Gastrectomy, subtotal, robotically assisted

The stomach with the attached omentum is elevated cranially and ventrally with the Cadiere. At the lower edge of the pancreas, the junction of the right gastroepiploic vein into the Henle's trunk is exposed. The vessel is clipped centrally with double green Hemoloc® clips and peripherally with a single clip, then transected. The origin of the right gastroepiploic artery from the gastroduodenal artery is similarly clipped and divided.

Caution: The Henle's trunk requires utmost care during dissection. It is particularly important to preserve the superior right colic vein at this step.

Now the omentum is repositioned caudally. This requires an initial adhesiolysis from the gallbladder. Visualization of the structures in Calot's triangle. The cystic duct is secured twice with Hem-o-lok clips and transected between them. A similar approach is taken with the cystic artery: double clipping with Hem-o-lok clips and transection between them. Antegrade dissection of the gallbladder from the gallbladder bed using the monopolar scissors. Hemostasis in the gallbladder bed is then achieved using the bipolar forceps. Retrieval of the gallbladder with a retrieval bag concludes this step.

Note: Whether a cholecystectomy is always indicated during a gastrectomy is a matter of debate. This is determined by the internal standard. In the presence of relevant gallbladder pathology, it is indicated regardless.

Lifting of the left liver with the Cadiere. Tensioning of the stomach by the assistant and incision of the lesser omentum at the underside of the liver beginning at the right diaphragmatic crus.

Caution: At this step, attention must be paid to replacing and accessory vessels to the left liver.

Remarks: For lifting the liver, a small compress is recommended as a pad between the Cadiere and liver tissue to avoid capsule injuries. We still always use the very small Cadiere as a grasping forceps, as collisions intra- and extracorporeally can be significantly better avoided than with larger grasping forceps.

Transverse incision of the serosa over the hepatoduodenal ligament at the liver hilum. Lifting of the greater omentum and the stomach and proceeding alternately "from below" and seeking the common hepatic artery. Displaying the origin of the gastroduodenal artery and removal of the fat and lymphatic tissue along it.

Pulling the stomach and omentum caudally and returning to the hepatoduodenal ligament. Seeking the proper hepatic artery and complete removal of all fat and lymphatic tissue along the hepatic arteries to the hilum. Clipping of the right gastric artery and transection of the same.

Remark: The lymphadenectomy of the hepatoduodenal ligament and the en bloc resection of the lesser omentum towards the lesser curvature is performed under safe visualization of the hepatic arteries, the portal vein, and the extrahepatic bile ducts.

Now work with two right arms for stapling (stapler on the 12 mm trocar, third from the right from the patient's perspective). The duodenum is circumferentially exposed 2-3 cm aboral to the pylorus. The duodenum is then transected with a robotic stapler (Sure Form 60 mm, blue cartridge).

Caution: Before transecting the duodenum, the gastric tube should be fully withdrawn or at least safely removed from the stomach.

Switch back to the configuration with two left hands. Now the stomach is placed in the left upper abdomen and the liver is lifted ventrally with the Cadiere. Completion of the lymphadenectomy along the common hepatic artery from the trunk to the origin of the gastroduodenal artery. When the crossing left gastric vein appears, the vessel is clipped centrally twice, peripherally once, and transected.

Then lymphadenectomy is performed along the splenic artery starting at the celiac trunk until the origin of the left gastroepiploic vessels is reached. These vessels remain intact to ensure the blood supply to the remaining stomach. Regardless, lymphadenectomy can be performed up to the splenic hilum. Finally, the origin of the left gastric artery at the trunk is identified, and the vessel is clipped centrally twice and peripherally once with purple Hemoloc® clips and transected.

Caution: During lymphadenectomy, the pancreatic capsule should remain intact. Otherwise, very troublesome pancreatic fistulas with behavioral situations at the upper edge of the pancreas can occur.

Note: The management of the left gastric artery is safest and clearest when both the common hepatic artery and the splenic artery are already cleanly dissected.

