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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_734_Библиотеки_им_академика_М_И_Перельмана.pdf
376
Fig. 21.6 Gastrohepatic
ligament dissection. CHA
common hepatic artery
Fig. 21.7 Hepatoduodenal
dissection. IVC inferior
vena cava, PHA proper
hepatic artery, CHA
common hepatic artery,
GDA gastroduodenal artery
S. Ross et al.
• The proper hepatic artery and gastroduodenal artery (GDA) are next identied,
and lymph node dissection is ensued along the porta hepatis (Fig.21.7).
• The GDA is clipped and divided following a test-clamp that veries pulsation
along the proper hepatic artery (Fig.21.8). A silk suture is placed to secure the
clips to the GDA stump.
• Tips and key points:
– Retraction of the pancreas caudally using arm #4 for better exposure.
– Intraoperative viewing the coronal section of the CT scan arterial phase is
useful to anticipate the course of the CHA, the GDA, the hepatic artery proper,
and any other aberrant vasculature.
– Meticulous dissection of the GDA using the hook cautery is key.
21 Robotic Pancreatoduodenectomy
Fig. 21.8 Division of
gastroduodenal artery
(GDA)
Step 3: Gastrocolic Ligament Dissection
andDuodenal Transection
• Arms setup:
– Arm #1: Fenestrated bipolar
– Arm #2: Camera
– Arm #3: Monopolar scissors, vessel sealer
– Arm #4: Small grasping retractor (bowel grasper)
– Bedside assistant: bowel grasper, suctioning device
377
• The stomach is retracted cephalad by the bedside surgeon using a bowel grasper
while the transverse colon is retracted caudally using arm #4. The gastrocolic
ligament is dissected and the dissection is carried on along the greater curvature
of the stomach while preserving the gastroepiploic arcades.
• The dissection continues toward the duodenum while gastro-pancreatic attach-
ments are being divided. The right gastroepiploic artery and vein are identied
and divided using the vessel sealer.
• When the duodenum is fully exposed, it is transected 2–3cm post pyloric using
a robotic blue load EndoWrist Stapler 45mm with SmartClamp™ technology
(Intuitive Surgical, Sunnyvale, CA, USA) (Fig. 21.9). The stomach is then
retracted toward the left upper quadrant to fully expose the head and neck of the
pancreas.
Step 4: Pancreatic Transection
• Arms setup:
378
Fig. 21.9 Duodenal
transection
Fig. 21.10 Pancreatic
transection. SMV superior
mesenteric vein
S. Ross et al.
– Arm #1: Fenestrated bipolar
– Arm #2: Camera
– Arm #3: Hook cautery
– Arm #4: Small grasping retractor (bowel grasper)
– Bedside assistant: suctioning device
• Dissection is carried along the inferior edge of the pancreatic neck using a hook
cautery and the superior mesenteric vein (SMV) is identied.
• A gentle blunt dissection using the fenestrated bipolar separates the SMV from
the pancreatic neck. This is followed by hook cautery to transect the pancreatic
neck (Figs.21.10 and 21.11).
• The transection of the pancreas begins at the inferior border and carried along in
the cephalad direction and parallel to the SMV while arm #4 retracts the meso-
colon caudally.
21 Robotic Pancreatoduodenectomy
Fig. 21.11 Pancreatic
transection, completed. PV
portal vein, SV splenic
vein, SMV superior
mesenteric vein
379
• The bedside surgeon may use the suctioning device to carefully retract and pro-
tect the SMV and portal vein (PV) during the transection.
• Tips and key points:
– Try to identify the pancreatic duct during the transection. Typically, when the
PD is blocked, a sudden outow of clear uid is seen when entering the duct.
– During pancreatic transection, make sure to identify the common hepatic
artery and the GDA stump to avoid inadvertent injury to these structures.
Step 5: PV/SMV andUncinate Process Dissection
• Arms Setup:
– Arm #1: Vessel sealer, fenestrated bipolar (needle driver as needed)
– Arm #2: Camera
– Arm #3: Hook cautery, vessel sealer, medium size clip (needle driver and scis-
sors as needed)
– Arm #4: Small grasping retractor (bowel grasper)
– Bedside assistant: bowel grasper and suctioning device
• Retract the mesenteric vessels medially using arm #4 to further expose the
attachments between the head of the pancreas and the PV/SMV. Dissect these
attachments using the hook cautery (Fig.21.12)
• While the bedside surgeon lifts cranially the proximal jejunum, use the vessel
sealer with arm #1 to divide the jejunal mesentery toward the SMV/SMA
(Fig.21.13)
• Continue dissection along the PV/SMV in a caudal to cephalad direction. Use
the vessel sealer or hook cautery in arm #3 to separate the uncinate process from
380
Fig. 21.12 Uncinate
process dissection
Fig. 21.13 Jejunal
mesentery dissection
S. Ross et al.
the PV/SMV. Use clips to divide large pancreaticoduodenal vessels or suture
ligation (Fig.21.14)
• Tips and key points:
– This is the hardest part of the dissection. It should be done with great caution.
