Updates in Surgery

Giuseppe Spinoglio Editor

Robotic Surgery
Current Applications and New Trends

In collaboration with
Alessandra Marano
Giampaolo Formisano
Updates in Surgery
Giuseppe Spinoglio
Editor

Robotic Surgery
Current Applications and New Trends

In collaboration with
Alessandra Marano and Giampaolo Formisano

Forewords by
Giorgio De Toma
Francesco Corcione

~ Springer
Editor
Giuseppe Spinoglio
Department of General and Oncologie Surgery
··ss. Antonio e Biagio·· Hospital
Alessandria, ltaly

In co/laboration with
Alessandra Marano and Giampaolo Fonnisano

The publication and the distribution of this volume have been supported by the
Italian Society of Surgery

ISSN 2280-9848
ISBN 978-88-470-5713-5 ISBN 978-88-470-5714-2 (eBook)

DOI 10.1007/978-88-470-5714-2

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To Lorenzo Capussotti
An honest man
Master of surgery
Unforgotten friend
Foreword

The symbol of technical evolution, in the last few years , in general surgery is
undoubtedly robotic-assisted surgery. The introduction of this technique goes back
a decade and as usually happens with advanced technologies , enormous steps for-
ward have been made in the development of devices and equipment that is increas-
ingly sophisticated and of reduced dinlensions. A very significant impetus has been
given to this kind of surgery by Prof. Giuseppe Spmoglio, who recently had the
honor of being elected to the position of President to the Clinical Robotic Surgery
Associatiol/ in Chicago, a surgical society that is a key player of this specific
branch, and so is fOf\vard looking and of relevance.
The hospital in which Prof. Spinoglio is Head of Department has become an
intemationally renowned point of reference for robotics in surgery, where all kinds
of general surgery interventions are practiced, that can be treated through a mini-
mally invasive approach. To Prof. Spinoglio's further credit is the energy devoted
to create a European Training Center to infonu and train younger surgeons in tIus
particular type of surgery. This present text has been carefully edited by him and
will certainly have an undeluable worth for Italian surgeons and will be of great
didactic value for the youngest amongst them.

Rome , September 2014 Giorgio De Toma

President , Italian Society of Surgery

vii
Foreword

Throughout the ages , there have always been men gifted with visions that in
time proved to almost be foresight . By way of example , at the end of the 15th
century, Da Vinci had already imagined the helicopter and the parachute among
other inventions, and Jules Vente conceived the submarine decades before the
first model was built.
Keeping the above in mind, what happened much more swiftly in the world
of surgery under our own eyes, is without comparison. If someone had told me
25 years ago (not 250) that I would have been perfonlling surgical interventions,
even challenging ones , by introducing a thin tube into an abdominal cavity filled
with C02 while watching operations on a screen, I would have been flabbergast-
ed. And if someone had predicted I would even be able to one day operate on a
patient remotely, and follow each step of the intervention in full 3D HD on a flat
screen, while maneuvering sophisticated instmments that are as articulate as a
human hand, I 'would have taken the speaker as mad. Nevertheless all this
proved to be tme , and in a short time span of 25 years! It may thus easily be
understood that the surgeon relies increasingly on technology, to the point of
being dependent of it. Robotic-assisted surgery is the latest and most demanding
technological development in the operating room and , leaving aside all consid-
erations arising from correct surgical indications and the still critical cost-bene-
fit analysis, it surely represents a possibility of inlprovement that surgeons can-
not disregard.
Even robotics evolves at a stunning pace , almost on a daily basis: after the
older robots that ""ere made available 15 years ago , nowadays devices are
incredibly more practical and efficient. Further mention could be made of the
monotrocar, surgical sealants and dissection devices , robotic suturing, imaging
systems for lymphatic and vascular diagnosis and intervention, and many others.
All this should be a cause for reflection from the clinical and scientific point
of view, before Isaac Asimov 's dream can come tme in the surgical sphere as
well: "A robot may not injure a human being, or, through inaction, allow one to
come to harm .. ."

ix
x Foreword

I am thus very pleased to introduce this work that has very rightly been
assigned to a friend and colleague Giuseppe Spinoglio, one of the Italian sur-
geons most devoted and committed in this specific field of surgery in recent
years, acquiring an undisputed and intemationally renowned competence.
To be aware of the latest technological innovations in robotics, to know the
correct related clinical applications, how the new devices work and to be
informed of all associated issues is an important function of professional growth
that should not be missed, and reading this monograph will certainly enrich our
knowledge and supply a most welcome update on one of the most revolutionary
aspects of modem surgery.

Naples, September 2014 Francesco Corcione

Department of Laparoscopic and Robotic Surgery
"Azienda Ospedaliera dei Colli·' - Monaldi Hospital
Naples, Italy
Preface

Robotics entered the lives of humans more than fifty years ago , with the technol-
ogy being applied to engine construction .
In medicine, the use of robotics was established in the early 2000s " 'ith the
dissemination of the outcomes of the nerve-sparing prostatectomy for cancer. In
urology, and later in gynecology, robotics has achieved an immediate and
favorable response and subsequent widespread usage. On the other hand, in
general surgery its application was limited initially to procedures with a high
degree of difficulty that could especially benefit from the advantages of the
robotic suturing . Only at the end of the first decade of the 2000s , was robotics
continuously applied to colorectal and digestive surgery, especially by Korean
and Italian surgeons.
The da Vinci# System of Intuitive Surgical Inc . is the only robotic platfonn
existing today and has undergone several evolutions from 1998 to present: standard
three and four-ann , STM HD, Si™ HD (including Si™ -e) and the newest Xint .
The complex nattue of the settlp of the first models and the fearnre of work-
ing in fixed and narrow surgical fields has hanlpered its routine use in general
surgery. Indeed, while its users consider the robotic system as a revolutionary
innovation, the opponents emphasize costs, tinle-consuming procedures and the
lack of clinical evidence when compared to laparoscopy. Many of the issues relat-
ed to the robotic settlp and its time-spending applications have been overcome by
the technical characteristics of the new models and by the standardization of sur-
gical procedures, sintilar to what happened to surgery after the pioneering phase.
Regarding robotic benefits , three different types of problems can be identified:
1. Robotics has been applied to general surgery for little more than five years
and for less time with a standardized technique: randontized clinical trials
with adequate follow-up providing sound data are expected to be available in
approximately ten years , as occurred with the CLASSIC and COLOR studies
for oncological outcomes.
2. About 3,000 da Vinci® systems of different generations are currently installed
worldwide and less than 2 ,000 are applied in general surgery for different pro-
cedures: in such conditions, it is difficult to collect a large enough sample to
be compared with single laparoscopic procedures . Comparative studies on
xi
xii Preface

short-term outcomes have been published to date but they have been per-
fOfllled on small series.
3. In robotic surgery, as occurred with other approaches, there is a learning
curve . The number of robotic-experienced surgeons is a small percentage of
those who have decided to implement it: this specific issue makes it hard to
recmit homogeneous centers involved in studies (the same surgeon may be
very experienced in laparoscopic teclmiques but not in robotic ones).
Nevertheless, the following main issues need to be underlined:
• To date , robotics technology has advantages over other present techniques
that are absolutely clear. Its superiority over an action perfonned manual-
ly results mainly in the 3DHD vision , up to lOx magnification, the
EndoWrist® instruments with seven degrees of freedom and the intuitive
motion.
• In every part of the world, surgeons vvho had the patience and persever-
ance to overcome the learning curve have not abandoned robotic surgery.
• Surgeons who are not convinced of the advantages of robotic surgery are
sticking to their opinion , as for the reasons mentioned above, these bene-
fits cannot be demonstrated as yet.
The purpose of this book is to spread the robotic surgical technique for stan-
dardized procedures with the most recent updates. Since Italian surgeons were
among the pioneers of this surgery, I had the pleasure of hosting in this volume
both experiences of the finest ones and those of surgeons who have spread robot-
ics abroad (i.e. Profs. Enrico Benedetti, Pier Cristoforo Giulianotti and Alessio
Pigazzi). I sincerely thank President Giorgio De Toma and all SIC's Board for
entmsting me with the lecture at the 116th SIC Congress and the subsequent writ-
ing of this book, with a focus on innovation, even \\'hen it is still questioned.
Finally, I would like to thank my assistants for their sound collaboration, mainly
Alessandra Marano and Gianlpaolo FOfllusano: without them, this book would
never have been completed.

Alessandria, September 2014 Giuseppe Spinoglio

Contents

1 History of Robotic Surgery ..... . ........ . ................... .

Giuseppe Spinoglio, Alessandra Marano, Fabio Priora,
Fabio Melandro, and Giampaolo Fonuisano

Part I Neck and Thoracic Surgery

2 Transaxillary Thyroidectomy and Parathyroidectomy . .. . .... .. .. 15

Micaela Piccoli, Barbara Mullineris, Davide Gozzo,
Nazareno Smerieri, and Casimiro Nigro

3 Zenker Diverticulum Treatment . ... . .. ... ... . . . . . . . .. .. . . . .. . 23

Gianluigi Melotti, Micaela Piccoli, Nazareno Smerieri,
Barbara Mullineris, and Giovanni Colli

4 Thoracic Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 29
Giulia Veronesi

Part II Upper Gastrointestinal Surgery

5 Esophagectomy for Cancer .... . .............. . .. . ..... . .. . .. 43

Richard van Hillegersberg

6 Anti-reflux Procedures and Cardioesophagomyotomy ...... . ..... 51

Gianluigi Melotti, Vi.1lcenzo Trapani, Marzio Frazzoni,
Michele Varoli , and Micaela Piccoli

7 Gastrectomy for Cancer ............................... . . . ... 59

Andrea Coratti, Mario Annecchiarico, and Stefano
Anlore Bonapasta

xiii
xiv Contents

8 Robotic Subtotal Gastrectomy: a Modified Korean Technique ... .. 73

Giuseppe Spinoglio, Giampaolo Formisano , Ferruccio Ravazzoni,
Francesca Pagliardi, and Alessandra Marano

Part III Hepatobiliopancreatic Surgery

9 Hepatic Resections . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 83
Alberto Patriti, Graziano Ceccarelli, and Luciano Casciola

10 Biliary Tract Tumors (Resection and Reconstruction) .... .. .. .... 95

Pier Cristoforo Giulianotti, Vivek Binda), and Despoina Daskalaki

11 Pancreatic Surgery for Cancer ... .... . . . ...... .. .... .. . .. . . . . 105

Pier Cristoforo Giulianotti, Despoina Daskalaki .
and Francesco Mario Bianco

Part IV Lower Gastrointestinal Surgery

12 Right Colectomy for Cancer: Three-arm Technique . .. ........... 117

Domenico Garcea, Francesca Bazzocchi, and Andrea Avanzolini

13 Right Colectomy with Complete Mesocolic Excision:

Four-arm Technique . ... . .. ... .... . . . . ........ . .... ..... .. .. 125
Giuseppe Spinoglio , Alessandra Marano, Fabio Priora,
Ferruccio Ravazzoni , and Gianlpaolo Fonllisano

14 Left Colectomy and Segmental Resections for Cancer .... . .... . .. 133
Paolo Pietro Bianchi. Igor MonseUato, and Wanda Petz

15 Hybrid Robotic Technique for Rectal Cancer: Low Anterior

Resection and Perineal Resection . . .. ... . ............ . . . ... . .. 147
TinlOthy F. Feldmann, Raul M. Bosio, and Alessio Pigazzi

16 Full robotic Technique for Rectal Cancer . . ... ..... .. ........... 159
Giuseppe Spinoglio, Gianlpaolo Fonllisano, Luca Matteo Lenti.
Fabio Melandro, and Alessandra Marano

17 Robotic Surgery for Complicated Diverticulitis . . .. . ... .... . . . .. . 171

Giuseppe Spinoglio, Gianlpaolo Fomllsano,
Francesca Pagliardi, Ferruccio Ravazzoni , and Alessandra Marano

Part V New Technologies in Robotic Platform

18 Single-Site TM Surgery .. .. . ... ..... . . .... . .. .. ... . . . . . .. .... . 179

Giuseppe Spinoglio . Giampaolo Fomllsano, Luca Matteo Lenti.
Fabio Priora, and Alessandra Marano
Contents

19 ICG Flourescence: Current and Future Applications .... . . ... . . . 193

Giuseppe Spinoglio, A1essandra Marano, Luca Matteo Lenti ,
Fabio Priora , and Giampaolo Fonllisano

Part VI Miscellany

20 Splenectomy and Hemisplenectomy . .. ... . .. ..... .... ... ... .. . 209

Giuseppe Spinoglio, A1essandra Marano, Luca Matteo Lenti,
Francesca Pagliardi , and Gianlpaolo Fonllisano

21 Transperitoneal Adrenalectomy ..... ... . . ... .... . . .. ... . . ..... 217

Giuseppe Spinoglio, Alessandra Marano, Ferruccio Ravazzoni,
Francesca Pagliardi, and Giampaolo Fomusano

22 Robotic-assisted Organ Transplantation . . . . . . . . . . . . . . . . . . . . . . . . 225

Raquel Garcia-Roca, Ivo Tzvetanov, Hoonbaen Jeon,
Jose Oberholzer, and Enrico Benedetti
Acknowledgements

The volume editor and the publisher gratefully acknowledge the educational
contribution offered by ab medica S .p.A. , and wish to thank Intuitive Surgical@ ,
Inc., for granting permission for the use of operating room setup and trocar lay-
out images .

xvi
Contributors

Stefano Amore Bonapasta General Surgery Unit , "Misericordia" Hospital,

Grosseto, Italy
Mario Annecchiarico Department of Oncology, Division of Oncological and
Robotic General Surgery, Careggi University Hospital, Florence, Italy
Andrea Avanzolini General, Gastrointestinal, and Minimally Invasive Surgery
Unit, "G .B. Morgagni - L. Pierantoni" Hospital, Forli, Italy
Francesca Bazzocchi General, Gastrointestinal, and Minimally Invasive Surgery
Unit, "G.B. Morgagni - L. Pierantoni" Hospital, Forli, Italy
Enrico Benedetti Department of Surgery, Division of Transplantation, University
of illinois Hospital and Health Sciences System, Chicago, IL, USA
Paolo Pietro Bianchi Minimally Invasive Surgery Unit, European Institute of
Oncology, Milan, Italy
Francesco Mario Bianco Division of General, Minimally Invasive and Robotic
Surgery, University of Illinois, Chicago, IL, USA
Vivek Bindal Division of General, Minimally Invasive and Robotic Surgery,
University of illinois, Chicago, IL, USA
Raul M. Bosio Department of Surgery, University of California Irvine , Irvine,
CA, USA
Luciano Casciola Minimally Invasive Surgery Unit, Casa di Cura Citta di Roma ,
Rome, Italy
Graziano Ceccarelli Department of Surgery, Division of General Surgery,
"San Francesco" Hospital, Nuoro , Italy
Giovanni Colli General Surgery Unit, "Sant'Agostino-Estense" New Hospital,
Baggiovara (MO) , Italy
Andrea Coratti Department of Oncology, Division of Oncological and Robotic
General Surgery, Careggi University Hospital, Florence, Italy

xvii
xviii Contributors

Despoina Daskalaki Division of General , Minimally Invasive and Robotic

Surgery, University of lilinois, Chicago, ll..., USA
Timothy F. Feldmann Department of Surgery, University of Califomia Irvine,
Irvine , CA, USA
Giampaolo Formisano Department of General and Oncologic Surgery,
'·SS. Antonio e Biagio" Hospital, Alessandria, Italy
Marzio Frazzoni General Surgery Unit , "Sanl' Agostino-Estense" New Hospital,
Baggiovara (MO) , Italy
Domenico Garcea General , Gastrointestinal, and Minimally Invasive Surgery
Unit, ·'G.B. Morgagtu- L. Pierantoni" Hospital, Forli, Italy
Raquel Garcia-Roca Department of Surgery, Division of Transplantation,
Uluversity of lilinois Hospital and Health Sciences System, Chicago, ll..., USA
Pier Cristoforo Giulianotti Division of General , Muumally Invasive
and Robotic Surgery, University of lllinois, Chicago, IL, USA
Davide Gozzo General Surgery Unit, "Sant'Agostino-Estense" New Hospital,
Baggiovara (MO), Italy
Hoonbaen Jeon Department of Surgery, Division of Transplantation, University
of lilinois Hospital and Health Sciences System, Chicago, IL, USA
Luca Matteo Lenti Department of General and Oncologic Surgery,
'·SS. Antonio e Biagio" Hospital, Alessandria, Italy
Alessandra Marano Department of General and Oncologic Surgery,
'·SS. AntOIUO e Biagio" Hospital, Alessandria, Italy
Fabio Melandro Department of General and Oncologic Surgery,
"SS . AntOIUO e Biagio" Hospital, Alessandria, Italy
Gianluigi Melotti General Surgery Unit, "SanfAgostino-Estense" New Hospital,
Baggiovara (MO), Italy
Igor Monsellato Muumally Invasive Surgery Unit , European Instinlte of
Oncology, Milan, Italy
Barbara Mullineris General Surgery Unit, "Sant'Agostino-Estense"
New Hospital, Baggiovara (MO) , Italy
Casimiro Nigro Department of Surgery, Tor Vergata Uluversity, Rome , Italy
Jose Oberholzer Department of Surgery, Division of Transplantation, Uluversity
of lilinois Hospital and Health Sciences System, Chicago, IL, USA
Francesca Pagliardi Department of General and Oncologic Surgery,
"SS. AntOIUO e Biagio" Hospital, Alessandria, Italy
Alberto Patriti Department of Surgery, Division of General, Minimally Invasive
and Robotic Surgery, "San Matteo degli Infemu" Hospital, Spoleto (PG) , Italy
Contributors xix