Starting at the esophageal hiatus, the lesser curvature of the stomach is freed from vessels and lymph nodes over approximately 4 cm. Subsequently, the omentum is retracted caudally, and the greater curvature is skeletonized while preserving the left gastroepiploic vessels. A very small portion of the omentum, where the short gastric vessels run to the upper pole of the spleen, is left orally. Then, using the 12mm robotic trocar on the far left, the stomach is stapled with usually two green 60mm robotic cartridges. The length of the remnant stomach is approximately 8 cm on the greater curvature and 4 cm on the lesser curvature.

Note: The indication for subtotal radical oncological gastrectomy is determined by the histological subtype, the grading of the carcinoma, and the localization. For well and moderately differentiated carcinomas of the intestinal type, minimum margins of 5 cm are required; for poorly and undifferentiated carcinomas of the diffuse type and signet ring cell carcinomas, 8 cm.

Briefly undock the robotic arms from the trocars and retrieve the resected specimen through a Pfannenstiel incision after inserting an abdominal wall protection foil. The specimen is sent for intraoperative frozen section examination (mandatory!) to verify the aforementioned safety margins. Place the cover cap on the protective foil and re-dock the robotic arms for reconstruction.

Now, approximately 20 cm aboral from the ligament of Treitz, a jejunal loop is sparingly skeletonized. This involves the preparation of a small mesenteric window with scissors, incision of the serosa, and further central preparation with the Sessel Sealer. Resection with another robotic stapler 60 mm, blue cartridge. Creation of a mesenteric window in the avascular left-sided transverse mesocolon for retrocolic elevation. Subsequently, the efferent jejunal loop is pulled infracolically into the upper abdomen. Now, using ICG, the perfusion of the gastric remnant and both resected jejunal ends is verified.

Caution: The skeletonization of the jejunum in minimally invasive surgery is prone to perfusion disorders at the resected jejunal ends, as diaphanoscopy is not possible in contrast to open surgery. Therefore, verification of perfusion in this area using ICG and immunofluorescence is mandatory. Small additional resections (before anastomosis!) are not uncommon.

Resection of the staple line of the transected stomach over a distance of 4-5 cm and corresponding opening of the elevated jejunal loop antimesenterically. A terminolateral gastrojejunostomy is then performed. Using a double-armed 4/0 Stratafix® RB suture, an initial continuous seromuscular suture line of 4-5 cm is sutured starting at the greater curvature side of the posterior wall. A gastric tube is advanced slightly over the anastomosis into the jejunum. Subsequently, the anterior wall is also sutured extramucosally, seromuscularly, and continuously with the second half of the Stratafix® suture. To prevent mucosal prolapse, a single U-suture is placed using PDS 4/0. Additionally, two more sutures are placed at the corners of the anastomosis to relieve tension from the anastomosis and avoid a dog-ear. The anastomosis is checked for tightness with blue dye, and then the gastric tube is removed.

In a similar manner, the afferent jejunal loop is anastomosed to the efferent loop as a side-to-side jejunostomy approximately 40 cm aborally. The two jejunal loops are opened 4 cm antimesenterically with monopolar scissors. The posterior wall is then sutured using a double-armed 4/0 Stratafix® RB suture in a continuous, seromuscular suture line. Subsequently, the anterior wall is also sutured extramucosally, seromuscularly, and continuously with the second half of the Stratafix® suture.

Note: This anastomosis can and does not need to be checked for tightness.

Note: We favor side-to-side enteroanastomoses using robotic seromuscular hand suturing in all areas with serosal bowel segments on both sides and prefer this technique over linear stapler anastomosis. The hand suture is clear, exactly corresponds to the technique in open surgeries, and is, in case of doubt, faster than the stapler suture.

Lavaging the abdominal cavity and suctioning the irrigation fluid. Insertion of an Easy-Flow drain through the far right trocar (from the patient's perspective) and placement at the gastrojejunostomy.

Definitive undocking of the robotic arms from the trocars. Removal of the working trocars under direct vision. Fascial closure with 2/0 slowly absorbable monofilament at the site of the two 12mm trocars and the retrieval incision, and skin closure with 4/0 rapidly absorbable monofilament intradermally.