Robot-assisted Total Gastrectomy Research Articles

Robotic radical gastrectomy - own experience and review of literature

IntroductionGastric cancer is the fifth most common cancer worldwide. Surgery or endoscopic treatment is essential in all disease stages. The most common procedure is total gastrectomy with D2 lymphadenectomy. Removal of stomach and lymph nodes can be performed using minimally invasive techniques. These include laparoscopic gastrectomy, present in gastric cancer surgery since 1994 and robotic gastrectomy, which appeared for the first time in 2003. Last-mentioned method is the youngest and the most technically advanced form of surgical treatment of gastric cancer. First laparoscopic robot-assisted total gastrectomy in Poland was reported by Marek Zawadzki. In this paper we present technique of totally robotic total gastrectomy.AimPresentation of our experience in robotic radical gastrectomy. Description of first in Poland totally robotic gastrectomy. Review of literature assessing novel minimally invasive technique in gastric cancer treatment - robotic gastrectomy.Material and methodsPresentation of our own experience in robotic surgery. Review of literature.ResultsRobotic gastrectomy as an alternative to the laparoscopic technique is associated with earlier return of bowel motility after surgery and earlier introduction of a liquid diet. In terms of perioperative and postoperative complications, morbidity, and mortality, as well as a need to convert to open surgery, the laparoscopic and robotic techniques do not differ from each other. In our Department for the first time in Poland totally robotic radical gastrectomy using da Vinci Xi ® Surgical System (Intuitive Surgical) was performed. No postoperative complications were observed.ConclusionsTotally robotic radical gastrectomy is a safe alternative to classic and laparoscopic surgery which can have additional benefits both for the surgeon (less exhaustion, ergonomy, lack of hand tremor on instruments) as for the patient (earlier tolerance of oral diet, earlier hospital discharge). Further study is needed to assess relevance of potential benefits and cost-effectiveness of this novel technique.

Robot-assisted Total Gastrectomy with D2 Lymphadenectomy and Intracorporal Reconstruction

Robot-assisted total gastrectomy for gastric cancer is a demanding operation that is increasingly being performed, not only in Asia but also in specialised centres in Europe. The minimally invasive resection - and above all the lymphadenectomy and the minimally invasive intracorporal reconstruction by oesophagojejunostomy - are technically demanding surgical steps. These techniques are performed internationally in different variations, but have not yet been well standardised. In the video presented, we show the DaVinci Xi-assisted minimally invasive technique of total gastrectomy with D2 lymphadenectomy and intracorporal reconstruction using side-to-side oesophagojejunostomy with linear stapling.

Robotic‐assisted total gastrectomy in a patient with gastric cancer associated with situs inversus totalis: With video

Situs inversus totalis (SIT) refers to an inverted position of the major visceral organ as a "mirror image" of the regular location. We present a video of a robotic-assisted total gastrectomy in a 84-year-old man with SIT. The patient was diagnosed with advanced gastric cancer in the U region. The port placement was done as mirror images of our usual settings. Lymph node dissection was performed with a completely reverse approach to the usual procedure. After total gastrectomy, an intracorporal esophagojejunostomy was performed by circular method. All procedures were performed safely with no intraoperative complications and the patient was discharged uneventfully. Pathological diagnosis confirmed moderately differentiated adenocarcinoma and the depth of invasion was to the subserosa; there were five metastatic lymph nodes. In patients who have gastric cancer with SIT, a robotic-assisted total gastrectomy can be performed safely without surgical complication. Robots are useful for performing a total gastrectomy in SIT.