Wanda Petz Minimally Invasive Surgery Unit , European Institute of Oncology,

Milan, Italy
Micaela Piccoli General Surgery Unit , "SanfAgostino-Estense" Ne'" Hospital,
Baggiovara (MO) , Italy
Alessio Pigazzi Department of Surgery, University of California Irvine, Irvine,
CA, USA
Fabio Priora Department of General and Oncologic Surgery, ·'SS. Antonio e
Biagio" Hospital, Alessandria, Italy
Ferruccio Ravazzoni Department of General and Oncologic Surgery,
"SS. Antonio e Biagio" Hospital, Alessandria, Italy
Nazareno Smerieri General Surgery Unit , "Sant'Agostino-Estense" New
Hospital, Baggiovara (MO) , Italy
Giuseppe Spinoglio Department of General and Oncologic Surgery, "SS. Antonio
e Biagio" Hospital, Alessandria , Italy
Vincenzo Trapani General Surgery Unit , "Sant'Agostino-Estense" NevI' Hospital,
Baggiovara (MO) , Italy
Ivo Tzvetanov Department of Surgery, Division of Transplantation, University of
Illinois Hospital and Health Sciences System, Chicago, IL, USA
Richard van Hillegersberg Department of Surgery, University Medical Center,
Utrecht, The Netherlands
Michele Varoli General Surgery Unit, "SanfAgostino-Estense" New Hospital,
Baggiovara (MO) , Italy
Giulia Veronesi Division of Thoracic Surgery, European Institute of Oncology,
Milan, Italy
History of Robotic Surgery
1
Giuseppe Spinoglio, Alessandra Marano, Fabio Priora,
Fabio Melandro, and Giampaolo Formisano

1.1 Introduction

The history of telerobotic surgery involves a revolutionary approach to mini-

mally-invasive surgery. The concept of "telemanipulation"" or '"telepresence"'
emerged in the 1940s and was first used to describe the sensation that a person
is in one location willIe being in another. It was driven by the need for certain
complex tasks to be perfoffiled by machines in hazardous and unhealthy envi-
ronment for human beings, such as the bottom of the ocean or in outer space.
In Robert Heinlein's 1942 science fiction , entitled "Waldo" , the lead character,
Waldo Fartlllngwaite-Iones , was bom frail and unable to lift his own body
weight. Heilnlein describes a glove and hamess device that allowed Waldo to
control a powerful mechanical arm by simply moving his hand and fingers.
About eight or nine years after the abovementioned publication, these kinds
of remote manipulators - popularly known as "Waldoes" - were developed in
the real world by Raymond Goertz, an early pioneer in the field of robotics .
His first master/slave robotic arm was used to handle radioactive material while
working for the Atomic Energy Comllllssion at Argo1llle National Laboratory. How-
ever, significant progress in telepresence and robotic activity was only achieved in
the 1980s because of major advancements inllllcroelectrOlllcs and computing.
At the same time , we were seeing significant advancement in the surgical
field . The first laparoscopy (millimally invasive surgery) ..vas also being con-
ducted . Specifically. an endoscope-like device was developed and the emer-
gence of the charge coupled device (CCD) - needed for digital imaging. video
electronics and display technologies - began to revolutionize the field of sur-

G. Spinoglio ( ~ )
Department of General and Oncologic Surgery, "Ss . Antonio e Biagio" Hospital,
Alessandria, Italy
e-mail: [email protected]

G. Spinoglio (Ed) , Robotic Surgery: C/lrrelll Applications and Nell' Trends.

Updates in Surgery
DOl: 10.l007/978-88-470-5714-2_1, © Springer-Verlag Italia 2015
2 G. Spinoglio et al.

gery and led to laparoscopic techniques for minimally invasive surgery. This
culmination of technological advancements led to the first laparoscopic appen-
dectomy by Gemlan gynaecologist Dr. Kurt Semm [1] and to the first report-
ed laparoscopic cholecystectomy in 1987 by French surgeon Dr. Philippe
Mouret [2] ; actually, the first laparoscopic cholecystectomy ,vas performed in
1985 by German surgeon Erich Mohe [3].
Soon after these landmark operations, laparoscopic technology and tech-
niques continued to gain popularity into the 1990s. However, the tools being
used for manual laparoscopy only worked well for relatively simple surgical
procedures that involved the removal of tissue and basic tissue closure .
Sophisticated mechanisms , such as staplers and other tissue closure devices
were developed but still did not allow laparoscopic techniques to gain traction
in more complex surgical procedures.
Though, in the strict sense of the word, the robotic systems developed for sur-
gical applications are not actually "robots" but remote "perfomlers" that work
using the master-slave style, robotic telepresence was beguUling to flourish at the
same time laparoscopy was experiencing lunitations. Many ulstitutions recognized
a potential opportunity to blend minimally invasive surgery (MIS) with robotics to
overcome the limitations of laparoscopic surgery. The goal was to make MIS an
option for even complex procedures with help from computers and mechanics .
The first robot-assisted surgical procedure was performed in 1983 with the
use of "Arthrobot" , which was designed to assist in orthopedic procedures. Later
on, a transurethral resection of the prostate and standard prostatectomy were car-
ried out in London vvith the PUMA (Programmable Universal Machine for
Assembly) and the SARP (Surgeon-Assistant Robot for Prostatectomy) systems ,
respectively. Further development on SARP led to the creation of PROBOT,
VRobot and SPUD, \vhich are abbreviation for "Prostate Robot", "Urology
Robot" and "Surgeon Programmable Urological Device" , respectively [4-6].
The first application of robotics in abdomulal surgery dates back to 1993 ,
when Yulin Wang succeeded in developing the first FDA-approved robotic
device for use in general surgery. The system, Automated Endoscopic System
for Optimal Positioning (AESOP) [7], consisted of a table-mounted articulatulg
arm that was used to control the movements of the camera during laparoscopic
surgery. Originally the AESOP was manipulated by hand or foot controls, but the
later version was capable of utilizing voice commands and ulcorporated voice
control of the endoscope and OR room lights .
The introduction in 2001 of the ZEUS system (Computer Motion Inc.) rep-
resented the real step towards the modem concept of robotically-assisted laparo-
scopic surgery. This platfonn allowed the surgeon to control a robotic slave
device that was docked to the patient remotely from a console.
The ZEUS robotic system had a camera arm that was voice controlled
(AESOP System), along with two other operating anus that provided four
degrees of freedom and were able to hold a variety of instruments that were tele-
manipulated with joysticks from the surgical console . The software that inter-
1 History of Robotic Surgery 3

faced the surgeon console with the robotic arms allovved tremor filtration and
motion scaling by a factor of 2-10 . The surgical field was visualized through a
regular two-dimensional screen or through polarized glasses that allowed for
three-dimensional images. This system was used for the first time in a full
laparoscopic procedure for fallopian tube anastomosis at the Cleveland Clinic in
1998 [8] and for coronary bypass by Reichenspumer in 1999 [9].
In 2001, Jacques Marescaux utilized the ZEUS system to perfoml a robot-
assisted cholecystectomy on a patient in Strasbourg , France , who was 4000 km
away from the surgeon in New York [10] . This procedure , nicknamed "Operation
Lindbergh" , gave an impressive demonstration of telepresence in surgery.
hI almost a parallel path, another group of researchers in Califomia set about
to develop a surgical robotic system for civilian use and founded Intuitive
Surgical Intemational in 1995: this group was eventually able to develop the
first FDA-approved fully robotic system for application in laparoscopic surgery
with licensed technologies from MIT, IBM and SRI Intemational.

1.2 Oa Vinci® Surgical System

1.2.1 Introduction

The design of the da Vinci® is the result of a long developmental process which
integrated many ideas and technologies to produce an intuitive and functional
surgical platfonn. The original project of the US Department of Defense was
started ,,,ith the aim of providing injured soldiers with a frontline surgical suite
controlled by surgeons operating from a safe remote location. Although imprac-
tical at the time, the ultimate goal of the surgical platfoml was to produce a reli-
able system which would deliver the benefits of minimally invasive surgery to
patients while preserving the benefits of the open approach to surgeons . The
technology specifically aimed to address port-access limitations in dexterity,
intuitiveness , visualization and ergonomics through advances in telepresence,
telemanipulation and stereoscopic capnlre.
Animal trials started in 1996 and clearly demonstrated the promise of seven-
degrees-of-freedom manipulators as well as the need for a mobile patient-side
cart . The next major i1l1lovation was called "Mona" and featured exchangeable
sterile components, which allowed human trial to proceed in 1997. In December
1998, the first commercial version of the da Vinci® system was delivered to the
Leipzig University Heart Center in Germany.
Refinement of the original da Vinci® design continued with the addition of a
fourth arm and with the expansion of instmment families.
The da Vinci® STM and da Vinci® Si™ (released in 2009 , Fig. 1.l) represent
an evolution of the fIrst generation system and are currently available on the mar-
ket . Novvadays , moreover, access to the latest da Vinci@ technology and future
innovation is available in an upgradable three-ann configuration: the da Vinci@
4 G. Spinoglio et al.

FIg. 1.1 da Vin-

ciil Sin< Surgi-
cal Platfonn.
(© 2014
Intuitive
Surgical, Inc.)

FIg. 1.2 da Vin-

ci® Xin< Surgi-
cal Platfonn.
(© 2014
Intuitive
Surgical , Inc .)

FIg. 1.3 da Vin-

ci® Xin< boom-
mounted anns .
(© 2014
Intuitive
Surgical, Inc .)

Si-e™ System has been designed to deliver da Vinci® core functionality, provid-
ing a flexible and economical solution for many robotic-assisted procedures .
The latest product interaction is the fourth generation of the da Vinci® sys-
tem (XiTM , Fig. 1.2 , 1.3), which features improvements to the vision , control
system and functionality.
1 History of Robotic Surgery 5

1.2.2 Da Vinci~ System Overview

The da Vinci® system is designed to represent the natural extension of the sur-
geon 's eyes and hands and its motion capabilities are intended to mimic those of
its human operator, as in open surgery.
The shared core technology of all systems offers the following distinguished
features:
• physical separation of the surgeon from the patient by operating at an
ergonomic console rather than at the patient's side, with less fatigue ;
• EndoWrist® technology: robotic instruments provide seven degrees of free-
dom with intuitive control (compared with five degrees of freedom for stan-
dard laparoscopic instruments), which replicates the experience of open sur-
gery by preserving natural eye-hand-instrument alignment (in contrast with
standard laparoscopy);
• three-dimensional stereoscopic HD images with magnification (up to lOx);
• complete tremor filtering and motion scaling.
All systems consist of three main components: the surgical console , the
patient cart and the vision cart .
The surgical console is the workplace of the robotic surgeon and contains
the following core elements: master controllers , stereo viewer, touchpad for sys-
tem configuration, left-side pod for ergonomic controls, right side pod for power
and emergency stop, and a foot-switch for operative mode selection and energy
devices activation.
The masters are built essentially like a human arm, with a wrist portion and
the elbow/shoulder joints for positioning: the wrist portion moves the instrument
tip in the surgical field , while the more proximal joints orient the instrument to
the desired location. The master controllers also possess finger clutches, which
decouple the joystick from the control of the corresponding instnunent to allow
for ergonomic repositioning during surgery.
The stereoviewer provides the 3D image of the operative field to the surgeon,
including extended instruments and system infomlation. The touchpad is the
main control interface for system functions: it provides system status, instru-
ment arm selection and control selections.
The patient cart has the prinlary function to support the operative amlS and
the camera aml. It contains five main components: the setup joints, instrument
amlS, camera arm, EndoWrist® instruments and an endoscope.
The setup joints enable movements of the instrument and camera ann to
position them for sterile draping by the scrub nurse and docking of the system
to the patient by the bedside assistant after trocar placement and correct table
positioning according to the procedure. Clutch buttons are used by the assistant
to free the setup joints, both for cart docking and ann repositioning, if needed,
during the procedure. To ensure patient safety, any actions of the patient-side
assistant should always preclude the telepresence of the robotic surgeon.
EndoWrist® instruments are installed onto the instrument amlS after the
6 G. Spinoglio et al.

patient cart is docked. Most instnuuents are capable of seven degrees of freedom
and about 90° of articulation in the wrist (distal) joint. Many different instm-
ments and energy devices (monopolar, bipolar, ultrasonic , radiofrequency) are
available with a diameter of 8 mm. A selection of 5 l111U instmments is also avail-
able for use with smaller access ports.
The instmments are made by the following elements:
• a tip that represents the effector of a specific surgical task;
• an EndoWrist® articulating joint (with the exception of some instmments , as
required by the underlying technology, i .e ., Harmonic ACE®);
• a shaft that represents the rotating amI of the instmment and through move-
ment are transferred from the robotic amI to the wristed tips;
• release levers for the instmment's removal;
• instmment housing that engages with the sterile adapter of the robotic arm.
The da Vinci@ endoscope provides a three-dimensional high-definition imag-
ing system. It is available with either a straight (0°) or angled (30°) tip and with
a shaft diameter of 8.5 mm or 12ll1111. In keeping with the anthropomorphic con-
cept , the endoscope contains two separate optical channels and focusing ele-
ments , and the camera head contains two separate cameras . When displayed on
two monitors to the left and right eye of the surgeon, a tme and natural three-
dimensional image is achieved.
The vision cart includes the image processing and vision equipment, a 24
inches touch screen monitor (touch screen not available on the Si-e™ system)
for the bedside assistant and system settings , and adjustable shelves for other
surgical devices such as insuffiators and electro surgical generators. The vision
cart is the system's central connection point ,,·here all auxiliary equipments and
audiovisual connections are routed.
A comparison between the different da Vinci~' Surgical Systems (STM /Si-
e™ /SiTM) currently available on the market is shown in Table 1.1.

1.2.3 da Vinci® Xi™ System

The recently designed da Vinci@ Xin! combines the advantages of a boom-mount-

ed system with the flexibility of a mobile platfonu. This hybrid architecture
enables placement of the surgical cart at any position around the patient while
allowing unobstmcted and fast four-quadrant anatomical access, with smaller and
lighter amIS with an extended range of motion if compared to previous versions.
Docking is facilitated by a laser-targeting system. The new endoscope is eas-
ier to handle and to use: draping , calibration and white balance are no longer
required. It can be mounted on every robotic amI improving the procedure's
flexibility and provides a crystal clear 3D HD visualization of the operative
field.
The da Vinci@ Xi™ has recently obtained FDA clearance for clinical use in
the United States and CE mark for sale in Europe . Additional technologies
(FireFlyThl inlaging system, EndoWrist# vessel Sealer and EndoWrist® stapler)
1 History of Robotic Surgery 7

Table 1.1 da Vinci s Model Side-by-Side Comparison

Technology Details da Vinci- ... da Vinci i-c'" da Vinci* i'"

Four Arms lip radable
3D HDVision
Enhanced 3D HD Vision
Inruitive~ Motion
EndoWris~
Instrumentation
Ergonomic Console
Upgraded Sllrgeon Console
Dual Console Capability IIpgradable
Fast , Foolproof Setup
Cross-Quadrant Access
Interactive Video Displays IIpgradable
OR Integration
Flllorescence Imaging Compatible IIpgradable
Single-Site lll Technology

have been also FDA cleared for the da Vinci® Xi nt system, ,,'hile CE mark is
expected to be obtained in the near future. The Single-Site nt technology will be
designed and integrated into a completely innovative platfoml.

1.3 Additional Evolving Technologies

1.3.1 Single-Site™ Platform

The Single-Site nt da Vinci® Si™ platform (Intuitive Surgical Inc., Sunnyvale,

CA, USA) has been developed in 2011 in an effort to overcome some technical
drawbacks of single incision laparoscopic surgery (SILS). Indeed, even if prom-
ising outcomes of tIus technique have been described [11], the most reported
limitations of SILS are that the parallel placement of the surgical instruments
and the surgeon's hands create internal and external conflicts that not even some
strategic expedients could completely solve [12] . Moreover, there is poor surgi-
cal exposure and the loss of the triangulation, that is conlllonly considered the
basis of a good and accurate manipulation in laparoscopic surgery.
The Single-Site™ port is made of silicone and thanks to its flexible shape
can be easily and safely inserted into the abdominal wall through a nearly 2.5 cm
incision down to the level of the fascia. The presence of a target anatomy arrow
indicator optinlizes its correct position and so the correct triangulation is
achieved in order to work in an unobstructed surgical field . Moreover. the five
marked lumens on the port provide guidance for proper setup and remote center
placement.
8 G. Spinoglio et al.

Fig. 1.4 da Vinci@ Sin< Single-Site na Sur-

gical Platform. Curved cannulae are inser-
ted through the silicone port. (© 2014 in-
tuitive Surgical, Inc .)

