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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_794_Библиотеки_им_академика_М_И_Перельмана.pdf
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Section I • General Principles
Sealers including PK dissecting forceps, Vessel Sealer
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Staplers
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Clip applier
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b) Straight instruments designed specically for robotic surgery:
Harmonic scalpel
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Suction/irrigator
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Fluorescence imaging
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c) Laparoscopic instruments used through an assistant port:
Graspers
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Retractors
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Suction
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Staplers
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Ultrasound probe
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d) Instruments used percutaneously:
Sutures for retraction
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Ablation devices
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Biopsy devices
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Contingency Plans for Emergency Conversion
One concern in robotic surgery is making an emergency conversion to an open procedure if severe
hemorrhage occurs. It generally will take longer to convert to open surgery from robotic than laparoscopic surgery, because (1) the robot is docked and is an obstacle to conversion, (2) the primary
surgeon is not at the surgical table, (3) anesthesia personnel are generally more remote from the
patient, and (4) the open surgical instrumentation may not be nearby and is not open for use.
Having a contingency plan for conversion to an open procedure increases the likelihood of
a favorable outcome. Implementing and rehearsing such a plan is essential. Having a “Robotic
Emergency Timeout” as part of every robotic case ensures availability of emergency instruments
and blood products and that all personnel involved understand the plan for emergency conversion
and their role in the process.
ere should be an instrument set available for emergency conversion that should include
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standard open surgical instruments and vascular surgical instruments.
ere should be self-retaining retractors available to provide exposure such as a ompson
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or Goligher retractor.
ere should be a list of standard vascular sutures and staplers that are made immediately
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available.
In cases in which hemorrhage is likely, consideration should be given to placing a gel port at
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the start of the operation to allow for rapid, manual tamponade of bleeding. Such a gel port
insertion site can be used for specimen extraction.
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Emergency Conversion Timeout should be performed at the beginning of each robotic surgical
case, and should include the following elements:
Delineation of personnel responsibility including who will maintain tamponade, perform
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resuscitation, undock the robot, and make the open incision.
Check to be sure emergency conversion instruments, retractors, vascular sutures, and sta-
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plers are readily available or in the room.
Check that necessary blood products for potential resuscitation are available.
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List other personnel who may be called to assist in an emergency such as vascular surgeons.
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Laparoscopic Versus Robotic
In the past two decades, laparoscopic surgery has transformed modern surgery dramatically. Numerous studies have shown these techniques to have resulted in decreased length of hospital stays,
im
proved postoperative pain, better postoperative immune function resulting in fewer surgical infections, and improved cosmetic results when compared with similar open procedures. For these reasons
minimally invasive techniques have become accepted by surgeons, patients, and insurance companies.
Chapter • Introduction to Robotic Surgery
within the abdominal cavity and surgeons are forced to watch a two-dimensional video representation of a three-dimensional operative eld. In addition laparoscopic instruments provide
surgeons with decreased haptic feedback and poor ergonomics. ese limitations make complex
dissections and anastomosis dicult. ere is also a substantial learning curve to develop and
maintain advanced laparoscopic skills. e shortcomings of laparoscopic surgery were the driving
force behind the development of robotic surgery.
scopic procedures with greater ease and less technical training. e robot’s articulating instruments
allow laparoscopic instruments to move with handlike motions. Performing delicate dissection
and intracorporeal suturing is made possible by the steady camera platform, three-dimensional
imaging, resting tremor ltration, the removal of tremor and motion artifact, and comfortable
ergonomics provided for the surgeon. e signicant advantages of robotic surgery are expanding
the scope of surgical procedures being performed through minimally invasive techniques. e
robot, however, as currently designed, provides much less haptic feedback to the surgeon because
of the computer interface between the surgeon’s hands and the patient. Visual experience with
tension and force during formal laparoscopy is essential for the robotic surgeon.