Short-term outcomes of robotic- versus laparoscopic-assisted Total Gastrectomy for advanced gastric Cancer: a propensity score matching study

BackgroundFew studies have been designed to evaluate the short-term outcomes between robotic-assisted total gastrectomy (RATG) and laparoscopy-assisted total gastrectomy (LATG) for advanced gastric cancer (AGC). The purpose of this study was to assess the short-term outcomes of RATG compared with LATG for AGC.MethodsWe retrospectively evaluated 126 and 257 patients who underwent RATG or LATG, respectively. In addition, we performed propensity score matching (PSM) analysis between RATG and LATG for clinicopathological characteristics to reduce bias and compared short-term surgical outcomes.ResultsAfter PSM, the RATG group had a longer mean operation time (291.14 ± 59.18 vs. 270.34 ± 52.22 min, p = 0.003), less intraoperative bleeding (154.37 ± 89.68 vs. 183.77 ± 95.39 ml, p = 0.004) and more N2 tier RLNs (9.07 ± 5.34 vs. 7.56 ± 4.50, p = 0.016) than the LATG group. Additionally, the total RLNs of the RATG group were almost significantly different compared to that of the LATG group (34.90 ± 13.05 vs. 31.91 ± 12.46, p = 0.065). Moreover, no significant differences were found between the two groups in terms of the length of incision, proximal resection margin, distal resection margin, residual disease and postoperative hospital stay. There was no significant difference in the overall complication rate between the RATG and LATG groups after PSM (23.8% vs. 28.6%, p = 0.390). Grade II complications accounted for most of the complications in the two cohorts after PSM. The conversion rates were 4.55 and 8.54% in the RATG and LATG groups, respectively, with no significant difference (p = 0.145), and the ratio of splenectomy were 1.59 and 0.39% (p = 0.253). The mortality rates were 0.8 and 0.4% for the RATG and LATG groups, respectively (p = 1.000).ConclusionThis study demonstrates that RATG is comparable to LATG in terms of short-term surgical outcomes.

Fluoroscopic balloon dilation for early jejunojejunostomy obstruction after gastrectomy with roux-en-Y reconstruction: a case series of three patients

BackgroundSmall bowel obstruction after gastrectomy with Roux-en-Y reconstruction (R-Y reconstruction) is not a rare complication. However, patients who need re-operation for this complication have a high rate of postoperative complications.We report a case series of three patients who underwent fluoroscopic balloon dilation (FBD) for early jejunojejunostomy obstruction (JJO) after gastrectomy with Roux-en-Y reconstruction (R-Y reconstruction).Case presentationThree patients were referred to our hospital for surgery for gastric cancer. Robot-assisted distal gastrectomy with D2 lymph node dissection and antecolic R-Y reconstruction were performed in two patients, and robot-assisted total gastrectomy with D1+ lymph node dissection and antecolic R-Y reconstruction was performed in one patient. The jejunojejunostomy was created as a side-to-side anastomosis using a linear 45-mm stapler. The entry hole was closed with a knotless barbed suture, and serosal-muscle layer suture reinforcement with an absorbable suture was performed at the jejunojejunostomy.Subsequently, all the patients were diagnosed with JJO by computed tomography and upper gastrointestinal series. The average time to JJO from gastrectomy was 5 days (range 2–7); initial clinical symptoms were vomiting in all three cases, with simultaneous upper abdominal pain in one case. We successfully performed FBD in all three cases after unsuccessful conservative treatment using an ileus tube. The clinical symptoms improved soon after FBD, and all the patients were able to avoid re-operation. The average period to FBD from JJO was 10 days (range 4–14). The average procedure time was 46 min (range 29–68), and the average duration to oral intake from FBD was 4 days (range 2–5). The average duration of hospital stay after FBD was 12 days (range 9–15). There were no complications in any of the cases.ConclusionFBD might be a feasible procedure to avoid surgery for early small bowel obstruction after gastrectomy with R-Y reconstruction.

