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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_5193_Библиотеки_им_академика_М_И_Перельмана.pdf
344
A. Abou Abbass and M. O. El Helou
pancreas using 3–0 silk sutures using the large suture cut instrument. The duct to
mucosa anastomosis is done with interrupted 5–0 Monocryl over a 5- or 7-French
stent. The technique is the same as open; only the sutures are much shorter (4–6
inches). The camera placement to the right of the umbilicus provides excellent view
for the anastomosis, and the articulated robotic instrument with the magnication
makes it easy to take perfect sutures.
Hepaticojejunostomy (Fig.25.23), Cholecystectomy
Around 15–20cm distal to the pancreaticojejunostomy, an enterotomy is made
in the jejunum and the bile duct anastomosis is made. The bile duct is divided above
the level of the cystic duct sharply with scissors. The cystic duct and artery are
divided but the gallbladder is left in place as it’s sutured to the abdominal wall to
provide exposure. A 4–0 PDS is used, running for the posterior and interrupted for
the anterior layer. Alternatively, a 3–0V-Loc suture can be used to run the whole
anastomosis. The anastomosis is checked for bile leak.
Then the gallbladder is removed off the liver bed with electrocautery and parked
over the liver to be removed later.
Gastrojejunostomy (Fig.25.24)
The transverse colon is lifted up and the mesenteric defect around the jejunum is
closed with sutures. The jejunum is followed distally for around 50cm and brought
over the transverse colon to lie next to the stomach without tension. The GJ is done
using robotic stapler and the common enterotomy is closed with 3–0V-Loc in two
layers. If a pylon preserving Whipple is done, the duodenal apple line is removed,
Fig. 25.23 Completed
hepaticojejunostomy
25 Robotic-Assisted Pancreaticoduodenectomy (Whipple)
Fig. 25.24 Completed
gastrojejunostomy
345
an enterotomy is made, and a single- or double-layer end to side duodenojejunostomy is performed with 3–0V-Loc sutures.
Final Steps
The procedure is almost done. A falciform ap can be harvested and placed over the
pancreatic anastomosis. The robot is undocked. A Pfannenstiel incision is made,
and a wound protector is placed. The two specimens are removed and sent to pathology. The Pfannenstiel incision is closed. The abdomen is insufated for nal look
and check for any bleeding or bile leak. A 19-F Blake drain is brought through the
right-sided trocar and placed anterior to the pancreatico-jejunal and hepato-jejunal
anastomosis. Any 12mm port sites are closed with 0 Vicryl for fascia. All tracers are
then removed, and skin closed.
Vascular Resections
It is important for the surgeon early in the robotic Whipple experience to select
clearly resectable cases without any evidence of vascular invasion. If intraoperatively there appears to be any concerns for venous involvement, the safest thing to
do is to convert to an open procedure. Venous resections however are doable with
the robot. A surgeon can consider attempting a venous resection only after certain
mastery with robotic Whipple has been achieved and the surgeon is experienced
with venous resection and reconstruction open.
The actual venous reconstruction is easy on the robot as there’s a magnied
view and articulated instruments that are suitable for ne suturing. The challenge
is with the dissection as it is more difcult in these cases. The goal is to obtain
346
Fig. 25.25 SMA rst
approach. The SMA is
accessed from the left side.
This is achieved by
retracting the SMV to the
right and the splenic vein
superiorly by vessel loops.
Intraoperative US is very
useful in nding the SMA
in these cases
Fig. 25.26 The tumor has
been dissected off
completely and is only
attached to the PV.Vessel
loops have been placed on
the SMV, PV, and SV
A. Abou Abbass and M. O. El Helou
proximal and distal control of the SMV and PV and any side branches like the
splenic vein. This is achieved by dissecting the tumor with the involved vein en
bloc and then performing the venous resection and reconstruction as the last step.
The tumor shouldn’t be attached to anything else at this point. In these cases, it
might not be feasible to access and dissect the SMA from the right side. In these
cases, the SMA is easier accessed and dissected from the left side, what is called
SMA rst approach (Fig.25.25).
Once the tumor is dissected completely and is only attached to the vein, vessel
loops are placed on the SMV, PV, and splenic vein (Fig.25.26). Vascular clamps are
then placed on each of these vessels, and part of the vein is resected with the tumor
(Fig.25.27).
25 Robotic-Assisted Pancreaticoduodenectomy (Whipple)
Fig. 25.27 Scanlan
bulldogs are easily
introduced into the
abdominal cavity through
12mm trocars and placed
using ProGrasp forceps
Fig. 25.28 Bovine
pericardium patch
347
Most of the time, the tumor is only attached to the lateral vein wall and all what
is needed is a lateral venorrhaphy which can be done with 5–0 or 6–0 Prolene or
Gore-Tex sutures. If there’s a larger defect, then a simple venorrhaphy would narrow the vein and then a bovine pericardium patch can be used (Fig.25.28). If a
circumferential resection of the vein is needed, then a primary end-to-end anastomosis can be done as long as the distance between the two ends is less than 5cm.
