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Robotic-assisted subtotal gastrectomy with extended lymphadenectomy for gastric cancer

Authors

Abstract

This video demonstrates the performance of a subtotal gastrectomy with extended lymphadenectomy for gastric cancer using the DaVinci system for robotic assistance.

Classification

routine cases, robotic

Keywords

robotic-assisted, subtotal gastrectomy, extended lymphadenectomy, gastric cancer

Media type

Duration

08'05''

Publication

2008-07

Popular

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Audio

Subtitles

E-publication

WeBSurg.com, Jul 2008;8(07).
URL: http://www.websurg.com/doi-vd01en2370.htm

Robotic-assisted subtotal gastrectomy with extended lymphadenectomy for gastric cancer

1. Case presentation and trocar placement 00'15''

This is a 4-arm DaVinci robotic procedure with 3 robotic working ports, one camera port and one assistant port.

2. Gastroscopy 00'25''

An on-table endoscopy is performed, which localizes this antral tumor and allows for laparoscopic identification.

3. Case commencement with initial perigastric dissection 00'35''

The operation begins by performing an omentectomy. The omentum is elevated off the transverse colon using electrocautery and the Harmonic scalpel. Afterwards, the lesser sac can be entered, the stomach can now be mobilized cephalad and the posterior aspect inspected. The operation proceeds towards the antrum along the greater curvature separating the posterior attachments of the duodenum.

4. Division of right gastroepiploic vessels 01'25''

The origins of the right gastroepiploic arteries are identified, isolated, and then divided with a vascular stapler.

5. Division of duodenum 01'45''

The pylorus is identified and the pars flaccida is entered. At this point, a window has been created around the proximal duodenum just below the pylorus. The duodenum is now divided with an Endo-GIA stapler. Care is taken to include the infraduodenal lymph nodes with the specimen. The proximal duodenum and the stomach are retracted superiorly.

6. Peripancreatic dissection and division of right and left gastric vessels 02'40''

The lymphatic dissection is begun identifying the gastroduodenal and hepatic arteries just superior to the pancreas. Using hook cautery, an extensive lymphadenectomy is carried out along the common hepatic artery. The right gastric artery, which has previously been ligated, can be seen to the right of the dissection. The dissection continues to the hepatic hilum until the proper hepatic artery has completely been skeletonized anteriorly. Once this has been completed, the dissection then continues along the common hepatic artery towards the coeliac trunk. And here you’re just starting to see the left gastric vein coming into view. It will be completely mobilized, ligated with clips, and then divided. Three robotic arms are used for this procedure, one for retraction of the liver, one for the hook cautery and one for dissection. Additionally, an assistant’s port can be seen being used here for both clipping and cutting. Lateral to the left gastric vein, the left gastric artery can now be seen. It is being carefully skeletonized and doubly ligated with endosurgical clips. Here the right pericardial nodes along the right crus are being dissected towards the specimen. The proximal splenic artery nodes are now being removed and this dissection will continue along the superior border of the pancreas to the splenic hilum, removing all of the nodes along the splenic artery. The splenic artery can be seen to the right of the screen. Lymph nodes are being removed between it and the pancreas, and finally the lesser curvature nodes are being removed. This is the final view of the skeletonized hepatic artery and coeliac trunk. After completion of the robotic lymphadenectomy, the procedure continues laparoscopically.

7. Transection of proximal stomach 06'00''

Now the point of transection along the greater curvature is selected and prepared. The stomach is now divided using an Endo-GIA stapler with adequate wide margins. An Endo-catch bag is now inserted for the removal of the specimen. The procedure is completed by performing a gastrojejunostomy.

8. Roux loop anastomosis 06'40''

An Endo-GIA stapler is used to create an antecolic side-to-side anastomosis. The common enterotomy is closed using a 2-layer hand-sewn technique.

9. Drain placement and procedure end 07'39''

Finally, a retrogastric drain is placed and port sites are closed.

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