Fig. 10.1
Parallel docking view showing foot of patient
Fig. 10.2
Parallel docking view showing position of anesthesiologist with head of patient accessible
Trocar Placement
A total of five or six trocar ports are placed for robotic-assisted RYGBP. The order of placement is shown in Figs. 10.3 and 10.4 and is as follows (1) a peritoneal entry with a zero degree scope on a 5 mm optical viewing in the right upper quadrant just to the right of the midclavicular line, one finger width below the costal margin—this port is subsequently changed to the robotic “number two arm” after all other ports have been placed, (2) a 12 mm umbilical port for the robotic camera, (3) a 5 mm left upper quadrant port placed at the level of the umbilicus at the anterior axillary line with the “number three robotic arm” docked, (4) the area between the umbilical port and left anterior axillary line port is bisected and an 8 mm robotic port is placed with the “number one robotic arm” docked, (5) a 12 mm right mid-abdominal assistant port is placed halfway between the umbilical port and the RUQ port, and (6) if the liver is small, we prefer to use a 3 mm retractor or an internal liver retractor fashioned out of a Penrose drain and sutures (Fig. 10.5), reducing the need for an epigastric incision. A sixth port is created if the liver is large, in which case an epigastric incision is made to facilitate a Nathanson liver retractor (Fig. 10.5) in order to elevate the left lateral lobe. When completed, the patient cart is ready to be docked. This trocar placement allows for the Roux-en-Y gastric bypass procedure to be accomplished without the reported challenge of moving the robot from one quadrant to another. Both upper and lower quadrants are easily visible and manageable for work without re-placing trocars and extending surgical and anesthesia time.
Fig. 10.3
Diagram of port placement
Fig. 10.4
Nathanson liver retractor
Fig. 10.5
Internal liver retractor
Three-Step Procedure
Step 1: Creation of the Gastric Pouch
The angle of His is identified with the fundus retracted laterally. The peritoneum, over the angle of His, is dissected with ultrasonic shears or scissors and carried posterior to identify the path for a linear stapler and the left crus of the diaphragm. Next, the pars flaccida is identified and opened. At this point it is important to identify the left gastric artery and its branches onto the lesser curve for preservation, as this will be the main blood supply to the gastric pouch and the gastrojejunal anastomosis. The mesentery to the lesser curve of the stomach is divided by a vascular load linear stapler. A retrogastric plane in the lesser curve is then created and the dissection is carried up to the angle of His. Once accomplished, two serial applications of a 60 mm linear stapler are used to create a 20 mL gastric pouch.
Step 2: Creation of the Gastrojejunal Anastomosis
The greater omentum is divided with an ultrasonic scalpel, to the level of the transverse colon. The proximal jejunum is identified at the ligament of Treitz and extended into the upper abdomen. It is critical to ensure that an adequate length of jejunum is measured to avoid tension on the anastomosis (approximately 50–70 cm is suggested). It is equally important to properly orient the jejunum so that proximal and distal ends are not misidentified during the creation of the gastrojejunal anastomosis.
Once the area to be anastomosed has been identified, the number three robotic arm is used to maintain and properly orient the jejunum in the upper abdomen. The outer posterior layer of the anastomosis is created first using a long 2-0 Vicryl suture. After the posterior outer layer is completed, the suture and needle are left in situ and attention is focused on constructing the inner layer of the gastrojejunal anastomosis. Using the number two robotic arm, the gastrotomy and enterotomy are performed with 8 mm robotic scissors while monopolar cautery is activated. The inner layer of the anastomosis is also performed with a running 2-0 Vicryl suture. Once the bowel has been opened, the posterior inner row is created. After this step has been performed, the gastric tube placed preoperatively is advanced under guidance of the operating surgeon into the jejunum and facilitates sewing the remainder of the gastrojejunostomy. Once the inner layer is completed, the anterior outer layer is constructed with the same running suture from the posterior outer layer that was left in situ. It is typical that the outer and inner layers are both done with a continuous running suture.
Step Three: Creation of the Jejunojejunostomy
We prefer to create an approximate 150 cm Roux limb. The Roux limb is measured out and draped into the RUQ. The number three robotic arm is utilized to place a stay suture at the estimated distal staple line and line up the bowel with the direction of the linear stapler. A harmonic scalpel is then used to make the enterotomies, followed by a 60 mm linear stapler to create the anastomosis. The common enterotomy that remains is closed with a single running layer of 2-0 Vicryl.
After the creation of the jejunojejunostomy, a silk suture is used to close the mesenteric defect between the Roux limb and the biliary limb of the small bowel. At this point, an intraoperative endoscopy is performed to evaluate a gastrojejunostomy. This ensures passage of the gastroscope into the Roux limb and ensures passage is airtight. The robot is then undocked.
Advantages to Robotic-Assisted Roux-en-Y Gastric Bypass (RARYGB)
A comparison of complication rates against standard laparoscopic techniques shows lower morbidity and mortality rates for robotic procedures [5]. A study by Yu et al. reviewed the first 100 robotic gastric bypasses during surgeons’ learning curves and found no anastomotic leaks and no mortality [6]. Standard laparoscopic gastrointestinal leak rates are commonly reported up to 6.3 % and mortality up to 2 % [7, 8]. A series of studies between 2002 and 2008 presented data on operative times and complications after robotically assisted Roux-en-Y gastric bypass [3, 6, 8–11]. A total of 603 patients received either totally robotic (129 patients) or a hybrid robotic procedure (474 patients). An average operative time of 201 min was long; however, the leak rate was significantly low at 0.3 % (2 fistulas or leaks). This was remarkable since the current-day literature reported fistula and leak rates at 6.7 % [8]. The safety of the robotic operation was supported with a 0 % 30 day mortality. At the time, the hybrid procedure, consisting of robotic gastrojejunostomy and laparoscopy for the remainder of the case, was more popular. However, Wilson reported, “Since 2008, the totally robotic approach has become more common with improved instruments and techniques where the robot is docked at the beginning of the case and the console surgeon performs the entire procedure with the help of a bedside assistant to deploy any staplers needed for creations of the gastric pouch and intestinal reconstruction (described earlier)” [4]. Additionally, the advent of the FDA’s approval of the robotic stapler has created the potential for a completely robotic one-surgeon operation, reducing the need for skilled bedside assistance.
Stay updated, free articles. Join our Telegram channel
Full access? Get Clinical Tree