Nevertheless laparoscopic surgery has limitations. ere is a decreased freedom of movement
Unlike laparoscopic surgery, robotic surgery allows surgeons to perform advanced laparo-
. Table7.1 Advantages and Disadvantages of Open, Laparoscopic, and Robotic Surgery
Open Surgery Laparoscopic Surgery Robotic Surgery
Advantages Long track record Well-developed technol-
Most aordable Widely deployed Improved dexterity
Easy control of bleeding Proven indications Tools with multi-degrees
Easy sewing Established teaching/cre-
Disadvantages Large incision Loss of touch sensation Loss of touch sensation
Evaporative losses Fulcrum eect Very expensive
Divided cutaneous nerves Expensive High start-up cost
Compromised muscular
function
Compromised post-op
respiratory function
Tricks of the Senior Surgeon
Transcutaneous sutures may be used to retract various organs and minimize the number of
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ports required.
Using a smoke evacuator is very helpful in cases in which many energy devices are used for
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hemostasis and maintains the advantages of clear, three-dimensional vision.
“Port in port” and “port in gel port” strategies allow exibility of use of alternating between
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robotic and laparoscopic instrumentation while minimizing number of ports.
Drop-in ultrasonography probes allow facile delineation of target lesions and may mitigate
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the loss in tactile sensation.
Use of a skilled assistant can be crucial for exposure.
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ogy
dentialing
Amplied tremor
Learning curve
Dicult sewing Training and creden-
3D visualization
of freedom
Elimination of fulcrum
eect
Elimination of tremors
Adjustable scaling
Telesurgery
Ergonomic
Requires skilled assistant
Unproven benet
tialing not uniform
Dicult emergency
conversions
Esophagus, Stomach,
and Duodenum
Jakob R. Izbicki, Michael G. Sarr
Chapter 8 Introduction: Esophagus, Stomach, and Duodenum – 57
Jakob Izbicki, Michael G. Sarr
Chapter 9 Cervical Esophagectomy – 59
Rainer Schmelzle, Phillip Pohlenz
Chapter 10 Left Thoracoabdominal Approach for Carcinoma
of the Lower Esophagus and Gastric Cardia – 67
Shoji Natsugoe, Takashi Aikou
II
Chapter 11 Subtotal Esophagectomy: Transhiatal Approach – 75
Matthias Reeh, Emre F. Yekebas, Jakob R. Izbicki
Chapter 12 Subtotal Esophagectomy: Abdominothoracic Approach – 89
Michael F. Nentwich, Asad Kutup
Chapter 13 Laparoscopic and Conventional Limited
Resection of the Gastroesophageal Junction with
Isoperistaltic Jejunal Interposition – 99
orsten Dohrmann, Oliver Mann, Jacob R. Izbicki
Chapter 14 Three-Field Lymphadenectomy for Esophageal Cancer – 107
Takashi Aikou
Chapter 15 Minimally Invasive Esophagectomy – 113
Jonathan D’Cunha, David D. Odell,
Ryan M. Levy, James D. Luketich
Chapter 16 Treatment of Zenker Diverticulum – 129
Yogesh Vashist, Stefan Groth, Uwe Seitz
Chapter 17 Epiphrenic Diverticula – 137
Chris G. Collins
Chapter 18 Techniques of Local Esophagoplasty in
Short Esophageal Strictures – 145
Asad Kutup, Emre F. Yekebas, Jakob R. Izbicki
Chapter 19 Operation for Achalasia – 149
Luigi Bonavina, Alberto Peracchia
Chapter 20 Subtotal Gastrectomy, Antrectomy, BillrothII,
and Roux-en-Y Reconstruction and Local Excision
in Complicated Gastric Ulcers – 153
Dean Bogoevski, Enrique Moreno Gonzalez,
Carmelo Loinaz, Dr. Reeh Matthias
Chapter 21 Total Gastrectomy with Conventional
Lymphadenectomy – 169
Jürg Metzger
Chapter 22 Total Gastrectomy with Radical Systemic
Lymphadenectomy (Classic Japanese Style D2) – 183
Mitsuru Sasako
Chapter 23 Abdominothoracic Esophagogastrectomy – 191
Enrique Moreno-Gonzalez, Carmelo
Loinaz, Carlos Jiménez-Romero
Chapter 24 Abdominothoracic Esophagohemigastrectomy – 209
Michael F. Nentwich, Dean Bogoevski
Chapter 25 Transhiatal Esophagohemigastrectomy – 215
Dean Bogoevski, Jakob R. Izbicki
