Fig. 9.1
Ports used for robotic gastrectomy
The proper placement of the ports are essential to ease of the robotic arm use during operation, and therefore, care should be taken to ensure that the port placement is accurate and adjusted for patient’s abdominal wall girth as well as the intra-abdominal anatomy. Once the ports have been correctly inserted, the patient is placed in 15° reverse Trendelenburg position and the surgical cart is aligned and brought straight in to the head of the patient. The robot arms are ready to be docked as described below. Instruments should be inserted into the abdominal cavity under direct visualization as in any laparoscopic operation:
The camera arm: the infraumbilical port (C)
The 1st arm: curved bipolar Maryland forceps [1]
The 2nd and the 3rd arms: the ultrasonic shears or a monopolar device and the Cadiere forceps, interchangeably
Three key maneuvers to optimize exposure and facilitate accurate resection during the main operation are recommended before proceeding with the main operative procedure.
Gastric Decompression
Gastric decompression should be performed to manipulate the stomach and to make the uncluttered view of the upper abdomen. This can be done with either the insertion of an orogastric/nasogastric tube or with a percutaneously placed needle (e.g., long 18–20 gauge spinal needle) [18].
Liver Retraction
To maximize the full use of the three robotic arms during robotic gastrectomy, a self-sustaining retraction of the left lobe of the liver is required. Proper liver retraction is necessary for adequate exposure of the hepatoduodenal and hepatogastric ligaments for complete dissection of the suprapancreatic lymph nodes and clearance of the soft tissues along the lesser curve of the stomach. Before beginning the dissection for the gastrectomy, any of the several described techniques may be used to retract the liver including the suture-gauze liver suspension method [19–21].
Intraoperative Determination of the Resection Extent
To determine the extent of resection, intraoperative tumor localization is required. Most lesions cannot be readily visualized due to the lack of serosal involvement or palpated during a robotic operation. Several methods of intraoperative tumor localization have been employed. These include preoperative endoscopic tattooing of the tumor, intraoperative endoscopy [8], or laparoscopic ultrasound [9, 22]. The authors prefer using preoperatively placed endoclips and an intraoperative abdominal x-ray, which has been found to be very successful [23].
Procedure of Robotic Distal Subtotal Gastrectomy and D2 LN Dissection
Five Major Steps and Associated Vascular Landmarks
1.
Left side dissection: left gastroepiploic vessels
2.
Right side dissection and duodenal transection: anterior superior pancreaticoduodenal vein and the right gastroepiploic vessels
3.
Hepatoduodenal ligament and suprapancreatic dissection: right gastric artery, proper hepatic artery, portal vein, and celiac axis
4.
Approach to the left gastric vessels and the splenic vessels
5.
Lesser curvature dissection and proximal gastric resection
Left Side Dissection
The left side dissection begins with a partial omentectomy from mid-abdomen toward the left gastroepiploic vessels along the greater curvature of the body the stomach. The necessary exposure of the omentum is achieved by grasping the soft tissues on the edge of the greater curvature of the stomach using the robot arm #3 (Cadiere) and pulling superiorly and anteriorly to create a draping of the greater omentum. This allows for safe division and efficient retrieval of LN stations 4sb and 4d (Fig. 9.2a):
Fig. 9.2
(a) Greater curve of the stomach is retracted cephalad and toward the anterior abdominal wall creating a fanning effect to facilitate the greater curve dissection of the #4 lymph node station. (b) Division of the gastrocolic ligament proximally allows for the identification of the root of the LGEA and LGEV and retrieval of the 4sb
Begin 4–5 cm from the greater curvature of the stomach near the mid-transverse colon and enter the lesser sac and divide the greater omentum toward the lower pole of the spleen.
Near the lower pole of the spleen, identify, ligate, and divide the left gastroepiploic vessels at their roots (Fig. 9.2b).
Identify the first short gastric vessel and clear the greater curvature of the stomach toward the proximal resection margin.
