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Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_861_Библиотеки_им_академика_М_И_Перельмана.pdf
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occurthatmayrequiretherebootingoftheentiresystem.Figure5-2 showstheplacementofthepatientinrelationshiptoanesthesia.Robotic dockingisdonefromtherightshoulderandFigures5-3and5-4showthe dockingfromtheviewofthesurgeonandthenursingstaff,respectively.
FIGURE5-2Patientpositioning.
FIGURE5-3Sisystemdocking.
FIGURE5-4Sisystemdockingplatformview.
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XiSystem
ThepatientispositionedsupineontheORtabletopreventsliding.All pressurepointsarecheckedandcorrected.Theoperatingsurgeonsitsat alocationintheroomwherehecanvisualizetheroboticarmsandcan communicateusinglineofsightwiththesurgicalassistant.TheORtable isairplanedrightsideupslightlytodisplacethesmallboweltothepelvis andtheleftupperquadrantexposingtheduodenumandvascularpedicle. Anesthesiaisusuallylocatedattheheadofthetable.
PortPlacement
SiSystem
Severalportplacementscanbeuseddependingonthesurgeon’s preference.Ourcurrentportplacementissetforintracorporeal anastomosisusingthefullbenefitofallthreearmsandthecamera.The cameraportisplacedinthesupraumbilicalportionoftheabdomen.This placementmayalsobemodifiedtoabout2–3cmbelowandtotheleftof themidline.Thiscamerapositionallowsabetterreachandvisualization oftumorsoverthehepaticandproximaltransverseareas.Therobotic staplerarm(arm1)islocatedovertheleftupperquadrant.Thisposition, inouropinion,helpsinthefiringofthestaplerfortransectionofthe terminalileumandcolonaswellastheanastomosis(iso-or antiperistaltic).Theretractingarm3islocatedoverthesubxiphoidarea. Caremustbetakenupondockingthearmtomakesurethefaceofthe patientwillnotbehitwiththearmandfacefoampaddingis recommended.Arm2islocatedoverthesuprapubicarea.Our instrumentofchoiceareahookorscissors(arm1),asmallgrasping retractor(arm2)andafenestratedbipolar(arm3).Figure5-5 demonstratestheportplacementformtheassistant’spoint.
FIGURE5-5Portplacement.
XiSystem
Therearetwomaintrocarplacementrecommendationsforarobotic righthemicolectomy.Thefirsttrocarplacementismostcommonly utilizedforanextracorporealanastomosis.Oneofthetrocarsitescanbe placedattheleveloftheumbilicusandtheincisioncanbeextendedto
becometheextractionsite(supraumbilicalarea).Thesecondtrocar placementrecommendationassumesthatanintracorporealanastomosis willbeperformedandthecameraportismovedtowardtheleftofthe umbilicus,achievingamorepanoramicview.Thistrocarsetupprevents beingtooclosetothetargetwhenperformingtheintracorporeal anastomosis.Theextractionsiteisoffthemidline.Thislowersthe incisionalherniarateforrighthemicolectomypatients(Fig.5-6).
FIGURE5-6Xiportplacement.
Procedure
Accesstotheperitonealcavityisobtainedusingthe8-mmstraight camerainthe12-mmopticalviewport.Whenthistechniqueisutilized,it isimportanttopointawayfromthemidline,toavoiddamagetovascular structures.Anoff-midlineportplacementtotheleftshouldallowthe surgeontoseeprogressivelytheanteriorrectussheath,themuscle,and theposteriorrectusbeforeenteringtheperitoneallayerandcavity.The patientisplacedatthattimeinslightreverseTrendelenburgandrotated totheleft.Thesmallintestine“falls”totheleftsideoftheabdomen.The leftupperquadrant(arm1inSisystem)portallowsalaparoscopicbowel graspertofurthermobilizetheviscera.
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Itisthesurgeon’schoicetoperformamedial-to-lateraldissection.For beginnerroboticsurgeons,ourcurrentrecommendationistoperform
whatevertechniquetheyarefamiliarwithwhenperformingastraight laparoscopicrightcolectomy.