Three out of these five lumens are straight and are designed for the 8.5 nm}
3D HD endoscope, the insufflation adaptor and the 5 nml assistant port, respec-
tively. The two more lateral lumens are curved and cross in the midline of the
Single-Sitent port (remote center) with the outlet holes on the opposite side of
entry: the semi-rigid instrument that enters the abdomen from the left reaches
the operative field on the right and vice versa . The curved 5 mm robotic camlll-
lae are inserted into these channels so that the instrument arms outside the body
wall are separated, maximizing the range of motion and minimizing potential
intemal and extemal crowding (Fig. 1.4).
Indeed, thanks to the abovementioned Single-Site™ configuration, the
instruments and the camera, crossed within the port, use remote center technol-
ogy to avoid cannula collisions , am} interferences and port-site movement.
Subsequently the da Vinci® system software automatically detects and re-associ-
ates the user' s hands with the instrument tips to create intuitive movement
through crossed cannulae. At the end , the triangulation is restored and the cor-
rect hand/instrument correlation is obtained with the da Vinci# software .
The placement of the remote center at the level of the abdominal wall and the
curvature of the cannulae guarantees an optimal focal distance of work allowing
the instruments to converge correctly on the anatomical target . If the target is clos-
er or further away to the optinlllm focus it will be necessary to advance or retract
the cannulae. These modifications can flrstly cause an incorrect positioning of the
remote center and secondly produce excessive stress on the port and on the
abdominal wall resulting in improper working of the instruments and loss of C02 .
 History of Robotic Surgery 9

Additionally, if the instruments come out too far from the call1lulae to reach
a distant target , during the lateral traction they could overly flex with a poten-
tially bullwhip effect. These issues can be mitigated by using one of the two sets
of robotic curved cannulae of different lengths (250 mm or 300 mm). However,
nowadays , the main drawback of this innovative platfonu is represented by the
absence of the EndoWrist® technology, as in traditional robotic instruments.
To date , the da Vinci® Single-Site™ piatfoffil is made up of the follovving
components:
• Single-Site™ accessories: Single-Site™ Port (with insufflation tubing and
stopcock) , a 8.5 mm endoscope cannula for the introduction of Intuitive
Surgical fluorescence or Basic three-dimensional high-definition endoscope
(30° or 0°), two fixed-shape 5 mm curved cannulae (250 nml or 300 mm
length) with flexible blunt obturator, a 5 nl1l1 and a 10 nml straight accesso-
ry call1lula for illsertion of mauuallaparoscopic illstruments with correspon-
ding flexible obturator, an 8 mm semi-rigid blunt obturator (250 mm and
300 nun length), a dock assist tool;
• Single-Site™ semi-rigid instruments: Maryland dissector, crocodile grasper,
fundus grasper, cadiere forceps , curved scissors , monopolar cautery hook,
Hem-o-Lok~ clip applier, Hem-o-lok® ML clips (Weck®), suctiOll irrigator,
curved needle driver and bipolar Marylaud;
• EndoWristed Single-Site™ lleedle driver is expected to be put on the market
in the near future.

1.3.2 FireFlyTM Imaging System

In 2011, a new optical system has been developed and integrated into the da
Vinciil Surgical System . It is capable of emitting laser light that is close to
infrared light with the ability to switch with dedicated conunands at the console
between white light and near-infrared (NIR) light view in real tinIe , thus offer-
ing the opportunities to perfonn fluorescence-guided surgery thanks to the prop-
erties of the Indocyanine Green (leG) vital dye [13] (Fig . 1.5).
leG has been widely used for the study of blood flow and microcirculation
for more thau 40 years . It binds to plasma proteins when injected in the blood
stream and reaches all the organs and body regions. Its routine use has widely
spread through different specialties (cardiac surgery, neurosurgery, ophthalmol-
ogy, hepatology, etc.) thanks to its excellent tolerability, few side effects,
extremely low toxicity and few allergic reactions; the optimal dose rauge is
between 0.1 aud 0 .5 mglkg and should not exceed 2 mglkg.
The leG has the ability to absorb light in the NIR wavelengths between 600
and 900 1l1l1. If its molecules are excited with infrared laser light, they emit a
very intense fluorescent signal. At the frequency of 780 nm, it is possible to sup-
press the exciting laser light through dedicated filters in order to detect only the
fluorescent signal.
10 G. Spinoglio et al.

Fig. 1.5 Indocyanine Green Near-Infrared fluorescence for the da Vinci@ Sint System. (© 2014
Intuitive Surgical, Inc.)

After intravenous injection, in a time interval that lies between 5 and 50 s ,

ICG reaches the arterial and venous vessels. After about one minute, it reaches
the kidney where it remains for about 20 min; after about two minutes , it is elim-
inated via the bile by the liver without being subject to enterohepatic recircula-
tion. The persistence in the liver and in extrahepatic bile ducts, before excretion
is completed, is approximately 1-2 h.
When injected intrademlally, subcutaneously, subserosally or submucosally,
ICG is drained through the network of lymphatic vessels; it reaches the first
lymph nodes (sentinel lymph nodes) and the locoregional lymph nodes after
10-20 min and 1-2 h , respectively. It is still detectable at time intervals between
24 and 48 h.
There are different fields of application of fluorescence in robotic general
surgery that include: fluorescent cholangiography, evaluation of bowel stumps
perfusion and lymph node mapping/sentinel lymph node biopsies . These proce-
dures will be discussed in Chapter 19.

1.3.3 New Devices

• The EndoWrist# One T )'! vessel sealer is a single-use, sterile instrument with
independent sealing and cutting functions and a dual-hinged jaw. It bears the
CE mark and is cleared in the US for bipolar coagulation and mechanical
transection of vessels up to 7 mm in diameter and tissue bundles that fit in
the jaws of the instrument. It is cleared for commercial distribution in the US
for use with the da Vinci® Si™ and Xi T ).! Surgical System and the ERBE VIO
300 D electrosurgical generator (identified by a label on the front bezel).
Like other da Vinci® instruments , it features fully-wristed architecture and
can he activated from the surgeon console. The single-use EndoWrist®
One™ vessel sealer comes with an integrated cable and requires a propri-
etary and dedicated upgrade mounted to the vision cart of the da Vinci~' Si™
System (ERBE VIO 300 D) that controls and activates the instrument and the
1 History of Robotic Surgery 11

Fig. 1.6 Endo-

Wris~ Stapler
45. (© 2014 In-
tuitive Surgical,
Inc .)

/C5OIJ
Motor pack
1m9sJ

Instrument
C~~)

Reloads
/
r./lMp· r2".,tIOl/

EndoWrist® Stapler 45 too. The generator is integrated in the vision cart of

the new da Vinci® Xi™ system.
• The EndoWrist# Stapler 45 (Fig. 1.6) is an endoscopic 45 mm stapler FDA
cleared for use with the da Vine iii' Si™ and Xi TY systems. CE mark for the
XiTM system is still pending. It is fully controlled from the surgeon console
and provides fully-wristed articulation and features SmartClamp# feedback:
this software detects if the instrument jaws are adequately closed on the tar-
get tissue based on each color of reload. The stapler guarantees a full cone of
articulation vvith 108 0 total side-to-side, 540 total up-and-down for precise
positioning around vital structures and access in deep spaces, such as the
pelvis. Additionally, thanks to a complete distal tip stability, it minimizes the
tremor experienced with positioning, clamping and firing of handheld sta-
plers .
• Advanced Robotic Ultrasound TechnologyTY (ARTTY BK Medical ApS , MA,
USA) is a system that provides a curved linear probe (ProARpM Robotic
Transducer) that is introduced through a standard trocar and it is designed to
fit ProGraspTM for maximum surgeon controL It guarantees a unique "real
time" 3D visualization with a mobile , plug-free and maneuverable system
vvith easy plug-and-play DVI for seamless integration of images with
TilePro™ . It is worth remembering that TilePro™ is a multi-input display
system integrated into the da Vinci# platform: it allows the surgeon to visual-
ize the operative field along with up to two additional digitalized infonllation.
12 G. Spinoglio et al.

1.4 Conclusions

Robotic surgery was born to extend the frontiers of minimally invasive surgery.
New robotic platforms are emerging for use in different surgical specialties and
distinct ne,,' features will enable more procedures to be perfornled with the help
of a computer-enhanced system. Additional technologies will be developed into
currently existing or new platforms to hold the promise of becoming the central
workstation of surgical care. However, although robotic surgery is growing , con-
cerns regarding the high costs involved still exist and the market is yet to be
fully matured.

References

1. Semm K (1983) Endoscopic appendectomy. Endoscopy 15:59-64

2. Mouret P (1991) From the first laparoscopic cholecystectomy to the frontiers of laparoscop-
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3. Miihe E (1991) Laparoscopic cholecystectomy, late results. LangenbecksArch Chir Suppl Kon-
gressbd 416-423
4. Davies BL, Hibberd RD , Coptcoat MJ , Wickham JE (1989) A surgeon robot prostatectomy-a
laboratory evaluation. I Med Eng Tech 13:273-277
5. Ho G , Ng WS , Teo MYet al (2001) Computer-assisted transurethral laser resection of the
prostate (CALRP): theoretical and experimental motion plan. IEEE transactions on bio-med-
ical engineering 48: 1125-1133
6. Ho G , Ng WS , Teo MY et al (2001) Experimental study of transurethral robotic laser resec-
tion of the prostate using the LaserTrode Iightguide . I Biomed Optics 6:244-251
7. Unger SW, Unger HM, Bass RT (1994) AESOP robotic arm. Surg Endosc 8:1131
8. Falcone T, Goldberg I, Garcia-Ruiz A et al (1999) Full robotic assistance for laparoscopic tubal
anastomosis a case report. I Laparoendoscop Adv Surg Tech A 9107-113
9. Reichenspurner H , Damiano RJ, Mack M et al (1999) Use of the voice-controlled and com-
puter-assisted surgical system ZEUS for endoscopic coronary artery bypass grafting. I Tho-
rae Cardiovasc Surg 118:11-16
10. Marescaux J, Leroy I, Gagner M et al (2001) Transatlantic robot-assisted telesurgery. Nature
413379-380
11 . Qadan M, Curet MI , Wren SM (2014) The evolving application of single-port robotic sur-
gery in general surgery. I Hepatobiliary Pancreat Sci 21:26-33
12. Leblanc F, Champagne BI, Augestad KM et al (2010) Single incision laparoscopic colecto-
my: technical aspects , feasibility, and expected benefits . Diagn Ther Endosc 2010:913216
13 . Marano A, Priora F, Lenti LM et al (2013) Application of fluorescence in robotic general sur-
gery: review of the literature and state of the art . World I Surg 37:2800-2811
 Part I
Neck and Thoracic Surgery
Transaxillary Thyroidectomy
and Parathyroidectomy
2
Micaela Piccoli, Barbara Mullineris, Davide Gozzo,
Nazareno Smerieri, and Casimiro Nigro

2.1 Procedure Overview

In the last ten years, minimally invasive approaches have increased their appli-
cations in neck surgery.
The minimally invasive surgery can be distinguished in two groups:
• direct cervical approach: mininlally invasive video-assisted thyroidectomy
(MIVAT) [I] or endoscopic technique with an anterior approach carried out
by Gagner and Cougard or with a lateral approach described by Henry and
Inabnet [2-5];
• indirect or extracervical approach [6-8]: endoscopic techniques outside
the neck region through a chest , axillary, or combined axillary-breast access,
described for the first time by two Japanese surgeons, Ikeda and Takami in
1999 [2,9].
Some of these techniques are totally gasless, such as the robotic transaxillary
access; others are performed with gas insufflation. However, endoscopic proce-
dures are limited by video camera platfonll instability, straight endoscopic instru-
ments, two-dinlensional inlaging and a difficult manipulation of the anatomical
structures. In the last years , some Asiatic surgeons have attempted to incorporate
surgical robots in thyroid surgery, reducing the limitations of conventional
endoscopy: improving freedom of motion through the use of multi-articulated
instruments; providing the surgeon with an ergonomically perfect position at the
robotic console; providing a three-dinlensional, stable, magnified imaging:
enabling the surgeon to perfonll minute, precise movements and allowing the
dampening of physiologic tremors [10). Prof. W.Y. Chung, from South Korea , in

M. Piccoli ( ~ )
General Surgery Unit, "Sant' Agostino-Estense" New Hospital,
Baggiovara (MO), Italy
e-mail: m [email protected]

G. Spinoglio (Ed) , Robotic Surgery: Cllrrelll Applications and Nell' Trends, lS

Updates in Surgery
DOl: 1O.l007/978-88-470-5714-2_2, © Springer-Verlag Italia 2015
16 M. Piccoli et al.

2007 , perfonned the first robot-assisted transaxillary thyroidectomy [10] .

The birth and the development of tlus new technique , in a well-defined geo-
graphical area , depends on epidenuological reasons. The incidence of thyroid
carcinoma is elevated in Korea , especially in young women; a well-organized
thyroid screelung allows the identification of suspicious thyroid nodules at an
early stage. Furthermore, many young women do not want to have a neck scar
after surgery, because hypertrophic scars are common in Asian people and also
because of religion and cultural Asian belief. Robotic facelift thyroidectomy and
trans oral robotic thyroidectomy [11] are the last suggested approaches in thyroid
surgery.

2.2 Patient Positioning

Under general endotracheal anesthesia , the patient is placed in the supine position
with the neck slightly extended; the ann on the axillary access side is raised upon
the head and positioned in such a way as to llunimize the distance from the axilla
to the anterior neck. The position of the ann is checked before the general anesthe-
sia in order to avoid any wrong position that could favor an injury of the brachial
plexus. The contralateral ann, with venous access , is placed along the body.
Another support is placed near the head in order to avoid any lateral movements
during the procedures (Fig. 2.1). A bladder catheter could be positioned only at the
begilllung of the experience, due to the more tinle consuming procedures.
The axillary access is chosen according to the side of:
• target parathyroidectomy;
• thyroid lobe to be removed in the case of a lobectomy;
• the larger nodule, in the event of a total thyroidectomy.

Fig. 2. 1 Patient
positioning
2 Transaxillary Thyroidectomy and Parathyroidectomy 17

a
Fig. 2.2 a Left axillary access _b Right axillary access _(:© 2014 Intuitive Surgical. Inc _)

2.3 Robot Positioning

The da Vinci® Sin! robot is docked contralateraUy to the axillary access (Fig.
2.2a , b). Three arnlS are generally sufficient for lobectomy and parathyroidecto-
my; four amlS are needed, however, for total thyroidectomy.

2.4 Procedure

The procedure is divided into three steps:

• Step I - transaxillary subcutaneous tunnel creation: flap or working space time
• Step 2 - robot position in the operative field or docking time
• Step 3 - thyroidectomy/target parathyroidectomy procedure or console time .

2.4.1 Step 1 (Working Space Time)

A 4-5 cm skin incision is made in the axilla , following the lateral edge of the
major pectoralis muscle; the subplatysmal skin flap from the axilla to the ante-
rior neck area is dissected over the anterior surface of the pectoralis major mus-
cle using laparoscopic instn1ments (such as the Johann grasper and monopolar
hook), under endoscopic vision with a 30° camera. The endoscopic vision
instead of direct vision (used by Korean surgeons) , allows all the surgical team
to follow the creation of the flap , reducing the learning curve of this step. An
external retractor - the so called "Modena Retractor" (CEATEC@
Medizintechnik) - is used from the beginning to create the flap . A suction tube
is directly connected to the retractor 's blade in order to avoid field fogging. The
myocutaneous flap is raised until the sternal and clavicular heads of the stern-
ocleidomastoideum muscle (SCM) are visualized; then the dissection continues
through the two SCM branches. During this time, care must be taken not to
cause thermal bums on the overlying skin . The "Modena retractor" is reposi-
18 M. Piccoli et al.

tioned beneath both the sternal branch of the SCM and the strap muscles and the
thyroid is discovered.
The omohyoid muscle is the superior landmark; behind it , there is the upper
thyroid pole . Care must be taken not to damage the internal jugular vein that is
the first main venous vessel that appears in the operative field. The contralater-
al strap muscles are identified and raised if a total thyroidectomy must be per-
fornled.

2.4.2 Step 2 (Docking Time)

The robot is positioned in the operative field and three robotic anns are intro-
duced all through the axillary incision: 30° optic , Hannonic curved shears
(5 mm) and ProGrasp forceps (8 nml). In the case of the three robotic arms tech-
nique , only t\\'0 anns are introduced in the incision: endoscope and Harmonic
shears (the operation is conducted without the help of the ProGrasp). The fourth
(or the third in case of three robotic arms technique) robotic ann is inserted
through an independent incision at the inferior part of the axillary incision for
the Maryland forceps . (Fig . 2.3a , b; Fig. 2.4a , b) . During the operation, the
Maryland forceps and Hannonic shears are interchangeable .

2.4.3 Step 3 (Console Time)

The operation proceeds in the same manner as conventional open thyroidectomy

with a surgeon sitting at the console and a surgeon sitting at the operating table .
All vessel dissections are perfonned using the HarulOniC shears. The middle thy-
roid vein is identified and dissected. The upper pole of the thyroid is drav\,n
downward and medially using the ProGrasp or Maryland forceps ; superior thy-
roid vessels are identified and individually divided close to the thyroid gland to
avoid injury of the external branch of the superior laryngeal nerve. The inferior
thyroid artery (ITA), the recurrent laryngeal nerve (RLN) and the parathyroid
glands are identified. The ITA is then divided close to the thyroid gland, and the
whole cervical course of the RLN is traced . The thyroid lobe is dissected from the
trachea and resected with the isthmus . The resected specimen is extracted through
the axillary skin incision. During these procedures, the surgeon, at the table ,
checks the correct positioning of the robotic arulS , cleans the canlera when it is
necessary, uses a suction laparoscopic device to clean the operative field and ,
with the same instnunent, perfornls movements \vhich v\'iden the operating field .
Contralateral lobectomy is perfonned using the same method with medial trac-
tion of the thyroid. The identification of contralateral RLN is the real difficult
time of this procedure . After the identification of the contralateral RLN, its whole
cervical course is traced. During this procedure, using the laparoscopic suction
device, a soft traction on the trachea is perfornled in order to obtain a better vision
2 Transaxillary Thyroidectomy and Parathyroidectomy 19

Fig. 2.3 a Right axillary access with four arms. b Left axillary access with four anns

Fig. 2.4 a Right axillary access with three anns . b Left axillary access with three anns

of the RLN. At this time also the contralateral thyroid lobe is resected and extract-
ed through the axillary skin incision. In the case of parathyroidectomy, the thy-
roid gland is turned medially and , with cautious dissection, the parathyroid ade-
noma is identified, than circumferentially dissected and excised. The venous
bleeding is checked ,""ith the Valsalva maneuver. A closed suction drain is insert-
ed through the separate incision under the axillary skin incision. The robotic anns
are removed and the wound is cosmetically closed. The small incision scar in the
axilla is completely covered when the arm is in its natural position .
20 M. Piccoli et al.

