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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_832_Библиотеки_им_академика_М_И_Перельмана
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Laparoscopic Assisted Robotic Sleeve Gastrectomy, Laparoscopic Assisted Robotic…
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Fig. 12 Creation of the
jejuno-jejunostomy.
Biliopancreatic (BP) limb
on the left. Roux limb and
common channel on the
right
Fig. 13 Completed
Jejuno-jejunostomy with
anti-obstruction sutures in
place. Note the gentle
curve of the intestine
during the transition from
alimentary limb to
common channel
205
Two additional interrupted anti-obstruction sutures are placed along the BP and
alimentary limb in order to create a gentle curve as the alimentary limb becomes
the common channel (Fig.13).
Once both anastomoses are completed, the mesenteric defects are closed. First,
the jejuno-jejunostomy is lifted upwards and the mesenteric defect is closed using a
running non-absorbable, barbed suture. Next, the transverse colon is reected
upwards and the Petersen’s defect is closed at the juncture of the colon and alimentary limb mesenteries using a running non-absorbable suture (Fig.14).
The liver retractor is then removed. The robot is undocked and 12mm port sites
are closed with gure of eight sutures. The 8mm port sites are closed at the skin.
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Fig. 14 Closing the
Petersen’s defect using a
running suture
G. Basishvili and C. Holcomb
7 Postoperative Care
Patients undergoing sleeve gastrectomy or Roux-en-y gastric bypass are typically
admitted to the oor following surgery. A Phase I, clear liquid bariatric diet for both
post sleeve gastrectomy and post Roux-en-Y patients is started on POD 0. If this is
tolerated without issue, patients are advanced to Phase II—full liquid diet including
protein replacement shakes. Enhanced bariatric recovery pathway also involves
early ambulation, pharmacologic thromboprophylaxis and minimizing opioid use.
Patients are typically discharged 24–48h after surgery. Extended pharmacologic
thromboprophylaxis is considered in select patients [9].
References
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Goodpaster KPS, Haddad A, Himpens JM, Kow L, Kurian M, Loi K, Mahawar K, Nimeri
A, O’Kane M, Papasavas PK, Ponce J, Pratt JSA, Rogers AM, Steele KE, Suter M, Kothari
SN. 2022 American Society for Metabolic and Bariatric Surgery (ASMBS) and International
Federation for the Surgery of Obesity and Metabolic Disorders (IFSO): indications for meta-
2. Peterli R, Wölnerhanssen BK, Peters T, etal. Effect of laparoscopic sleeve gastrectomy vs
laparoscopic Roux-en-Y gastric bypass on weight loss in patients with morbid obesity: the
SM-BOSS randomized clinical trial. JAMA. 2018;319(3):255–65.
3. Grönroos S, Helmiö M, Juuti A, etal. Effect of laparoscopic sleeve gastrectomy vs Roux-en-Y
gastric bypass on weight loss and quality of life at 7 years in patients with morbid obesity: the
SLEEVEPASS randomized clinical trial. JAMA Surg. 2021;156(2):137–46.
4. Salminen P, Grönroos S, Helmiö M, etal. Effect of laparoscopic sleeve gastrectomy vs Rouxen- Y gastric bypass on weight loss, comorbidities, and reux at 10 years in adult patients with
obesity: the SLEEVEPASS randomized clinical trial. JAMA Surg. 2022;157(8):656–66.
Laparoscopic Assisted Robotic Sleeve Gastrectomy, Laparoscopic Assisted Robotic…
https://t.me/med1917
5. McTigue KM, Wellman R, Nauman E, etal. Comparing the 5-year diabetes outcomes of sleeve
gastrectomy and gastric bypass: the National Patient-Centered Clinical Research Network
(PCORNet) bariatric study. JAMA Surg. 2020;155(5):e200087.
6. Biter LU, van Buuren MMA, Mannaerts GHH, Apers JA, Dunkelgrün M, Vijgen GHEJ.Quality
of life 1 year after laparoscopic sleeve gastrectomy versus laparoscopic Roux-en-Y gastric
bypass: a randomized controlled trial focusing on gastroesophageal reux disease. Obes Surg.