2554 A Hefty Hematoma: A Rare Case of Pancreaticobiliary Obstruction After Gastrectomy With Roux-en-Y

INTRODUCTION: Pancreaticobiliary obstruction is an uncommon complication of total gastrectomy with Roux-en-Y reconstruction. We present a case of a patient with a closed loop obstruction due to a hematoma at the location of jejunojejunal anastomosis. The patient underwent EGD with clot evacuation resulting in decompression of the pancreaticobiliary limb. CASE DESCRIPTION/METHODS: A 57-year-old male, with hypertension, who had recently immigrated from China presented for evaluation of persistent heartburn. He underwent an upper endoscopy, which showed erythematous gastric mucosa and pathology was positive for superficial invasive adenocarcinoma. He was referred to surgery and underwent laparoscopic esophagogastroduodenoscopy, robotic assisted total gastrectomy and Roux-en-Y reconstruction with jejunostomy tube placement. On postoperative day one, there was bright red blood on aspiration from his nasogastric tube and J-tube. Laboratory tests were notable for downtrending hemoglobin and he required 2 units of packed cells. Due to concern for active bleeding, the patient underwent an upper endoscopy in the operating room, which demonstrated no active bleeding and presence of a blood clot at the JJ anastomosis. Epinephrine was injected at the site of the clot. Post procedure, he had increasing total bilirubin which peaked at 5.9. A computed tomography was done on postoperative day 3, demonstrating marked dilation of the pancreaticobiliary limb, which was suspicious for a clot within the small bowel at the level of the JJ anastomosis, concerning for a closed loop obstruction. He then underwent a repeat endoscopy using a duodenoscope. A 9 cm clot was visualized at the JJ anastomosis causing pancreaticobiliary obstruction. The clot was removed with cold soft snare, grasping forceps and roth net with resultant free flow of bile at the site of JJ anastomosis. Total bilirubin subsequently downtrended and returned to normal. The patient's recovery was uneventful, and he was discharge 16 days after clot evacuation. DISCUSSION: The most common early complications of total gastrectomy with Roux-en-Y reconstruction include SBO and anastomotic leak. Our case highlights a rare complication of pancreaticobiliary limb obstruction due to hematoma at the JJ anastomosis. Early EGD allowed for clot evacuation and limb decompression without need for re-operation.

Systematic assessment of complications after robotic-assisted total versus distal gastrectomy for advanced gastric cancer: A retrospective propensity score-matched study using Clavien-Dindo classification.

Despite increasing evidence demonstrated robot-assisted distal gastrectomy (RADG) is safe and feasible for the treatment of advanced gastric cancer (AGC), robot-assisted total gastrectomy (RATG) remains a challenging procedure due to its technical difficulties and possible postoperative complications (POCs). This study aimed to systematically evaluate POCs following RATG. Between January 2017 and January 2019, 319 AGC patients with pathological stage T2-4aN0-3M0 who underwent RADG or RATG were enrolled. POCs were stratified using the Clavien-Dindo classification. One-to-one propensity score matching was performed to reduce confounding differences. After matching, 266 patients met the criteria for further analysis. Ultimately, 64 patients (24.1%) who developed POCs had 126 clinical manifestation events. Overall the POCs rate was significantly greater after RATG in comparison with RADG (29.3% vs. 18.8%; P = 0.045), and more major POCs (Clavien-Dindo grade ≥ IIIa) were observed in the RATG group (14.3% vs. 5.3%; P = 0.013). The POCs were then classified into local and systemic POCs. The rates of local POCs (35.3% vs. 19.5%; P = 0.004) and systemic POCs (24.8% vs. 15.0%; P = 0.046) were significantly higher in the RATG group than the RADG group. Subgroup analysis showed that the anastomotic leakage rate was higher after RATG (5.3% vs. 0.8%; P = 0.031), whereas the remaining POCs were similar between the two groups. Patients with higher POCs significantly had longer postoperative length of stay (R = 0.895, P = 0.003). Multivariate analysis confirmed age, extent of resection, and TNM stage were risk factors for all POCs. These findings demonstrated that RATG is technically feasible and safe for treatment of AGC with acceptable morbidity and mortality rates. The POCs rate of RATG was higher than RADG, especially for anastomotic leakage. More effective anastomotic techniques are needed in RATG to prevent leakage.

