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15 Robot-Assisted Partial andTotal Gastrectomy
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Port placement can vary depending on the extent of resection and/or lymphadenectomy required. Generally, a 4-port conguration with the addition of single
assistant port is adequate for the most extensive gastric resections. Three 8mm ports
can be placed in a semi-lunar orientation in the supraumbilical/umbilical space,
with one additional 12 mm port to allow for stapler introduction and specimen
extraction. An additional xed, liver retractor can also be used in the subxiphoid
position.
Local Resection: “Wedge Gastrectomy”
For indications that do not require extensive margins nor lymphadenectomy, limited
local resections may be appropriate. If a tumorous growth is the target, that is, GIST,
then localization can be difcult if there is no extensive extraluminal component or
high-delity tactile feedback. In these situations, intraoperative endoscopy plays a
crucial role. Notably, there are situations in which the resistive ability of the pylorus
is overcome by intraluminal air pressure, and an additional clamp on the proximal
small bowel via the assistant port may aid in preventing excessive gaseous small
bowel dilatation and consequent loss of operating domain. Alternatively, preoperative endoscopic tattooing may serve a similar function analogous to its use in the
localization of colonic polyps.
Following patient positioning and port placement, a 30-degree videoscope is
used to explore the abdomen and identify the lesion. For targets that are on the anterior surface of the stomach, a division of the gastrocolic ligament may be omitted.
If the lesion is located in an amenable position, a wedge gastrectomy can be performed using either a robotic stapler or a hand-held equivalent. For locations such
as the gastric fundus or the lesser curvature, the application of the stapler may not
be possible because of physical restraints. Importantly, one must consider the anatomic sequelae of the resection as well; the use of the stapler on more precarious
regions could lead to mechanical and functional issues with esophagogastric transit.
In this situation, a more limited resection using a combination of sharp dissection
and focal electrocautery may allow for a “closer” margin excision and preservation
of gastric tissue in certain important territories. For this maneuver especially, the
dexterity afforded by the robotic platform allows for a very tailored excision. The
resultant defect can subsequently be closed with either a single- or dual-layer
sutured approximation.
A completion upper endoscopy can be selectively applied to examine the closure. There are multiple adjuncts to ensuring the absence of a leak beyond visual
examination. One method utilizes the instillation of saline into the upper abdominal
region to inundate the now-closed defect while simultaneously instilling intragastric
air. Air bubbles identied intra-abdominally would indicate an inadequate closure
and need for additional maneuvers. Another method utilizes near-infrared uoroscopy (either available inbuilt on certain robotic platforms or as a separate laparoscopic videoscope). Intragastric dilute indocyanine green (ICG) is used to pressurize
the luminal space either via endoscope or orogastric tube, and then the extraluminal
178
R. G. Vaghjiani
area is examined with the specialized camera to identify any extravasation of
the ICG.
Lymphadenectomy
As mentioned, the indication for gastric resection may necessitate concomitant
removal of draining lymph nodes. The lymphatic efferent of the stomach is anatomically varied, although for the most part predictable and described according to
multiple standards. The Japanese gastric cancer treatment guidelines are one experience that provides a stat-driven outline to the gastric lymphadenectomy (Fig.15.2) [5].
Lymphadenectomy of the immediate perigastric stations (1,2, 3, 4, 5, and 6) can
be accomplished en bloc during the gastric dissection or as separate maneuvers as
long as attention is paid to the anatomic envelopes where these stations reside. If
taken en bloc, care must be taken to ensure that an overly aggressive skeletonization
Fig. 15.2 The Japanese Gastric Treatment Guidelines 2021 delineation of relevant lymph node
stations depending on the extent of gastrectomy and tumor location. Clockwise: Total gastrectomy,
distal gastrectomy, and proximal gastrectomy. (Reproduced from Japanese Gastric Cancer
Treatment Guidelines 2021, 6th edition, under the Creative Commons License CC BY 4.0)
15 Robot-Assisted Partial andTotal Gastrectomy
179
of the stomach does not lead to retained or inadequate lymph node dissection.
Particularly in overweight and obese patients, a larger amount of perigastric adipose
tissue may need to be resected in order to achieve adequate harvest. This dissection
can be accomplished with a bipolar sealer or with sharp/blunt dissection and clip
placement, with the former technique being particularly useful in the rotund patient.