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7. Che F, Nguyen B, Cohen A, Nguyen NT.Prevalence of hiatal hernia in the morbidly obese.
Surg Obes Relat Dis. 2013;9(6):920–4.
8. Wadden TA, Sarwer DB.Behavioral assessment of candidates for bariatric surgery: a patientoriented approach. Surg Obes Relat Dis. 2006;2:171–9.
9. Aminian A, Andalib A, Khorgami Z, Cetin D, Burguera B, Bartholomew J, Brethauer SA,
Schauer PR. Who should get extended thromboprophylaxis after bariatric surgery? A risk
assessment tool to guide indications for post-discharge pharmacoprophylaxis. Ann Surg.
2017;265:143–50.
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Gastric Resection: Laparoscopic Wedge
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Resection, Laparoscopic Subtotal
Gastrectomy, Laparoscopic Total
Gastrectomy
EricChuang, AlexanderHienVu, MohammadSulemanBajwa,
andFareedCheema
1 Introduction
In the recent decade, laparoscopic and robotic approaches have made advancements
and improved outcomes in foregut surgery. We can now achieve minimally invasive
oncologic resection in the setting of gastric cancers [1]. Here we summarize the
management of gastric adenocarcinoma and GISTs and provide an illustrative
breakdown on the major minimally invasive techniques in managing gastric
malignancies.
2 Gastric Adenocarcinoma
2.1 Perioperative Work-Up
NCNN guidelines categorize gastric adenocarcinoma into three groups based on
their characteristics: localized cancer (stages cTis or cT1a), locoregional cancer
(stages cT1b–cT4a; cM0), and metastatic cancer (stage cT4b; cM1). Workup begins
with a history and physical and labs, progressing to imaging, endoscopy with biopsy
of the primary tumor, and genetic testing.
E. Chuang · A. H. Vu · F. Cheema (*)
Department of General Surgery, New York University Langone Health, Brooklyn, NY, USA
e-mail: eric.chuang@nyulangone.org
M. S. Bajwa
Department of General Surgery, Monteore Medical Center, Brooklyn, NY, USA
Switzerland AG 2024
H. Chen, B. Lindeman (eds.), Illustrative Handbook of General Surgery,
https://doi.org/10.1007/978-3-031-63878-7_18
209© The Author(s), under exclusive license to Springer Nature
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In terms of imaging, a CT scan with oral and intravenous contrast of the chest,
abdomen and pelvis is recommended. FDG-PET/CT from the skull base to midthigh may be useful in providing additional information. Further, endoscopic ultrasound can be utilized to determine if the disease is locally advanced; in the case of
early-stage cancers, endoscopic resection can be therapeutic. For esophagogastric
junction adenocarcinoma, Siewert classication should be determined as part of
initial work up.
With genetic testing, microsatellite instability and mismatch repair protein dysfunction can be identied by PCR/NGS and immunohistochemistry. In the case of
metastatic disease, patients should undergo screening for HER2 and PDL1 abnormalities. Lifestyle changes such as dietary restrictions and smoking cessation is also
strongly recommended. Finally, if clinically indicated, a diagnostic laparoscopy can
be performed to more accurately identify and stage the gastric malignancy.
E. Chuang et al.
2.2 Indications forSubtotal vs. Total Gastrectomy
The main indication for subtotal vs. total gastrectomy is the ability to achieve negative margins, which is highly dependent on the location of the tumor and whether
integrity of the gastric remnant can be maintained. Subtotal gastrectomy, with
4–6cm margin clearance, has superior short-term quality-of-life indices compared
to total gastrectomy [2]. However, this benet may be confounded by factors including greater tumor burden and comorbidities. Total gastrectomy is indicated if
4–6 cm margins cannot be obtained, and for multifocal, diffuse cancer patterns.
Diffuse adenocarcinoma with linitis plastica appearance may also require total
gastrectomy.
2.3 D1 vs. D2 Lymphadenectomy
Japanese studies have shown the safety and efcacy of gastrectomy with D2 lymphadenectomy for the complete surgical resection of gastric adenocarcinoma [3].
However, removing the entire nodal structure is not without its risks—the most
common being lymph leakage or injury to adjacent structures. A multicenter randomized trial comparing the survival benet of D1 vs. D2 lymphadenectomy in
patients with gastric cancer showed no difference in the overall 5-year survival rate.
