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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_5193_Библиотеки_им_академика_М_И_Перельмана.pdf
240
M. Nessen and C. A. Galvani
Troubleshooting
• The fundoplication prevents reux and acts to anchor the stomach in the
abdomen.
• Insertion of the bougie by the anesthesia team should be closely monitored by
the operating surgeon. Frequent verbal communication is key. Gentle anterior
traction of the Penrose drain by the surgeon straightens up the esophagus to
facilitate the entrance of the bougie into the abdominal esophagus.
• We routinely use 56F bougie; however, in smaller patients, a smaller bougie size
is used to prevent mucosal tearing.
• Construction of the fundoplication should be with the fundus of the stomach and
not with the body of the stomach to avoid redundant gastric tissue posterior to the
esophagus. Retroex view on postoperative endoscopy should demonstrate
proper position and conguration of the wrap [20]. Endoscopy also decreases the
incidence of postoperative dysphagia by assessing resistance to the passage of
the endoscope.
• Conversion to a Roux-en-Y Near Esophago-jejunostomy
When the decision is to proceed with an acid diverting procedure, a Roux-en-Y
near esophago-jejunostomy is our preferred procedure [21]. This is performed in
very specic situation such as severe damage to the fundus, the presence of gastroparesis, multiple previous fundoplications, or obesity the patient should be consented
and adequately counseled in advance since this procedure involves additional risks.
If the patient is agreeable, this is our preferred procedure instead of a “wedge
gastroplasty.”
After identication of the GE junction, the angle of His, and the lesser curvature
of the stomach, a window is created behind the stomach just below the rst hepatic
branch. Then, the stomach is divided with linear robotic stapler (blue load) with one
re horizontal and 1 1/2 res vertical towards the angle of His with buttress material
to create a small gastric pouch. This is followed by the creation of an “omega loop”
with a 50–75cm bilio-pancreatic limb and a 75–120 Roux limb. Then the small
bowel is divided just to the left of the gastric pouch to separate the biliary limb form
the Roux limb. A stapled side-to-side jejuno-jejunostomy was created with a robotic
linear stapler 60mm (white load). All defects are closed with nonabsorbable barbed
sutures. A “hand-sewn” gastrojejunostomy is performed in two layers with running
absorbable 3-0 absorbable barbed sutures. Once this is completed, the Roux limb is
clamped distally and the upper abdomen is lled with water to perform an air leak
test. The gastroscope was inserted into the patient’s esophagus insufating along the
way. The gastric pouch is entered and the anastomosis is traversed while insufating. If no air leak is noted, the procedure is completed.
Troubleshooting
• Port placement for this procedure is slightly different than the one used for redofundoplication, and the surgeon should plan accordingly. Specically, trocars are
placed lower to allow access to the inframesocolic space like our bariatric procedures.
19 Revisional Foregut andBariatric Surgery
241
• Complete takedown of the fundoplication is a key step of this procedure to allow
identication of the GE junction and prevent ring the stapler across the wrap.
• Wedge Gastroplasty
A wedge gastroplasty is rarely performed in our practice, but it is sometimes
necessary if one cannot obtain at least 2–3cm of intra-abdominal esophagus with
no tension. For this procedure, the same port placement is utilized as for the redofundoplication; however, a 12mm trocar is placed in the left upper quadrant (arm
#3) for the robotic stapler. We use the original technique described in 2004 [22].
A 54/6-French taper tip bougie is passed down the esophagus and kept close to
the lesser curve of the stomach. The stomach is marked about 3cm from the angle
of His parallel to the bougie. Starting at the greater curvature the robotic linear stapler 60 (blue load) is red until the 3cm mark is reached. Subsequent res are
directed vertical toward the angle of His parallel to the bougie (Fig.19.11). The
fundoplication is placed as close as possible to the native gastroesophageal junction.
A partial posterior fundoplication is preferred.
Troubleshooting
• Placing fundoplication as close as possible to the native gastroesophageal junction keeps the staple line of the neo-esophagus covered by the fundoplication.
• Careful inspection of the stomach to ensure adequate perfusion is paramount and
can be achieved with the use of Firey with ICG-green.