For a longer distance, then an interposition graft might need to be used. It might be
better in these situations to open before the portal vein is clamped unless the surgeon is extremely comfortable with both robotic and vascular suturing.
348
A. Abou Abbass and M. O. El Helou
Postoperative Care
The patient is transferred to the surgical oor. An early recovery after anesthesia
(ERAS) protocol is implemented with minimization of narcotics. Foley and NGT
are removed on postoperative day 1. Patients are typically walking in the hallway
the morning after surgery. Patient is started on clear liquid diet and advanced when
patient has return of bowel function. Drain amylase is checked on postoperative day
3 and drain is removed if it’s<3x upper normal blood level. Patient is discharged
when they meet discharge criteria.
Evidence toSupport Robotic Whipple
Robotic Whipple is a relatively new approach, primarily documented by individual
centers detailing early experiences, with the University of Pittsburgh presenting the
most extensive report, showcasing favorable short-term outcomes [21]. Current literature on robotic Whipple is from centers reporting their early experience which emphasizes outcomes within the learning curve, but as experience grows and larger series are
conducted, we anticipate increased support for robotic Whipple. Existing studies on
the robotic approach suggest comparable and even superior outcomes compared to the
open counterpart, with reports highlighting less gastric emptying, less blood loss,
shorter hospital stay, and lower wound infection risk [2, 4, 6]. Oncologic outcomes,
including margins and lymph node harvest, appear uncompromised or potentially
enhanced with the robotic approach, attributed to magnication benets for meticulous dissection around critical vessels like the SMA to get the uncinate margin and to
perform a complete lymphadenectomy [4, 5]. Moreover, the robotic approach holds
promise for improving long-term outcomes by potentially expediting post-surgery
recovery, facilitating prompt initiation of adjuvant chemotherapy, a crucial factor for
enhanced survival in resectable pancreatic cancer patients [18].
Conclusion
Minimally invasive techniques have been slow to integrate into hepatobiliary surgery, particularly for complex procedures like the Whipple operation. However, the
introduction of robotic technology has marked a signicant advancement in this
eld. Robotic surgery is experiencing exponential growth, with an increasing number of surgeons incorporating robotic Whipple procedures into their routine practices. While robotic Whipple surgeries currently exhibit longer operative times and
higher costs, these drawbacks are expected to diminish with improved prociency,
potentially offsetting expenses through reduced hospital stays and fewer complications, particularly those requiring reinterventions. Although the robotic approach
won’t entirely replace open Whipple surgery, it will undoubtedly play a crucial role.
Effective case selection will be key in determining which patients stand to benet
most from each approach.
25 Robotic-Assisted Pancreaticoduodenectomy (Whipple)
Conict of Interest Dr. Ahmad Abou Abbass is a proctor and instructor at Intuitive. There are no
other conicts of interest to disclose.
349
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A. Abou Abbass and M. O. El Helou
Right Hemicolectomy
26
IbrahimH.Ozata andEmreBalık
Introduction
Complete mesocolic excision has recently been the gold standard for the treatment
of nonmetastatic colon cancer demonstrating improved oncological outcomes and
lowered recurrence risk [1–5]. Similarly in the last years, minimally invasive colon
surgery has become increasingly popular meeting the standards established by open
surgery. This includes ligation of the vascular pedicles at their origin, oncologic
lymphadenectomy, and distal and radial clearance of the tumor from the resection
margins. The newest of these techniques is robotic surgery.
Robotic surgery offers great promise due to the fact that it involves smaller incisions,
specialized instruments, and enhanced precision. It enables surgeons to operate with
enhanced dexterity, as the instruments can mimic human hand movements. This results
in improved surgical outcomes allowing for less tissue damage, reduced blood loss, a
lower risk of infection, and shorter patient recovery time compared to open surgery [6].
Indications
Right colectomy is indicated for invasive cancers or noninvasive neoplastic lesions
located in in the right colon that cannot be endoscopically removed. In addition, it
is also performed for appendiceal neoplasm with certain conditions and neoplastic
Supplementary Information The online version contains supplementary material available at
https://doi.org/10.1007/978- 3- 031- 86927- 3_26.
I. H. Ozata
Department of General Surgery, Koç University School of Medicine, Istanbul, Turkey
E. Balık (*)
Maltepe Mahallesi, Zeytinburnu, Istanbul, Turkey
e-mail: ebalik@ku.edu.tr
© 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_26
351
352
I. H. Ozata and E. Balık
polyps where resection margins are incomplete or there is a high risk of nodal
metastasis.
Factors that inuence the decision to perform a right hemicolectomy for appendiceal neoplasms include tumor size, extent of invasion, malignant potential, lymph
node involvement, specic histopathological features, and the presence of certain
types of neoplasms.