2.S Indications and Contraindications

Benign and malignant thyroid lesions could be treated with tlus approach:
benign hlmors not larger than 5 cm, follicular neoplasms , Graves' disease , well-
differentiated thyroid cancer and early-stage medullary cancer. When initially
gaining experience, it is better to treat TINo and N la oThe current indications are:
all stages except NIb posteriorly located , T3 , T4a, and T4b [12] .
In the case of lack of experience, it is better to avoid thyroiditis and Graves '
disease . Other contraindications are: previous neck or breast surgery and/or neck
radiotherapy. The presence of a pacemaker in the major pectoralis region is a
contraindication to perfonn the flap at that side , too. Other contraindications
could be shoulder arthrosis and previous shoulder surgery that does not allow
the required ann extension.
The body mass index (BMI) is another important parameter. The working
space is more difficult in patients ,,·ho have a BMI > 30. If the distance between
the axilla and the stemalnotch is more than 15 cm, it would be difficult to per-
fom} the hlllnel creation of Step I . The procedures that may be possible to per-
fom} with the robotic technique are : lobectomy, loboisthmectomy, subtotaUnear
totaUtotal thyroidectomy and target parathyroidectomy, following the ATA
guidelines [10].
The central compartment node dissection (CCND) , is feasible and it is also
possible to perfonn a laterocervical neck dissection that importantly avoids the
scar on the neck [12, 13].

2.6 Peri operative and Postoperative Complications

It is possible to divide complications in two categories: intraoperative and post-
operative .
Intraoperative complications include thermal burns on the overlying skin; bleed-
ing from the extemal jugular vein or from the internal jugular vein, during the
flap time ; or bleeding from the carotid artery, RLN injury, tracheal lesions ,
esophageal lesions, thoracic duct lesion, during the console time.
Postoperative complications include bleeding , pennanent or transient RNL
palsy, penllanent or transient ipocalcenua, infection, seroma , anterior chest wall
paresthesia, brachial plexus lesions, Horner syndrome.
Between all the complications , only two are really new: thermal burns and
brachial plexus lesion. Cases of esophageal and tracheal perforation after open
thyroidectomy are described in the literature while only very few cases of tra-
cheal lesions are reported during robot-assisted endoscopic thyroidectomy (all
conservatively treated) . Only some cases of jugular vein lesions (which the
authors were able to control without any consequences), and one case of
esophageal perforation are reported in the literahlre .
2 Transaxillary Thyroidectomy and Parathyroidectomy 21

2.7 Personal Experience

From September 2010 to May 2014, 191 patients underwent robot-assisted thy-
roidectomies (only four endoscopic, due to robotic technical problems) and five
target parathyroidectomies using a unilateral trans axillary approach. The indica-
tions were: benign tumor, not larger than 5 cm; follicular neoplasm from FNAB;
Graves' disease , well-differentiated thyroid cancer and parathyroid adenoma.
The final pathologies were: 107 nodular hyperplasia , 25 follicular adenoma, II
Hurtle adenoma, 2 diffuse hyperplasia , 38 differentiated thyroid carcinoma , 13
thyroid totalization (12 free thyroid tumor tissue and I contralateralmicrocarci-
noma), 5 parathyroid adenoma. The median size of the dominant thyroid nodule
was 28 .6 mm (range: 5-60) . Mean total operative time (from the end of induc-
tion of anesthesia to the completion of skin closure) was 160.2 min for total thy-
roidectomy (IT) and 115.1 min for lobectomy (LT) . The mean time required to
create the working space was 63 .8 min (30-180 min) , to dock the robot was
14.9 min (4-60 min). The mean console time was 53.7 min (10-135 min): mean
LT, 39.0 min; mean TT, 77 .1 min.
These intraoperative complications have been observed: two bums skin
lesions , one external jugular vein lesion, and one internal jugular vein lesion, all
resolved without conversion. As regards postoperative complications: 7 tempo-
rary RLN injury (3.5%), 27 transient hypocalcemia (13.7%), 6 transient ipsilat-
eral arm paralysis (I brachial plexus injury), 4 seromas (only one treated by per-
cutaneuos aspiration), I subcutaneous tunnel infection, 4 postoperative
hematoma: 2 conservatively treated and 2 reoperated. Median hospital stay is
2.0 days (1-15).

2.8 Conclusions

The robotic gasless trans axillary thyroidectomy is feasible and safe if perfornled
by a surgeon skilled in endocrine and robotic surgery. Robotic thyroid and
parathyroid surgery is often associated with longer operation time than conven-
tional open/endoscopic surgery but with same outcomes in surgical complete-
ness and safety. Compared to the conventional cervical approach , robotic neck
surgery is associated not only with excellent cosmetic results, but also with
reduced postoperative neck discomfort (pain, decreased voice and swallowing).
Furtheonore , another advantage is that the robotic surgery improves ergonomics
and has a shorter learning curve than open or endoscopic surgery [13-15] .
Prospective, controlled randomized studies with long-teon follow-up are
needed.
22 M. Piccoli et al.

References

1. Miccoli P, Berti P, Bendinelli C et al (2000) Minimally invasive video-assisted surgery of the

thyroid: a preliminary report. Langenbeck'sArch Surg 385:261-264
Slotema ET, Sebag F, Henry JF (2008) What is the evidence for endoscopic thyroidectomy
in the management of benign thyroid disease? World J Surg 32: 1325-1332
3. Cougard P, Osmak L, Esquis Pet al (2005) Endoscopic thyroidectomy. A preliminary report
including 40 patients. Ann Chir 2005 130:81-85
4. Henry JP, Sebag F (2006) Lateral endoscopic approach for thyroid and parathyroid surgery.
Ann Chir 13151-56
5. Inabnet WB m, Jacob BP, Gagner M (2003) Minimally invasive endoscopic thyroidectomy
by a cervical approach. Surg Endosc 17:1808-1811
6. Cho YU, Park II, Choi KH et al (2007) Gasless endoscopic thyroidectomy via an anterior chest
wall approach using a flap-lifting system. Yonsei Med J 48:480-487
7. Sasaki A , Nakajima J et al C~OO8) Endoscopic thyroidectomy by the breast approach: a sin-
gle institution's 9-years experience World J Surg 32:381-385
8. Koh YW, Kim JW, Lee SW, Choi EC (2009) Endoscopic thyroidectomy via a unilateral ax-
illo-breast approach without gas insufflation for unilateral benign thyroid lesion. Surg Endosc
232053-2060
9. Ikeda Y, Takami H. Sasaki Yet al (2000) Endoscopic resection of thyroid tumors by the ax-
illary approach. J Cardiovasc Surg 41:791-792
10. Kang SW, Chung W Y, Park C S et al (2009) Robot-assisted endoscopic surgery for thyroid
cancer: experience \vith the first 100 patients . Surg Endosc 23:2399-2406
11 . Richmon JD, Pattani KM, Benhidjeb T, Tufano RP (20 11) Transoral robotic-assisted thyroidec-
tomy: a preclinical feasibility study in 2 cadavers. Head Neck 33:330-333
12. Lee J, Yun IH , Nam KH et al (2011) Perioperative clinical outcomes after robotic thyroidec-
tomy for thyroid carcinoma: a multicenter study. Surg Endosc 25 :906-912
13. Lee J, Lee IH, Nah KYet al (2011) Comparison of endoscopic and robotic thyroidectomy.
Ann Surg OncoI18 :1439-1446
14. Li X, Massasati SA, Kandil E et al (2012) Single incision robotic transaxillary approach to
pedorm parathyroidectomy. Gland Surg 1: 169-170
15. Lee J , Chung WY (2013) Robotic surgery for thyroid disease . EurThyroid J 2:93-101
Zenker Diverticulum Treatment
3
Gianluigi Melotti, Micaela Piccoli, Nazareno Smerieri,
Barbara Mullineris, and Giovanni Colli

3.1 Introduction

Zenker's diverticulum (ZD), first observed by Ludlow in 1769 [1], became

..videly known after it was described by Zenker and von Ziemssen [2] in 1878 .
The anatomy of ZD was described in detail by Killian in 1908.
The place of origin of the diverticulum is posteriorly located in the midline,
where the oblique fibers of the inferior pharyngeal constrictor, and the transver-
se cricopharyngeal fibers delinlit a triangular space of relative weakness, the so
called Killian's triangle.
ZD is a relatively rare pathology, with an annual incidence of about two
cases per 100,000 people [3] , occurring most often in men between the seventh
and eighth decade of life . A variety of open and endoscopic surgical approach-
es for the treatment of ZD have been described.
The transaxillary gasless robotic access to the thyroid was first described by
Kang et a1. in 2009 [4, 5]. This kind of access to the neck has resulted in safe
and precise procedures, with notable cosmetic and functional benefits as com-
pared to the traditional open approach [6] . This chapter describes, for the first
time, the author's technique of left transaxillary gasless robot-assisted endo-
scopic Zenker diverticulectomy and its applicability in the surgical management
of cervical esophagus diseases .

M. Piccoli ( )
General Surgery Unit, "Sant' Agostino-Estense" New Hospital,
Baggiovara (MO), Italy
e-mail: m [email protected]

G . Spinoglio (Ed) , Robotic Surgery: Cllrrelll Applications and Nell' Trends. 23

Updates in Surgery
DOl: 10.1007/978-88-470-5714-2_3, © Springer-Verlag Italia 2015
24 G. Melotti et al.

3.2 Patient Positioning

Under general endotracheal anesthesia , the patient is positioned supine with the
neck slightly extended, and the left arm is raised and positioned in such a way
as to minimize the distance from the axilla to the anterior neck. This position is
the same as for transaxillary robotic thyroidectomy (Figs. 3.1a , b) .

3.3 Step-by-Step Review of the Surgical Technique

A 4-5 cm skin incision is made in the left axilla , following the lateral edge of the
major pectoralis muscle; the subplatysmal skin flap from the axilla to the anterior
neck area is dissected over the anterior surface of the pectoralis major muscle using
reusable laparoscopic instmments (such us a Johann grasper or monopolar hook) ,
under endoscopic vision with a 30 0 camera. An extemal retractor - the so called
"Modena Retractor" (Ceatec Medizintechnik GMBH) - is used from the beginning
to execute the flap (Fig . 3.2) . The retractor is mounted at the operating table on the
robot side , but aU the adjustments are perfonlled from the operation side: vertical
height of the pillar, horizontal depth of the boom tube and blade angle. A suction
tube was directly C0l111ected to the blade in order to avoid field fogging . The
myocutaneous flap is raised until the stemal and clavicular heads of the stemoclei-
domastoideum (SCM) muscle are visualized; then the dissection continued through
the two SCM branches . Next, the extemal retractor placed beneath the strap mus-
cle is replaced with a larger one to maintain adequate working space.
After the creation of the working space and before the docking, the head is
slightly turned on the right side. Then the da Vinci® Si robot is docked from the
side of the bed, contra-lateral to the operative field . Three robotic arnlS are intro-

Fig. 3.1 a Patient positioning and trocar layout . I, Hannonic curved shears; 2, ProGraspnl for-
ceps; 3, Maryland dissector. b OR setup (© 2014 Intuitive Surgical, Inc)
3 Zenker Diverticulum Treatment 2S

duced all through the axillary incision: dual channel endoscope (central, down) ,
Harmonic curved shears (right) and ProGraspT~ forceps (up) . The fourth robot-
ic amI is inserted through an independent incision in the inferior part of the axil-
lary one , for Maryland dissector (left) (Fig. 3.la). All vessel dissections are per-
fomled using the HamlOnic curved shears . Under robotic guidance, the thyroid
is drawn medially by the ProGrasp forceps in order to identify and spare the
inferior thyroid artery and the inferior laryngeal nerve . It is necessary to cut the
middle thyroid vein , and sometimes also the omohyoid muscle. The prevertebral
fascia is identified , and the diverticulum can be isolated from its adhesion with
the hypopharynx. The loose connective tissue surrounding the pouch is dissect-
ed to identify its neck on the posterior pharyngeal wall. This procedure must be
carried out under esophagoscopic control. The neck of the diverticulum is fully
exposed by tractiouing the diverticulum to the left with the Maryland dissector.
A complete myotomy must be performed, including the cricopharyngealmuscle
and the first 5 cm of the circular layer of the cervical esophagus . The myotomy
could be perfomled with a robotic monopolar hook allowing dissection and
resection of the fibers, proceeding downward, starting from the upper
esophageal sphincter. Then a surgical linear stapler (Endopath RTS-FLEX
Endoscopic Articulating Linear Cutter 35 mm; Ethicon Endo-surgery, LLC) with
a blue cartridge is inserted through the axilla and it is applied to the neck of the
diverticulum, which is cut and sutured and then removed (Fig . 3.3).

Fig. 3.2 Videoassisted working space , using

"Modena retractor" positioning
26 G. Melotti et al.

Fig. 3.3 Stapling device applied to the neck of the diverticulum

The complete diverticultml removal and its staple line could be checked endoscop-
ically. A suction-type drain is left in place lUltil the X-ray examination is perfonlled.
Intravenous broad-spectrum antibiotics are administered only perioperatively.

3.4 Literature Evidence

Treatment options for a Zenker diverticulum include open surgery, flexible endo-
scopic and rigid endoscopic therapy. Based on current evidence, traditional open
surgery is suitable for all kinds of diverticula, providing satisfactory long-tenll out-
comes, although with a significant incidence of complications including medias-
tinitis , recurrent laryngeal nerve injury, esophageal stricture , fistula, esophageal
perforation, hematoma, wound infection, pneumonia and even death, with a 11 %
median incidence of major morbidity [I] . It also needs general anesthesia.
Rigid endoscopic treatment can be done under general anesthesia and hyper-
extension of the neck. It might be technically difficult when the diverticular sep-
tum cannot be well exposed. Flexible endoscopic therapy can be conducted
without general anesthesia or neck hyperextension; however it is only suitable
for selected patients.
The poor quality of current evidence renders it difficult to establish a sound
conclusion for the optimal treatment of ZD [3, 7, 8]. Actually there is not strong
evidence for a gold standard technique .

3.5 Personal Experience

Eight consecutive patients undecvvent surgery for symptomatic ZD from July

2013 to April 2014 in our Department. All the patients were treated with a left
3 Zenker Diverticulum Treatment 27

transaxillary robotic approach. The median age was 70.3 years , seven patients
were male and one female . The preoperative work-up included a barium swal-
lovv, which allowed detemunation of the diverticulum size and location and
upper gastrointestinal endoscopy, and was mandatory to rule out malignancy.
An X-ray check with an oral soluble contrast swallow study was carried out
4 days after the operation . In the absence of leakage, oral feeding was adnunis-
tered to the patient and the patient could be discharged. Patients were scheduled
for a clinic visit 5 days after discharge , and after 1 month a barium swallow
study was perfomled .
The mean diameter of the ZD, on preoperative barium swallow, was 4.25 cm
(range: 3-9 cm). The mean time for setting up the working space was 66 nlln-
utes (range 40-90 nlln .), the mean docking time was 12.8 nun . (range 6-23 nun.)
and the mean robotic time 85.1 nunutes (range 60-115 min) . The mean hospital
stay was 7 days. There vvere no conversions to open cervicotomy, no transient or
definitive left recurrent nerve palsies . There vvas only one postoperative leak,
which was conservatively treated and fully recovered. There was no evidence of
persistence or recurrence at the postoperative , although short , follow-up .

3.6 Conclusions
The results of this technique show that the left trans axillary robotic approach is
a safe and effective surgical procedure in the treatment of any kind of ZD . This
procedure camlOt be considered a cosmetic treatment, as ZD mostly occurs in
men between the seventh and eighth decade of life , but the advantage offered by
the da Vinci® Si™ surgical robot system is a three-dimensional field of view and
a more accurate sense of perspective. Moreover, the magnification of target
structures, made possible by the system, facilitates the preservation of the recur-
rent laryngeal nerve , thus preventing both transient and definitive left recurrent
nerve palsy, and spares the esophageal mucosa during the myotomy, reducing
the incidence of postoperative leakage.
It is also worth considering that the robot system incorporates features for
hand-tremor filtration , fine motion scaling, negative motion reversal (allovving
minute and precise tissue manipulation); in conjunction with the ergononucally
designed console, they help decrease the surgeon's fatigue .
The robotic assisted trans axillary Zenker's diverticulectomy is a procedure
that requires experience in perfomung the flap and, due to the rarity of this
pathology, the only way for the surgeon to complete the learning curve is to per-
foml robotic transaxillary thyroid surgery; so tIus procedure can be attempted
only by surgeons well versed in neck robotic surgery, and skilled in esophageal
diseases surgery.
Open diverticulectomy has low but significant adverse events, including
mediastinitis , recurrent laryngeal nerve injury, esophageal stricture, fistula ,
esophageal perforation, hematoma , wound infection, pneumonia and even death.
28 G. Melotti et al.

Various techniques have been described for rigid and flexible endoscopic treat-
ment of ZD . Despite overall good results, follow-up has been often inadequate [2 ,
3] and technical refinements are still in progress to avoid adverse events [7, 8].
The robot-assisted trans axillary Zenker's diverticulectomy is a technically
demanding procedure. According to our preliminary data , this procedure appears
safe and effective.
However, our results need to be confirmed in larger cohorts of patients and
further randomized controlled studies comparing this technique with rigid and
flexible endoscopic diverticulotomy.