Outcomes
At least two systematic reviews and meta-analysis of laparoscopic revisional antireux surgery have demonstrated increased conversion rates (7–8.7%), with an overall complications rate of 14–15.6%, reafrming that laparoscopic reoperative
antireux surgery has signicantly higher morbidity than primary antireux surgery
[13, 23] In addition, the long-term outcomes of revisional procedures are generally
less satisfactory than primary surgery. This is potentially related to the intrinsic
Fig. 19.11 Wedge
gastroplasty. Stapler ring
toward angle of His during
wedge gastroplasty
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M. Nessen and C. A. Galvani
technical difculties due to dense adhesions and distortion of the anatomy from the
previous surgery.
On the other hand, robotic surgery offers camera stability for long periods of
time, articulated instruments, and self-retraction. These features offer increased precision, dexterity, improved exposure, control, and improved ergonomics that make
the surgery less mentally stressful and less physically taxing. The clinical value
observed while using this technology is validated by decreased operative times,
conversions, morbidity, pain, and hospital stay. Robotic foregut surgery has demonstrated favorable short-term outcomes compared to the laparoscopic approach
despite the increased incidence of higher incidence of reoperative cases in the
robotic group [24, 25]. Another advantage several authors have reported is decreased
use of esophageal lengthening procedures [25]. Furthermore, a very high complete
or partial resolution of symptoms has been reported and the majority of patients no
longer requiring daily PPIs [16].
In summary, the use of robotics in revisional foregut surgery may result in sig-
nicant improvements in perioperative outcomes for these challenging procedures.
Part II: Revisional Bariatric Surgery
Introduction
Due to an ever-increasing number of bariatric procedures performed and length of
follow-up, the number of patients who need revisional surgery is climbing [4]. The
number of revision procedures performed has observed a 311% increase since
2011 [26].
The rate of revisional surgery varies in different bariatric procedures. It could be
as high as 40% after AGB, 10–20% after RYGB, and 5.5% after sleeve gastrectomy
(SG) [27]. There are various reasons for revision of an index procedure. They can be
categorized into two main groups: (1) complications after primary bariatric surgery,
not including immediate postoperative complications, and (2) patients who have
insufcient weight loss or weight regain after primary bariatric surgery (5).
Revisional bariatric procedures can also be classied as
• Conversion. Procedures that change from an index procedure to a different type
of procedure.
• Corrective. Procedures addressing complications or incomplete treatment effect
of a previous bariatric operation.
• Reversal. Procedures that restore original anatomy.
The complication rate after laparoscopic revisional surgery is 15–31% and is
highly dependent on the specic revisional procedure [28]. The application of
robotics in primary bariatric surgery is emerging but not yet widespread. In primary
surgeries, it has been demonstrated to decrease anastomotic leaks, reoperations, and
decreased length of hospital stay when compared to laparoscopy [29, 30].
19 Revisional Foregut andBariatric Surgery
243
As it pertains to revisional bariatric surgery, some series have demonstrated its
feasibility and safety, although recent advances in robotic technology can potentially
improve upon those outcomes and demonstrate clear advantages favoring the routine
use of robotics [31]. Here, we describe our evaluation and treatment of patients requiring reoperative bariatric surgery and the potential benets of robotic- assisted surgery.
Preoperative Assessment
The rst step for patients being evaluated for revisional surgery is to perform a
detailed history and physical examination. It is important to obtain the operative
reports from previous operations to better understand the surgical technique used in
the initial surgery. One should also investigate patients’ dietary habits, percentage
of initial weight loss, and subsequent weight regain, symptoms such as dysphagia,
GERD, food regurgitation, and postprandial abdominal pain. These symptoms
could be a sign of anatomical issues such as stenosis at the anastomosis, hiatal hernia, marginal ulcer, pouch dilation, gastro-gastric stula in patients with a history of
gastric bypass, or inadequate removal of gastric fundus in initial SG.