Robotic-assisted versus conventional laparoscopic-assisted total gastrectomy with D2 lymphadenectomy for advanced gastric cancer: short-term outcomes at a mono-institution

BackgroundRobotic-assisted surgery, a developed technology, is becoming more and more accepted by surgeons. However, the comparison between robotic-assisted total gastrectomy (RATG) and conventional laparoscopy-assisted total gastrectomy (LATG) for advanced gastric cancer (AGC) is seldom reported, or usually the sample sizes reported are small. The current research was designed to compare the short-term outcomes of RATG and LATG with D2 lymphadenectomy for AGC in a mono-institution from China.MethodsA total of 205 patients from June 2015 to October 2018 were included in this study. Among them, 106 patients underwent LATG, and 99 patients underwent RATG. The patients’ clinicopathological characteristics, surgical performance and short-term outcomes were retrospectively analyzed.ResultsThe clinicopathological characteristics showed no difference between the LATG group and the RATG group. However, compared with the LATG group, the operation time was longer (P = 0.000), and the operative blood loss (P = 0.000) and the volume of abdominal drainage was less (P = 0.000) in the RATG group. Moreover, the RATG took less time to remove abdominal drainage tube than LATG (P = 0.000). The plasma levels of CRP at 72 h post-operation was lower (P = 0.000), and the number of retrieved lymph nodes was more (P = 0.000) in the RATG group. Nevertheless, the postoperative length of stay (P = 0.890), the time to first flatus (P = 0.448), the postoperative complication (P = 0.915) and the visual analogue pain score at 24 h post-operation (P = 0.457) were comparable between the two groups.ConclusionsRATG with D2 lymphadenectomy shows safety and feasibility for AGC and could be served as an alternative treatment for AGC in the future.

Robot-Assisted Total Gastrectomy: Preliminary Evaluation

Background: Laparoscopic total gastrectomy with extended lymphadenectomy is a technically demanding surgical procedure with steep learning curve that has limited its widespread use. The aim of this study was to evaluate the feasibility of the robotic approach in total gastrectomy for cancer. We present our experience of 17 consecutive patients who underwent robotic total gastrectomy with intracorporal sutured Roux-en-Y esophagojejunostomy and jejuno jejunostomy between 2014 and 2017. Methods: Data were collected, and patients' demographics and outcomes were examined retrospectively. Results: Seventeen patients with a median age of 68 years (range 32-81) were identified (10 males, 7 females). Mean operative time was 198 minutes (range 108-277) including mean anastomosis time of 25 minutes (range 18-35). There was no conversion to open surgery or requirement for perioperative blood transfusion. Median length of hospital stay was 9 days (range 2-30). Two patients developed postoperative complications including one anastomotic leakage treated conservatively and one internal hernia requiring surgical revision. There was no 90-day mortality or readmission. Conclusion: Robot-assisted total gastrectomy is feasible and reproducible. It overcomes several laparoscopic technical difficulties especially regarding anastomosis. It has the potential to become an alternative to open gastrectomy for gastric cancer. Nevertheless, further follow-up and randomized clinical trials are needed to evaluate mid-term and long-term outcomes of this approach.

Gastric cancer in a situs inversus totalis patient with multiple intestinal and vessel variations related to gastrectomy surgery: A case report and literature review.

Rationale:Situs inversus totalis (SIT) is a rare congenital anomaly characterized by complete inversion of the abdominal and thoracic organs, and often involves multiple genetic mutations. The most suitable surgical technique for patients with multiple vessel and organ variations as well as SIT remains unclear. Furthermore, there has been insufficient clinical evidence that demonstrates which surgical techniques achieve the best outcomes. Finally, the standard of care has not yet been determined. We present the case of a 60-year-old man with SIT, who was diagnosed with moderately and poorly differentiated adenocarcinoma at the gastroesophageal junction. We further describe the advantage of using robotic-assisted laparoscopic surgery in patients with this anomaly.Patient concerns:A 60-year-old man complained of pain in his upper abdomen for 3 months. Physical examination revealed an apex beat in the right fifth intercostal space, and vascular anomalies were noted on abdominal angiographic computed tomography.Diagnoses:Moderately and poorly differentiated adenocarcinoma at the gastroesophageal junction with SIT.Interventions:Robot-assisted total gastrectomy with D2 lymph node dissection and hand-sewn Roux-en-Y anastomosis was performed.Outcomes:The postoperative course was uneventful, and the patient was discharged on the seventh postoperative day.Lessons:Robotic surgery for gastric cancer is a safe and feasible alternative to laparoscopic surgery and it can be successfully used to treat gastric cancer in patients with SIT with multiple anatomic variations. As exemplified by our case, SIT might be accompanied by multiple anatomic variations. Detailed preoperative detailed imaging of the blood vessels and gastrointestinal tract is useful in these patients.