References
1. Dzeletovic I, Ekbom DC, Baron TH (2012) Flexible endoscopic and surgical management of
Zenker's diverticulum. Expert Rev Gastroenterol Hepato16:449-466
2. Law R, Katzka DA, Baron TH (2014) Zenker's diverticulum. Clin Gastroenterol Hepatol.
doi:lO.1016/j .cgh.2013 .09 .016
3. Yuan Y, Zhao Y-F, Hu Y, Chen L-Q (2013) Surgical treatment of Zenker's diverticulum . Dig
Surg 30:214-225
4. Kang SW, Jeong JJ, Yun JS et al (2009) Robot-assisted endoscopic surgery for thyroid can-
cer: experience with the first 100 patients . Surg Endosc 23:2399-2406
5. Kang SW, Lee SC, Lee SH. Lee KY, Jeong JJ, Lee YS, Nam KH, Chang HS, Chung WY, Park
CS (2009) Robotic thyroid surgery using a gasless, transaxillary approach and the da Vmci S
system: the operative outcomes of 338 consecutive patients. Surgery 146: 1048-1055
6. Lee S, Ryu HR, Park JH (2011) Excellence in robotic thyroid surgery: a comparative study
of robot-assisted versus conventional endoscopic thyroidectomy in papillary thyroid micro-
carcinoma patients . Ann Surg 253: 1060-1066
7. Huberty V, EI Bacha S, Blero D et al (2013) Endoscopic treatment for Zenker's diverticulum:
long-term results (with video). Gastrointest Endosc 77:701- 707
8. Manno M, Manta R, Caruso A et al (2014) Altemative endoscopic treatment of Zenker's di-
verticulum: a case series (with video). Gastrointest Endosc 79:168-170
Thoracic Surgery
4
Giulia Veronesi

4.1 Procedure Overview

Video-assisted thoracic surgery (VATS) is a minimally invasive approach with

several advautages over open thoracotomy for resectable lung cancer [I, 2] .
However VATS use is limited because the instruments are rigid and difficult to
use, aud vision is limited. Robot techuology appears to overcome these limita-
tions as the robotic arms are more comfortable to use , and allow more precise,
flexible and intuitive movements. This , combined with high-definition three-
dimensional vision, renders operations easier for the surgeon , with probably a
shorter learning curve than for VATS [3 , 4] .
Retrospective studies demonstrate that robot-assisted lobectomy is feasible
and safe [3-6]; limited long-term data indicates that oncological radicality is
similar to that of open/VATS approaches [2], although randomized controlled
trials are not available. The few available papers on robotic resection of medi-
astinallesions describes the procedure as safe and effective [7] .
High capital and nlllning costs [8], limited availability of robotic systems ,
and long operating times are important disadvautages of robotic thoracic sur-
gery. Only one company is currently producing robotic systems (Intuitive
Surgical) aud entry of competitor companies should drive down costs . Further
studies are required to assess the quality of life , morbidity, oncological radical-
ity, and cost effectiveness .

G . Veronesi ( ~ )
Division of Thoracic Surgery, European Institute of Oncology,
Milan, Italy
e-mail: [email protected]

G . Spinoglio (Ed) , Robotic Surgery: Cllrrelll Applications and Nell' Trends. 29

Updates in Surgery
DOl: 10.l007/978-88-470-5714-2_4, © Springer-Verlag Italia 2015
30 G. Veronesi

4.2 Patient Positioning, Robot Positioning and System

Docking

The patient is positioned in a lateral decubitus position with the arnIS in front of
the face as in Figs. 4.lb and 4.lc . The operating table should ideally fold down
at the level of the fifth intercostal space , to lower the level of the hips; alterna-
tively a pillow can be placed under the chest. The patient is intubated with a dou-
ble lumen endotracheal tube. The operation starts with the introduction of the
high-definition endoscope through the port at the level of the seventh intercostal
space in the anterior axillary line (Fig. 4.la). Under endoscopic control, the util-
ity incision is made through the fourth or fifth intercostal space. In 10ng-linIbed
patients, use of the fifth intercostal space may make it easier to reach the
diaphragm and the lower ligament.
Entry port positioning is standard for all lobectomies and segmentectomies
(Fig . 4.la), although on the left the endoscope port may moved 2 cm posterior-
ly compared to the right side inorder to avoid the heart obscuring hilar stmc-
tures. Furthenllore, if CO~ insufflation is required (obese patients and small cav-
ities), the utility incision for specimen removal is made at the end of the proce-
dure , and in a lower position thannonllal- just above the diaphragm . The robot
is positioned behind the patient's head, 20-30° off the midline (Figs . 4.lb and
4.lc). Docking requires 5-10 minutes, starting " 'ith the endoscope amI , fol-
lowed by the two posterior arms, and then the anterior arm through the utility
mC1Slon.
For mediastinal lesions the patient is positioned in a semilateral decubitus
position with the preferred side (usually left) above. The arms are positioned
along the side of the body. The room setup is described in Figs. 4.2b and 4.2c
for the left and right approach.
Three ports are used (Fig . 4.2a): fifth intercostal space in the middle axillary
line (submammary sulcus), fifth intercostal paramediastinic site , and third inter-
costal space at the anterior axillary line . A 30° endoscope is used, introduced via
the central port. Lifting of the chest wall with the endoscope helps enlarge the
chest cavity; C02 insufflation (8-10 mmHg) is also used. In some cases a right
approach is used depending on the position of the lesion or surgeon preference .

4.3 Step-by-Step Review of Critical Elements

of the Procedure

4.3.1 Lobectomy

An anterior approach lobectomy using four robotic arms is described. The resec-
tion begins by isolating hilar elements using a hook (or Maryland bipolar for-
ceps) and two forceps. The hook is manipulated by the right robotic arm intro-
duced through the utility port for right lung lobectomies, or the posterior eighth
4 Thoracic Surgery 31

c
Fig. 4.1 a Positions of entry ports for right lobectomy. b, c OR setup for right (b) and left (c) lung
resection. « (~ 2014 Intuitive Surgical. Inc.)
32 G.Veronesi

'~~
..,...
(j),

...•
a

c
Fig. 4.2 a Port placcmcnt for resection of anterior mediastinal lesions. b OR setup for right
approach to anterior mediastinal lesions. c OR setup for left approach to anterior mediastinal
lesions. (<<-j 2014 Intuitive Surgical, Inc.)
4 Thoracic Surgery 33

intercostal port for left-side lobectomies . One of the forceps (fourth robotic ann)
is used to retract the lung and expose the stmctures . The other forceps are
manipulated by the left robotic arm and used to grip stmctures during dissection:
it is introduced through the utility thoracotomy for left-side lobectomies or the
posterior eighth intercostal space for right-side lobectomies. When a hilar ves-
sel or bronchus is ready to be surrounded with a vessel loop and stapled, a third
pair of forceps is introduced (substituting the hook). The vessels and bronchus
are sectioned with a stapler introduced by the assistant surgeon through the util-
ity incision for upper lobes and through the posterior port after removing the
robotic arm for lower lobes . The pulmonary vein is usually the first stmcture to
be exposed and divided. If the lesion is in the right upper lobe, vein division is
followed by exposure of the pulmonary artery branches and sectioning, and then
bronchus exposure and sectioning. Anterior and posterior parenchyma division
is completed with an EndoStapler (fissureless technique). If the lesion is in the
right lower lobe, the sequence is usually: vein, artery, fissures and bronchus . If
the anterior fissure is incomplete it can be completed after bronchus stapling.
When performing a middle lobectomy, the most favorable sequence is vein,
bronchus, artery.
For the left upper lobe , after pulmonary vein sectioning, the first mediastinal
artery is exposed and transected to allow for the introduction of the stapler for
bronchus sectioning. The posterior and lingular arteries are then isolated and sta-
pled or cut between Hem-o-lok@ clips, and the lobe is removed.
Left lower lobectomy starts with vein exposure and transection, followed by
the artery and bronchus. Incomplete fissures are usually completed with an
EndoGIA introduced by the assistant through one of the ports. The lobe 1S
extracted through the anterior utility thoracotomy using an EndoCatch.

4.3.2 Segmentectomy

For suspected primary lung cancer but no preoperative diagnosis, a VATS wedge
resection with frozen section examination may be performed to confirm malig-
nancy before proceeding to segmentectomy. However, if possible this phase
should be avoided as intersegmental planes can be dismpted by the atypical
resections . For centrally located cancers , the operation proceeds directly to
anatomical segmentectomy. Pulmonary artery and vein branches are divided
with a Hem-o-lok@' or a stapler; bronchi and parenchyma are divided with the
stapler, which is introduced by the assistant. Dissection is usually perfonned
with Cadiere forceps in one hand and hook in the other. A spatula with monopo-
lar cautery or a bipolar tool (Maryland) in the right hand can be used as an alter-
native to hook cautery. Fibrin glue is used to control parenchyma air leakage
when required.
For right upper lobe dorsal segmentectomy, the first step is dissection of the
interlobar portion of the pulmonary artery so as to identify the posterior ascend-
34 G.Veronesi

ing segmental artery, to the dorsal upper lobe, and the 10vI'er lobe apical segmen-
tal artery. The ascending branch is then cut between Hem-o-Iok® clips. The
upper lobe is pulled anteriorly with the forceps on the fourth arm and the
bronchial tree is isolated to expose the upper lobe and intennediate bronchus.
The dissection continues by identifying the branch to the dorsal segment, which
is encircled and divided by the stapler. When visible, the segmental vein is
divided between Hem-o-Iok® clips. The segmentectomy is completed by divid-
ing the parenchyma betVl'een the dorsal and apical segments with a stapler. The
resected specimen is extracted in an Endobag through the anterior utility inci-
SIon.
For right upper lobe anterior segmentectomy, the mediastinal pleura is com-
pletely incised anteriorly from the middle lobe vein to the truncus arteriosus .
The anterior segmental vein is isolated and divided; the anterior segmental
artery coming from the lower truncus arteriosus is isolated and divided. The
anterior portion of the horizontal fissure is completed with the endovascular sta-
pler, and the anterior segmental bronchus is isolated and divided. The remaining
segmental fissures are divided with staplers, and the segment is removed .
For right lower lobe upper segmentectomy, if performed from posterior to
anterior, the sequence of hilar structure transection is vein, bronchus , artery;
when the approach is from the fissure , the sequence is artery, bronchus, vein.
The posterior to anterior technique is described: with the lung retracted anteri-
orly, the pulmonary ligament is divided, and the lower pulmonary vein dissect-
ed bluntly to expose the lower lobe apical segmental vein. After division of the
vein, the bronchus is exposed with the lung still retracted anteriorly. The lower
lobe apical segmental artery is then identified in the fissure and stapled (or
clipped with Hem-o-Iok® clips). Lastly, the parenchyma is transected using a
stapler introduced through the anterior utility incision.
For right lower lobe basilar segmentectomy, the sequence is vein, artery,
bronchus. The lung is first retracted posteriorly, the lung liganlent is transected,
and the vein branch is isolated and divided. The next step is to identify the seg-
mental artery within the fissure , which is then cut by a stapler. The bronchus is
then isolated and divided by a stapler followed by parenchyma division with an
articulated stapler.
Left lower lobe trisegmentectomy with lingual sparing proceeds in the
sequence vein, upper artery, bronchus, ventral artery, dorsal artery. The proce-
dure starts with blunt dissection of the upper pulmonary vein. The main branch
is isolated from lingular branch and divided by the stapler. This is followed by
gentle dissection of the artery to the upper segment (one or two branches) . The
culmen bronchus is than isolated and divided by the stapler. One or more ven-
tral and dorsal branches are then isolated and cut after Hem-o-Iokilt clipping.
Fissure division is the last step.
The sequence for lingual segmentectomy is artery, vein, bronchus. The artery
in the fissure is first exposed so as to identify the lingular artery, which is then
divided between Hem-o-Iok® clips or with stapler. The segmental vein is isolat-
4 Thoracic Surgery 3S

ed and divided betvveen Hem-o-Iok® clips while the bronchus is divided by a sta-
pler. Fissure division is the last step.
The techniques for superior segmentectomy and basilar segmentectomy of
the lo\\'er left lobe are similar to those for right-side segmentectomies.

4.3.3 Mediastinal Lymph Node Dissection

Radical lymph node dissection can be perfomled before or after lobectomy. but
suspicious lymph nodes are usually removed before lobectomy. The technique is
similar to that used in open surgery. The paratracheallymph nodes on the right
side are removed first, usually avoiding division of the azygos vein. The medi-
astinal pleura, between the superior vena cava and the azygos vein, is then
incised and the lymph nodes, together with the fatty soft tissue of the paratra-
cheal region are removed en bloc using the hook and forceps . Sometimes a PK
system, UltraCision, is used in patients with large quantities of mediastinal fat
or enlarged lymph nodes .
The nodes of the subcarinal station are removed after resection of the pul-
monary ligament and retraction of the lung toward the anterior mediastinum to
expose the posterior mediastinum. The bronchial arteries can usually be avoid-
ed since visibility is generally good , if not they are coagulated and a clip is not
usually required. Fibrin sealant (Tissucol, Baxter) may be used at lymphadenec-
tomy sites to reduce lymphorrhea, but is rarely required; sealant may also be
applied to the bronchial stump and fissure surface, to reduce air leakage.
Absorbable hemostatic agent is applied , and a single 28Ch pleural drain is
emplaced at the end of the operation .

4.3.4 Resection of Anterior Mediastinal Lesions

The stereoendoscope is introduced through the central port of the fifth inter-
costal space. The forceps for the right hand , and hook for the left hand, are intro-
duced under endoscopic visual control. Radical thymectomy begins by incising
the mediastinal pleura above the phrenic nerve . The lower part of the thymus
and mediastinal fat are dissected moving toward the apical region. The anony-
mous vein is best isolated from the right side where the subclavian vein is clear-
ly visible . Intercostal mammary vessels are spared and mark the boundary of the
anterior chest wall incision . Radical extended thymectomy is usually perfonned
en bloc with mediastinal fat tissue . The fatty tissue of the superior poles, peri-
cardium, and brachiocephalic truncus is removed. Hook cautery or ultracision is
used for the dissection and a Cadiere forceps for retraction. The boundaries of
the resection are the diaphragm below, the thyroid above, and the phrenic nerves
laterally. The small veins are controlled with monopolar cautery or ultracision.
Large vessels are clipped. The controlateral pleura can be left intact if the lesion
36 G.Veronesi

is small; for larger tumors the contralateral pleura can be opened to remove all
the mediastinal tissue without injury to the phrenic nerve, which is identified
and spared. The specimen is removed through the parasternal incision, which
may sometinles require enlargement. A single 28Ch chest tube is emplaced via
the same port.

4.3.5 Postoperative Care

Intensive care is not nonnally necessary. Patients are typically awakened in the
operating room soon after surgery has been completed and are then brought to
the ward. Chest X ray and blood tests are done in the inmlediate postsurgical
period. Patients are mobilized and start pulmonary rehabilitation (for those who
have undergone lung surgery) on the first postoperative day; the vesical catheter
is removed on the same day if diuresis is adequate (>30 cclh) and there are no
other contraindications. The drain is removed when less than 350-400 cc has
accumulated over the preceding 24 hours, and air leaks are absent. Discharge is
possible on the same day as the drain removal (third postoperative day at the ear-
liest). In the event of prolonged air leakage, a Heinllich valve is attached to the
chest tube , and discharge planned for the fifth postoperative day in the absence
of further contraindications .

4.4 Advantages, Limitations and Relative Contra indications

Robotic thoracic surgery is still relatively new, but sufficient experience has
accumulated to justify considering it as the future of minimally invasive surgery.
Nevertheless, the claimed advantages of robotic surgery - high-definition
stereoscopic view, improved dexterity due to more degrees of movement of the
instuments, lack of the instrument fulcnlln effect that occurs with VATS , tremor
filtration, and greater surgeon comfort - have not been shown to produce supe-
rior clinical outcomes, so data supporting these perceived benefits are urgently
required. The high capital and running costs [7], together with the requirement
for the entire operating teanl to learn a new set of skills, have slowed down the
adoption of robotic systems . Although it may be easier for the surgeon to learn
robotic thoracic surgery than VATS, team learning may be longer and more dif-
ficult. Other disadvantages of robotic systems are the lack of tactile feedback
with an inability to feel small lung nodules. However robotic technology is
evolving quickly and the use of robotic thoracic surgery increased more than in
any other surgical discipline in 2012-2013. Our own experience with the da
Vinci® Surgical System (Intuitive Surgical) suggests that about 20 operations are
required, for a surgeon experienced in open thoracic surgery (but not VATS), to
achieve competence in robotic lobectomy [9]. Available data on complications,
number of lymph nodes removed, and patient survival are encouraging, [3-6,9,
4 Thoracic Surgery 37

10] supporting the safety and oncological radicality of the robotic approach to
lobectomy in lung cancer patients.
There are a number of variations in surgical technique. We use a four-ann
approach - three robot arms and the utility incision [1]. Some surgeons use only
three anns [5]; others make the utility incision at the end of the procedure
because they insufflate the chest cavity with C02 [5, 6]. The position of the util-
ity incision varies with surgeon preference. Other teams use a hybrid robot-
VATS approach [11].
hl these cases , the robot is used for vascular, hilar, and mediastinal dissec-
tion, followed by VATS lobectomy.
The radicality of minimally invasive approaches to mediastinal lymph node
dissection has long been debated [2] . Extent of pathologic nodal upstaging can
be a surrogate for the completeness of node dissection and the quality of surgery.
Wilson et al. [12] detemuned the rate of hilar (pNl) nodal upstaging in 303
patients with stage I non-small-celliung cancer, who underwent robotic surgery
for their disease , and compared them historic lular upstaging rates for VATS, and
thoracotomy. They found that nodal upstaging follovving robotic resection
appeared superior to VATS and comparable to thoracotomy, suggesting that the
completeness of node dissection by robotic surgery is sinular to that obtained by
open surgery. In a study by our group [3], the median number of lymph nodes
removed from patients undergoing lobectomy did not differ between robotic and
open lobectomy, again suggesting that node dissection is reassuringly complete
with the robotic approach.
Literature data on robotic mediastinal surgery are linuted. Rea et al. [13]
reported on 33 thymectomies performed on myasthenia gravis patients . Total
thymomectomy is often necessary to obtain long-lasting or pennanent renussion
of muscle weakness in patients with myasthenia gravis and thymoma. More con-
troversially it is also used on myasthenic patients without thymoma. The study
concluded that robotic thymectomy was safe and effective, with complete remis-
sion or much improved symptomatology in 92% of the series. The advantages of
the left-sided approach were emphasized, but it was considered that long-tenn
follow-up was essential to COnfiml benefit. Ruckert et al. [14] compared tradi-
tional monolateral VATS with a robotic approach for thymectomy myasthenia
gravis patients. Duration of surgery, rate of conversion and morbidity vvere sim-
ilar in the tvvo groups, however patients receiving robotic surgery had a higher
rate of complete renussion that was attributed to more complete removal of thy-
mus tissue with the robotic approach.
The largest published experience to date on robotic thymectomy is a study
that assessed early and late results in patients with early-stage (Masaoka I or II)
thymoma, treated at four European centers betvveen2002 and 2011 [7]. Seventy-
nine patients of median age 57 years received left-sided (82.4%), right-sided
(12.6%), or bilateral (5%) robotic surgery. Forty-five (57%) had myasthenia
gravis. The mean operating tinle was 155 minutes and median hospital stay was
3 days. The median resected tumor diameter was 3 cm (range: 1-12 cm). After
38 G.Veronesi