An upper gastrointestinal endoscopy and barium swallow are initial tests that are
helpful in understanding surgical anatomy and diagnosis of some of the above conditions. The endoscopy can detect sequel of GERD such as esophagitis, stricture
and Barrett’s esophagus, hiatal hernia, marginal ulcer or anastomotic stenosis,
bleeding, and gastro-gastric stula. A barium swallow is a complementary study to
better understand the altered surgical anatomy. It can also delineate anatomical and
functional stenosis, obstruction, or stula. If a patient has dysphagia without obvious mechanical reasons, esophageal manometry or gastric emptying study can be
benecial to rule out functional issues.
Reviewing the operative report(s) from previous surgeries is always valuable in
understanding the surgical technique used in the primary operation. For example, in
the case of RYGB, it is useful to know how the bypass was reconstructed (retrocolic
vs. antecolic, etc.) or whether the mesenteric defects were closed. In the case of an
SG, it is important to know what size bougie was used to construct the sleeve and
whether a hiatal hernia was identied and repaired. This will allow the surgeon to
appropriately prepare preoperatively.
Patient Selection forRobotic Revisional Bariatric Surgery
The decision to perform revisional surgery should be based on the index procedure:
1. Complications after primary bariatric surgery, not including immediate postop-
erative complications.
(a) Laparoscopic adjustable gastric band (LAGB): Postoperative complications
after LAGB are band slippage, erosion, stenosis, band intolerance, esophageal dilation, severe GERD, and port-related problems.
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M. Nessen and C. A. Galvani
(b) Nonadjustable gastric band (NAGB): Most complications post NAGB are
nausea, vomiting, severe GERD, malnutrition, band erosion, and esophageal
dilation.
(c) Roux-en-Y gastric bypass (RYGB): Marginal ulcer, bleeding, anastomotic
stricture, dilated gastric pouch, and gastro-gastric stula are common
after RYGB.
(d) Laparoscopic sleeve gastrectomy (LSG): Severe GERD is the most common
cause for revisional surgery after SG.Patients can also suffer from sleeve
dilation and strictures.
(e) Duodenal switch (DS): Malnutrition is one of the most common complica-
tions of DS.Because of the SG associated to the DS, GERD is a possible
complication of the DS.
(f) Vertical banded gastroplasty: Patients with VBG most common complains
are severe GERD, band erosion, stricture, dysphagia, and disruption of the
staple line.
2. Patients who have insufcient weight loss, weight regain, or recurrence of
obesity- related medical conditions after primary bariatric surgery. Prior to any
revisional surgery, all patients with weight regain or insufcient weight loss
should go for consultation with the program psychologist and dietician.
Figure 19.12 shows a decisional owchart according to the index procedure and
the indication for RRBS.
Technical Aspects ofRobotic Revisional Bariatric Surgery
• Access
• Adhesiolysis
– Identication of the surgical anatomy (upper endoscopy)
– Identication of the right crus
• Hiatal hernia repair
• Anatomy
– Takedown
– Reconstruction
Gastric/intestinal stapling (staple size, stomach anatomy, wall thickness)
GI reconstruction (hand-sewn anastomosis)
• Leak test (upper endoscopy)
Setup
Four robotic trocars, a liver retractor, and assist port are utilized in revisional cases.
Setup and port placement for revisional cases are generally similar to the setup for
RYGB.It is recommended to use an assistant port for easy access to bedside suctioning and insertion and removal of sponges/sutures.
19 Revisional Foregut andBariatric Surgery
245
Fig. 19.12 Decisional owchart for revisional surgery. Goals and decisions based on index operation and patient-specic factors
• Arm #1: fenestrated bipolar; stapler
• Arm #2: 3DHD endoscope
• Arm #3: vessel sealer (or SynchroSeal); monopolar scissor; suture cut needle driver
• Arm #4: Cadiere (or Tip-Up)
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M. Nessen and C. A. Galvani
Access/Port Placement/Liver Retraction
The port placement described it is specic for the da Vinci Xi System. Entry into the
abdominal cavity is obtained through a gasless optical technique in the periumbilical area, just to the left of the midline, using an 8mm robotic optical trocar. However,
if history of open surgery, the entry to the abdominal cavity will migrate to the left
upper quadrant, right upper quadrant, and sometimes periumbilical using a Hassan
technique. If gasless technique is used, a 5mm 0/30 degree laparoscope is used for
access and port placement. The rst port is placed in the left mid-abdomen two
ngerbreadths lateral to the umbilicus and one palm-width inferior to the left costal margin.
