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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_794_Библиотеки_им_академика_М_И_Перельмана.pdf
Robotic Gastrectomy and D2Lymphadenectomy
Woo Jin Hyung, Yanghee Woo
Robotic surgery is a successful approach to the management of curable patients with gastric
cancer. Since the rst laparoscopic radical gastrectomy was reported by Kitano etal. in 1994, the
minimally invasive approach for gastric cancer surgery has gained favor as the procedure of choice
for many experts. Minimally invasive radical gastrectomy oers the benet of shorter hospital
stay, decreased postoperative pain, earlier return of bowel function, and less blood loss than open
gastric cancer operations. e widespread application of the laparoscopy in gastric cancer surgery, however, has been limited owing to the technical complexity of a radical gastrectomy with
extended lymphadenectomy (LND) and the concerns about maintaining oncological principles
during the laparoscopic procedures.
Gastric cancer surgeons are adopting the robotic technology of the da Vinci Surgical Systems
to assist in the technically challenging procedure of radical gastrectomy with extended LND. e
technical advantages of the improved three-dimensional magnied operative view, the precision
of the tremor lter and articulating instruments, along with the ability of the surgeon to control
four arms provide the surgeon with superior control over the entire procedure. Robotic surgery
for gastric cancer has been demonstrated to be safe and feasible with an expected shorter learn
ing curve. e data from retrospective studies and limited prospective comparisons support the
hort-term benets of robotic gastrectomy (RG) to be comparable with those of laparoscopy and,
s
when compared with open surgery, to oer the advantages of the minimally invasive approach.
Moreover, adherence to the oncological principles of gastric cancer treatment, such as the no-touch
technique, negative margins, and adequate lymph node (LN) dissection is being practiced using da
Vinci Surgical Systems (Intuitive Surgical, Sunnyvale, California, USA).
Debate continues on the eciency of robotic radical gastrectomies, however, because the disadvantages such as longer operative time, limited training opportunities, and increased cost of the
r
obotic system fuel the controversies. In the absence of randomized trials evaluating the operative
morbidity, mortality, long-term outcome, quality of life, and cost-eectiveness of RG, the decision
to perform RG is based largely on the perceived advantages for the surgeon conferred by the new
technology and the known improved postoperative patient outcomes of minimally invasive surgery.
Robotic radical gastrectomy is a sound minimally invasive option for the surgical treatment
of gastric cancer patients with the potential for great benet for both the surgeon and the patient.
As surgeons become increasingly sophisticated in the use of emerging robotic technology, robotic
surgical treatment of gastric cancer patients will evolve in the years to come.
Since the robotic approach to gastric cancer treatment was initially reported in 2003, surgeons
at experienced centers have adopted robotic radical gastrectomy as a minimally invasive alternative
to laparoscopy. As with all gastric cancer operations, robotic radical gastrectomy must adhere to
the oncological principles governing the treatment of gastric cancer requiring a multidisciplinary
treatment strategy, complete preoperative evaluation, and intensive operative planning. RG and LND
requires thorough knowledge of the vascular anatomy of the stomach and the accompanying nodal
stations as dened by the Japanese Gastric Cancer Association (JGCA). e steps of the operative
procedure are explained relative to the dissection of the LN stations in D2LND.
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P.-A. Clavien, M. G. Sarr, Y. Fong, M. Miyazaki (Eds.), Atlas of Upper Gastrointestinal and Hepato-Pancreato-Biliary Surger y,
DOI 10.1007/978-3-662-46546-2_37, © Springer-Verlag Berlin Heidelberg 2016
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Section II • Esophagus, Stomach, and Duodenum
Indications
Indications for robotic radical gastrectomy are the same as for laparoscopic gastric cancer operations. Currently, minimally invasive radical gastrectomy is recommended for early gastric cancer
based on the Japanese gastric cancer treatment guidelines.18 In practice, the indications have been
expanded to locally advanced gastric cancer according to surgeon’s experience and expertise.