Table 4.1 Summary of results of major pUblications (>30 cases) on robotic lung resections (lobec-
tomies and segmentectomies)

Study Year N. Mean Mean Postoperative

[Reference) Patients operating post0per3b comphcations
nme (nun) stay (days) (0:.)
Robotic lobectomy! egmentectomy with utility incision a t th beginning and no <n
Melfi et aL 2004 107 220 5 NA 1 NA
[10)
Gharagozloo 2009 100 2 16 4 _1 3 13
et al . (11)
Veronesi 2010 54 224 4 .5 _0 0 9 .4
et al . (3]
Park 2011 325 2 10 5 25 A 8
et al . (4)
Veronesi 2011 91 2 13 5 20 0 10
et al . (9)
Robotic lobectomy/segmentectom without utility incision at th e beginning and with <n
Dylewski 2011 165135 90 3 26 0 15
et al . [5]
Cerfolio 2011 106/16 132 2 27 o 10
et al . [6]
NA. not available

a median follow-up of 40 months , 74 patients were alive and five had died (four
from non-thymoma causes and one of disseminated intrathoracic recurrence).
Five-year survival vvas 90% comparing favorably vvith historical results.
It is important to remove all thymic tissue when perfomung thymectomy in
myasthenic patients in order to maxinuze the chance of long-tenll renussion .
When using a unilateral approach, identification of the contralateral phrenic
nerve is a key landmark for ensuring maxinlUm removals of thynuc tissue.
Waegner et al. [15] used fluorescence imaging with indocyanine green dur-
ing right robotic thymectomy to assist with identification of the contralateral
phrenic nerve. The technique consists of bolus iv injection of indocyanine green
solution. The robot visual system is switched to fluorescent mode and a fluores-
cence response in mediastinal blood vessels is observed about to seconds after
the injection. The contralateral phrenic nerve was thus identified as it nIns par-
allel to the pericardiophrenic neurovascular bundle, which shows up as fluores-
cent. It was found that the contralateral pericardiophrenic neurovascular bundle
was visualized in 80% of patients from a left pleural view, rarely from a medi-
astinal vie ..", and never distal to the aortopuhnonary window. The authors con-
cluded that this technology had the potential to maximize thynuc tissue resec-
tion using the lllulateral approach, while reducing operating time and nerve
injury.
4 Thoracic Surgery 39

References

I . Boffa D, Kosinski AS , Paul S et al (2012) Lymph node evaluation by open or video-assisted

approaches in 11,500 anatomic lung cancer resections . Ann Thorac Surg 94:347-353
Whitson SS, Groth SJ , Duval SJ, Swanson MA (2008) Maddaus Surgery for early-stage non-
small cell lung cancer: a systematic review of the video-assisted thoracoscopic surgery ver-
sus thoracotomy approaches to lobectomy. Ann Thorac Surg 86:2008-2016
3. Veronesi G, Galena D, Maisonneuve Pet al (2010) Four-arm robotic lobectomy for the treat-
ment of early-stage lung cancer. J Thorac Cardiovasc Surg 140:19-25
4. Park BJ, Melfi F, Mussi A et al (2011) Robotic lobectomy for non-small cell lung cancer
(NSCLC): long-term oncologic results. J Thorac Cardiovasc Surg 143:383-389
5 Dylewski MR, OhaetoAC , Pereira JF (2011) Pulmonary resection using a total endoscopic
robotic video-assisted approach. Semin Thorac Cardiovasc Surg 23:36-42
6. Cerfolio RJ, Bryant AS, Skylizard L, Minnich DJ (2011) Initial consecutive experience of com-
pletely portal robotic pulmonary resection with 4 arms. J Thorac Cardiovasc Surg 142:740-746
7. Marulli G, Rea F, Melfi F et al (2012) Robot-aided thoracoscopic thymectomy for early-stage
thymoma: a multicenter European study. J Thorac Cardiovasc Surg 144:1125-1130
8. Barbash GI, Glied SA (2010) New technology and health costs - the case of robot assisted
surgery. N Engl J Med 363:701-704
9. Veronesi G, Agoglia B, Melfi F et al (2011) Experience with robotic lobectomy for lung . In-
novations (Phila) 6:355-360
10. Melfi FM,Ambrogi MC, Luccbi M, Mussi A (2005) Video robotic lobectomy. Multimed Man
Cardiothorac Surg doi: lO.l51O/mmcts.2004 .000448
11 . Gbaragozloo F, Margolis M, Tempesta B et al (2009) Robot-assisted lobectomy for early-stage
lung cancer: report of 100 consecutive cases. Ann Thorac Surg 88:380-384
12 . Wilson JL, Louie BE , Cerfolio RJ et al (2014) Prevalence of nodal upstaging during robotic
lung resection in early stage non-small cell lung cancer. Ann Thorac Surg 97: 190 1-1907
13. Rea F, Marulli G, Bortoloni L et al (2006) Experience with the "da Vinci" robotic system for
thymectomy in patients with myasthenia gravis: report of 33 cases . Ann Tborac Surg
81:455-459
14. Ruckert JC, Swierzy M, Ismail M (2011) Comparison of robotic and nonrobotic thoracoscop-
ic thymectomy: a cohort study. J Thorac Cardiovasc Surg 141:673-677
15 . Wagner OJ, Louie BE, Vallieres E et al (2012) Near-infrared fluorescence imaging can help
identify the contralateral phrenic nerve during robotic thymectomy. Ann Tborac Surg
94:622-625
 Part II
Upper Gastrointestinal Surgery
Esophagectomy for Cancer
5
Richard van Hillegersberg

5.1 Procedure Overview

Minimally invasive esophagectomy (MIE) for patients with esophageal cancer
..vas designed to reduce surgical trauma, resulting in lower rates of morbidity
and mortality. MIE has been shown to decrease the blood loss, reduce postop-
erative complications and shorten hospital stay, vvith comparable oncologic
results [1].
In 2003 the robot-assisted minimally invasive esophagectomy (RAMIE) was
developed at UMC Utrecht [2].

5.2 Patient Positioning

The patient is positioned in the left lateral decubitus position, tilted 45 0 toward
the prone position . This semi-prone position keeps the lung out of the operating
field . The operating table is flexed, lowering the legs and upper thorax (the
patient is positioned with the xyphoid above the pivoting point of the table) .
This extends the thorax and \videns the intercostal space for introducing trocars .

5.3 Robot Positioning and Docking

The bedside cart is brought to the table from the dorsocranial side of the patient
(Fig. 5.1).

R. van HiUegersberg ( i8:)

Department of Surgery, University Medical Center,
Utrecht, The Netherlands
e-mail: [email protected]

G. Spinoglio (Ed) , Robotic Surgery: Cllrrelll Applications and Nell' Trends, 43

Updates in Surgery
DOl: 10.l007/978-88-470-5714-2_5, © Springer-Verlag Italia 2015
44 R. van Hillegersberg

Fig. 5.1 OR Setup .

The patient is in left
lateral position,
toward 45 prone .
The robot is docked from
the dorsocranial side .
(© 2014 Intuitive
Surgical , Inc .)

5.4 Trocar Placement

Before incision, the right lung is desufflated after double lumen tube intubation.
A lO-mm camera port is placed at the sixth intercostal space, posterior to the
posterior axillary line. Under vision, two 8-nlll robot-ports are placed just ante-
rior to the scapular rim in the fourth intercostal space and more posterior in the
ninth intercostal space. These ports are used for the monopolar thermal hook at
arm 1 and Cadiere forceps at amI 2. Two thoracoscopic ports are used in the fifth
and seventh intercostal spaces just posterior to the posterior axillary line . These
ports are used for conventional thoracoscopic assistance such as suction, trac-
tion , and clipping (Fig . 5 .2). C02 insufflation of the thoracic cavity with
6 nuuHg penu.its excellent vision , without the need for retracting the lung from
the operative field. In the case of a noncompliant lung, a retractor can be used.

5.5 Step-by-Step Review of Critical Elements of the

Procedure

After division of any pulmonary adhesions and when a proper overview of the
operating field is achieved, the right pulmonary ligament is divided. The parietal
pleura is dissected at the anterior side of the esophagus from the diaphragm up
to the azygos arch. The azygos arch is carefully ligated ..vith robotic Hem-o-lok®
ligation clips in ann 1. (Fig. 5.3) . Then dissection of the parietal pleura is con-
tinued above the aortic arch for a bilateral paratracheal lymph node dissection
(Fig . 5.4). The right vagal nerve is dissected just above the level of the carina .
Right para tracheal lymph nodes (2R and 4R) are dissected over the superior
5 Esophagectomy for Cancer 45

<D o

• 0 Asststant 4
Camera
o
<D . Assistant 6"

.,.
.,.r
a
FIg. 5.2 a Port position. Robotic arms 1 (reI/ow), 2 (greell) and camera (blue) . Two assisting ports
(white) . b Port position. Robotic arms 1 (veIlOlv) , 2 (greell) and camera (blue). Two assisting ports
(white) . (t) 2014 Intuitive Surgical , Inc .)

caval vein up to the level of the right subclavian artery and vein (Fig . 5.5) . Left
paratracheallymph nodes (2L and 4L) are dissected along the left pleura and left
recurrent nerve , that runs just at the tracheal rim. Often the left carotid artery is
visualized. Subsequently, the parietal pleura is dissected at the posterior side of
the esophagus, cranially to caudally, along the azygos vein toward the
diaphragm, including the thoracic duct. At the level of the diaphragm, the tho-
racic duct is clipped vvith a IO-nml endoscopic clipping device (EndoclipTM II;
Covidien, Mansfield, Massachusetts, USA) to prevent postoperative chylous
leakage.
At the level of the diaphragm , a Penrose drain is placed around the esopha-
gus to provide traction by the assistant , facilitating esophageal lifting off the
pericardium and pulmonary veins. The esophagus is then resected en bloc with
the periesophageal (station 8) mediastinal lymph nodes and the thoracic duct
from the diaphragm up to the thoracic inlet. The aorta is completely exposed and
aortoesophageal vessels are identified and clipped with Endoclip by the assist-
ing surgeon . Finally the aortopulmonary window (station 5), subcarinalnodes
(station 7) are dissected. The subcarinalnodes are very fragile and bleed easily,
therefore first the nodes are dissected along the carinal cartilage and then the
surrounding fascia is dissected, preventing grasping of the nodes . A 24-Fr chest
tube is placed, and the lung is insufflated under direct vision.
After completion of the robot-assisted thoracoscopic esophageal mobiliza-
tion , the patient is put in the supine position. An 11-n1111 camera port is intro-
duced left paraumbilically, and an 11-m111 working port is placed at the left mid-
clavicular line at the umbilical level. A 5-nml working port is placed more cra-
46 R. van Hillegersberg

Fig. 5.3 Division of

the Azygos vein over
the esophagus

Fig. 5.4 Identification

and dissection
of a bronchial artery
(BA) at the level of
the crossing azygos
vein after dissection
of the vein

nially at the right midclavicular line . A 5-n1111 assisting port is placed in the left
subcostal area, and a 12-nml port is placed pararectally right for the liver retrac-
tor. The abdomen is insufflated to a carbon dioxide pressure level of 15 n1111Hg.
The hepatogastric ligament is opened. The greater and lesser curvatures are
dissected with ultrasonic hannonic scalpel (Hannonic Ace®, Ethicon Endosurgery,
Johnson&Johnson , New Bnmswick, New Jersey, USA). The hiatus is opened, and
the distal esophagus is dissected from the right and left crus. The carbon dioxide
pressure level is reduced to 6 nmilig to avoid excessive intrathoracic pressure and
a chest tube is placed in the left pleural sinus. Dissection and lymphadenectomy
5 Esophagectomy for Cancer 47

Fig. 5.5 Excellent view of thoracic inlet

then continues around the celiac tmnk . The left gastric artery and vein are then
transected at their origin with Hem-o-Iok® ligation clips (Teleflex Medical, NC,
US) . Abdominal lymphadenectomy includes lymph nodes surrounding the left
gastric artery and the lesser omental lymph nodes.
The cervical esophagus is mobilized through a left-side longitudinal neck inci-
sion along the stemocleidoid muscle. No fomlal cervical lymph node dissection is
carried out, but cervical lymph nodes are dissected if lymph node metastases are
suspected macroscopically during the cervical phase of esophagectomy. The esoph-
agus is dissected and a cord is attached to the proxinlal part of the specimen to
enable pull-up of the gastric conduit along the anatomical tract of the esophagus.
The esophagus and surrounding lymph nodes are pulled into the abdomen under
laparoscopic vision. A 7-cm transverse incision is made at the level of the left paralUll-
bilical port for extraction of the specimen and stomach using a wOlUld protector.
Outside the abdomen, a 5-cm-wide gastric tube is constmcted with staplers (GIA
TM 80, 3.8 nUll; Covidien, Dublin, Ireland), and the stapled line is oversewn with
3-0 polydioxanone. Routine extracorporal oversewing \vas reintroduced as two seri-
ous complications occurred when the staple line was not oversewn [3] .The specinlen
consisting of the esophagus and cardia of the stomach is sent for pathological exam-
ination. After the gastric tube has been pulled to the neck, a hand-sewn end-to-side
esophagogastrostomy is perfonned in the neck using 3-0 polydioxanone single-layer
mmung sutures. Excess gastric tubing is removed using a GIA stapler.
A feeding jejunostomy (Freka® FCJ-Set, Fresenius Kabi AG, Bad Homburg
vd H., Gennany) is placed at the level of the transverse incision.
48 R. van Hillegersberg

5.6 Advantages, Limitations and Relative Contra indications

(Personal Experience and Literature Outcomes)

Optimal treatment for esophageal cancer consists of transthoracic en bloc

esophagectomy (TTE) \vith an extensive mediastinal lymph node dissection.
This approach through thoracotomy is accompanied by significant morbidity,
mainly consisting of cardiopulmonary complications. To reduce surgical trauma
and morbidity of open transthoracic esophagectomy, less invasive surgical tech-
niques such as transhiatal esophagectomy (THE) and minimally invasive
esophagectomy (MIE) have been introduced.
Recent analyses of the MIE to date have shown a decreased operative blood
loss, reduced complication rate and shorter hospital stay [1,4,5]. However, con-
ventional endoscopic surgery has important limitations, such as a two-dimen-
sional view, a disturbed hand-eye-coordination and limited degrees of freedom.
Robotic systems have been developed to overcome these limitations [6] . During
esophagectomy, the robotic platfonn enables the surgeon to perfoml an accurate
mediastinal dissection of the esophagus en bloc with surrounding lymphatic tis-
sue and mediastinal fat, often harboring metastatic disease . Robot-assisted min-
imally invasive esophagectomy (RAMIE) in conjunction with conventional
laparoscopy has been shown to be technically feasible. Moreover, it provides
sufficient oncological resection and is associated with low blood loss [2, 7]. The
abdominal phase of the operation can also be pedomled robotic ally. In our expe-
rience tills is easily feasible , however there are several drawbacks. The large
area in the upper abdomen that needs to be dissected can often not be reached
from a single docking position. Most importantly, the dissection of the greater
curvature is difficult with robotic hamlOnic scissors as the articulation of the tip
is lacking. We expect a much better pedomlance with the Vessel sealer®.
HO\vever, much care should be given not to damage the gastroepiploic vessels
which supply the future gastric tube .
For the thoracic part, the left lateral decubitus position is preferred as con-
version to thoracotomy is easily pedonned. When the robotic system is in place,
access to the patient in case of emergency is limited. Therefore, the surgical
team should be capable of rapidly removing the robot if required. This is not
possible in the prone position .
Post-operatively, patients are transferred to the intensive care unit (leU).
After leaving the operating room, mechanical ventilation is continued briefly
and the patients are usually extubated later that evening. After 1 day in the leU,
patients are transferred to a medium care (Me) ward.
Important for postoperative care are a nasogastric tube, feeding jejunostomy
and an epidural catheter. The nasogastric tube is used for gastric decompression
and to provide splinting in case of anastomotic dehiscence.
Appropriate patient selection is essential to a successful esophageal surgery
program. Approximately 30-40% of esophageal cancer patients are eligible to
undergo an esophagectomy with curative intent, taking into account tumor stage
5 Esophagectomy for Cancer 49

and co-morbidity. The minimally invasive approach may offer a greater percent-
age of patients a potentially curative surgical resection. Patients with stage I-III
disease, i.e ., TI-T4a tumors, and no evidence of distant metastases are eligible
to RAMIE [8].
With our growing experience , especially patients with tumors in the upper
mediastinum and ..vith para tracheal lymph node metastases were resected suc-
cessfully with the thoracoscopic robotic approach (Fig. 5.5). These tumors are
often in close contact with the upper mediastinal blood vessels (superior caval
vein , carotid artery and subclavian artery and vein) . The thoracic inlet is very
difficult to reach with an open or conventional thoracoscopic approach . With the
robot, this area can be reached without any limitations . This extends the opera-
tive and potentially curative options in these specific groups of patients substan-
tially. A recent report of a Korean group shows that a very extensive complete
paratracheallymph node dissection can be performed with the robot [9] .