This port is used for the robotic camera (arm #2). If previous open surgery (mid-
line incision, hernia repair, etc.), the rst entry port is placed left subcostal. From
this position, 2–3 additional trocars are placed along the left midclavicular line.
Depending on the complexity of the adhesions, the robot can be docked to facilitate
and expedite the adhesiolysis (Fig.19.13).
Insufation is started to 15mmHg. Two 8-mm trocars and one 12-mm trocar are
then placed at the same level of the camera port: 12-mm port on the right midclavicular line (arm #1), one on the left midclavicular line (arm #3), and one in the left
anterior axillary line (arm #4). A 5-mm subxiphoid incision is used for the placement of the Nathanson liver retractor. Finally, an assistant port (8mm) is inserted in
between arms #2 and #3 or between #1 and #2 (see Fig.19.2, post placement). At
this point, the robotic surgical cart was approximated into position and the arms are
attached to the four specic trocars. The da Vinci Xi System can be docked from the
patient’s right or left side.
Fig. 19.13 Adhesiolysis.
Early docking of the robot
to facilitate adhesiolysis, as
seen here between pouch
and liver
19 Revisional Foregut andBariatric Surgery
247
Troubleshooting
• If the liver retractor cannot be placed at the beginning of the case due to adhesions, we still dock the robot to expedite the adhesiolysis. Once this is completed, the left lobe of the liver can be retracted using an internal liver retractor
such as a liver sling (see Fig.19.3). This could be done with barbed sutures
between the diaphragm and the abdominal wall.
Surgical Technique
Regardless of the indication for index procedure, robotic-assisted gastric bypass is
the most common revisional procedure in our practice. The most common revisional bariatric procedures are either conversions from LAGB, NAGB, LSG, VBG,
or corrective of the RYGB anatomy due to either pouch/anastomosis dilations or
strictures. Since the specic surgical revision is dependent on the index procedure
for the purpose of this chapter, we will describe general technical aspects that can
be applied in several circumstances. Revisional procedures are performed in one
stage whenever possible.
1. Adhesiolysis
One of the most challenging aspects of bariatric revisional surgery is adhesioly-
sis. Depending on whether the previous procedure was done open or laparoscopic,
the adhesions could form around the midline incision, and most frequently between
the stomach and liver. Other common areas for adhesions are at the angle of His and
around the hiatus and also to retrogastric structures such as the pancreas. In our
experience, the adhesiolysis can be started laparoscopically in order to create
enough space for the insertion of the robotic trocars and docking of the robotic system. However, we try to dock the robot as early as possible to facilitate the adhesiolysis and shorten operative time. Sometimes this can represent starting with two
working arms.
Once the robotic system is docked, the adhesiolysis continues with monopolar
scissors in arm #3 and a fenestrated bipolar instrument in arm #1. The main advantages of the robotic system at this stage of the revisional procedure are self- assisting,
better exposure/visualization of structures, and the articulated energy device. These
benets decrease the incidence of iatrogenic perforations and bleeding. While separating the left lobe of the liver from the anterior stomach, the identication of the
right crus is our main anatomic landmark and will facilitate the recognition of the
anatomy of the hiatus, identication of hiatal hernias, and prevent injuries to vascular structures such as the inferior vena cava (IVC). This portion of the procedure
could be relatively bloody and for that reason the utilization of two energy sources
(arms #1/#3) is a signicant progress from laparoscopic surgery.
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M. Nessen and C. A. Galvani
• The fourth robotic arm gives the console surgeon greater autonomy during
robotic-revisional bariatric surgery by providing tireless self-retraction and
improved exposure.
• The purpose of the bedside assistant is to be able to suction, retract, and insert/
remove sponges and sutures throughout the duration of the case. The assistant
will also help with changing the robotic instruments as needed.