Indications for RG with limited LND: pT1a, pT1b, pN0. Mucosal and submucosal tumors
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that do not meet criteria for endoscopic resection or have failed treatment with endoscopic
mucosal resection or endoscopic submucosal dissection
Indications for RG requiring D2LND: pT1N1M0, pT2N0/N1M0, pT3N0/N1/N2M0
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Expanded indication for RG requiring D2: pT4a
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Relative contraindications to RG
Extensive lymphadenopathy
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cT4a (serosa-positive tumors)
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Absolute contraindications to robotic gastric cancer operations are the same as those of the laparoscopic approach.
Preoperative staging of T4b or distant metastasis
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Inability to tolerate general anesthesia
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Refractory coagulopathy
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Hemodynamic instability
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Preoperative Evaluation
e preoperative evaluation of patients includes comprehensive work-up of the patient’s clinical
status, pathological conrmation of the diagnosis, the localization of the tumor, and determination of the extent of disease. For thorough preoperative surgical planning, the following tests are
required:
Upper endoscopy with biopsy
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Endoscopic marking of the proximal edge of tumor
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Endoscopic ultrasound
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CT scan of the abdomen
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Patient Positioning, Port Placement, Robot Docking
Under general anesthesia, the patient is placed in the supine position with both arms tucked to the
patient sides and the table in 15° reverse Trendelenburg position (. Fig. 37.1a). e abdomen is
prepared from the nipple line to the suprapubic region as widely as possible. e operation is performed with ve ports (two 12 mm and three 8 mm) placed in a V-shaped position (. Fig. 37.1b).
e port placements are adjusted to account for the patient’s body habitus; especially, the No.2
arm robot trocar on the patient’s right midclavicular line should be placed just caudal to the level
of the duodenum. e robot surgical cart is brought directly over the head of the patient parallel
to the operating table and the robot arms are docked (
Infraumbilical port (. Fig. 37.1b) is the camera arm.
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No.1 arm holds the Maryland curved bipolar graspers.
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Nos. 2 and 3arms hold the ultrasonic shears or a monopolar device and the Cadiere for-
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ceps, interchangeably.
. Fig. 37.1c).
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Chapter • Robotic Gastrectomy and DLymphadenectomy
. Fig.37.1
Liver retraction
e liver is retracted to facilitate exposure of the hepatoduodenal ligament, the lesser curvature
of the stomach, the suprapancreatic area, and the gastroesophageal junction. Whereas several
self-sustaining liver retraction methods have been described, we prefer the gauze-suspension
method.
Procedure of D2LN Dissection During Distal Subtotal Gastrectomy
Five essential steps and associated anatomical landmarks
1. Left side dissection
e Cadiere forceps in the third robot arm is used to retract the stomach cephalad and toward
the anterior abdominal wall to create a draping of the greater omentum. is lis the omentum
away from the colon and exposes the gastrocolic ligament for safe division and retrieval of LN
stations No. 4sb and 4d.
Using an energy device like the harmonic ultrasonic shears, enter the lesser sac in the area
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of the midtransverse colon and the divide greater omentum toward the lower pole of the
Section II • Esophagus, Stomach, and Duodenum
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spleen (. Fig. 37.2a). e dissection is facilitated with repositioning of the Cadiere forceps
and the use of the Maryland bipolar grasper to gain greater exposure between the stomach
and pancreas. Take down the adhesions between the posterior stomach and the anterior
surface of the pancreas.
Carefully identify and isolate the le gastroepiploic vessels at its root during the proximal
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dissection and ligate using clips or an energy device (
along greater curvature of the stomach from the proximal resection margin to the short
gastric vessels because it contains part of the No.4sb nodal station.
. Fig. 37.2b). en clear the so tissue
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. Fig.37.2
2. Right side dissection
e dissection of the right side of the patient is performed by mobilizing the distal stomach and
2 cm of the proximal duodenum from the head of the pancreas. At this time care is taken to dissect the so tissues containing LN station No.6, which is bordered by right gastroepiploic vein
(RGEV) and anterior superior pancreaticoduodenal vein (ASPDV). Exposure is gained in this
area using the third arm to li the stomach in the area of the pylorus along the greater curvature
away from the head of the pancreas.