Negative pressure pulmonary edema related to bronchospasm during anesthetic recovery

Negative pressure pulmonary edema (NPPE) related to upper airway obstruction is a well-described phenomenon [1], but NPPE related to bronchospasm has only rarely been reported [2]. We experienced NPPE during recovery from anesthesia in 77-year-old male with gastric cancer patient who underwent robot-assisted total gastrectomy. The patient was 157 cm tall and weighed 47.5 kg, and was a non-smoker with no allergy or medico-surgical history except for antihypertensive medication (bisoprolol for 1 yr). Preoperative laboratory findings, including pulmonary function test, were within normal ranges. Anesthesia was induced with propofol, remifentanil, and rocuronium and the anesthetic procedure proceeded without incident. Although peak airway pressure and PetCO2 increased during CO2 insufflation for pneumoperitoneum, they normalized after intravenous patient controlled analgesia (PCA) (fentanyl 1,000 µg/100 ml normal saline, 2 ml/hr) connection during surgery. Surgery was completed uneventfully in 190 min, and fentanyl (35 µg) was administered for analgesia. The endotracheal tube was removed when the patient responded to verbal commands, and neuromuscular function was then ascertained by train-of-four stimulation. However, after several minutes of assisted ventilation with a mask, the patient became drowsy, unresponsive to verbal commands or physical stimulation, and his spontaneous respiration weakened. Because pupil constriction was noted, PCA was discontinued and naloxone (0.4 mg) was slowly administered. Manual ventilation was maintained for 2-3 min while waiting the patient's awakening, when the patient coughed severely and subsequently developed signs of bronchospasm, such as, wheezing at forced exhalation and use of accessory muscles. Because ventilation was difficult via the oropharyngeal airway despite appropriate manipulations, tracheal intubation was performed with thiopental 50 mg and succinylcholine 50 mg. On auscultation, inspiratory and expiratory wheezing were apparent over the entire lung field. Arterial blood gas analysis (ABGA) immediately before intubation revealed pH 7.156, PCO2 75.8 mmHg, and PO2 84.4 mmHg. Controlled ventilation was maintained by isoflurane administration. Peak airway pressure was 48 mmHg at a tidal volume of 400 ml. Repeat ABGA revealed pH 7.283, PCO2 50.8 mmHg, and PO2 113.1 mmHg with a FiO2 of 1.0. Airway pressure was gradually decreased to 15 mmHg and signs of bronchospasm resolved 3 min after epinephrine 0.05 mg i.v. was administered. After 3-4 min of controlled ventilation, a pink and frothy secretion was noted inside the endotracheal tube, and breathing sounds were coarse over the entire lung field on auscultation. Furosemide 20 mg was administered and 8 cmH2O positive endexpiratory pressure was applied for possible pulmonary edema. Plain chest radiography revealed bilateral perihilar interstitial and alveolar infiltrates (Fig. 1). The patient was transferred to the intensive care unit for ventilatory care. After applying synchronized intermittent mandatory ventilation and continuous positive airway pressure mode for 12 hr under sedation, symptoms and signs improved. He was then extubated and nasal oxygen was supplied. ABGA showed values within normal range and the patient's general condition was improved. The patient was transferred to a general ward on POD 2. Fig. 1 Chest AP just after the pulmonary edema was detected. In this patient, bronchospasm, which occurred during recovery from anesthesia, is believed to have been a cause of the pulmonary edema. Negative intrathoracic pressure is generated in the chest when a patient attempts to inspire against constricted airways during bronchospasm. Furthermore, this acute drop in intrathoracic pressure increases venous return to the right heart, and thus, increases pulmonary venous pressure. In addition, this increase in pressure in the venous circulation creates a transpulmonary hydrostatic pressure gradient and generates fluid movement. Allergic bronchospasm is not a rare phenomenon in patients with a hypersensitive airway or asthma during anesthesia or recovery. However, our patient (a lifelong non-smoker) had no history of airway disease, and his preoperative pulmonary status was in the normal range. Non-allergic bronchospasm may also occur immediately after nonspecific stimuli [3]. In a survey of perioperative bronchospasm, non-allergic bronchospasm was found to be more frequent (79%) than allergic bronchospasm, and 20% of non-allergic bronchospasms were found to occur during the emergence/recovery period [4]. An acute increase in airway responsiveness may result from irritation of the well-innervated airway by a foreign body, such as, an endotracheal tube or suction catheter, or by secretions. In a large cohort study conducted by Schwilk et al. [5], the incidence of perioperative bronchospasm was 0.2% among 15,415 non-smoking patients without respiratory disease. In our patient, we believe that bronchospasm resulted from irritation by aspirated oral secretions during manual ventilation during re-narcotization. Non-allergic bronchospasm is usually not associated with cardiovascular symptom, but hypoxia following inadequate ventilation may lead to cardiovascular collapse, and may occasionally result in NPPE [3].