An extended right hemicolectomy, characterized by ligation of middle colic pedicle in addition to standard right hemicolectomy, is recommended for lesions that
are located in hepatic exure to mid-transverse colon. This modication is necessary because of the potential for regional lymph nodes metastases around the arterial blood supply.
The surgical approach to colon cancer has been signicantly inuenced by
Hohenberger’s concept of complete mesocolic excision (CME). CME entails meticulous dissection along the avascular embryonic plane separating the parietal retroperitoneum and visceral peritoneum of the mesocolon. This procedure ensures an
adequate longitudinal resection of the bowel and involves ligating the central blood
vessels at the origins of the supplying arteries and draining veins. This precise technique aims to completely remove the mesocolon while preserving its integrity,
adhering to anatomical and embryological principles in order to achieve the best
possible outcomes in terms of cancer treatment. The underlying philosophy of CME
is to apply the principles of total mesorectal excision to surgery involving the colon.
Through the process of dissecting along the embryological planes and ensuring the
complete removal of the mesocolon, CME offers a more thorough and standardized
surgical approach for treating colon cancer.
While there are no absolute contraindications for robotic surgery, conditions
such as severe cardiovascular disease, pulmonary disease, large bulky tumors, intestinal obstruction, and extensive adhesions resulting from previous surgeries are considered relative contraindications in robotic surgery, similar to laparoscopic surgery.
On the other hand, the surgeon’s history and experience with robotic surgery will
also be determinative in both the indication and the decision regarding the surgical
technique.
In light of all these considerations, the surgical technique should be chosen in a
way that maximizes benet to the patient.
Preparation
Obtaining informed consent from patients before surgery is a crucial component of
ethical and legal standards in healthcare. It is essential to prepare the patient psychologically and emotionally for the surgical treatment by informing them of what to
expect, the potential risks and advantages, and any accessible alternatives [7].
Before surgery, patients undergo a thorough evaluation process to achieve the best
possible results. This assessment usually includes a comprehensive review of the
patient’s medical history and an in-depth physical examination. A comprehensive
family history is gathered to uncover any possible hereditary illnesses. Regular
26 Right Hemicolectomy
353
laboratory tests are performed, which involves measuring carcinoembryonic antigen levels to establish a reference point and employ it for the purpose of monitoring.
Radiographic staging is an essential part of the preoperative assessment, which
includes a CT scan of the chest, abdomen, and pelvis using both oral and intravenous contrast to precisely determine the disease’s severity. If abnormalities are
found on the CT scan that need more explanation for surgical planning, MRI and
PET scans may be used as needed. Additionally, it is crucial to conduct a comprehensive examination of the colon, including histologic study of any detected lesions,
before starting treatment. Preoperative medical consultation is requested to assess
the patient’s risk level according to their medical history. This thorough preoperative assessment guarantees that patients are well prepared for surgery and that necessary steps are implemented to enhance their surgical results.
Patients are initiated on a clear diet the day before surgery, along with bowel
preparation and oral antibiotics. Castagneto-Gissey etal. [8] conducted a study that
examines the relationship between mechanical bowel preparation with oral antibiotics before to elective colorectal surgery and its effects on surgical site infections and
anastomotic leaks [8]. The meta-analysis examined 13 randomized clinical studies
with 4334 participants and concluded that combining mechanical bowel preparation
with oral antibiotics was associated with reduced rates of anastomotic leakage and
surgical site infections. Using bowel preparation along with oral antibiotics is
offered to avoid postoperative complications. A technical concern regarding this
topic is that bowel preparation decreases feces bulk, which consequently results in
diminished contamination when utilizing stapler devices during anastomosis.
Additionally, manipulating the colon during dissection and anastomosis will be
facilitated with more space in the abdomen.
At our institution, we do not administer oral bowel cleansing. Despite the existence of studies recommending it, we prefer for cleansing using enemas.
Low molecular weight heparin is recommended for prophylaxis before and after
surgery. Additionally, to reduce the risk of thromboembolism, it is advised to use
intraoperative sequential compression devices and encourage early ambulation [9].
Patient Positioning
The patient is placed on an anti-slip surface in a supine position. During general
anesthesia, care should be taken not to give excessive air to the stomach and the
small bowel. Additionally, an orogastric catheter should be inserted to deate the
stomach and to prevent loss of space. A urinary catheter is inserted to monitor, prophylactic antibiotics are administered on induction, and sequential compression
devices are used for deep vein thrombosis prophylaxis. The patient is sterilized and
draped. The robot is positioned on the right side of the patient (Fig.26.1). When
docking and positioning the robot, careful attention must be paid to the maintenance
of each body part. Over the years, the table motion technology of the Da Vinci
robotic surgery platform has made signicant breakthroughs. The da Vinci Xi
Surgical System is equipped with Integrated Table Motion, which allows for the