Again using the Maryland bipolar grasper to dissect out the layers and harmonic ultrasonic
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shears to divide with hemostasis, dissect the so tissues leading to the head of the pancreas
in layers until the RGEV is identied. Isolate the RGEV, ligate, and divide it as it joins the
ASPDV (
Continue clearing of the so tissue in the area to identify, ligate, and divide the right gastro-
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epiploic artery (RGEA) as it branches from the gastroduodenal artery (GDA). e infrapyloric artery may be encountered during this portion of the dissection and should also be
ligated using clips or an energy device.
Next, release the attachments between the posterior duodenum and the pancreas along the
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GDA until the common hepatic artery (CHA) is reached.
Insert a 4"× 4" gauze anterior to the head of pancreas to protect the GDA from injury during
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the suprapancreatic dissection (
Clear the supraduodenal region approximately 2 cm distal to the pylorus and divide the
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proximal duodenum using an Endo-linear stapler (
. Fig. 37.3a).
. Fig. 37.3b).
. Fig. 37.3c).
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Chapter • Robotic Gastrectomy and DLymphadenectomy
. Fig.37.3
3. Suprapancreatic dissection
At this time, LN dissection is performed in the hepatoduodenal region and the suprapancreatic
area en bloc by meticulous dissection along the vessels using a combination of harmonic shears
and the Maryland bipolar grasper. e Cadiere forceps is again used for retraction and exposure
as needed. Retracting the stomach to the patient’s le and slightly toward the anterior abdominal
wall, and identify the right gastric vessels on tension.
Dissect along the anterior surface of the proper hepatic artery (PHA) to identify and divide
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the right gastric artery (RGA) at its origin and retrieve LN station No.5.
Clear the so tissues containing LN station No.12a by dissecting anteriorly and medially to
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the PHA until the portal vein (PV) is exposed medially (
area can be facilitated by the bedside assistant who gently retracts the PHA to the patient’s
right for the CHA inferiorly.
Continue to clear the so tissues around CHA that contain LN station No.8a
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(
. Fig. 37.4b).
Retract the stomach to expose the lesser curvature and note the le gastric vein as so
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tissue is cleared from this area. Divide the le gastric vein as it drains into the portal vein.
(In some patients the le gastric vein can be found draining anteriorly into the splenic
vein.)
. Fig. 37.4a). e exposure in this
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Section II • Esophagus, Stomach, and Duodenum
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. Fig.37.4
4. Dissection around the left gastric artery and skeletonization of the splenic vessels
e retroperitoneal dissection of the so tissues along the le gastric artery (LGA), celiac trunk,
and splenic vessels permits retrieval of LN station Nos.7 and 11p, respectively (
Improve exposure to access the root of the LGA by dividing the retroperitoneal attachments
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to the lesser curvature of the stomach.
Expose and place clips on the root of the LGA before diving the LGA leaving two clips on
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the patient side (
Continue the dissection with skeletonization of the CHA toward the celiac axis and retrieve
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the so tissues containing LN station No.9 around the celiac artery (
Aer moving the stomach to the le upper quadrant, skeletonize the anterior and supe-
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rior surfaces of the splenic artery. As the so tissue is lied away from the artery, superior
dissection helps expose the anterior surface of the splenic vein. (Once the midpoint of the
splenic vessels or the posterior gastric is reached, the dissection of LN station No.11p is
complete.) (
. Fig. 37.5a).
. Fig. 37.5c).
. Fig. 37.5a,b).
. Fig. 37.5b).
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. Fig.37.5
Chapter • Robotic Gastrectomy and DLymphadenectomy
5. Lesser curvature dissection and proximal resection
e lesser curvature of the stomach is released from the retroperitoneum up to the esophageal
crus (
. Fig. 37.6).