Chapter 26 Extended Gastrectomy – 233
Asad Kutup, Jakob R. Izbicki
Chapter 27 Laparoscopic Gastrectomy – 239
Geert Kazemier
Chapter 28 Laparoscopic and Conventional Gastroenterostomy – 247
John Tsiaoussis; Gregory G. Tsiotos
Chapter 29 Percutaneous Endoscopic Gastrostomy – 255
Eleazer Yousefzadeh, Capecomorin S. Pitchumoni
Chapter 30 Conventional and Laparoscopic-Assisted Gastrostomy – 261
Nathaniel Melling, Oliver Mann
Chapter 31 Fundoplication for GERD: Laparoscopic Approach – 269
Nathaniel J. Soper
Chapter 32 Operation for GERD: Conventional Approach – 277
Chapter Directory-1_Part
Chapter 33 Operation for Paraesophageal Hernia – 283
Chapter 34 Management of the Duodenal Stump – 291
Chapter 35 Operations for Morbid Obesity – 295
Chapter 36 Pancreas-Sparing Duodenectomy – 315
Chapter 37 Robotic Gastrectomy and D2Lymphadenectomy – 321
Karim A. Gawad, Alexandra M. König
Jean-Marie Michel, Lucas Krähenbühl
Yogesh K. Vashist, Florian Gebauer, Jakob R. Izbicki
Stefan Wolter, Jakob R. Izbicki, Oliver Mann, Markus
Weber, Markus K. Müller, Michael G. Sarr
Maximilian Bockhorn, Michael G. Sarr
Woo Jin Hyung, Yanghee Woo
Chapter 38 Robotic-Assisted Minimally Invasive
Esophagectomy (RAMIE): Ivor Lewis – 331
Inderpal S. Sarkaria, Nabil P. Rizk
Introduction: Esophagus, Stomach, and Duodenum
Jakob Izbicki, Michael G. Sarr
is section presents the ambitious eld of open and laparoscopic surgery in benign and malignant
diseases of the esophagus, stomach, and duodenum.
Attempts to treat esophageal cancer surgically emerged at the beginning of the twentieth
century. Torek successfully resected the thoracic esophagus in 1913, but real progress came as a
result of the development of thoracic surgery during and aer the Second World War. e concept
of extensive lymph node resection in combination with en bloc esophagectomy was proposed by
Logan in 1963 but with considerable morbidity and mortality.
Surgical procedures, pre- and postoperative management and treatment, and prognosis aer
surgical treatment have improved considerably in the past three decades. Expertise of the surgeon
and the institution, patient selection, choice and radicality of operation, and pre- and postoperative care are the most important parameters for outcome.
For this reason, the rst eight chapters present a comprehensive survey of the dierent open
and laparoscopic surgical procedures, indications, and choice of operation in esophageal cancer.
ey give clear guidelines as to how and when to operate with regard to the biological characteristics of the tumor. e focus then turns to benign esophageal diseases such as diverticula,
strictures, and achalasia.
e following chapters address the techniques of subtotal, total gastric resections in benign and
malignant diseases, respectively. Four chapters then outline the open and laparoscopic strategies
in the case of palliation such as gastroenterostomy and gastrostomy. Next the laparoscopic procedure is described as the gold standard for gastroesophageal reux, and then the open approach is
covered followed by dierent laparoscopic techniques for hiatal repair in paraesophageal hernia.
Another chapter comprehensively covers the available strategies for morbid obesity, and the last
chapter in the section deals with the ambitious pancreas-sparing duodenectomy.
e section has been prepared by experts in their surgical elds, and we hope that
it will provide the reader with a comprehensive overview of current surgical standards for the
various procedures.
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_8, © Springer-Verlag Berlin Heidelberg 2016
Cervical Esophagectomy
Rainer Schmelzle, Phillip Pohlenz
Esophagectomy for neoplasia includes removal of the cervical part of the esophagus combined
with cervical lymphadenectomy and reconstruction by interposition of a free jejunal transplant
with microvascular anastomoses.
Resection of a segment of up to 3 cm can be performed with primary anastomosis of the
esophagus aer adequate mobilization.