5.7 Results of RAMIE

Following our initial report of RAMIE in 2009 , we analyzed the following consec-
utive series of 108 patients until 2011 . Esophageal dissection vvas completed thora-
coscopically in 88 patients. Conversion to thoracotomy was necessary in 12
patients due to: bulky adhesive tumor in the mediastinum (4): bleeding that could
not be controlled thoracoscopic ally (4); insufficient collapse of the right lung (2);
or inadequate thoracoscopic trocar position (2). Conversion to a transhiatal proce-
dure was necessary in 9 patients due to: insufficient collapse of the right lung (6);
inadequate thoracoscopic port position (1); pleural adhesions (1); or enlarged right
cardiac atrium (unusual anatomy) (1). Conversion of the laparoscopic abdominal
phase was required in 3 patients due to bleeding that could not be controlled laparo-
scopic ally (1) , locally advanced tumor requiring total gastrectomy with colonic
interposition (1) or very low position of the greater curvature (1) . There was a sig-
nificant decrease in the percentage of conversions between the first 54 and second
54 patients (13 (24%) vs. 7 (13%) respectively; p <0·001).
The median set up time for the robot was 17 minutes (range 5-91) . The medi-
an duration of the total procedure was 381 minutes (range 264-550) . The thora-
coscopic phase (88 patients) had a median duration of 175 minutes (range
108-241). There vvas a significant decrease in thoracoscopic operative time
betv.'een the first 44 and second 44 patients who completed the thoracic phase
thoracoscopic ally (199 min versus 166 min respectively; p < 0·001) .
We found a high percentage (95%) of radical resections despite the high rate
of T3 tumors (78%) and only 64% neoadjuvant therapy. A median of 26 dissect-
ed lymph nodes were retrieved . Follow-up was at least 25 months with a medi-
an follow-up of 34 months. Median disease-free survival was 21 months and
median overall survival was 29 months , with a 5-year overall survival of 40%.
The percentage of in-hospital puhuonary infections after RAMIE in our series
50 R. van Hillegersberg

was 34% (unpublished data).

Our results from robot-assisted esophagectomy are in concordance with a
recently published systematic review [10]. This systematic revie\\' included 9
articles (130 cases) describing robot-assisted esophagectomy. It was concluded
that robot -assisted esophagectomy was a feasible and safe technique. hI tenus of
short-tenu oncological outcomes , RAMIE was at least equivalent to the open
transthoracic approach for esophageal cancer. The systematic review strongly
emphasized the need for well conducted randomized controlled trials including
long-tenu survival to prove the superiority of robot-assisted minimally invasive
thoracolaparoscopic esophagectomy over open transthoracic esophagectomy.
Therefore, we initiated the ROBOT trial (ClinicaITrial.gov Identifier:
NCTOI544790) to compare RAMIE with open transthoracic esophagectomy.
Results from tltis randomized controlled trial are to be expected in 2016 [11] .

References
1. Luketich JD, Pennathur A. Awais 0 et al (2012) Outcomes after minimally invasive esophagec-
tomy: review of over 1000 patients. Ann Surg 256:95-103
2. van Hillegersberg R, Boone J, Draaisma WA et al (2006) First experience with robot-assist-
ed thoracoscopic esophagolymphadenectomy for esophageal cancer. Surg Endosc 20:1435-1439
3. Boone I , Rinkes ill, van Hillegersberg R (2006) Gastric conduit staple line after esophagec-
tomy: to oversew or not? I Thorac Cardiovasc Surg 132: 1491-1492
4. Biere SS, van Berge Henegouwen MI, Maas KW et al (2012) Minimally invasive versus open
oesophagectomy for patients with oesophageal cancer: a multicentre, open-label, randomised
controlled trial. Lancet 379: 1887-1892
5. Verhage RJ, Hazebroek EJ, Boone J, van Hillegersberg R (2009) Minimally invasive surgery
compared to open procedures in esophagectomy for cancer: a systematic review of the liter-
ature . Minerva Chir 64: 135-146
6. Ruurda JP, Draaisma WA. van Hillegersberg R et al (2005) Robot-assisted endoscopic sur-
gery: a four-year single-center experience. Dig Surg 22:313-320
7. Kerustine KH (2004) Robotics in thoracic surgery. Am I Surg 188: 89S-97S
8. Boone J, Schipper ME, Moojen WA et al (2009) Robot-assisted thoracoscopic oesophagec-
tomy for cancer. Br I Surg 96:878-886
9. Kim DI , Park SY, Lee S et al (2014) Feasibility of a robot-assisted thoracoscopic lym-
phadenectomy along the recurrent laryngeal nerves in radical esophagectomy for esophageal
squamous carcinoma. Surg Endosc 28: 1866-1873
10. Clark I , Sodergren MH, Purkayastha S et al (2011) The role of robotic assisted laparoscopy
for oesophagogastric oncological resection; an appraisal of the literature. Dis Esophagus
24:240-250
11 . van der Sluis PC, Ruurda IP, van der Horst Set al (2012) Robot-assisted minimally invasive
thoraco-Iaparoscopic esophagectomy versus open transthoracic esophagectomy for resectable
esophageal cancer, a randomized controlled trial (ROBOT trial). Trials 13:230
Anti-reflux Procedures
and Cardioesophagomyotomy
6
Gianluigi Melotti, Vincenzo Trapani, Marzio Frazzoni,
Michele Varoli, and Micaela Piccoli

6.1 Anti-reflux Procedures

6.1.1 Introduction

Currently, gastroesophageal reflux disease (GERD) is defined as a condition

that develops when the reflux of gastric contents into the esophagus leads to
troublesome symptoms and/or complications [1] . In Western countries , GERD
is the most common chronic disease in the adult population with a 20% preva-
lence. The typical reflux syndrome includes heartburn and regurgitation .
Barrett's esophagus is the most dreaded complication of GERD , occurring in
2% of the general adult population: it predisposes sufferers to esophageal ade-
nocarcinoma, the fastest grovving cause of cancer mortality in Western countries
[2]. No more than 20% of patients with typical reflux symptoms have erosions
of the esophageal mucosa at endoscopic examination, i.e. have erosive reflux
disease. The vast majority of patients with the typical reflux syndrome have
nonnal endoscopic findings: those responding to proton pump inhibitor (PPI)
therapy have nonerosive reflux disease whereas those VI'ith PPI-refractory typi-
cal symptoms should undergo 24 h impedance-pH monitoring to discriminate
between PPI-refractory GERD and functional heartburn [3, 4]. PPls provide
rapid symptomatic relief in up to 80% of patients with the typical reflux syn-
drome, transfornling the vast majority of acid refluxes into less toxic weakly
acidic refluxes . However, typical GERD symptoms recur within I year in more
than 90% of patients after PPI-withdrawal, in many of them within few days:
thus, many patients become PPI-dependent and surgical therapy has been
regarded as a treatment option for these patients [5].

M. Piccoli ( ~ )
General Surgery Unit, "Sant' Agostino-Estense" New Hospital,
Baggiovara (MO), Italy
e-mail: m [email protected]

G. Spinoglio (Ed) , Robotic Surgery: Cllrrelll Applications and Nell' Trends, 51

Updates in Surgery
DOl: 10.1007/978-88-470-5714-2_6, © Springer-Verlag Italia 2015
52 G. Melotti et al.

Currently, laparoscopic fundoplication is considered the standard surgical

treatment for GERD because it affords persistent relief of heartburn in 90% of
PPI-responsive patients at 20-year follovv-up [6, 7]. Up to 20% of patients fail to
respond, either partially or completely, to PPI therapy at standard and even high
dosages. Given the high efficacy of laparoscopic fundoplication in curing PPI-
responsive GERD, it is the only treatment modality currently recommended for
overcoming PPI failures [5].
Before surgical intervention, a fiml diagnosis of GERD is required, particular-
ly in patients with endoscopy-negative heartbum. Currently, impedance-pH mon-
itoring is the gold-standard preoperative reflux test; it must always be preceded by
esophageal manometry to rule out severe esophageal motility disorders [5].

6.1.2 Procedure Overview

In 1991 , Dallemagne [8] described the laparoscopic technique for the Nissen fun-
doplication. The laparoscopic approach had a lot of benefits over the traditional
open approach, including improved cosmesis, reduced morbidity, decreased hos-
pital stay, decreased respiratory complications , and faster recovery.
The Nissen fundoplication , consisting of a total (360°) vvrap , is the most
commonly perfonlled anti-reflux operation. Despite general reflux alleviation,
dysphagia and gas bloating are the primary causes of dissatisfaction after Nissen
fundoplication. In order to reduce the postoperative dysphagia and gas bloating,
a variety of procedures in which the fundus is only partially v,'Tapped have been
proposed, including the Toupet fundoplication, consisting of a posterior (270°)
wrap, and the Dor fundoplication , consisting of an anterior (180°) wrap. Sinular
efficacy on heartbUrn/regurgitation and reflux parameters but less dysphagia and
gas bloat have been reported when the Toupet fundoplication has been compared
with the Nissen fundoplication [9 , 10]: it should be noted, however, that with
both techniques the fundoplication was perfornled by fixing the wrap to the
anterior wall of the esophagus . The Nissen procedure can also be carried out
without anchoring the fundoplication: no wrap slipping, negligible gas bloating,
and cumulative incidence of postoperative dysphagia quite sinular to that report-
ed with the Toupet procedure, in conjunction vvith nomlal reflux parameters and
sustained symptom remission in the vast majority of cases have been found with
tlUs technique [11, 12] . To prevent postoperative dysphagia , other key technical
issues must be considered, including division of the short gastric vessels v.'hen-
ever deemed necessary in order to adequately mobilize the esophagus and to
make the fundoplication tension-free , and insertion of a 52-Fr bougie into the
esophagus during construction of the wrap .
Robot-assisted surgery was developed to overcome the linutations of laparo-
scopic technology and to expand the benefits of minimal invasive surgery. The
first report of robot-assisted fundoplication was published by Meininger in 2001
[13] and its use has been increasing since then.
6 Anti-reflux Procedures and (ardioesophagomyotomy 53

Fig. 6.1 OR Setup. (© 2014 Intuitive Surgical. Inc)

6.1.3 Patient Positioning

After satisfactory induction of general endotracheal anesthesia, the patient is

placed in the semi-lithotomy position (head up approximately 30°) , legs spread.

6.1.4 Robot Positioning and Docking

The patient-side cart is positioned at the head of the patient and it includes four
robotic arms; the vision system is at the left side of the bed, and the surgeon con-
sole is distant from the bed, but in the same operating room (Fig. 6.1).

6.1.5 Trocar Placement

After a 12 mmHg pneumoperitoneum is created vvith a Veress needle in the left

hyphocondriulll, four robotic trocars (one 12-nll11 disposable for the camera,
three 8-111111 reusable) are inserted as shown in Fig. 6.2.
The first trocar (12 I1ml for camera) is placed about 3 cm to the left of the
umbilicus, approximately two finger-breadths above the umbilicus. Two 8-nml tro-
cars are placed in the right and left upper quadrant in the mid-clavicular line for two
operative robotic arms . One 8-nll11 trocar, inserted about two finger-breadths below
the costal margin in the right anterior axillary line, is used for the third robotic arm
54 G. Melotti et al.

Flg.6 .2 Trocarpositioning. (© 2014 Intuitive Sur-

/~
gical , Inc.)

• <D . camera • 0 0

Assistant 0

to retract the liver. A S-ll1ll111 assistant port is placed about 2 cm under the umbil-
icalline , between the midline and the mid-clavicular line, in the left side . The senlp
of the robot is usually perfomled by the assistant at the bedside.

6.1.6 Critical Elements of the Procedure

The operative technique perfonlled by robot is essentially the same as described

by Dallemagne [14] and Cadiere [15] for the laparoscopic approach . The main
differences are in the trocar position (as shovl'n before) . Operative robotic amlS
perfonu the same procedure that is made by a surgeon's amlS in a laparoscopic
technique .
The assistant surgeon sits between the patient legs and uses the assistant port
to insert instruments (clip-applier, stitches, scissors, etc). The whole dissection
can be carried out utilizing monopolar cautery by a hook dissector with a full
degree of articulation. A floppy 360 0 fundoplication is constructed using the
anterior wall of the fundus . The division of the upper gastric vessels is usually
necessary. The fundoplication is sutured neither to the esophagus nor to the
diaphragm but is calibrated onto a 52 Fr bougie. which is inserted at the start of
the procedure .

6.1.7 Advantages of Robot-assisted Laparoscopic Fundoplication

T,,'o prospective randomized srudies have compared robot-assisted and conven-

tionallaparoscopic fundoplication [16 , 17] . In the snldy by Morino and co-work-
ers [16], conventional or robot-assisted laparoscopic Nissen fundoplication
6 Anti-reflux Procedures and (ardioesophagomyotomy 55

(LNF) was carried out by three expert surgeons: nonsignificant differences were
found in the postoperative clinical outcome and in pH-metric parameters between
the two groups of patients. In the study by Draaisma and co-workers [17], 25
patients treated with conventional LNF were compared to 25 patients treated with
robot-assisted LNF: similar postoperative pH-metric results were found in the
two groups of patients but the study detected a statistically significant difference
of only 35% and the two surgical procedures were carried out by seven surgeons.
In a recent study comparing 44 patients who underwent robot-assisted
laparoscopic fundoplication with 44 patients who underwent conventional
laparoscopic fundoplication. at a 3-month postoperative follow-up no difference
in temlS of heartbum remission was found but normalization of acid reflux was
detected significantly more frequently in patients treated with robotic surgery
(100% vs. 86%. P =0.026) [18] . It should be noted that in this study all the inter-
ventions were carried out by the same surgeon. The potential advantages of
robotic surgery include greater precision due to the anti-tremble filter. better
vision as a result of the three-dimensional imaging of the surgical field. and
reduced bleeding . Taken together. these advantages can explain these slightly
but significantly better results after robot-assisted laparoscopic fundoplication in
temlS of postoperative acid reflux control. Currently. anti-reflux surgery is main-
ly advised for PPI-refractory GERD patients and altematives of proven efficacy
are not available [5]. Even a 14% gain in nonllalization of postoperative acid
reflux parameters provided by the robot-assisted technique can be clinically rel-
evant for PPI-refractory patients. It can be concluded that in centers vvhere
robot-assisted laparoscopic fundoplication is available, it should be preferred to
the conventional technique in patients with PPI-refractory GERD.

6.2 Cardioesophagomyotomy

6.2.1 Introduction

Cardioesophagomyotomy is the standard surgical procedure currently recom-

mended for achalasia. Achalasia is a rare primary motility disorder of the esoph-
agus that affects one person in 100.000 per year and is characterized by the
absence of esophageal peristalsis and incomplete relaxation of a frequently
hypertensive lower esophageal sphincter (LES) in response to swallowing. Most
patients present with dysphagia for solids and liquids and regurgitation of undi-
gested food. Other common symptoms include chest pain, heartbum. VI'eight
loss, and noctumal cough. The first diagnostic step is to rule out anatomical
lesions by using endoscopy or radiology. In early stages, both endoscopy and
radiology may be completely normal. Manometry represents the diagnostic gold
standard with over 90% accuracy.
No treatment can restore muscular activity to the denervated esophagus and
every treatment for achalasia is directed at reducing the gradient across the LES.
56 G. Melotti et al.

Treatment options include medical therapy, such as nitrates and calcium channel
blockers; endoscopic therapy, such as pneumatic dilation or botulinum toxin
injection; and operative cardioesophagomyotomy [19].
Botulinum toxin injection is safe but less effective than balloon dilation; it
requires retreatment and leads to scar fornlation in the submucosal plane, which
can result in a more difficult myotomy and greater rates of mucosal perforation
(up to 30%) during dissection. It should be reserved for patients who are poor
candidates for other more effective treatment options.
Currently, except for high-risk or elderly patients, pneumatic dilation or
laparoscopic cardioesophagomyotomy with anterior fundoplication (Heller-Dor)
represent the standard management for achalasia. Using a graded approach vvith
increasing diameters of the polyethylene balloon dilator from 3.0 to 4 .0 cm, up
to a 93% response rate has been achieved during a follow-up period of up to 4
years vvith a relatively low perforation risk (3%). In a recent multicenter ran-
domized trial, endoscopic dilation (up to three series of pneumatic dilations) and
laparoscopic Heller-Dor had comparable success at two years: 92% for dilation
and 87% for myotomy [20].
The robot-assisted cardioesophagomyotomy has been described for the first
time by Horgan et al. in 2005 [21].
Recently, peroral endoscopic myotomy (POEM) has been introduced as a
promising alternative to the current treatments [22]. Several open label studies
have been published showing excellent short tenll results with only a few com-
plications. However, there is currently insufficient evidence to perform POEM
as routine achalasia treatment. Until the long-ternl efficacy data from random-
ized controlled trials are available, POEM should be restricted to centers partic-
ipating in clinical trials.

6.2.2 Patient and Robot Positioning, Trocar Placement

and Docking

This is described in Sections 6.1.3-6.1.5.

6.2.3 Critical Elements of the Procedure

The operative technique to perfornl a robot-assisted Heller-Dor procedure is

essentially the same as described by Ancona et al. for the laparoscopic procedure
[23]. The main differences are in the trocar position [21] . We usually insert an
endoscope at the begitUling of the surgical procedure, to detect the squamo-
columnar junction as the landmark to start esophagomyotomy, to check the com-
plete dissection of muscular fibers, and to identify possible microperforations of
the mucosa and to assist the related suturing procedure. The same endoscope is
used at the end of the procedure to calibrate the Dor fundoplication. Only the
6 Anti-reflux Procedures and (ardioesophagomyotomy 57

anterior part of the esophagus is dissected, respecting the posterior attachments.

The dissection and myotomy are carried by robotic articulated hook electro-
cautery that, thanks to the elimination of physiological tremor, allows a finest
dissection with less bleeding .

6.2.4 Advantages of Robot-assisted Cardioesophagomyotomy

In a retrospective, multicenter snldy, esophageal perforations were more fre-

quent after conventional laparoscopic (16%) than robot-assisted cardioe-
sophagomyotomy (0%) [21] . These findings have been confimled in a prospec-
tive, single-center study [24]. However, it must be acknowledged that perfora-
tions are immediately recognized and repaired using intracorporeal suturing
techniques and a recent multicenter retrospective analysis concluded that robot-
ic and laparoscopic cardioesophagomyotomy can be considered equivalent in
tenus of safety and efficacy [25].