Right Side Dissection and Duodenal Transection
The second major step moves the focus of the operation to the patient’s right side. Right side dissection begins with mobilization of the distal stomach from the head of the pancreas and dissection of the soft tissues containing LN station #6. The borders of LN station #6 is defined by right gastroepiploic vein (RGEV), anterior superior pancreaticoduodenal vein (ASPDV), and the middle colic vein (MCV) (Fig. 9.3):
Fig. 9.3
The soft tissue containing lymph node station #6 has been cleared above the ASPDV to identify the root of RGEV on the head of the pancreas before ligation and division
Release the posterior stomach attachments to the anterior surface of the pancreas and the first portion of the duodenum from the colon.
Dissect the soft tissues on the head of the pancreas until the RGEV and ASPDV are identified.
Isolate, ligate, and divide the RGEV as it joins the ASPDV.
Retrieve the soft tissues anterior to and superior to the ASPDV and superior to the MCV on both sides of the RGEV.
Identify the right gastroepiploic artery which is usually located behind the RGEV ligate and divide it as it branches from the gastroduodenal artery (GDA).
Release the attachments anterior to the GDA until the common hepatic artery (CHA). Free the immediate supraduodenal area using caution to avoid injury to the GDA and PHA (4″ × 4″ gauze placed anterior to the GDA may provide a visual mark to identify the area of dissection). The duodenum approximately 2 cm distal to the pylorus has been cleared, transect using an Endo-linear stapler.
Hepatoduodenal Ligament and Suprapancreatic Dissection
Proper en bloc retrieval of soft tissues in the hepatoduodenal ligament and the suprapancreatic region is one of the most challenging steps of the D2 lymphadenectomy. After identification and ligation of the right gastric artery, a meticulous and precise dissection along the proper hepatic artery (PHA), the portal vein (PV), and the CHA is essential to success. Identify and dissect along the PHA to the origin of the RGA. Ligate and divide the RGA and retrieve the associated soft tissue of LN station #5 (Fig. 9.4).
Fig. 9.4
Isolation of the right gastric artery is being performing using the Maryland dissector in arm #1 (right) with the harmonic in arm #2 (left)
Carefully lift and dissect to free the soft tissues containing LN station #12a, which is anterior and medial to the PHA and medial to the PV (Fig. 9.5a).
Fig. 9.5
(a) The portal vein is exposed in the hepatoduodenal ligament after on block lymphadenectomy has been performed to retrieve lymph node stations 12a and 8. (b) Dissection is being carried out along the celiac axis after division of the left gastric artery to retrieve the #9 lymph nodes
Additional exposure with the third arm by upper lifting of the liver and gentle downward retraction of the CHA by the assistant maybe necessary during this portion of the procedure.
Continue dissection inferiorly along the PHA to clear the soft tissues superior to the CHA, which contain LN station #8a.
Identify and ligate left gastric vein, which will become visible during the clearance of the soft tissues in the suprapancreatic area as it drains into the portal vein (Caution: In some cases, the left gastric vein drains into the splenic vein and can be found running anterior to the splenic artery).
Skeletonize the CHA toward the celiac axis to retrieve the soft tissues around the celiac artery, which contain LN station #9 (Fig. 9.5b).
Approach to the Left Gastric Artery and the Splenic Vessels
The soft tissues along the left gastric artery (LGA) and splenic vessels are retrieved as LN station #7 and #11p, respectively (Fig. 9.6):
Fig. 9.6
The soft tissues along the left gastric artery (LGA) and splenic vessels are retrieved as LN station #7 and #11p, respectively
To improve access to the origin of the LGA as it branches from the celiac axis, divide the retroperitoneal attachments along the lesser curvature of the stomach.
Using the Cadiere grasper (the robot arm #3), grasp the soft tissues containing the distal portion of the LGA by the stomach and lift the pedicle superiorly and anteriorly to tent up the LGA.
Clear the soft tissues surrounding the root of the LGA for more complete exposure and identification then securely ligate and divide the LGA at its root.
