione Policlinico Universitario A.Gemelli IRCCS, Catholic
University of the Sacred Heart, Rome, Italy
e-mail: domenico.dugo@policlinicogemelli.it
© 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_4
*)
Fig. 4.1 XR swallow with barium documenting a typical oesophageal
dilatation with rat tail sign at the cardia level in a patient with Type II
achalasia
27
28
a
Fig. 4.2 CT scan showing a dilatated oesophagus lled with ingest
(same patient as above). Red arrow showing oesophageal diameter
MONITOR
L. Lorenzon et al.
b
Reverse Trendelemburg
ASSISTANT
Fig. 4.3 Operating room setting. (a) The patient is positioned with
abducted legs, the monitor is placed on the right shoulder and the assistant operates between the legs of the patient. The robot (Da Vinci Xi)
enters from the patient’s right side. Pneumoperitoneum is induced using
a Veress needle in the left hypochondrium. After insufating the abdomen with CO
(target pressure 14mmHg), four robotic trocars (8mm)
2
are placed, all of them above the umbilicus: two in the right quadrant
(one below the costal arch margin and one lateral to the rectus abdominis), one left to the midline and one in the left quadrant. A further
12mm trocar for the assistant is placed in the left iliac fossa. (b) Finally,
the patient is placed in reverse Trendelenburg position before starting
the docking