However, subgroup analysis revealed an improved 5-year disease-specic survival
for patients with advanced disease and lymph node metastases [4]. Thus, disease
severity is an important factor to consider in the patient selection process—D2
lymphadenectomy, despite its benets, is associated with higher mortality compared to D1, which decreases its therapeutic benet. Figure1 shows the anatomy of
the stomach including its vasculature and lymphatic drainage.
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2
4sa
20
1
12a
12p
12b
6
7
9
3a
19
8
5
16
3b
4d
10
6
4sb
4d
5
12a
12b
12p
13
17
4d
3
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16
8a
9
8b
11p
14v
15
4sa
2
10
11d
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Fig. 1 Gastric neurovasculature and lymph node basins (right-anterior surface, left-posterior sur-
face). Arteries anastomose towards the greater curvature on the anterior cardia, and more medially
on the posterior surface. Vessels travelling perpendicular to the gastric axis are larger. The right
gastric artery is one third of the diameter of the left. The posterior antrum is perfused by the posterior branch of the left gastric artery. The gastroepiploic vessels are mostly within 4cm of the
greater curvature. Veins parallel arteries. Vagal nerve trunks, greater splanchnic and phenic nerves
are drawn. Posterior mediastinal and inferior para-aortic basins are not. Lymph node basins are
numbered according to the Japanese Gastric Cancer Association classication (https://doi.
org/10.1007/s10120- 011- 0040- 6)
2.4 Technique
Laparoscopic surgery is a viable alternative to laparotomy for gastric or total resection. Critical differences exist between minimally invasive gastrectomy and open
gastrectomy in terms of approach to resection and lymph node dissection [5].
Positioning of the patient in supine or lithotomy/split leg allows the surgeon access
to the gastroesophageal junction during laparoscopic total gastrectomy. Tucking the
right arm is essential if the surgeon needs to switch to an open approach.
Abdominal entry is via a periumbilical 12mm port. A 5mm assistant port is
placed on the left lateral subcostal margin and a right lateral subcostal 5mm port is
used to aid in liver retraction. Two 12mm ports are placed superolateral to the right
and left of the umbilicus. Alternatively, an additional 5mm port can be placed in the
subxiphoid area to help retract the liver, dissect, irrigate, and suction. After obtaining intraperitoneal access, the surgeon needs to carefully explore the abdomen to
determine the extent and location of the disease and conrm the resectability of the
tumor, as well as the absence of metastatic disease prior to initiating the dissection
in cases of gastric cancer.
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E. Chuang et al.
2.4.1 Laparoscopic Subtotal Gastrectomy
1. The rst step in obtaining exposure of the stomach and surrounding structures is
to mobilize the greater curvature. This is accomplished with entering the omental
bursa (also known as the lesser sac) by dividing the avascular plane between the
transverse colon and the gastrocolic ligament, which is an extension of the greater
omentum. Since the omentum will be resected along with the specimen in a cancer operation, it can be detached from the transverse colon during the entry of the
omental bursa (Fig.2). Once the gastrocolic ligament is detached, the surgeon
can retract the stomach superiorly. This allows the surgeon to enter the avascular
plane between the posterior gastric wall, the omental bursa, and the transverse
mesocolon. Careful dissection along this plane includes avoidance of injury to
the middle colic vessels, and subsequent ischemia of the transverse colon.
2. Once this avascular plane has been cleared, the surgeon will visualize the
exposed pancreas, duodenum, and the origin of the right gastroepiploic vessel.
The surgeon proceeds to identify, ligate and divide the origin of this artery
(Fig.3) and dissect and remove the lymph node basin in this region (Fig.4). The
left gastric artery is then followed to its origin on the celiac axis, ligated and
Fig. 2 Omentectomy (A
liver, B omentum, C
transverse colon)
Fig. 3 Right
gastroepiploic nodal basin
(A) and artery (B) isolated
for division (C pancreas)
Gastric Resection: Laparoscopic Wedge Resection, Laparoscopic Subtotal Gastrectomy…
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Fig. 4 Dissection of the
Right Gastro-epiploic
nodal basin and artery—
nal aspect (A node tissue,
B duodenum, C
gastroduodenal artery, D
transected stump of right
gastroepiploic artery, E
pancreas)
Fig. 5 Duodenum is
divided (A liver, B
duodenum, C stomach)
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divided. In gastric cancer patients, resecting the lymph nodes associated with
each vascular structure is necessary. The left gastric vein is divided once encountered just a few centimeters inferior from the artery. Dissection of the celiac axis
and aorta should be completed by clearing the anterior surface of these lymphatic tissue structures.