2. Hiatal Hernia Repair
After identifying the right crus, its dissected carefully off the esophagus. This
dissection is typically carried out from anterior to posterior along the right crus
starting at the right side of the phrenoesophageal membrane until fully exposing the
right crus. After complete exposure of the right crus, a retroesophageal window is
created and extended exposing the conuence of the crura. At this point, the Penrose
drain is passed behind the esophagus and used to encircle the esophagus and vagus
nerves. Then attention is focused on the left crura, typically the dissection starts
from posterior to anterior, and is continued in a circular manner around the rim of
the hiatus with complete takedown of the phrenoesophageal membrane. The dissection is continued with a combination of blunt dissection and the vessel sealer until
complete exposure of the left crus is achieved. Transhiatal dissection of the esophagus is started and continued in a cephalad direction. The articulated vessel sealer
device and the fenestrated bipolar grasper are used for the circumferential dissection
of the esophagus. Mobilization of the esophagus can typically be accomplished
using blunt dissection of relatively thin alveolar tissue by exercising traction and
countertraction maneuvers always dissecting away from the esophagus. The esophageal mobilization is completed only after 2–3cm of intra–abdominal esophagus
are observed to be well into the abdomen without tension. The esophagus is retracted
anteriorly and to the left by arm #4, and the vessel sealer is replaced with a suture
cut needle driver. Closure of the diaphragmatic defect is started at the junction of the
right and left crus to decrease tension on every stitch and is carried out anteriorly.
The closure is performed using running nonabsorbable barbed suture. We routinely
utilize a “shoe lacing technique” in order to decrease tension of the repair (see
Fig.19.6).
• The incidence of hiatal hernias during reoperative surgery is much higher than
reported for after primary bariatric surgery. Simultaneous repair of hiatal hernias
during reoperative surgery is warranted.
3. Identication of the Surgical Anatomy (Upper Endoscopy/Tilepro)
At any point during the procedure if the anatomy cannot be dened, upper endos-
copy is used. The TilePro™ feature is used to project intraoperative endoscopic
images onto the console screen. The upper endoscopy can be performed by the
bedside assistant.
19 Revisional Foregut andBariatric Surgery
249
• TilePro is a multi-image video display mode of the da Vinci Xi that allows the
surgeon to simultaneously view up to two additional images, such as intraoperative endoscopy, as a picture-on-picture on the three-dimensional console screen
and assistant monitors (Fig.19.14).
4. Anatomy Take-Down/Reconstruction
After the adhesiolysis is completed and anatomy of the previous surgery is
outlined, the previous anatomy is taken down according to the surgical plan. The
risk of leak after revisional surgery is higher than primary surgery likely due to
the less predictable tissue thickness. For that reason, when using staplers for
resection of previous anastomosis, distal stomach, rst portion of the duodenum,
devascularized stomach, or thickened small bowel, one should use a staple load
with proper height due to chronic inammation and edema scarring. This point
deserves special consideration when using staple line reinforcement. It is also
important to be cognizant of previous staple lines, suture materials, clips, and
silastic/mesh banding that could cause the stapler to jam and cause a misre and
damage the tissue. Irrespective of the index procedure, it is critical to identify
and preserve in the left gastric artery unless an esophago-jejunostomy is the plan
procedure. The Firey feature of the robotic system can facilitate the identication of the vascular supply after intravenous injection of indocyanine green
(Fig.19.15).
Our preference is to use the robotic linear stapler (SureForm60™) with stapler
line reinforcement to decrease bleeding and potentially leaks. The stapler comes
with white, blue, green, and black reloads that can be selected according to the tissue thickness. This stapler also offers a 120-degree cone of articulation that allows
for less tissue pulling and improved tissue transection. In addition, the increased
articulation of the stapler could decrease the need for two 12mm trocars in the eld.
An additional feature of the robotic stapler that is also practical in revisional cases
is the “ForceFire” option. This option becomes available mainly after the tissues are
clamped unsuccessfully due to increased thickness. At this time, the system
Fig. 19.14 Intraoperative
endoscopy. The TilePro™
function can be used to
help delineate anatomy,
such as the location of the
GE junction and to conrm
full reduction of hiatal
hernia