The additional stations (7, 8, 9, 10, 11, and 12) are where the robotic platform’s
manual dexterity can be extraordinarily advantageous. Access to these stations is
accomplished with ventral retraction of the stomach body following completion of
the retrogastric dissection. In resections where the left gastric artery is planned to be
left in situ, we nd that division of the coronal vein can aid in the mobilization of
the station 7 lymph node packet.
There has been growing interest in novel approaches to aid lymph node dissection, particularly to increase yield. One such maneuver utilizes near-infrared imaging and ICG instillation into various locations (peritumoral, subserosal, submucosal,
etc.). Although initial data is still evolving, the widespread adoption and long-term
clinical outcomes of international patient cohorts are still awaited.
Proximal Gastrectomy
Proximal gastrectomy is begun with exposure of the gastrocolic ligament at the
level of the transverse mesocolon. Once incised, the greater omentum can be freed
from the transverse mesocolon using a bipolar sealer. Consequent exposure of the
omental bursa and visualization of the posterior aspect of the stomach is a key
maneuver. The greater curve of the stomach is thus dissected with a bipolar sealer.
This maneuver should be undertaken with great care as a medial deviation can lead
to inadequate lymph node harvest in addition to inadvertent partial transections of
the gastroepiploic vessels. By maintaining a distance of anywhere from 2 to 4cm
away from the stomach, the dissection can be carried cephalad.
Once the left gastroepiploic artery and vein are encountered, the bipolar sealer or
a stapling device is used to divide the bundle. A combination of ventral and caudad
gastric retraction can aid in this portion of the dissection. Finally, the short gastric
vessels will be encountered. Attention must be paid to vector of retraction applied
to the stomach at this juncture as overzealous maneuvers will lead to inadvertent
vascular avulsion or splenic damage. In most situations, the short gastric vessels can
be divided with a bipolar sealer. Once completed, the ventral-most portion of the
left diaphragmatic crus is exposed and will serve as the anatomic boundary of the
lateral dissection. For some patients, this portion of the dissection can only be
accomplished after freeing the posterior aspect of the stomach. The retrogastric dissection, including the division of any gastropancreatic attachments, is achieved
using sharp dissection as this minimizes the chance of inadvertent thermal injury to
the pancreatic parenchyma. Focal electrocautery can be applied for any small vessels encountered.
The right crus can then be dissected. This is begun by incising the lesser omentum and carrying this plane cephalad. Retraction of the esophagogastric junction
180
R. G. Vaghjiani
toward the patient’s left with simultaneous tension on the right crus will allow for
ideal visualization so the distal-most esophagus can be dissected from the hiatus. A
similar counter-maneuver can be applied circumferentially so that the left, anterior,
and posterior portions of the junction are freed. A penrose drain about esophagogastric junction can also aid with these retractions.
Once these initial dissections are completed, then the point of transection on the
stomach can be identied. Both arteriovenous arcades (gastroepiploic and right gastric) are separately identied and divided so as to allow for an uneventful gastric
division. Sequential res of either the handheld or robotic stapler are then used, and
the proximal stomach (and attached omentum) can then be placed in the left upper
quadrant. This exposes the left gastric artery and vein and allows access to any additional lymph node stations that require extirpation.
At this point, adequate mobilization of the distal esophagus can be conrmed.
The vagal nerves are identied and divided, and division of the esophagus is done
with a linear stapler device. Stay sutures may be utilized to xate the dissected
esophagus at an intrabdominal position at the crus. Depending on tumor location,
consideration should be given to intraoperative pathology consultation to ensure
adequate margins.
Distal Gastrectomy
The initial dissection for the distal gastrectomy is begun similar to the proximal
gastrectomy. Accordingly, after division of the left gastroepiploic arcade, the dissection is then carried rightward along the greater curvature. Gentle cephalad and ventral stomach retraction will allow for a clear visualization of the investment that
exists between the colonic mesocolon and the gastroepiploic arcade. This dissection
is carried toward the liver, with the gallbladder serving as the anatomic border of the
rightward dissection.
The retrogastric dissection is carried out as above; however, now a more inferior
and rightward extent is required. In many patients, identication of the gastroduodenal artery (GDA) as it exits the inferior boarder of the pancreas is a key landmark.
