Totally robot-assisted sleeve gastrectomy

This video shows how to perform a sleeve gastrectomy in a morbidly obese patient with a BMI of 46. Surgery is performed entirely using a robot-assisted approach from beginning to end. The second generation of the three-armed Da Vinci S™ robot is used. The robotic arms are orientated so as to simulate laparoscopic maneuvers.

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Totally robot-assisted sleeve gastrectomy

Authors

F Costantino, J Marescaux

Abstract

This video shows how to perform a sleeve gastrectomy in a morbidly obese patient with a BMI of 46. Surgery is performed entirely using a robot-assisted approach from beginning to end. The second generation of the three-armed Da Vinci S™ robot is used. The robotic arms are orientated so as to simulate laparoscopic maneuvers.

Mots-clés

Totally robot-assisted sleeve gastrectomy

Type de vidéo

Vidéo chirurgicale

Durée

10'52''

Publication

2011-05

Popularité

Favoris

Favorites Media

Audio

Sous-titres

E-publication

WeBSurg.com, May 2011;11(05).
URL: http://www.websurg.com/doi-vd01en3252.htm

Totally robot-assisted sleeve gastrectomy

1. Introduction 00'22''

This video shows how to perform a sleeve gastrectomy in a morbidly obese patient with a BMI of 46. Surgery is performed entirely using a robot-assisted approach from start to finish. The second generation of the three-armed Da Vinci S™ robot is used. The robotic arms are orientated so as to simulate laparoscopic maneuvers.

2. Operative setting 01'07''

Since we do not have an instrument allowing us to achieve coagulation using a robotic approach, a 5mm trocar is added and coagulation is achieved at the level of the lesser curvature and at the level of the branches of the left and right gastro-omental arteries, 6cm proximally to the pylorus. This limit has been defined from the partial gastrectomy performed posteriorly. As can be observed, one of the robotic arms maintains the liver retracted, and the other two arms are used to retract the greater omentum at the greater curvature of the stomach.

3. Dissection of greater curvature 01'56''

A 5mm Ligasure® vessel-sealing device has just been used to coagulate cranially and proximally towards the short vessels.

4. Insertion of calibration tube 02'13''

A 28-French calibration tube is then placed. It allows to achieve a calibrated division of the stomach.

5. Division of stomach 02'26''

The division is made possible by applying an Endo-GIA linear stapler, green cartridge, at the level of the gastric antrum where the wall is thicker. This allows to carry on the surgical procedure by performing another linear division until the stomach is completely divided. Hemostatic control is progressively achieved as the division of the stomach is completed. Once the left diaphragmatic crus has been reached, the freeing of the attachments of the short vessels is completed. This makes it possible to observe the two anterior and posterior aspects of the stomach and to perfectly calibrate and completely mobilize the stomach. This approach had been performed by mobilizing the short vessels lastly because our objective was to preserve as much vascular supply as possible at the level of the GE junction. Indeed, this region is at a higher risk of postoperative fistula. As can be observed here, dissection is carried on at the level of the short vessels by means of the 5mm Ligasure® device. The attachments are then freed, thus allowing to retract and completely dissect the stomach.

6. Stapling line reinforcement 04'50''

Once the stomach has been completely divided, it is removed from the operative field. The stapling line is systematically buried. This is rendered all the easier thanks to the robot, as it allows to place a good quality suture in a very confined space situated far away. 3/0 PDS monofilament material is used here. The division line is completely buried. Stomach-related maneuvers are now complete. The nasogastric tube can now be extracted. A hemostatic control is carried out at the level of the division slice. Oral intake is initiated on the following day in this patient. He is discharged on postoperative day 3. This procedure has been carried out using 5 trocars, among which one 10-12mm optical trocar placed between the xiphoid process and the umbilical port, 3 robotic operating trocars placed 8cm away from one another and situated respectively at the right, left hypochondrium, and right subcostal region, and a 5mm trocar situated at the left subcostal region for the Ligasure® device. The stomach is removed through the optical trocar opening using a protection bag, thus making the removal easier.