Total gastrectomy, robotically assisted with D2 lymphadenectomy

The patient is positioned in a supine position with a slight reverse Trendelenburg position of approximately 10-15 degrees on the large vacuum cushion. The left arm is positioned on an arm support rail to the side to keep the surgical area clear and to optimize access for the surgical team and the robotic arms. The use of the vacuum cushion typically eliminates the need for additional supports, which speeds up preparation.

Note: The precise positioning of the patient is crucial for the success of the surgery, as it ensures optimal access of the robotic arms to the surgical sites in the abdominal cavity and minimizes the risk of complications.

The surgical team usually consists of two surgeons: the console surgeon, who controls the robot from a console, and the table assistant, who assists directly at the operating table. The table assistant is seated to the left of the patient. The video tower, which transmits the images from the robotic camera, is positioned on the right at torso height. Anesthesia is located at the head of the patient. The OR nurse stands to the left of the table assistant.

Caution: Correct positioning is of particular importance due to the docking of the patient to the robot's manipulator. Incorrect positioning or slipping of the patient during the operation poses a significant risk of injury to the abdominal wall by the robotic arms or instruments. Therefore, a careful check of the positioning before the start of the operation is essential.

Remark: Vacuum cushions can develop leaks over time. Before the sterile draping of the patient, the integrity of the vacuum cushion must be checked again to ensure a secure and stable hold of the patient throughout the procedure. Regular maintenance of the vacuum cushions is also advisable.

The creation of a pneumoperitoneum is performed using a Veress needle at the Palmer's point in the left upper abdomen. Palmer's point is a safe access point for creating the pneumoperitoneum because it is generally free of major vessels. It is located in the left upper abdomen, approximately 2–3 cm below the costal margin in the midclavicular line. Due to the varying abdominal wall compliance, it is advisable to determine the optimal position of the trocars on the inflated abdomen with pneumoperitoneum.

The four robotic trocars are positioned in a line 15 cm below the anticipated course of the transverse colon (always below the umbilicus). The trocars are inserted symmetrically, with a distance of 8 cm between each. The trocar on the far left is a 12-mm robotic trocar, while the other three are 8-mm trocars. In the left lower abdomen, between trocar 3 and 4, a 12-mm assistant trocar is inserted 3 cm caudal to the aforementioned trocar line. The patient is placed in a moderate Trendelenburg position.

Caution: The insertion of the trocars and the removal of the Veress needle are always performed under camera optical control.

The patient cart is positioned slightly to the left over the patient's head (daVinci X). On the Xi platform, the robot can alternatively be docked from either side of the patient. For the X, the arm sequence follows the order 4, 1, 2, 3. The arms are connected (docked) with the four robotic trocars. Subsequently, the instruments are introduced under visual control and parked under the ventral abdominal wall.

Caution: The trocars must be positioned with the wide black ring (Remote Center) at the level of the muscular abdominal wall to avoid injuries during movements.

Note: Ideally, the robotic trocars are inspected with the camera via the assistant trocar when introducing the robotic instruments. This allows the position of all robotic trocars to be easily checked again before the start of the operation.

o Incision in the left upper abdomen, insertion of the Veress needle

o Pneumoperitoneum

o Marking the line (15-20 cm caudal of the target area) and points for trocars

o Insertion of a robotic trocar

o Manual insertion of the camera

o Insertion of 3 Xi trocars each 8 cm apart under vision (far left: 12mm)

o Assistant trocar 12 mm caudal between 3 and 4

o Positioning: 15° Anti-Trendelenburg

o Dock camera arm + insert camera (3)

o Targeting with Xi

o Dock 3 additional arms

o Arms always one fist width apart

o Insertion of instruments and introduction into target anatomy (1: Cadiere forceps, 2: bipolar forceps, 3: camera 4: monopolar scissors) (order from right to left)

o Control of the remote center via assistant trocar

o Burping (press Port-Clutch 2x to relieve the abdominal wall)

o Switch to the console

The operation is performed with a Cadiere forceps through the right trocar, a bipolar forceps to the left of it, followed by the camera and the monopolar scissors on the far left.

The omentum is tensed ventrally and cranially with the Cadiere grasping forceps. The table assistant holds the transverse colon caudally to create countertraction.

The procedure begins in the midline by initially lifting the omentum from the transverse colon in layers until the bursa is reached. The dissection proceeds to the left, detaching the omentum from the left flexure and, if adherent, from the left-sided colon. Subsequently, the dissection proceeds to the right, where the transverse mesocolon is detached from the “mesogastrium” (trunk of the right gastroepiploic vessels). Finally, the omentum is detached from the right flexure and, if necessary, from the ascending colon.

Caution:

The omentum extends very close to the transverse colon. During dissection, thermal lesions of the transverse colon must be avoided!

Note:

Omentectomy is a complex and often time-consuming surgical step. However, for oncological reasons, we adhere to en bloc omentectomy, as it can be performed quickly and safely with the robot.

The stomach with the attached omentum is held cranially and ventrally with the Cadiere. At the inferior border of the pancreas, the confluence of the gastroepiploic vein into the Henle's trunk is demonstrated.

The vessel is double clipped centrally and single clipped peripherally with green Hemoloc® Clips and then transected. The origin of the gastroepiploic artery from the gastroduodenal artery is also clipped and divided.

Subsequently, the postpyloric fine dissection is performed, both ventrally and dorsally, to the other side in preparation for later transection.

Grasping and contracting of the stomach as well as the transverse colon and dissection of the colon in the correct layer caudally. This is done up to the splenocolic ligament, which is transected, and the colon is further dissected caudally.

Subsequently, there is a switch to the vessel sealer and the release of adhesions to the spleen until the large flexure is completely freed from it.

Caution: Extreme caution is required here to avoid capsule tears due to traction, which can cause troublesome bleeding, or if recognized late, could lead to postoperative bleeding.

Now follows the exposure and careful preservation of the vessels at the splenic hilum. Further preparation cranially along the greater curvature with transection of the short gastrics.

After the initial preparation, the hiatus oesophageus is now focused on. First, the exposure of the diaphragmatic crura is performed, which run on both sides of the esophagus and through which the organ passes. The diaphragmatic musculature is gently mobilized to widen the access to the esophagus. The distal part of the esophagus is now exposed. It must be separated from the adjacent tissues to create sufficient space for later transection and resection. After exposing the esophagus, the detachment of the lesser omentum (Omentum minus) from the liver follows. To allow an undisturbed continuation of the resection, this tissue is carefully dissected. During detachment, care must be taken to ensure a safe separation to avoid bleeding from the smaller vessels that pass through the omentum.