Sudhir Rawal (Delhi – India)

A new post has been published on Clinical Robotics.

A. Coratti , M. Annecchiarico, F. Coratti, M. Di Marino

The Robot is docked head on from the patient’s head.
The procedure is started by sectioning the gastro-colic ligament.
The pancreas is accessed and the inferior margin is dissected.
Lymphadenectomy of the retropyloric and retropancreatic stations is carried out.
Follwoing this step, Kocher manouver is performed: The vena cava and the left renal vein are identified. The duodenum is then sectioned.
Lymphadenectomy of the hepatic hilum id carried out. The retropancreatic passage is opened and after mobilization of the Treiz the duodenum is reached. Pancreas is sectioend with ultrasound energy scalpel and uncinate process dissected.
Due to the pancreatic tissue fragility and the small calibre of the pancreatic duct this reconstructive part was performed as a pancreato-gastrostomy. Hepatico-jejunostomy and duodeno-jejnostomy on single small bowel loop completed the reconstruction.

A new post has been published on Clinical Robotics.

Pier C. Giulianotti (Chicago – USA) Subhashini Ayloo (Newark – USA)

Disease: Infected pancreatic pseudocyst after acutenecrotizing pancreatitis.

Age: 34

ASA score: 1

History: a 34-year-old gentleman with the past medical history of alcoholism complicated by acute pancreatitis, which is of the severe type further complicated by infected pseudocyst. The patient after an acute necrotizing pancreatitis developed a pseudocyst suspected for infection, and endoscopy was attempted to drain endoscopically transgastrically, putting a small stent through the opening in the stomach, but the persistence of the pseudocyst and signs of infection showed that probably the endoscopic treatment failed.

Description: Trocars: Open Hasson technique through the umbilicus. Once the pneumoperitoneum is established, we are looking around with the scope. There are some minor adhesions but we can place more trocars for the procedure, two 8-mm size trocars are placed in the right upper quadrant and then one in the left upper quadrant, and another assistant port is placed on the right side of the umbilicus.
Steps:
1 – The stomach is displaced anteriorly for the presence of the pseudocyst that is compressing. An ultrasound scanning of the pancreas with a laparoscopic probe is performed.
2 – The anterior aspect of the stomach is opened robotically, and the small stents that were positioned endoscopically are removed.
3 – Purulent material is evident. The opening is enlarged with a longitudinal stapler, in order to endure communication between the posterior wall of the stomach and the pseudocyst.
4 – The necrotic material that is placed into an endobag and extracted. After repeated procedure, debridement is achieved. Pseudocyst is checked and Now with irrigation, we are checking inside the pseudocyst.

The procedure allowed a satisfactory including debridement and creation of a larger communication between the stomach and the pseudocyst.

Blood loss has been no more than 50 cc.

A new post has been published on Clinical Robotics.

Pier C. Giulianotti (Chicago – USA) Subhashini Ayloo (Newark – USA)

Disease: Giant liver hemangioma, segment 7/6

Age: 46

Previous Surgeries: Hysterectomy, tonsillectomy and aneurysm clipping for cerebral aneurysm 8 years before.

Histology: Cavernous hemangioma (10 x 5 x 5 cm), subcapsular, with foci of thrombosis, organization and sclerosis

History: Patient developed chest pain approximately 3 to 4 months before with spasms radiating to her back. She had further imaging performed and was found to have a 9 cm hemangioma of her liver. An MRI demonstrated a 10.2 cm lesion in the superior aspect of the right hepatic lobe extending toward the inferior aspect.

Description: Trocars: A 5-mm cannula is inserted in the left upper quadrant. One 10/12 port is placed in the right pararectal line on the right side of the umbilicus, then
another 10/12 on the left side of the umbilicus. Three 8-mm ports are placed
one in the right upper quadrant, two in the left upper quadrant.

Steps
1 – Ultrasound evaluation of the liver using a laparoscopic probe and confirming the lesion located in the segment 7 and segment 6, and almost reaching the right subhepatic vein.
2 – Cholecystectomy: the fluorescence is very useful in this case because we are able to identify a small aberrant duct that is from the gallbladder bed going to the cystic duct. This anomaly is clearly recognized and recorded. Finally, the small duct is transected having the confirmation of the nature and a stitch of Prolene 4-0 to secure the proximal stump of the duct, even though the small duct will be removed together with the specimen.
3 – Hilum dissection: Identification of the right hepatic artery. Whith the use of a bulldog clamp, we ensure that the discoloration connected to the ischemia is limited to the right side. The two branches of the right hepatic artery are doubly ligated and the portal vein underneath is exposed. The right trunk of the portal vein is completely isolated. The right portal trunk is encircled and then with the suture of 3-0 Prolene and one clip, the portal vein is transected.
The bifurcation of the bile duct is identified and confirmed with fluorescence.
The right lobe is lifted with the fourth arm and the vena cava is exposed. The main discharge is the right hepatic vein plus another big branch that is joining the right hepatic vein coming from the segment 6. As an extracapsular control looks suboptimal, we are deciding to control the hepatic veins
inside the capsule.
4 – Transection of the parenchyma using the Harmonic and perfecting hemostasis either with the bipolar or Prolene stitches. The central area is characterize multiple deep connections with the hepatic vein system requiring a stapler.

The overall blood loss during the hepatectomy has been containing no more than 350 cc of blood. The patient was fine for the entire procedure, stable, and now she is sent stable and in good condition to the medical ICU.