This annotates the fusion of the aforementioned investment as the GDA meets the
gastroepiploic arcade and can be divided with the bipolar sealer or between clips to
allow for a full dissection of the infrapyloric region. During this maneuver, a gastric
band dissector can be used to create a retrovascular tunnel and thus allow for an
easier en bloc dissection of the nodal tissue before the stapler/clip division.
The lesser omentum is then entered and the supra-pyloric dissection is accomplished after the right gastric artery is identied and ligated either with bipolar
energy or between clips. The proximal duodenum is then divided with a stapling
device, and the specimen can then be retracted cephalad and to the left to allow for
any additional lymph node dissection required.
As described above for the distal transection site during a proximal gastrectomy,
in this operation the proximal transection site is cleared identically and the stomach
divided with sequential stapler res. Again, intraoperative pathologic consultation
can be a valuable adjunct to ensure margin status.
15 Robot-Assisted Partial andTotal Gastrectomy
181
Total Gastrectomy
A total gastrectomy, for the sake of brevity, can be thought of as a functional combination of the proximal and distal gastrectomy; however, there are some sequential maneuvers that can make a total removal of the stomach a more efcient
endeavor.
First, routine use of the xed liver retractor will aid immensely in the hiatal dissection. The dissection of the greater curve begins toward the right analogous to the
distal gastrectomy. This is the time at which an omentectomy can also be completed
and kept with the specimen. Once the proximal duodenum is divided, any additional
retrogastric lymph node dissection is completed and the remainder of the cephalad
dissection is performed according to the proximal gastrectomy.
Reconstruction
The reestablishment of enteric ow is an oft-overlooked, yet critically important
consideration after liberation of the stomach. Each method of reconstruction has its
benets and drawbacks and should be discussed with the patient in conjunction
with their resection plan. The specics of nutritional outcomes, subsequent quality
of life, weight maintenance, and need for future revisional procedures is a topic
worthy of its own discourse; however, the robotic gastrointestinal surgeon should
have a familiarity with a majority of techniques so that they can be applied expeditiously as needed.
The conrmation of adequate blood ow to a newly created anastomosis can also
be a point of great surgical ire, especially following extensive resection and perivascular lymph node harvest. The robotic and MIS platform is again well suited as
intraoperative intravascular ICG and near-infrared uoroscopy can not only reafrm adequate ow, but potentially alter reconstruction choices if early malperfusion
is detected.
Billroth I
A direct anastomosis between the divided duodenum and the remaining proximal
stomach in the case of a distal gastrectomy can be achieved using a hand-sewn technique. The distal staple line is sharply excised as is the proximal staple line, and a
two-layer hand-sewn gastro-duodenal anastomosis is fashioned. Alternatively, a circular stapler can also be used to achieve the same fusion.
Billroth II withBraun Enteroenterostomy
The transverse colon is retracted cephalad, and the ligament of Treitz is identied.
A distance of approximately 20–30cm is traced distally and will serve as the point
of anastomosis. This loop of jejunum is brought cephalad in either an antero- or
182
retro-colic fashion and apposed to the divided stomach. The posterior aspect of the
stomach is preferred as a site of anastomosis to allow for physiologic emptying of
the gastric reservoir. A dual-layer, hand-sewn gastro-jejunal anastomosis is then
completed. Alternatively, a linear stapler can also be used to create the anastomosis
with subsequent closure of the common gastro-jejunal enterotomies.
Following this, the afferent and efferent limbs of the newly apposed jejunal loop
are approximated. A linear stapler is used to create a common channel with subsequent closure of the common enterotomies.
R. G. Vaghjiani
Roux-en-Y
A Roux-en-Y conguration for the re-establishment of continuity can be achieved
in similar fashion. In this situation, the length of the Roux limb must be considered
heavily. During the common application of the Roux-en-Y reconstruction during
bariatric reconstruction, the long length of the Roux limb can portend a more signicant weight loss; a metric that is not so desired when reconstructing the potential
cancer patient.
When creating either the gastro-jejunal or esophago-jejunal anastomosis, a handsewn, two-layer anastomosis is fashioned. The hand-sewn method is also particularly useful in the setting of an esophagojejunostomy where the anatomic limitations
of a linear stapler within the hiatus are magnied, although the use of an intraluminal anvil and circular stapler could also be used in this limited space.