After placing the stomach in the left upper quadrant, dissect the soft tissues off of the anterior surface of the splenic artery and continue to skeletonize the artery until the splenic vein is exposed. Retrieve lymph node station #11p along the splenic vessels until halfway point is reached.
Lesser Curvature Dissection and Proximal Resection
At this point in the operation, the proximal stomach is freely retracted to the patient’s left to improve exposure of the remaining attachments of the lesser curvature of the stomach to the retroperitoneum and the diaphragmatic crus. The soft tissues along the intra-abdominal esophagus, the right cardia, and the lesser curvature of the stomach containing LN stations #1 and #3 are cleared until the proximal resection margin. Perform the truncal vagotomy at this time by dividing the anterior and posterior branches of the vagus nerve.
Be sure to fully mobilize the stomach from its posterior attachments to prepare for proximal gastric resection. Confirm the proximal resection line from the greater curvature to the lesser curvature with sufficient margin and divide the stomach using a 60 mm blue load Endo-linear stapler ensuring sufficient proximal margin (Reloads are usually required).
This completes the procedure of robotic D2 lymphadenectomy for distal subtotal gastrectomy.
Procedure of D2 Lymphadenectomy During Total Gastrectomy
The recommended procedure for advanced gastric adenocarcinoma located in the upper body of the stomach is a total gastrectomy with D2 lymphadenectomy. D2 lymphadenectomy for a proximal gastric adenocarcinoma requires the retrieval of LN #11d (along the distal splenic vessels) and LN #10 (in the splenic hilum). The procedure can be performed using two different methods: spleen-preserving total gastrectomy or total gastrectomy with splenectomy.
Complete dissection of the splenic hilum to preserve the spleen during LN #10 retrieval is challenging and complex procedure which may lead to unexpected bleeding and prolonged operative time. While splenectomy-related postoperative complications, such as subphrenic abscesses and post-splenectomy syndrome, are well known [7], spleen preservation might be recommended for experienced surgeons.
Spleen-Preserving Total Gastrectomy (Fig. 9.7)
Fig. 9.7
Spleen-preserving total gastrectomy
Robotic spleen-preserving total gastrectomy requires three of the following additional steps:
After the division of the left gastroepiploic vessels, the dissection continues along the greater curvature of the stomach to ligate and divide the short gastric vessels. The esophagophrenic ligament is released to completely free the left side of the stomach. This portion of the procedure is facilitated by retracting the stomach to the right side of the patient to expose the left diaphragmatic crus.
Approach to the splenic hilum by first identifying the distal splenic vessels dorsal to the distal pancreas and carefully skeletonizing the vessels toward the spleen.
To ensure retrieval of the LN #10, completely removal the soft tissues encasing the splenic hilum must be achieved.
Then, return to the proximal splenic vessels to retrieve the remaining soft tissues along the distal splenic artery and vein for the LN #11p and 11d dissection.
Reconstruction
After robotic gastric resection and complete lymph node dissection, several methods for creation of an intracorporeal or extracorporeal gastrointestinal anastomosis have been described. The advantages and disadvantages to each approach exist. The surgical extent and surgeon’s preference dictate the selection of the gastrointestinal reconstruction after robotic gastric cancer surgery. In general, stapled anastomoses are preferred as it is less time consuming, but sutured anastomosis using robot assistance is another option [8]. Reconstruction using the stapling device requires the patient-side assistant and can be an opportunity for a hybrid operation. Therefore, many methods used during laparoscopic gastroduodenostomy, gastrojejunostomy, and esophagojejunostomy can be applied after robotic gastric resections [3, 4, 9–11]:
Gastroduodenostomy, gastrojejunostomy, or Roux-en-Y gastrojejunostomy
Intracorporeal or extracorporeal
Linear or circular staplers including transoral anvil placement
Postoperative Management
Postoperative management of patients who have undergone robotic gastrectomy is identical to those patients who have undergone a laparoscopic gastrectomy for gastric cancer. The patients are monitored for ability for oral intake while given appropriate fluid maintenance, pain control, deep vein thrombosis prophylaxis, and blood tests:
Gastrointestinal function is expected to return approximately in 3 days after operation in patients without complications.
