R. Pugliese, GC Ferrari, P. De Martini, C. Magistro, M. Gualtierotti

SUMMARY
A 4/5 Robot assisted subtotal gastrectomy with D2 nodal clearence is performed. The robotic procedure begins with lymphadenectomy on the anterior aspect of proper hepatic artery (group 12a,12b), then the right gastric artery is divided and the suprapyloric nodes are removed (group 5). Lymphadenectomy is completed by ablation of nodal tiers 8a,9,11p followed by division of the left gastric artery with removal en bloc of group 7 with tiers 1,3 and 5 along the lesser curvature. The stomach is transected and digestive restoration is obtained by a transmesocolic gastro-jejunal anastomosis with a 50 cm Roux-en-Y jejunal limb. The opening is closed by robotic running suture.

Background
The aim of this video was to assess the feasibility of robot–assisted D2 lymph nodal dissection associated to gastrectomy for adenocarcinoma.

Patients and methods
A 71 years old woman presented with early gastric cancer located at the antrum. No metastatic lesions were observed. She underwent a 4/5 Robot assisted subtotal gastrectomy with D2 nodal clearence by a 3-armed da Vinci ® Robotic Surgical System. The coloepiploic detachment and the dissection of the underpyloric nodes is performed by laparoscopy. The robotic procedure begins with lymphadenectomy on the anterior aspect of proper hepatic artery (group 12a,12b), then the right gastric artery is divided and the suprapyloric nodes are removed (group 5). Lymphadenectomy is completed by ablation of nodal tiers 8a,9,11p followed by division of the left gastric artery with removal en bloc of group 7 with tiers 1,3 and 5 along the lesser curvature. The stomach is transected by linear stapler by the first assistant to obtain a 4/5 gastrectomy. A 50
cm Roux-en-Y jejunal limb is chosen for restoration of the digestive tract. A transmesocolic gastro-jejunal anastomosis is fashioned by the first assistant by a linear cutting stapler on the posterior wall of the gastric stump, with the loop in vertical position. The opening is closed by robotic running suture.

Results
No intraoperative complication was registered. The operating time was 352 minutes, the set up of robot was 18 minutes. The histological report was T1No with 37 lymph nodes collected. The resection margin was 6.5 cm .The hospital stay was 10 days. The follow up at 25 months showed no recurrence.

Conclusions
Robotic gastrectomy for cancer yielding adequate D2 nodal clearance is safe and feasible with respect of oncologic principles. Robotic techniques can represent a remarkable tool to improve laparoscopic surgeon’s ability and precision in small surgical fields.

A new post has been published on Clinical Robotics.

R. Pugliese

A new post has been published on Clinical Robotics.

R. Pugliese , D. Maggioni, GC. Ferrari, A. Forgione, C. Magistro, M.Gualtierotti

SUMMARY
This video shows the feasibility of robot-assisted transhiatal esophagectomy. The long EndoWrist instruments allow a precise dissection of the esophagus from the right and left crus with an easy access to the mediastinum avoiding pleura opening. Transhiatal dissection of the esophagus is continued in a cephaled direction proximal to carina. The left gastric artery and vein are isolated and transacted between clips. The gastric conduit, created along the lesser curvature ,using stapler device, is pulled up into the mediastinum and out through the cervical incision where gastroesophageal anastomosis is performed. Robotic assistance overcoming traditional pitfalls of laparoscopy, increase the surgeon’s ability to work in the narrow space of the mediastinum

Background
Minimally invasive esophagectomy is a technically demanding procedure. Robotic technology can help the surgeon in this field. This video shows a robot assisted transhiatal esophagectomy.

Patients and methods
Patient under general anesthesia with legs divided in reverse Trendelenburg. The first part of the operation: gastrocolic opening, short gastric vessels transection with preservation of gastroepiploic ones is performed by laparoscopy. Then the da Vinci® Robotic Surgical System is brought cephalad to the patient. The gastrohepatic ligament is opened. The right crus is mobilized from the phrenoesophageal membrane. Blunt dissection is performed to separate the esophagus from the left crus and a retroesophageal window is created. Transhiatal dissection of the esophagus is continued in a cephaled direction proximal to carina. The left gastric artery and vein are isolated and transacted between clips. Mobilization of the proximal esophagus along the mediastinum is completed by a cervical access. The gastric conduit, created along the lesser curvature using stapler device, is pulled up into the mediastinum and out through the cervical incision where gastroesophageal anastomosis is performed

Results
No intraoperative complication was registered. The operating time was 320 minutes, the set up of robot was 20 minutes. The post-operative course was uneventful.

Conclusions
This video shows the feasibility of robot-assisted transhiatal esophagectomy. The long EndoWrist instruments allow a precise dissection of the esophagus with an easy access to the mediastinum avoiding pleura opening. Robotic assistance overcoming traditional pitfalls of laparoscopy like straight and shorts instruments, two dimensional imaging and poor ergonomics increase the surgeon’s ability to work in the narrow space of the mediastinum.

A new post has been published on Clinical Robotics.