Depending on the location of the tumor and the level of the inammatory
process, this step may be completed in a different order.
– View the CT scan intra-op to anticipate the course of the major blood vessels
and their branches as well as to rule out aberrant blood supply.
– During the dissection of the uncinate process along the PV/SMV, identify the
SMA and make sure it is not over-retracted laterally. An injury to this vessel
can result in major bleeding or unnecessary conversion.
21 Robotic Pancreatoduodenectomy
Fig. 21.14 Uncinate
process dissection
– In a case of a replaced right hepatic artery, it is crucial to identify and pre-
serve it.
– When the dissection between the SMV/PV and the uncinate process is chal-
lenging, you may use the back side of the robotic hook to gently dissect these
structures.
381
Step 6: CHD Transection andCholecystectomy
• Arms setup:
– Arm #1: Fenestrated bipolar
– Arm #2: Camera
– Arm #3: Vessel sealer, hook cautery
– Arm #4: Small grasping retractor (bowel grasper)
– Bedside assistant: Suctioning device
• Identify the common bile duct and continue dissection toward the common
hepatic duct (CHD).
• Complete lymphadenectomy next to the bile duct and the portal vein.
• Transect the hepatic duct, remove biliary stent if present (Fig.21.15).
• Expose the cystic artery and cystic duct and complete cholecystectomy.
• Once the hepatic duct is transected, the specimen is completely disconnected. It
is removed through a laparoscopic EndoCatch Bag (Applied Medical, Rancho
Santa Margarita, CA) inserted through the gel port.
• All specimen margins are marked and sent for pathological evaluation.
• Resection margins of pancreatic neck, distal CHD, and duodenum are sent for
frozen sections which may dictate further resection.
382
Fig. 21.15 CHD
transection
S. Ross et al.
Reconstruction
All anastomoses are done using a jejunal loop in a retro-mesenteric approach. The
rst anastomosis is the hepaticojejunostomy, followed by the pancreaticojejunostomy and the duodenojejunostomy. Arm setup for all anastomoses is the same.
• Arm #1: Needle driver
• Arm #2: Camera
• Arm #3: Monopolar scissors/megacut/needle driver
• Arm #4: Small grasping retractor (bowel grasper)
• Bedside surgeon: Needle driver, suction device
Hepaticojejunostomy
• Place the jejunal limb at the right direction where the stapler line is next to the
pancreatic neck and the bowel courses along the pancreas to the hepatic duct.
• Approximately 10–12cm distal to the staple line, make a 5–10mm incision on
the anti-mesenterial side of the bowel using monopolar scissors.
• We use two 3-0 absorbable V-loc™ sutures (Medtronic™, Minneapolis, MN,
USA), 6–9 inches in length, starting at the 9 o’clock position (lateral side) to the
3 o’clock position (medial side)
• Begin with the posterior aspect of the anastomosis by passing full-thickness
sutures from the extra-luminal to the intra-luminal surface of the bowel and from
the intra-luminal to the extra-luminal surface of the transected CHD (out-in,
in-out).
21 Robotic Pancreatoduodenectomy
383
• Using additional 3-0 or 4-0 absorbable V-Loc™ sutures, the anterior surface is
sutured in a similar technique.
• In cases where the CHD is not dilated, a longitudinal ventral incision of the duct
may increase the surface area of the anastomosis (Fig.21.16).
• Once reaching the 3 o’clock position, both sutures are tied (Fig.21.17).
Fig. 21.16 Hepaticojejunostomy using a longitudinal ventral incision
Fig. 21.17 Hepaticojejunostomy, completed
384
S. Ross et al.
Pancreaticojejunostomy
• The jejunal limb is approximated to the pancreatic neck, the pancreatic duct is
identied and accordingly, a small enterotomy is made for the anastomosis.
• The rst layer is done using a running non-absorbable 3-0 V-lock™ starting on
the superior part of the pancreas (Fig.21.18).
• The rst stitches are full thickness of the pancreatic substance. When reaching
the pancreatic duct, we continue suturing the posterior wall only to avoid compressing the pancreatic duct.
• The inner layer includes interrupted 4-0 absorbable V-Loc™ sutures starting at
the posterior side of the pancreatic duct. Four to ve sutures are placed to complete the duct-to-mucosa layer (Fig.21.19).
• A second running 3-0 non-absorbable V-Loc™ suture is then used to form the
anterior-outer layer between the pancreatic parenchyma capsule and the
seromuscular layer of the jejunal limb when the anterior and posterior outerlayer sutures are eventually tied together (Fig.21.20).
Fig. 21.18 Pancreaticojejunostomy
21 Robotic Pancreatoduodenectomy
Fig. 21.19 Pancreaticojejunostomy, inner layer
385
Fig. 21.20 Pancreaticojejunostomy, completed
Ligament ofTreitz Restoration
• A 3-0 non-absorbable V-Loc™ suture is used to adhere the small bowel to a
supercial layer of the transverse mesocolon, thus closing the Treitz-mesentery
defect and preventing internal herniation of the small bowel.
• This suture is placed supercially to prevent injury to the bowel mesentery.