Double-Tract Reconstruction
Following a proximal resection, the use of a double-tract reconstruction may also be
used. This is begun by fashioning a Roux limb as described. Following the creation
of the esophagojejunostomy, an end-to-side gastrojejunostomy between the Roux
limb and the remaining stomach is created. This is accomplished with a sharp enterotomy on both viscera followed by a two-layer hand-sewn anastomosis. A variation
of this can also be accomplished with a circular stapler.
Conclusion
The robotic platform is an immensely versatile and efcacious tool that can allow
for increasingly complex surgical resections with improved recovery. Mastery of
these techniques requires detailed surgical forethought, but once planned and executed, can lead to excellent patient outcomes.
Disclosures None.
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References
1. Pappas TN.The rst 40 years of Gastrojejunostomy: from Billroth to Murphy to Mayo. Ann
Surg Open. 2022;3(3):e200. https://doi.org/10.1097/as9.0000000000000200.
2. Kitano S, Iso Y, Moriyama M, Sugimachi K.Laparoscopy-assisted Billroth I gastrectomy. Surg
Laparosc Endosc. 1994;4(2):146–8.
3. Bray F, Laversanne M, Sung H, Ferlay J, Siegel RL, Soerjomataram I, Jemal A.Global cancer
statistics 2022: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers
in 185 countries. CA Cancer J Clin. 2024;74(3):229–63. https://doi.org/10.3322/caac.21834.
4. National Comprehensive Cancer Network, Gastric Cancer (Version 4.2024). https://www.nccn.
org/professionals/physician_gls/pdf/gastric.pdf. Accessed Aug 2024.
5. Japanese Gastric Cancer Association. Japanese gastric cancer treatment guidelines 2021 (6th
edition). Gastric Cancer. 2023;26(1):1–25. https://doi.org/10.1007/s10120- 022- 01331- 8.
Robotic Sleeve Gastrectomy
16
MariaS.Altieri
Introduction
With the rise in the prevalence of obesity in the United States and around the world, the
eld of bariatric surgery is witnessing an increasing demand. Sleeve gastrectomy is a
metabolic procedure that involves resection of approximately 60–70% of the greater
curvature of the stomach. Due to its perceived safety prole and excellent weight loss,
sleeve gastrectomy has surpassed the Roux-en-Y gastric bypass as the most commonly
performed metabolic and bariatric surgery today in the United States [1].
The utilization of the robotic platform in the area of metabolic and bariatric surgery has been evolving since the late 1990s [2]. The robotic platform offers several
theoretical advantages, including precision in tissue manipulation, greater dexterity
due to the elimination of physiological tremor, and enhanced three-dimensional
(3-D) imaging. Patients with body mass index (BMI) >50kg/m2 present a particular
challenge to both surgery and anesthesia due to body habitus and comorbidities.
There are several considerations, making conventional laparoscopy more difcult,
mainly because of the limited space due to excessive hepatomegaly and intraabdominal fat and thick abdominal wall, which may require excessive torque on the
laparoscopic instruments and ports. Robot-assisted approaches have the potential to
alleviate a number of these challenges, thus making the platform particularly useful
[3, 4]. The main perceived limitations of the robot-assisted surgery are cost and time
to set-up. However, with increased utilization, time to set-up has been improving
and perceived intraoperative cost can be neutralized by lower rates of complications
and shorter hospital time.
Studies have compared conventional laparoscopy and robot-assisted sleeve gastrectomy and have had mixed results. Nasser etal. compared patients undergoing
robot-assisted sleeve gastrectomy versus laparoscopic sleeve gastrectomy between
M. S. Altieri (*)
Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
e-mail: Maria.Altieri@pennmedicine.upenn.edu
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2025
S. Samreen et al. (eds.), The SAGES Manual of Robotic Surgery,
https://doi.org/10.1007/978-3-031-86927-3_16
185
186
M. S. Altieri
2015 and 2017. The study compared 685 RSG versus 56,808 LSG cases. The RSG
group had a longer operative time, longer hospital length of stay, and overall similar
morbidity and mortality. After multivariable logistic regression, patients undergoing
RSG had a higher risk for an organ space surgical site infection [5]. A systematic
review in 2017 showed that robotic sleeve gastrectomy showed signicantly higher
mean operative time and increased length of hospital stay. Complications such as
incidence of leak, wound infection, and bleeding were comparable [6]. Another
recent study showed that the outcomes in robotic bariatric surgery were comparable
with the laparoscopic approach despite longer operative times [7]. As higher BMI
can lead to increased risk of complications [8], the robotic platform can help
decrease that risk. In addition, while it may have longer operative time, robotic
sleeve gastrectomy has a less-steep learning curve compared to laparoscopic sleeve
gastrectomy [8, 9].