Oral intake is resumed on postoperative day (POD) 2 and advanced as tolerated usually to liquid diet (POD3), soft diet (POD4), and regular diet (POD5).
Median length of hospital stay is usually 5 days without complications.
Complications
The reported complication rates for robotic gastrectomy vary. The largest series evaluating the short-term outcomes of robotic and laparoscopic gastric cancer surgery report wound-related issues, intraluminal bleeding, and anastomotic leakage to be the most common complications encountered after robotic gastrectomies [1]. These complications are not directly related to robot assistance since the ports placements and anastomoses are not performed using the robot.
In general the morbidity and mortality associated with radical gastrectomies depend on the extent of resection, LN dissection, experience of the surgeon, and the experience of the institution where the surgery is being performed [12–14]. Many of the complications are related to the extent of LN dissection and expectedly are higher with D2 lymphadenectomy than for D1 lymphadenectomy. Improved surgical outcomes have been reported with spleen-preserving total gastrectomies when compared to total gastrectomy with splenectomy. No differences in complication rates have been found between laparoscopic and robotic gastric cancer surgeries.
Other possible complications are:
Intra-abdominal fluid collections/abscesses
Intraluminal and intra-abdominal bleeding
Pancreatitis/pancreatic leak/pancreatic fistula
Anastomotic leak/stricture
Gastroparesis or ileus
Obstruction
Benefits for the Patient
Less pain
Shorter length of hospital stay
Decreased blood loss
Faster gastrointestinal recovery
Faster physical recovery
Better quality of life after surgery
Better cosmesis
Benefits for the Surgeon
The robotic surgery system facilitates the process of performing laparoscopic surgery and provides the surgeon with ergonomics, 3D view, control of 4 arms, and accuracy of dissection, shorter learning curve that is provided by the inherent functions of the robotic system. This computer-enhanced surgical system thus allows surgeons to overcome various difficulties of laparoscopic surgery [4, 8]. The benefits specific to robotic gastric cancer operation is realized during the most difficult portions of the procedure including the dissection of the splenic vessels, isolation of the esophageal crux, and the suprapancreatic lymphadenectomy.
Dissection of Splenic Vessels
The small branches of the splenic vessels are easily identified and preserved allowing a pancreas–spleen-preserving D2 lymph node dissection, thanks to image magnification, tremor filtering, and fine circumferential robotic arm movements. This approach allows surgeons to drive the vascular dissection around and to completely clear the lymphatic tissue without any vascular injury with minimal intraoperative bleeding [13, 14].
Isolation of Diaphragmatic Crura
It is a fundamental step to an en bloc dissection of cardia lymph nodes and is greatly facilitated by wristed instruments that allow complete encircling of the distal esophagus [13, 15]. Moreover, the four-arm robotic surgery system will facilitate the insertion of the anvil head into the esophageal stump that could be not so easy to do in conventional laparoscopy [15], and esophagojejunostomy, which is usually performed in the deep and narrow space of the abdominal cavity, is feasible to execute by the robot-sewing technique [24].
Lymphadenectomy Include LN #14v, #8a, #9, #11p, #11d, and #12a
Relatively difficult areas to access during laparoscopic lymphadenectomy include LN #14v, #8a, #9, and #11. Moreover, the infrapyloric area and the superior mesenteric vein, including LN stations #6 and #14v, are the most frequent sources of intraoperative bleeding, while the suprapancreatic area including stations #7, #8a, and #9 is the second most frequent source [13, 25]. If the dissection along these vessels is easily conducted, the risk of bleeding can be reduced and lymphadenectomy can be better performed. The EndoWrist, tremor filtration, stable operative platform, and three-dimensional vision offered by the robotic surgical system aid the surgeon to perform a more accurate lymph nodes and vessels dissection [25].
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