To expose this area, have the assistant retract the mobile stomach to the patient’s le and
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clear the so tissues along the right side of the intra-abdominal esophagus, the right cardia,
and the lesser curvature of the stomach.
Perform the truncal vagotomy at this time by dividing the anterior and posterior vagus
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nerves. is completes the dissection of LN stations Nos.1 and 3.
Aer the stomach is fully mobilized, transect the stomach using a 60-mm blue load Endo-
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linear stapler ensuring sucient proximal margin. (Additional load for the stapler may be
required.)
is completes the procedure of robotic D2LND for distal subtotal gastrectomy.
. Fig.37.6
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Section II • Esophagus, Stomach, and Duodenum
Reconstruction
e extent of gastric resection and the surgeon’s preference guide the appropriate selection of
gastrointestinal reconstruction method. Depending on the size of the remnant stomach, we perform a gastroduodenostomy, loop gastrojejunostomy, or Roux-en-Y gastrojejunostomy to restore
gastrointestinal integrity aer robotic gastric resections. Most distal gastrectomies involve the
removal of two thirds of the stomach and usually require a gastrojejunostomy.
Loop gastrojejunostomy
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Once the specimen is completely resected and margins of resection are satisfactory, the reconstruction begins by inspecting the size of the remnant stomach and the mobility of the jejunal loop to
be used for reconstruction.
Prepare the greater curvature of the stomach by clearing at least 6 cm of the serosal surface
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proximally from the staple line. At times, the rst set of short gastric artery may need to be
ligated and divided. If so, the gastric remnant may be too small for a loop gastrojejunostomy
Bring up a loop of jejunum 15 to 20 cm from the ligament of Treitz with the proximal
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jejunal end aligned with the proximal remnant stomach greater curvature (
loop can be passed either antecolically or retrocolically through the transverse mesocolon.
Create a gastrotomy and jejunotomy to accommodate the insertion of the Endo-linear sta-
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pler load to enter through the le-sided assist port in the proximal to distal bowel orientation (
. Fig. 37.7b).
Close the common enterotomy with the stapler coming in from the right side of the patient.
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In order to perform this part of the procedure, the No.2 arm of the robot needs to be
undocked and the 8-mm robot port switched out for a 12-mm trocar, which will accommodate the Endo-linear stapler (
Alternative option is to suture closed the common enterotomy using robotic assistance.
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Switch out the harmonic ultrasonic shears and the Maryland bipolar with needle drivers.
Use the third arm to position the common enterotomy and close the enterotomy using running 2-0Vicryl and 3-0silk sutures.
. Fig. 37.7c).
. Fig. 37.7a). e
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Chapter • Robotic Gastrectomy and DLymphadenectomy
. Fig.37.7
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Section II • Esophagus, Stomach, and Duodenum
Roux-en-Y Gastrojejunostomy
To limit bile esophagitis and gastritis aer vagotomy and distal gastrectomy, some surgeons prefer
Roux-en-Y gastrojejunostomy as the method of choice for reconstruction.
Transect the jejunum 15 to 20 cm from the ligament of Trietz using the Endo-linear stapler
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and bring up the distal jejunum either antecolically or retrocolically and position the antimesenteric side of the jejunum side by side with the greater curvature of the stomach with
the stapled end of the jejunum proximally placed.
Create a gastrotomy in the proximal edge of the cleared greater curvature and an enter-
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otomy on the antimesenteric edge of the jejunum near the staple line.
Carefully pass the Endo-linear stapler through the enterotomies, approximate the two
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edges, and re the stapler. Close the common enterotomy in two layers using robotic needle
holders.
Measure 50 to 60 cm from the gastrojejunal anastomosis and line up the biliary jejunal limb
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and the enteric limb using the robotic grasper and Maryland bipolar grasper. Make enterostomies and create a stapled side-to-side anastomosis using the assist port to introduce the
stapler. Close the common enterotomy with two-layer running sutures.
Verify the orientation of the reconstructed small bowel.
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