V. Schraibman, M.G. Epstein, G. Maccapani, M. Fernandes

A new post has been published on Clinical Robotics.

Alberto Patriti (Perugia – Italy) Alessandro Spaziani (Perugia – Italy)

The video shows a robot-assisted Nissen Fundoplication with Hiatoplasty for a large hiatal hernia with GERD

A new post has been published on Clinical Robotics.

Graziano Pernazza (Rome – Italy)

Age: 62 ASA score: 2 Previous Surgeries: no Histology (if any): gastric adenocarcinoma T2 N1 M0 History: Female patient 62yrs old, good general condition, sent to our attention by her physician, who had indicated an endoscopic study after the onset of a symptomatology characterized by postprandial abdominal pain, abdominal swelling, loss of appetite for flesh foods and mild anemia. The endoscopy revealed the presence of an excavated and ulcerated lesion, in the antral region. Biopsies were positive for adenocarcinoma. The total body CT scan was negative for distant lesions and suspicious lymphadenopathy. The vascular reconstruction, performed after the surgical procedure, confirmed the intraoperative finding of the accessory hepatic artery. Surgery Description: Induction of pneumoperitoneum with open technique One umbilical port for the endoscope, two robotic ports on right pararectal line and left flank. Two accessory ports on left pararectal line and right hypochondrion. The tumor is placed along the greater curvature of the stomach, not appearing to infiltrate the serosa. Absence of peritoneal carcinomatosis. No detectable liver lesions. No free fluid. The procedure is carried out with a full robotic approach. Coloepiploic detachment. Isolation and section of the right gastroepiploic vessels after infra-pyloric lymphadenectomy (4d ? 6). Isolation and section of the right gastric vessels and regional lymphadenectomy (5) Preparation of the duodenum and section with linear GIA stapler. Dissection of the hepato-duodenal ligament performing an en-bloc counterclockwise D2 lymphadenectomy along the branches of the common hepatic and proper hepatic artery, removing the periportal, celiac, left gastric, splenic and proximal gastric lymphnodes (12a, 8a, 9, 11p, 7) exposing the right diaphragmatic pillar. It is present a large caliber accessory left hepatic artery coming from the left gastric artery (Hyrtl?s artery), which is spared, performing the lymphadenectomy (1 and 3) along its main course, selectively closing and sectioning the gastric branches. Gastric section at the proximal third with linear GIA stapler.

A new post has been published on Clinical Robotics.

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.