Indications and Contraindications
Indications
Contraindications
Cervical esophageal neoplasia
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Benign esophageal stricture
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Local irresectability (inltration of larynx, trachea, or vertebrae)
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Multifocal lesions
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Distant metastasis
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Florid gastroduodenal ulcer
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Crohn’s disease
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Procedure
Access
For the cervical part, a unilateral or bilateral (U-) incision at the medial margin of the sternocleidomastoid muscle is performed. It extends from the margo inferior of the mandible to the
jugulum, where it meets with the contralateral side. For cervical-mediastinal lymph node dissection, the incision is combined with a partial or complete median sternotomy. For harvesting the
transplant, a small upper abdominal transverse incision is sucient.
Exposure
Retraction is performed by hand-held retractors of dierent shapes and sizes according to the
anatomy. If available, a self-retaining retraction system will help.
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_9, © Springer-Verlag Berlin Heidelberg 2016
Section II • Esophagus, Stomach, and Duodenum
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Step 1
Preparation of the Cervical Region
Aer transection of the platysma, the sternocleidomastoid muscle is retracted and the omohyoid
muscle is divided. Along with the internal jugular vein, the common carotid artery and the vagal
nerve are identied along the entire length of the incision and a lymphadenectomy around these
structures is performed. e superior thyroid artery can be preserved for reconstruction. From
the carotid artery, the anterior longitudinal ligament is reached and the posterior dissection of
the cervical esophagus is completed under vision.
Aer mobilization of the le (or right) thyroid lobe, the recurrent nerve and the parathyroids
are identied and preserved. Injuries to the recurrent nerve should be repaired immediately.
Autotransplantation of dissected parathyroids should be performed in the forearm if radiation
therapy is an option.
Quite frequently a hemithyroidectomy facilitates the further procedure signicantly. Now the
posterior aspect of the trachea is dissected, and aer identication of the contralateral recurrent
nerve, the cervical esophagus is completely mobilized from the hypopharynx to the upper thoracic
aperture or below.
Occasionally the identication of important blood vessels can only be guaranteed using intraoperative Doppler ultrasound. Especially following extensive tumor resections of the oropharyngeal region, vast alterations of the typical anatomy must be expected. Injuries of the thoracic duct
can lead to the development of persistent stulas associated with signicant uid loss, protracted
by a previous radiotherapy.
In cases of extensive tumor growth that warrant resection, more extensive procedures may
become necessary (e. g., larynx or trachea).
Before resection, place retaining sutures on the potential proximal and distal stump (. Fig. 9.1).
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. Fig.9.1
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Chapter • Cervical Esophagectomy
Step 2
Transection of the Esophagus
e cervical esophagus is transected and the nasogastric tube withdrawn to the level of the neck
so that the specimen can be removed. Conrm free margins by frozen section on both sides. In
case negative margins cannot be achieved, an esophagectomy should be performed (
. Fig. 9.2).
. Fig.9.2
Section II • Esophagus, Stomach, and Duodenum
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Step 3
Preparation of the Jejunal Loop
e jejunal loop is harvested aer exploration of the abdominal cavity with sucient arterial and
venous length and lumen. If the mesentery is very thick, a meticulous removal of fatty tissue may
enable diaphanoscopy. However, under diaphanoscopy, an artery and a vein of sucient length
and lumen are identied. Aer clamping on the mesenteric side and excision of the gra, the
artery is ushed with heparinized saline until the venous outow is clear.
If the vascular pedicle or one of the vessels is too short, it becomes necessary to harvest a
venous or arterial interponate. e primary source for viable venous interponates is the forearm,
whereas for the artery the saphenous vein can be employed. Vessels harvested from the arm or
foot region are equally suitable for the arterial interponate whereas the saphenous vein, owing to
its dimension and susceptibility to spasm, proves to be hardly suitable for venous interpositioning
and should thus be reserved only for arterial lengthening. At times it is very dicult to dierentiate between the artery and the vein in the intestinal ap. To avoid confusing the two, prior to
harvesting, the artery or vein should be unmistakably marked.
An end-to-end jejunostomy is performed to reconstruct the bowel, and the abdomen is closed
without drainage (. Fig. 9.3).
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. Fig.9.3
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