Iatrogenic intramural esophageal dissection secondary to insertion of nasogastric tubes and the transorally inserted anvil during robot-assisted total gastrectomy

A 37-year-old female patient (height, 161.5 cm; weight, 49.5 kg) was scheduled to undergo robot-assisted total gastrectomy for early gastric cancer. Her past medical history and physical examination were unremarkable. In the operation room, the patient was induced with 2.0-3.0 vol% sevoflurane after receiving 110 mg of propofol by intravenous injection. Tracheal intubation using a 7.0 mm internal diameter endotracheal tube was performed without difficulty 3 minutes after the patient received 10 mg of cisatracurium by intravenous injection. A 16 French silicone nasogastric tube (Levin tube, Yushin Medical, Bucheon, Korea) was inserted through the left nostril with some difficulty. The nasogastric tube was passed to 55 cm and was noted to drain a small amount of turbid fluid. Twenty minutes after induction of anesthesia, a skin incision was made. The duodenum was resected, the esophagus was clamped and stomach was removed. One and a half hours later, the nasogastric tube was removed. The surgeon made a request to insert the OrVil TM transorally and said that the anvil head should be passed as the convex surface of the anvil head is directed at the posterior wall of the esophagus. At first, the OrVil

Robot-assisted total gastrectomy is comparable with laparoscopically assisted total gastrectomy for early gastric cancer

Laparoscopically assisted total gastrectomy (LATG) is technically difficult. Robot surgery has theoretical advantages such as increased degrees of freedom of instruments and a three-dimensional view. The current study aimed to determine whether a robot-assisted total gastrectomy (RATG) has a real benefit over LATG in terms of surgical and oncologic outcomes. A single-center case-control study was conducted. The study included 36 patients who underwent RATG and 65 patients who underwent LATG at the National Cancer Center in Korea between February 2009 and May 2011. No patients were excluded from the analysis within the study period. Clinicopathologic data, operative data, postoperative morbidity, and pathologic data were analyzed by Student's t-tests and Chi-square tests, as indicated. The mean age of the patients was 53.9 ± 11.7 years in the RATG group and 56.9 ± 12.3 years in the LATG group (P = 0.236). The mean BMI was 23.2 ± 2.5 kg/m(2) in the RATG group and 23.6 ± 3.4 kg/m(2) in the LATG group (P = 0.494). The mean postoperative hospital stay was 8.8 ± 3.3 days in the RATG group and 10.3 ± 10.8 days in the LATG group (P = 0.416). The mean operative time was 305.8 ± 115.8 min in the RATG group and 210.2 ± 57.7 min in the LATG group (P < 0.001). The mean number of dissected lymph nodes was 42.8 ± 12.7 in the RATG group and 39.4 ± 13.4 in the LATG group (P = 0.209). Postoperative complications were experienced by 6 patients (16.7%) in the RATG group and 10 patients (15.4%) in the LATG group (P = 0.866). Despite early experiences, RATG was shown to be comparable with LATG in terms of surgical and oncologic outcomes. However, no apparent benefit is associated with RATG to date.