A new post has been published on Clinical Robotics.

Pier C. Giulianotti (Chicago – USA) Francesco Bianco ( Chicago – USA) K. Venkata

Disease: Myasthenia gravis.

Age: 37

ASA score: 1

Histology: Involuted thymic tissue with focal calcifications

History: A 37-year-old Caucasian female who has myasthenia gravis with complaints of arm and leg weakness, fatigue and some difficulty chewing.

Description: Trocars: introduction of a 5-mm trocar in the fifth intercostal space, very lateral, close to the posterior axillary line. The right lung is excluded by the anesthesiologist when a low pressure is reached. Two more trocars, one in the third intercostal space anterior axillary line and the other is in the fifth intercostal space, always in the anterior axillary line, are placed. The posterior Trocar is upsized to 10 for the scope and another 5-mm port is placed between the camera port and the upper port in the third intercostal space.

Steps
1 – Opening of the Pleura in the anterior mediastinum. The right phrenic nerve and the internal mammary vessels are identified and preserved.
2 – The thymus is completely isolated and dissected without breaking the capsule, removing some pericardial fat as well and the horns of the thymus that
are particularly long, mainly on the right side. The two thymic veins that are going to the innominate vein are identified and those veins are clipped with the Hemo-loch clips and then transected. The left pleura is open and the phrenic nerve on the other side identified. A radical thymectomy is completed. Blood loss is less than 50 mL.

A new post has been published on Clinical Robotics.

Pier C. Giulianotti (Chicago – USA) Francesco Bianco ( Chicago – USA) Luca Milone (New York – USA)

Previous Surgeries: Cholecystectomy and appendectomy.

Histology: Intraductal papillary mucinous neoplasm, Tumor size: 1.5 x 1.0 x 1.0 cm, Margins of resection are free of tumor, the closest esection margin (anterior) is 1.0 cm from the lesion. Pancreatic intraepithelial neoplasia (PANIN), grade 2/3. Margins of resection are free of PANIN.

History: a past medical history significant for recurrent episodes of pancreatitis and presence of pancreatic cyst

Surgery Description: The patient has been diagnosed with a cystic lesion in the head of the pancreas and one of the differential diagnosis of benign mucinous cyst or mucinous dysplasia of the ducts and for the risk of developing cancer. Finally the resection of the head of the pancreas has been considered. A minimally invasive approach has been offered and after consent has been obtained the procedure was planned.
Ports: Introduction of a 5-mm port in the left upper quadrant and preliminary exploration of the abdominal cavity. There are a few omental adhesions in the upper quadrant. Another 5-mm trocar close to the umbilicus and more trocars are placed to complete the procedure. Two 10 mm trocars placed on both sides of the umbilicus, two 8 mm size trocar laterally in the right upper quadrant, one 8 mm size in the left upper quadrant.
Steps:
1 – Dissection of the right colonic flexure from the liver. The flexure is mobilizes and the second portion of the duodenum identified in the Kocher maneuver with mobilization of the head of the pancreas and the descending portion of the duodenum. Cava and the aortocaval space are exposed.
2 – Dissection of gastrocolic ligament using the harmonic device. The lower border of the pancreas is exposed.
3 – After exposing the neck of the pancreas and the confluence of the superior mesenteric vein with the portal vein, we are working at the hilum of the liver taking down some adhesions, exposing the common bile duct. Using the fluorescence we are able to confirm the anatomy of the bile duct, the
bifurcation and to follow the bile duct distally: note the anatomy of the hepatic artery that has a normal bifurcation with the right branch posterior to the bile duct. Transection of the right gastric artery in between sutures and of the common bile duct.
4 – The common hepatic artery is prepared until reaching the celiac artery. After the transection of the gastroduodenal artery, we are exposing the portal vein and the superior edge of the neck of the pancreas.
5 – Then the first portion of the duodenum is transected. The following step is to go to the Treitz and transecting the first jejunal loop in between the stapler device and retracting the duodenojejunal flexure on the right side posterior to the superior mesenteric vessel. Two stitches of Prolene 3-0 are applied on the neck of the pancreas and using Harmonic device, the neck of the pancreas is transected.
6 – Dissection of the uncinate process. The superior mesenteric vein is prepared on a vessel loop. We are exposing the SMA and removing all the lymphatic tissue between the SMV and the SMA.
7 – Completion of a radical pancreaticoduodenectomy Whipple type with the preservation of the pylorus. Momentarily the specimen is left inside the abdominal cavity and we are starting the immediate reconstruction.
8 – The pancreatic duct is small in size and a small stent is placed inside the pancreatic duct. A Gastrostomy is performed. Interestingly, stomach shows presence of multiple polyps that are biopsied and sent to permanent pathology. Then the first jejunal loop is brought retromesenterically up to the liver and an anastomosis between the bile duct and the jejunal loop and hepaticojejunostomy end-to-side are performed. using PDS 5-0. The last reconstruction in between the stomach, the pylorus and the jejunum is performed using the same jejunal loop 40 cm distal to the hepaticojejunostomy.
The patient has been stable for the entire procedure. Overall blood loss between 250 and 300
cc of blood, not requiring an intraoperative transfusion.

A new post has been published on Clinical Robotics.

A. Coratti

A new post has been published on Clinical Robotics.

A. Coratti

A new post has been published on Clinical Robotics.

A. Coratti

A new post has been published on Clinical Robotics.

A. Coratti

A new post has been published on Clinical Robotics.