Robotic sleeve gastrectomy

This video shows the bariatric procedure of sleeve gastrectomy performed using a daVinci surgical robot. The patient had undergone gastric banding previously so the robot is useful in the dissection of a difficult hiatus, and also for suturing in a confined space. An experienced patient side assistant complements the procedure by performing the stapled resection of the greater curvature of the stomach. This video is suitable for bariatric surgeons.

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Robotic sleeve gastrectomy

Authors

M Vix, J Marescaux

Abstract

This video shows the bariatric procedure of sleeve gastrectomy performed using a daVinci surgical robot. The patient had undergone gastric banding previously so the robot is useful in the dissection of a difficult hiatus, and also for suturing in a confined space. An experienced patient side assistant complements the procedure by performing the stapled resection of the greater curvature of the stomach. This video is suitable for bariatric surgeons.

Classification

robotic

Keywords

robot, sleeve gastrectomy, bariatric

Media type

Surgical video

Duration

09'50''

Publication

2007-06

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E-publication

WeBSurg.com, Jun 2007;7(06).
URL: http://www.websurg.com/doi-vd01en2067.htm

Robotic sleeve gastrectomy

1. Preparation of robot 00'15''

The patient is a 50-year-old lady with a BMI of 44. She previously underwent laparoscopic adjustable gastric banding but this was complicated by erosion of the band into the stomach. The band was subsequently removed laparoscopically but dense adhesions resulted in the region of the gastric cardia and fundus. The 2 instrument arms as well as the camera arm are sequentially draped by the scrub nurse and the circulating nurse. The draping is specific for each type of arm. The arms are draped up to the central column of the surgical cart. Sterile adapters are installed for the camera cannula as well as the camera itself. The touchscreen is also draped to allow handling by the patient’s side assistant. The monitor is equipped with an intercom system to facilitate communication between the surgeon and the console and the patient’s side team. The sterile surgical cart is then compacted to avoid contamination by the OR personnel. After insufflation and trocar insertion, the surgical cart is then rolled into the sterile field. The instrument arms are double cannulated in 5 to 12 mm ports to allow the use of staplers later during the procedure. The instruments are engaged in the arms and introduced under visual control in the operating field. The double channel sterile laparoscope is then prepared. Then the bifurcated light guide is attached. This type of light guide is necessary for a sterile laparoscope to ensure a uniform illumination. To guarantee a perfect alignment of the 2 images, the scope needs to be calibrated. The scope and camera are then ready to be installed.

2. Dissection of cardia and fundus 04'00''

The surgery may now commence. The surgery starts with a grasper in a left arm and a hook in a right arm. From this point onwards, the surgeon is seated comfortably at the robotic console. The dissection in the upper abdomen aims to expose the main landmarks at the diaphragmatic hiatus. The adhesions between the lesser curvature of the stomach and the liver are taken down to identify the right crus of the diaphragm. The fat pad around the cardioesophageal junction is removed in order to clearly delineate the gastric cardia, fundus, angle of His, and left crus of the diaphragm. The spleen must also be dissected clear from the operative field to avoid inadvertent injury during the stapling procedure. Thorough exposure is essential to perform this resection correctly and without complications. Observe the manipulating ability of the grasper and hook during adhesiolysis. Because of the handle/wrist technology (5:12) behind these instruments, they are capable of 7 degrees of freedom. Standard laparoscopic instruments are capable of 5 degrees of freedom: insertion, rotation, up and down, side-to-side, which is known as pitching and yawning, and finally opening and closing of the instrument tip, for example, scissors and graspers. Robotic instruments have an articulation just before the tip called the handle/wrist, which allows the tip to deflect in 2 additional planes, vertical and horizontal, giving these instruments their remarkable dexterity. Further down along the lesser curvature of the stomach more adhesions between the liver and the stomach are taken down. This is to help identify the distal branches of the anterior vagus nerve, the nerve of Latarget running along the lesser curvature. After this point, the pyloric region is supplied by separate vagal fibers emanating from the hepatic branch of the vagal nerve and these are known as the superior and inferior pyloric nerves.

3. Dissection of greater curvature 06'20''

Therefore the stomach can be divided safely at this level without affecting the innervation of the pylorus. Injury to the parasympathetic nerve supply to the pylorus can lead to problems of gastric emptying. This landmark is noted on the greater curvature where the gastric stapling will commence subsequently. Once the adhesiolysis is completed the greater curvature of the stomach is mobilized. A ligasure device is introduced by an assistant through the trocar in the left flank. The right and left gastroepiploic arcade is dissected off the greater curvature of the stomach using a combination of the robotic grasper and hook and the ligasure device, which is able to seal and divide vessels up to 7 mm in diameter. The dissection commences at the pyloric antral region at the terminal branches of the vagal nerve and continues upwards until the fundus is mobilized. Further up along the greater curvature the short gastric vessels are divided with a ligasure device.

4. Sleeve gastrectomy 07'41''

After the greater curvature of the stomach is fully mobilized, the assistant introduces the endoscopic stapler to perform the gastric resection. This is started 6 cm proximal to the pylorus of the stomach. Multiple firings of the stapler are necessary to complete the construction of the gastric sleeve. A 36 French bougie is placed in the stomach along the lesser curvature in order to calibrate the gastric tube that is created (8:22). On completion of the sleeve gastrectomy hemostasis is controlled along the staple line using a bipolar diathermy introduced by the assistant.

5. Suture of staple line 08'30''

Then a reinforcing suture is performed robotically. In morbidly obese patients, working space is limited in the peritoneal cavity because of visceral adiposity. Furthermore, the weight of the abdominal wall makes it difficult to achieve the same dome-like pneumoperitoneum, which is usually observed after insufflation in thin and normal-sized individuals. Finally, the thickness of the abdominal wall increases the resistance to movement of the instruments limiting their comfortable working range and adding to surgeon’s fatigue. The dexterity of the robotic instruments and the mechanical strength of the robot arms reduce these disadvantages making the robot a very useful tool for bariatric surgery. Once again, note the ease with which a potentially difficult procedure is performed by the robot. Finally, the resected portion of the stomach is retrieved in an endoscopic bag.