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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_541_Библиотеки_им_академика_М_И_Перельмана.pdf
5 Robotic Gastric Neurostimulator Placement
39
Fig. 5.9 The needle is then tunneled through the muscularis layer of
the stomach, taking care to avoid the larger vessels on the greater curvature of the stomach. The lead must be placed precisely so as not to
enter the gastric lumen or be visible under the serosa
Fig. 5.10 The needle direction is perpendicular to the major axis of the
stomach and traverses the muscularis layer
Fig. 5.11 After a minimum of 1cm of gastric wall tunneling, the needle may be resurfaced and exit the serosa. It is then grasped again and
pulled through until the bare metal of the neurostimulator lead enters
the tunnel and the provided silicone ange is ush with the stomach
wall
Fig. 5.12 The second neurostimulator lead is similarly placed in the
stomach wall, 1cm away from the rst lead in parallel fashion
40
Fig. 5.13 Neurostimulator lead placement checks are performed
before the leads are secured to the stomach wall. The robotic instruments can be used to stabilize the leads in position while the placement
checks are performed
W. C. Sherrill III and M. M. Awad
Fig. 5.14 The rst placement check is performed endoscopically. The
upper endoscope is used to ensure no metal from the neurostimulator
leads are visible within the gastric lumen. The robotic TilePro feature
can be used to simultaneously view the robotic and endoscopic elds
during this step
Fig. 5.15 The other end of the leads are gently held outside of the
12mm assistant port to prevent them from being inadvertently pulled
into the abdomen
5 Robotic Gastric Neurostimulator Placement
41
Fig. 5.16 The second lead placement check is then performed by conrming an appropriate current through the circuit. First, the two neurostimulator leads are inserted into the gastric neurostimulator in the
provided slots. Either lead can be placed in either slot
Fig. 5.17 Leads are then secured in place using the provided torque
wrench. All four screws are tightened through the holes in the plastic
generator housing. The torque wrench prevents overtightening of the
screws
42
W. C. Sherrill III and M. M. Awad
Fig. 5.18 The leads are gently tugged to conrm they are securely
anchored to the generator
Fig. 5.19 The paddle of the programming device is then placed into a
transparent, sterile cover and introduced into the surgical eld. The
paddle of the programmer is placed in contact with the neurostimulator
generator. (The entire programmer can also be sterilely prepped into the
eld and controlled by the bedside assistant)
5 Robotic Gastric Neurostimulator Placement
43
Fig. 5.20 Slide the “P” button on the side of the programmer to turn it
on
Fig. 5.21 Tap the “OK” icon to begin the diagnostic check
44
W. C. Sherrill III and M. M. Awad
Fig. 5.22 The programmer will take a few moments to communicate
with the neurostimulator generator
Fig. 5.23 Impedance through the circuit is checked. Leads are properly placed when the impedance is between 200 and 800 ohms
Fig. 5.24 Once these checks are successful, the neurostimulator leads
can be secured to the gastric wall. The leads are then unscrewed from
the stimulator using the torque wrench
5 Robotic Gastric Neurostimulator Placement
45
Fig. 5.25 Next, the silicone anges of the two leads are secured to the
gastric wall. This is performed by placing interrupted 2-0 Ethibond™
sutures between a serosal bite of the stomach wall and through the provided holes in the anges. Care must be taken to avoid damage to the
tunneled leads when placing these sutures
Fig. 5.26 Shown is the cranial stitch being placed for the proximal
gastric lead
Fig. 5.27 Completed image showing all securing stitches placed
through the anges
Fig. 5.28 The leads are further secured at their distal ends where they
exit the stomach wall. The provided silicone discs are used for this
purpose
46
W. C. Sherrill III and M. M. Awad
Fig. 5.29 The gastric neurostimulator ski needle is passed through the
discs as shown, threading the Prolene suture portion of the lead through
the appropriate holes
Fig. 5.30 The disc is then secured to the anterior stomach wall.
Additional 2-0 Ethibond suture is placed through the provided side
holes of the disc and then to the stomach wall using a serosal bite
Fig. 5.31 Completed xation of the disc to the anterior gastric wall is
shown
Fig. 5.32 The process is then repeated with the other neurostimulator
lead using another silicone disc. The disc is secured away from the rst
one
5 Robotic Gastric Neurostimulator Placement
47
Fig. 5.33 A robotic clip applier is then used to further secure the leads
where the Prolene suture portion exits the silicone discs
Fig. 5.34 Two clips are placed on each Prolene suture, close to where
it exits the silicone disc
Fig. 5.35 The two ski needles are then cut off the suture and removed
from the abdomen. Completed placement of the two gastric neurostimulator leads is shown. This concludes the robotic portion of the
procedure
Fig. 5.36 The robot is undocked from the patient, pneumoperitoneum
is released, and the 12mm assistant trocar is carefully removed leaving
the ends of the leads outside of the patient’s body
48
W. C. Sherrill III and M. M. Awad
Fig. 5.37 The generator pocket is then prepared. The 12mm trocar site
incision is extended medially to 4cm in length
Fig. 5.38 Monopolar electrosurgical energy must not be used at any
point in the remaining portion of the procedure. Current may travel
through the leads causing stomach wall thermal injury or damaging the
leads themselves. Hemostasis may be achieved with simple direct pressure or a bipolar forceps device