Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_1050_Библиотеки_им_академика_М_И_Перельмана

■ Thegastrocolicligamentisdividedbeyondthepyloruswithcareofstaying awayfromtheoriginoftherightgastroepiploicvessels.

■ AKochermaneuverisperformedtofurthermobilizethepylorus.Onegood assessmentofmobilityofthestomachiswhetherthepyloruscanbeplaced adjacenttotherightcrus.

■ Wedonotperformapyloromyotomyorpyloroplastyandinsteadinject botulinumtoxinintotheanteriorwallofthepylorus.

■ Botulinumtoxin(100units)isdilutedinto5mLofsalineanddrawnintoa syringe.A20-gaugespinalneedleisinsertedintotheanterioraspectofthe pylorus(FIG6).Thetotalvolumeofbotulinumtoxinisdividedintoatleast threetofourseparateinjectionsitesalongtheanteriorpylorus.

■ Thelessercurvatureisclearedofomentumatapproximatelythelevelofthe incisuratoallowforanavascularlandingzoneforthefirststapleloadonthe stomach(FIG7).

■ ThesurgeonthenplacesthePenrosedrainandproximalstomachintothe posteriormediastinum.Wedonotroutinelyenlargethehiatusunlessthere appearstobeconstrictionoftheconduit.

■ AlaparoscopicJ-tubeisplacedifnotalreadypresentperstandardlaparoscopic techniquetooptimizepostoperativenutrition.

■ Thefirstportplacedisthecameraport,whichis9cmfromtherightaxillary port.Weusea5-mmporthereinitially,witha5-mmthoracoscopetoassistin placingtheotherports.Carbondioxide(CO2)isinsufflatedintothechestata

■ PortplacementisshowninFIG9.Itisimportanttonotethatthethreeanterior portscompriseroboticarm1;thecameraportandroboticarm2areinaline thatrunsslightlyposterior,headedtowardthepatient’srighthip.Ifthelineis intheanterioraxillaryline,youwillbetooclosetothediaphragmforrobotic arm2.Afterthecameraportisplaced,theroboticarm3isplacedasposterior andinferioraspossibleandaseekerneedleisinsertedfirsttoensureitssafe trocarplacement.Roboticarms1and2arethe8-mmportsthroughwhich mostofthedissectiontakesplace;roboticarm3isa5-mmportandused primarilyforretractionofstructuresduringthedissection.

■ Theaccessportfortheassistantispositionedlast.Thisportshouldbe triangulatedbehindroboticarm2andthecameraportsothattheroboticarms willnotinterferewiththeassistant.Careshouldbetakentoavoidtheinternal mammaryarteryandthediaphragmwhenthisaccessportisplaced.The insufflationtubingisswitchedtotheaccessportsothatitdoesnotinterfere withthemovementoftheroboticarms.

■ Themediastinalpleuraalongtherightmainstembronchusisopenedanddivided allthewayuptotheazygousveinandallthewaydowntothediaphragm. Thesubcarinallymphnodesarelocatedposteriorandinferiortotheright mainstembronchusandresected.Careshouldbetakentoachieveproper hemostasisofthisarea,asthesubcarinalnodestendtobewellvascularized.

■ Theesophagusshouldbecompletelymobilizedfromthethoracicinlettothe diaphragmatichiatus.Performingthispartoftheoperationroboticallyallows forathoroughharvestoftheperiesophagealtissue,includinglymphnodes. Theparaesophageallymphnodesaredissectedcarefullyofftheleftandright mainstembronchiandaorta.Useofthebipolardeviceandcarefuldissection duringthisphasehelpsavoidthermalinjurytotheairway,whichmaypresent asanesophagobronchialfistulaandcanbecatastrophicforthepatient.The subcarinalnodesshouldbeincludedinthespecimen.Aftercompletionofthe dissection,thepericardiumshouldbevisibletotheleveloftheinferior pulmonaryveinsbilaterally(FIG15).

■ Thethoracicdissectorinroboticarm1(rightarm)isexchangedforthebipolar scissors.Withtractionappliedtopullitdistally,theproximalesophagusis dividedjustabovetheazygousveintoensurethebestpossiblemarginaway fromcancerand/orBarrett’sesophagus;itisbeveledsothattheposterior aspectoftheesophagusislonger.Cauteryisappliedtocutandcoagulate simultaneously(FIG16).

■ Thescissorsinroboticarm1areswitchedbacktotheCadiereforceps,andthe assistanthelpspulltheresectedesophagusandgastricconduitgentlyintothe chestwithanatraumaticclamp(ratherthanusingtheroboticarm,which becauseofitsstrengthcandamagetheconduit)(FIG17).Priortodividing thesuturesattachingtheesophagustotheconduit,silksuturesareplaced anteriorlyandposteriorly,tackingtheconduittothepleura.Thishelpsreduce theamountoftensionontheanastomosisandmaintainorientationofthe conduit.Careshouldbetakentoavoidtwistingtheconduit;thestaplesfrom conduitcreation(i.e.,theformerlessercurve)shouldbeorientedtowardthe lung.Theesophagealspecimenisthendetachedfromtheconduit(FIG18).

■ Adouble-layeredesophagogastrostomyiscreated.Ingeneral,wehavefound thatthebestinstrumentstouseforroboticsuturingarealongatraumatic forcepsinroboticarm2andasuture-cutneedledriverinroboticarm1.