3. During this procedure, the peritoneum is incised on the superior edge of the
pancreas. This facilitates the dissection of the common hepatic artery as it
emerges from the celiac axis. Following this artery, the surgeon will identify
where the right gastric artery emerges. The right gastric artery is then divided at
the origin, completing the stomach devascularization. In gastric cancer patients,
this will conrm the dissection of the prepyloric nodes with the specimen. A
Kocher maneuver of the duodenum and dissection of the superior margin of the
pancreas, the splenic artery, and the paraduodenal region are performed next.
After the duodenum is mobilized, it is transected in the rst portion using a surgical stapler (Fig.5). According to the surgical indication, the surgeon determines the specimen’s proximal margin at the resection’s nal step. The tumor
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E. Chuang et al.
extent is examined, and the stomach is divided at least 8–10cm from the tumor
(Fig.6).
4. Gastrointestinal continuity is then restored with either a Billroth II gastrojeju-
nostomy or a Roux-en-Y gastrojejunostomy. A Roux-en-Y reconstruction is preferred: after completion of the gastric resection, an appropriate segment of
jejunum is identied and transected with a linear stapler about 30cm from the
ligament of Treitz (Fig.7). The mesentery is then divided to allow the alimentary
jejunal limb (the distal limb) to reach the upper abdomen and gastric remnant
without tension. The bilio-pancreatic limb (the proximal limb) is then reconnected to the alimentary limb 60–70 cm distal to its blind end. We favor a
side- to- side linear stapled jejunojejunostomy (Fig.8). The resulting mesenteric
defect is then closed with a running, non-absorbable stitch (Fig.9). The alimentary limb is then brought up in an antecolic fashion to the upper abdomen and
laid adjacent to the gastric pouch. The anastomosis may be completed either in a
hand sewn, linear stapled, or circular stapled fashion. In the circular stapled technique, a 25 mm anvil is passed trans-orally and the stapler is passed trans-
Fig. 6 Stomach
transection (A spleen, B
gastric pouch, C resected
stomach)
Fig. 7 Division of
jejunum creating
biliopancreatic and
alimentary limbs (A
biliopancreatic limb, B
alimentary limb)
Gastric Resection: Laparoscopic Wedge Resection, Laparoscopic Subtotal Gastrectomy…
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Fig. 8 Side-to-side stapled
Jejunojejunostomy (A
biliopancreatic limb, B
alimentary limb)
Fig. 9 Jejunojejunostomy
mesenteric defect is closed
(A jejunum, B mesenteric
defect)
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abdominally. The alimentary limb is opened at its blind end, and the stapler is
guided into the opening. The stapler and anvil are mated through the wall of the
jejunum and the anastomosis is created, taking care not to twist the gastric or
jejunal side when closing the stapler (Fig.10). The remaining open jejunal stump
is then resected with a linear stapler, ush to the anastomosis (Fig.11). Stay
sutures are place on either side of the anastomosis to relieve tension. A leak test
is performed; this can be done by submerging the anastomosis in normal saline
and insufating the gastric pouch with a nasogastric tube or performing an
esophagogastroduodenoscopy. The latter has the advantaged of checking for
intraluminal staple line bleeding. The outow of the alimentary limb needs to be
clamped to avoid insufating the small bowel.
5. In cases where the surgeon needs to perform a near-total gastric resection, 1 to
2cm of the gastric wall is preserved for the anastomosis. Most of the branches
of the left gastroepiploic artery and short gastric arteries are ligated and divided.
To ensure adequate blood supply to the gastric side of the anastomosis, the left
gastric and/or uppermost short gastric vessels must be preserved.
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