Some of the opponents of the utilization of the robotic platform have cited concerns about higher costs. Several studies have noted higher costs for robotic sleeve
gastrectomy [10]. In a publication in 2019, cost analysis of robotic sleeve gastrectomy compared to laparoscopic sleeve gastrectomy revealed no substantive differences in surgery-associated costs. While operative costs were signicantly higher,
robotic sleeve gastrectomy had a shorter length of stay [11].
Operative Technique
The surgical team consists of a surgeon and bed-side assist. At teaching institutions,
a teaching console may be present. As such, the trainee, either resident or fellow,
can perform parts of the procedure, while the primary surgeon observes and directs,
controls one of the arms, and has the ability to take over in certain instances. In
smaller operating rooms, the bed may need to be positioned in a way to be able to
dock the robotic platform.
Once anesthesia is induced, the patient is placed in a supine position. Both
patient’s arms can be extended. We usually do not place foleys as this procedure is
relatively short. As most institutions have a Xi platform, the robot can be docked
from either side of the patient. The robot is draped in a sterile fashion prior to the
procedure start.
A nasogastric tube or a suction bougie is inserted to decompress the stomach.
After the patient is being positioned and draped, entry into the abdomen is performed, dependent on surgeon’s preferences. We prefer either a Veress at Palmer’s
point or an optical entry. The abdomen is insufated to 15mmHg. All ports are
placed after obtaining pneumoperitoneum. The camera port is about 15–20cm from
the xiphoid slightly to the left of the midline. A 12mm port is placed at least 8cm
lateral to that and 2 8-mm ports are placed to the left of the camera. It is important
to note that in obese patients with insufated abdomen, intra-abdominal distance is
less than expected based on the location of the skin incisions. Thus, it is critical that
all ports are placed at least 8cm apart in order to prevent arm collision. A liver
retractor is placed with care to have an adequate clearance while docking the robotic
16 Robotic Sleeve Gastrectomy
187
platform. We prefer a Nathanson liver retractor in the subxiphoid location, but others like a snake retractor on the patient’s right side.
When docking, the robot must be in position such as that the angle between the
robot column and the camera is at around 10°. The robotic platform is targeted
toward the stomach. The patient is placed in reverse Trendelenburg position, usually
at about 12°; however, if higher, BMI can go to 18–21°, in order to see the hiatus.
After positioning the robotic platform, the 30° camera is inserted rst as the
camera is 30° down (R2). The targeting setting is used to align the rest of the arms.
The rest of the arms are attached. All the essential equipment is inserted into the
abdomen under direct visualization. In our case, we use 2 Cadiere graspers (R1 and
R4) and a vessel sealer (R3). We do not use an assistant port (Fig.16.1).
The surgery begins by entering into the lesser sac by dividing the gastrocolic
ligament (Fig.16.2). If two surgeons are working, the rst surgeon can control R1–
R3, while the second surgeon can control R4 for retraction. The dissection is carried
toward the angle of His. Posterior gastric adhesions must be completely divided in
order to prevent inadvertent injury to the pancreas or rotation of the sleeved stomach.
As the dissection is carried cephalad, care must be taken as the fundus is mobilized away from the spleen by dividing the gastrosplenic ligament, so that there is
no injury to the spleen. The goal is to be able to identify left crus and clear the posterior attachments of the fundus and mobilize the fat pad. Complete mobilization of
the fundus is very important so that there is no injury to the esophagus or the spleen
during ring of the staple, as well as being able to take the whole fundus. In
Fig. 16.1 Port position for
robot-assisted sleeve
gastrectomy