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Robotic gastrectomy


Introduction

The application of laparoscopic techniques to gastric operations has become the preferred approach whenever feasible because of the known advantages of minimally invasive surgery. However, laparoscopy for advanced operations, such as gastric surgery, is beyond the technical abilities of many general surgeons.

The application of the robotic approach to gastric surgery has been increasing steadily and may soon become preferred for the vast majority of gastric operations. The robotic system offers solutions to the inherent limitations of laparoscopy by providing increased dexterity, ease of suturing, more precise tissue/vessel dissection, superior visualization, and better ergonomics. Beyond the known advantages of robotics, gastric resections for carcinoma performed robotically are associated with a higher lymph node harvest than conventional laparoscopy. Herein, we will include general thoughts regarding various aspects of gastric operations, as well as focus on the application of the robotic platform to gastric surgery.

Some general thoughts

Duodenal stump

It is best to avoid creating a duodenal stump altogether. When a duodenal stump is constructed, stapling across the duodenum seems to be an efficient and effective way to close the duodenal stump. Then, the duodenal stump should be rolled onto the ventral surface of the pancreas, utilizing interrupted sutures or a running suture so that the staple line is buttressed by the ventral surface of the pancreas, minimizing chances of a “blowout.” If the duodenal stump involves scarred and/or thickened tissue, it can be sewn and rolled onto the ventral surface of the pancreas, as just described. This approach to the duodenal stump will reduce the risk of a duodenal stump leak.

Gastrojejunostomy

When a gastrojejunostomy is constructed to bypass a gastric outlet obstruction or as a drainage procedure with concomitant truncal vagotomy, the gastrojejunostomy should be constructed, as much as possible, as a pylorojejunostomy. Bringing the jejunum to the pylorus allows preservation of the antral pump, as weak as it might be following longstanding gastric outlet obstruction and/or truncal vagotomy. The jejunum should not be sewn to the greater curve of the stomach because that is the “dependent” portion of the stomach. Utilization of the antral pump to assist in emptying through the gastrojejunostomy is an important concept to mind.

Techniques of reconstruction after partial/near-total gastric resection

If after resection there is a significant gastric reservoir, a loop gastroenterostomy should be constructed and not a Roux-en-Y gastroenterostomy, as the latter is associated with suboptimal gastric emptying. If after resection the gastric reservoir is small, a Roux-en-Y gastrojejunostomy should be constructed. If a total gastrectomy is being undertaken, it is desirable to leave a very small rim of stomach distal to the esophagus to aid in reconstruction. If a proximal gastrectomy is undertaken, there is generally no reason to preserve the distal stomach to avoid bile reflux. Furthermore, retention of the distal stomach will enhance the ulcerogenesis of the operative design because of the retention of gastrin-producing cells.

Patient positioning and trocar placement

Patients are placed supine with the right arm extended. Arm extension gives the anesthesiologist(s) access to the arm and does not encumber the robot docking. This is particularly true for the da Vinci Xi platform (Intuitive Surgical, Inc., Sunnyvale, CA). The scrub tech stands on the left and the first assistant on the right side of the patient ( Fig. 17.1 ).

• Fig. 17.1, Operating Room Setup.

We make a small incision in, not around, the umbilicus. This incision is just large enough to accommodate an 8-mm robotic trocar. Because of the importance of maintaining the pneumoperitoneum, it is our routine to utilize the AirSeal insufflation system (Conmed Corporation, Utica, NY). Diagnostic laparoscopy is first undertaken and then the additional trocars are placed under videoscopic visualization ( Fig. 17.2 ). We place an 8-mm trocar at the level of the umbilicus just to the right of the right midclavicular line. A 12-mm trocar to accommodate the 45-mm EndoWrist Stapler (Intuitive Surgical, Inc., Sunnyvale, CA) is placed to the level of the umbilicus at the left midclavicular line. An 8-mm trocar is placed along the left anterior axillary line just cephalad to the umbilicus. A 5-mm trocar to accommodate the AirSeal Access Port (Conmed Corporation, Utica, NY) is placed along the right anterior axillary line at or near the right costal margin. If extraction of a specimen will be part of the operation, a small incision (approximately 2–3 cm in length) is made caudal to the umbilicus and an Applied GelPoint (Applied Medical, Rancho Santa Margarita, CA) is placed. At this point, the bed is placed in reverse Trendelenburg (approximately 10 degrees) and tilted to the left (approximately 4 degrees) and the robot is docked.

• Fig. 17.2, Port Placement.

The operations described in this chapter are ranked in the order of difficulty.

Tangential gastric resections

Generally, such resections are undertaken for non-healing gastric ulcers (for diagnosis only, except for patients not suitable for a gastric resection) or neoplastic processes with limited local or distant invasion. A classic example of the latter is a gastrointestinal stromal tumor.

  • Arm 1: Robotic fenestrated bipolar forceps (fenestrated bipolar) or robotic small Graptor (bowel grasper) and a robotic mega needle driver (needle driver)

  • Arm 2: Camera

  • Arm 3: Robotic permanent cautery hook (hook cautery), EndoWrist 45 instrument (robotic stapler), needle driver

  • Arm 4: Small Graptor

Bedside assistant: laparoscopic suction device

With trocars placed as previously described, intraoperative endoscopy is undertaken to visualize the location and extent of the pathology to be removed. Once the proposed resection has been mapped out, it is easiest to utilize a robotic stapling device to “wedge” the pathology out. Conversely, the stomach wall can be incised and the stomach opened and the offending pathology completely removed before the defect in the stomach is closed. It is our preference when sewing the stomach to utilize 6-inch 3-0 V-Loc (Medtronic Inc, Dublin, Ireland) sutures, starting from each corner of the gastrotomy and sewing to the middle with a transverse closure. A second layer of closure is generally not utilized.

Endoscopy is undertaken following the gastric closure to ensure an airtight closure and complete extirpation of the pathology. A frozen section of the excised material and tumor should always be undertaken to ensure clean margins. As in all our gastric operations, we spray dilute bupivacaine solution throughout the peritoneal cavity. Liposomal bupivacaine is injected into each of the incisions.

Drainage operations for benign gastric outlet obstruction or peptic ulcer disease

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