Lateral-to-MedialApproach
Thececumisretractedcraniallyandtotheleftofthepatient,exposing theileocecalarea.Thefenestratedbipolarandthescissorsorhookisused tocreateasmallincisionovertheperitonealsurfaceatthemostcaudal foldofthelineofToldt(Fig.5-7).Thehookallowsperformingblunt dissectionwithitsheel.Thececumisretractedbytheassistanttoward theleftsideoftheabdomenuntilGerota’sfasciaandtheduodenumare exposedalongtheretroperitoneum.Therightureterandgonadalvessels areidentifiedandprotected.Incaseswherethereisaninflammatory massintherightlowerquadrant,theuseofstentsisrecommended.Itis possibletoinjectindocyaninegreen(ICG)dyeretrogradeintothestent andusethenear-infraredtechnology(Firefly,IntuitiveSurgical, Sunnyvale,CA)tovisualizetheureters.
FIGURE5-7Paracolictakedown.
Theentirerightcolonismobilizedandbroughttothemidline.The colonandterminalileummustbefullyfreeandpastthemidline.
Thehepaticflexureandgastrocolicligamentarereleasedasthececum ismovedwithcaudalretractiontothelefthip(Fig.5-8).Theomentumis liftedandthehook/scissorsareusedtoenterthelessersac.Thesecond portionoftheduodenumwillbevisible.Therightbranchofthemiddle colicvesselmaybeinjuredatitsoriginwithforcefulretraction.Bleeding willbebrisk.Therightbranchmaybecontrolledwithvesselclipsora
sealingdevice.
FIGURE5-8Hepaticflexuretakedown.
Oncefullmobilizationofthecolonisperformed,thedecisionto performanintra-orextracorporealanastomosisislefttothesurgeon. Earlyreportsindicateapossibleadvantageinlengthofstayandrecovery byusingintracorporealanastomosis.Obesepatients,especially,benefit fromtheintracorporealtechnique.
Medial-to-LateralApproach
Liftingtheileocolicpedicleallowsventingintotheareolarspacebehind therightcolonmesenteryandovertheduodenum(Fig.5-9).The dissectioniscontinuedcraniallyuntilthehepaticflexureismobilizedina medial-to-lateralmanner.Theliverandgallbladderarevisualizedwhen thehepaticfixturesuspensoryligamentsaredivided.Lateralattachments ofthecolonaredividedlast.Gerota’sfasciaandtheretroperitoneal structuresareprotectedthroughoutthedissection.
FIGURE5-9Ileocolicpedicleidentification.
Theileocolicpedicleisskeletonizedanddivided.Theavascular mesenteryisthendissectedtotherightbranchofthemiddlecolic. Anteriortensiononthemesocolonofthetransversecolonexposesthe middlecolicpedicle.Therightbranchisdividedwithasealingdeviceor clips.
Intra-VersusExtracorporealAnastomosis
Theterminalileumandcolonareskeletonizedandcleanedtotheviscera, transectingthemwiththeroboticstapler.Anisoperistalticanastomosisis linedupusingacornersutureof3/0polydioxanone(PDS)betweenthe endoftheantimesentericborderoftheterminalileumandthe antimesenterictaeniacoliofthedistaltransversecolon.Thissutureiscut approximately25cmandleftwiththeneedletoclosetheenterotomy aftertheanastomosisisfashioned.Theproximalportionofthe transectedstaplelineisalsoliftedandapproximatedtotheproximal antimesentericborderoftheileum.Toliftthisarea,astraightneedle introducedintherightupperquadrantintothecolonandsmallintestine andreturnedoutoftheabdominalcavityfacilitatesliftingandliningup theintestineforthefiringofthestaplerline(Fig.5-10).Anenterotomyis performedinthedistalileumandcolon.Theroboticstaplerisintroduced throughthearm1port.Bothendsoftheintestineareenteredanda singlefiringisdone(Fig.5-11).Thestaplerisreplacedwiththerobotic needledriverandthe3/0PDSsutureisusedtoclosetheenterotomyina runningLembertmanner(Fig.5-12).Beforetheanastomosisweverify thevascularflowofbothendsoftheintestineusing3.5mgIVofICG
(Firefly,IntuitiveSurgical,Sunnyvale,CA)andthenear-infraredcamera oftheroboticplatform.
FIGURE5-10Isoperistalticsetup.
FIGURE5-11Isoperistalticstaplefiring.
FIGURE5-12Closureenterotomy.
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