References
1. Katz P, Gerson L, Vela M (2013) Guidelines for the diagnosis and management of gastroe-
sophageal reflux disease . Am J GastroenterolI08:308-328
Fitzgerald RC, Di Pietro M, Ragunath K et al (2014) British Society of Gastroenterology guide-
lines on the diagnosis and management of Barrett's oesophagus . Gut 63:7-42
3. Frazzoni M, Conigliaro R. Mirante VG et al (2012) The added value of quantitative analysis
of on-therapy impedance-pH parameters in distinguishing refractory non-erosive reflux dis-
ease from functional heartburn. Neurogastroenterol MotiI24:141--e87
4. Frazzoni M , Manta R, Mirante VG et al (2013) Esophageal chemical clearance is impaired
in gastro-esophageal reflux disease - A 24h impedance-pH monitoring assessment. Neuro-
gastroenterol MotiI25 :399--e295
5. Katz P, Gerson L, Vela M (2013) Guidelines for the diagnosis and management of gastroe-
sophageal reflux disease. Am J GastroenteroI108:308-328
6. Dallemagne B , Perretta S (2011) Twenty years oflaparoscopic fundoplication for GERD. World
J Surg 35:1428-1435
7. Engstrom C, Cai W, Irvine T et al (2012) Twenty years of experience with laparoscopic an-
tireflux surgery. Br J Surg 99: 1415-1442
8. Dallemagne B , Weerts 1M , Jehaes C et al (1991) Laparoscopic Nissen fundoplication : pre-
liminary report. Surg Laparosc Endosc 3: 138-143
9. Broeders JA, Bredenoord AJ, Hazebroek EJ et al (2012) Reflux and belching after 270 de-
gree versus 360 degree laparoscopic posterior fundoplication . Ann Surg 255 :59-65
10. Koch 00 , Kaindlstorfer A , Antoniou SA et al (2013) Comparison of results from a random-
ized trial 1 year after laparoscopic Nissen and Toupet fundophcations . Surg Endosc
27 :2383-2390
11. Frazzoni M, Conigliaro R, Melotti G (2011) Reflux parameters as modified by laparoscopic
fundoplication in 40 patients with heartburn/regurgitation persisting despite PPI therapy. A
study using impedance-pH monitoring. Dig Dis Sci 56: 1099-1106
12 . Frazzoni M, Piccoli M , Conigliaro R et al (2013) Refractory gastroesophageal reflux disease
as diagnosed by impedance-pH monitoring can be cured by laparoscopic fundoplication.
Surg Endosc 2013; 27:2940-2946
58 G. Melotti et al.

13. Meininger DD, Byhahn C , Heller K et al (200 1) Totally endoseopic Nissen fundoplication with
a robotic system in a child. Surg Endose II : 1360
14. Dallemagne B (1999) Treatment of the gastroesophageal reflux syndrome. In Meinero M.
Mouret Ph. Melotti G, (eds.): Laparoseopic surgery; the nineties. Masson, Milan pp. 251-260
15 . Cadiere GB (1995) Trattamento video-Iaparoseopico del reflusso gastro-esofageo-E.M .C . Ro-
ma Tecniche Chirurgiche-Addominale, 40 189 , p 10
16. Morino M , Pellegrino L , Giaccone C et al (2006) Randomized clinical trial of robot-assisted
versus laparoseopic Nissen fundoplication . Br J Surg 93 :553-558
17. Draaisma WA, Ruurda IP, Scheffer RCH et al (2006) Randomized clinical trial of standard
laparoseopic versus robot-assisted laparoscopic Nissen fundoplication for gastro-oesophageal
reflux disease . Br J Surg 93:1351-1359
18 . Frazzoni M, Conigliaro R, Colli G et al (2012) Conventional versus robot-assisted laparoseop-
ic Nissen fundoplication. A comparison of postoperative acid reflux parameters . Surg Endose
26:1675-1681
19. Stefanidis D, Richardson W, Farrell TM et al (2012) SAGES guidelines for the surgical treat-
ment of esophageal achalasia. Surg Endose 26:296-311
20 . Boeckxstaens GE, Annese V, Bruley des Varannes S et al (2011) Pneumatic dilation versus
laparoscopic Heller's myotomy for idiopathic achalasia . New Engl J Med 364:1807-1816
21 . Horgan S, Galvani C, Gorodner MV et al (2005) Robotic-assisted Heller myotomy versus la-
paroseopic Heller myotomy for the treatment of esophageal achalasia: multicenter study. J Gas-
trointest Surg 9 :1020-1030
22 . Bredenoord AI , Rosch T, Fockens P (2014) Peroral endoscopic myotomy for achalasia . Neu-
rogastroenterol Motil26: 3-16
23. Ancona E , Zaninotto G, Costantini M (2003) Miotomie Esofagee. In: Encycl Med Chir (Edi-
tions Scientifiques et Medicales Elsevier SAS, Paris) Tecniche Chirurgiche-Addominale, pp.
40-183
24. Huffmanm LC, Pandallai PK, Boulton I et al (2007) Robotic Heller myotomy: A safe oper-
ation with higher postoperative quality-of-Iife indices. Surgery 142:613-20
25 . ShaligramA, Unnirevi J, Simorov Aet al (2012) How does the robot affect outcomes? A ret-
rospective review of open, laparoscopic, and robotic Heller myotomy for achalasia. Surg En-
dosc 26:1047-1050
Gastrectomy for Cancer
7
Andrea Coratti, Mario Annecchiarico,
and Stefano Amore Bonapasta

7.1 Procedure Overview

The first experiences of robot-assisted gastrectomy (RAG) were published by

Giulianotti et al. and Hashizume and Sugimachi in 2003 [1, 2].
Nowadays, the reported results are satisfactory in terms of surgical compli-
cations, mortality, conversion rate, length of hospital stay and oncological ade-
quacy; no differences are demonstrated between patients vvho had robotic and
laparoscopic gastrectomy (LG) [3-5].
Robotic surgery for gastric cancer has been demonstrated to overcome
intrinsic limitations of conventional laparoscopic surgery thanks to the wristed
instmments that allow seven degrees of freedom, the tremor-filter, the three-
dimensional vision and the steady image, thus minimizing blood losses , surgi-
cal trauma and the inIprovement of surgeon's dexterity when fine manipulation
is required. This can be especially helpful during maneuvers in restricted fields
and around major vessels such as in extended lymphadenectomy. Robotic sur-
gery allows the surgeon to reproduce routine D2-lymphadenectomy and to per-
form enlarged resections and complex reconstmctions in the case of advanced
disease [6, 7].
Mininlally invasive surgery (MIS) can have an inIportant role in the thera-
peutic strategy for advanced disease . Hovvever, to date, MIS is indicated for
early gastric cancer but its oncologic safety for advanced gastric cancer remains
controversial. Because of the short follow-up tinle of the major published series,
the number of harvested lymph nodes and resection margins have been used as
indicators of oncologic acceptability of robotic resection.

M. Annecchiarico ( )
Department of Oncology, Division of Oncological and Robotic General Surgery,
Careggi University Hospital, Florence, Italy
e-mail: [email protected]

G. Spinoglio (Ed) , Robotic Surgery: C/lrrelll Applications and Nell' Trends, S9

Updates in Surgery
DOl: 1O.l007/978-88-470-57 14-2_7, © Springer-Verlag Italia 2015
60 A.(oratti et al.

According to the articles present in the up-to-date literature, RAG with limi-
ted lymphadenectomy is indicated for Stage la, while RAG with D2 lymphade-
nectomy is indicated for Stage Ib-2a. Mucosal and submucosal tumors, if eligi-
ble, are considered for endoscopic resection first [3, 8]. RAG for more advanced
stages is the object of investigations and at present should be performed only in
highly specialized centers.
We describe the technique of distal subtotal and total gastrectomy with D2
lymphadenectomy.

7.2 Patient Positioning

The patient is placed in the supine position on a split table. After placing the
ports, the patient is moved to an about 15-20° reverse-Trendelenburg position.
A nasogastric hlbe is inserted for gastric decompression.

7.3 Robot Positioning and Docking

The robotic cart is docked from the patient's head (Fig. 7.1a). Correct positio-
ning of the robotic cart is fundamental because its axis must coincide with the
working axis , coming from the opposite site.
Because the operating table call11ot be changed once the robot has been
docked, the height and slope of the operating table must be reconfirmed before
the robot is docked.

7.4 Trocar Placement

The placement of the ports can be summarized as follows except for some minor
variations between authors:
• Pneumoperitoneum of 12 mmHg is achieved with open or blind technique;
• The camera port is inserted in the periumbilical region;
• Under direct vision, three 8-mm robotic ports are placed, two in the upper
abdomen at the anterior axillary line on the left (robotic arm, RI) and on the
right (robotic arm, R3), and one at the right midclavicular line (robotic ann,
R2). In addition, a 12-mm port for the assistant surgeon is placed between the
Rl port and the camera port along the left midclavicular line (Fig. 7.1b) .
However, ports positioning can partially change due to the anatomy of the
abdomen and depends on the procedure being performed (subtotal or total
gastrectomy) , especially for what concems the camera port;
• The console surgeon controls Rl by the right master, while R2 and R3 are
controlled switching the left master. Rl carries the cautery hook or hamlonic
scalpel for the dominant hand. R2 is used by the nondominant hand vvith
7 Gastrectomy for Cancer 61

a b

(i)
/ (i)
• G>• 0

•
C~1IM!n
Anlstllll

9l\. S(.,l

./
~
~ I ~

Fig 7.1 OR setup (a) and trocar placement (b) . (© 2014 Intuitive Surgical , Inc.)

bipolar forceps . R3 is armed with a grasper and used for retraction and expo-
sure;
• The assistant surgeon aids the console surgeon using the accessory port for
aspiration/irrigation, for clip or stapler application and other additional
maneuvers .

7.5 Step-by-Step Review of Critical Elements of the

Procedure

7.S.1 Distal Subtotal Gastrectomy

7.5.1.1 Exploration
The abdominal cavity is explored in order to assess a definitive staging of dis-
ease . Diagnostic peritoneal lavage is perfonlled routinely. Intraoperative ultra-
sound is performed only if hepatic metastases are suspected. Intraoperative
endoscopy can be conducted to establish the location of the tumor and to mark
the proximal resection margin.
After laparoscopic exploration, the robotic cart is docked as previously
described.

7.5.1.2 Coloeplploic Detachment

A complete coloepiploic detachment is performed dissecting the avascular plane
betvveen great omentum and transverse colon. The dissection is extended toward
the lovver pole of the spleen and the right colonic flexure by using monopolar
cautery and bipolar forceps. In case of fatty or obese patients, an advanced
62 A.(oratti et al.

energy device (robotic ultrasound dissector or other devices controlled by assi-

stant surgeon) may be helpful during tills surgical step.
Given the wideness of operative field, coloepiploic detachment may be per-
fomled even \vith conventionallaparoscopy before docking the robotic artns.

7.5.1.3 Section of Left Gastroepiploic Vessels

The dissection is then continued to the more distal short gastric vessels , which
are sectioned at their roots between bipolar coagulation and clips along with the
left gastroepiploic vessels . Lymph nodes of stations 4sb and 4d are removed .

7.5.1.4 Section of Right Gastroepiploic and Gastric Vessels

The right gastroepiploic vessels are dissected en bloc with lymphatic tissue.
Usually, prelinllnary exposure of the inferior pancreatic edge is a helpful trick in
order to avoid incorrect planes of dissection. A second landmark is represented
by the right colonic vein and the Henle 's venous tnlllk: following these ones, the
origin of right gastroepiploic vein is identified and sectioned between clips or
ligatures . After this, a wide vision is achieved and the right gastroepiploic artery
may be dissected safely and divided at its origin from the gastroduodenal artery.
Lymph node station 6 is removed en bloc with gastroepiploic vessels . In case of
py loric tumor or lymphatic metastatic disease in station 6 , the dissection is
extended at the nodes of station 14v (Fig. 7 .2a, b).
Finally, the pyloric vessels are identified and sectioned between clips or liga-
tures, removing the lymph nodes of station 5.

7.5.1.5 Duodenal Section

The duodenum is circumferentially dissected and transected about 2 cm distally
to the pylorus, using an endoscopic linear stapler. The staple line of the duode-
nal stump is not reinforced by oversewing sutures; some stitches are put in case
of bleeding.

7.5.1.6 Section of Left Gastric Vessels and Lymphadenectomy

The hepatogastric ligament is divided up to the right side of the cardia. The
hepatic hilum and COlllmon hepatic artery are exposed by the retraction of the
left lobe of the liver, using R3 .
The lymph nodes are dissected by hook cautery and bipolar forceps by remo-
ving, en bloc , the lymphatic stations along the proper hepatic artery (l2a), com-
mon hepatic artery (8a/p), celiac trunk (9), proximal splenic artery (lIp), and
origin of left gastric artery (7) (Fig. 7 .2c , d).
The left gastric artery is usually sectioned at its origin between a ligature
(proximal stump) and a clip; otherwise, it can be divided using a vascular sta-
pler. A left hepatic artery arising from the left gastric artery may be found in the
case of a gastrectomy. In the case of great size or in the absence of a left hepa-
tic artery originating from the common hepatic artery, it should be preserved: the
comlllon trunk of the left gastric artery is exposed, the gastric branches are divi-
7 Gastrectomy for Cancer 63

Fig. 7 .2 Lymph node dissection. a Station 6 . b Section of right gastroepiploic artery. c Retraction
of hepatic artery by vessel loop. d Station 7

ded and the nodes of station 7 are removed. The left gastric vein is divided bet-
ween clips or ties .
The gastropancreatic connective tissue is dissected up to esophagogastric
junction along the lesser curvature and the lymphatic nodes of station 1-3 (along
the right cardia and lesser curvature) are removed.

7.5.1 .7 Gastric Transection

Once lymphadenectomy is completed, the stomach is divided at its proximal
third by the assistant surgeon, using an articulated linear stapler. The specimen
(including stomach, omentum and lymphatic tissue) is placed into a large endo-
scopic bag and retrieved through a mini-laparotomy (perfomled on a suprapubic
site or enlarging a 12 mm port-site).

7.5.1.8 Reconstruction
The digestive continuity is restored by intra-corporeal gastrojejunal anastomosis
(GJA) on a Roux-en-Y jejunal loop. In elderly patients , a Billroth II GJA is usu-
ally preferred. In both cases, the jejunal loop is transposed with antecolic recon-
stmction .
A mechanical GJA is carried out with a side-to-side fashion , on the posterior
64 A.(oratti et al.

wall of the stomach, using a linear stapler. The gastroenterostomy is closed by

running absorbable suture . A hand-se"'n GJA is an interesting option in case of
difficult application of linear stapler, as in case of very small remnant gastric
fundus. Whichever technique is used, anastomosis is always tested by injection
of methylene blue via the gastric tube.
In the case of GJA on Roux-en-Y, the enteroenterostomy is perfonlled intra-
corporeally using a linear stapler, or extracorporeally through a left side mini-
laparotomy perfomled for the specimen retrieval. Finally, a drain is placed near
the duodenal stump .

7.5.2 Total Gastrectomy

The surgical steps are the same as for distal gastrectomy, except for the follo-
wing: division of the short gastric vessels and dissection along the gastro-sple-
nic ligament, extent of lymphadenectomy, restoring of the digestive continuity.

7.5.2.1 Section of Short Gastric Vessels

The gastrosplenic ligament is sectioned and all short gastric vessels are divided: the
hemostasis is ensured by clips and bipolar forceps (or advanced energy devices) .
The lymphatic station 4sa is removed and the gastric fundus is mobilized.

7.5.2.2 lymphadenectomy
In order to achieve a correct D2 lymphadenectomy, the dissection is extended
removing the nodes on the distal splenic artery (station lId) and the splenic
hilum (station 10); the spleen is preserved, unless there is massive lymphatic
metastasis of the hilum or direct infiltration of the organ.
The lymphatic dissection is enlarged to remove the nodes on the left side of
the cardia (station 2) .

7.5.2.3 Esophageal Transection

The distal esophagus is exposed to achieve a safe resection margin and a good
stump for the anastomosis. The cardia is closed with a loop and the distal esoph-
agus is divided by robotic scissors .

7.5.2.4 Reconstruction
A long Roux-en-Y is made extracorporeally through the left-side mini-laparoto-
my. The esophagojejunal anastomosis (EJA) can be fashioned both with a circu-
lar stapler or robot-assisted hand-sewing technique.
Up to a year ago, we mainly perfomled mechanical EJA. To fashion this anasto-
mosis, a purse string is carried out on the esophageal stump by robotic hand-
sewn technique; the anvil of a 25 nilll or 29 mm circular stapler is inserted into
the esophageal stump, and the purse string is closed (Fig. 7.3c, d). The circular
stapler is then inserted into the jejunal loop and introduced inside the abdomen
7 Gastrectomy for Cancer 6S

Fig. 7.3 Esophagojejunostomy. Hand-sewn end-to-side esophagojejunostomy (8, b); insertion of

the anvil into the esophageal stump and closure of the purse string (c, d)

through the left-side mini-laparotomy; it can be facilitated by the application to

the mini-laparotomy of a hand-port device . When the stapler is inside the abdo-
minal cavity and the pneumoperitoneum is re-established , the end-to-side EJA is
performed with standard laparoscopic control. The shimp of jejunal loop is clo-
sed by a linear stapler.
More recently, we have introduced a technique of hand-sewn end-to-side EJA
with Roux-en-Y reconstruction. After the division of the esophagus, the mucosa
is approached to the muscular layer of the proximal esophageal stump vvith absor-
bable 4.0 or 5.0 stitches. The EJA is then carried out with two 3.0 absorbable mn-
ning suhlres (posterior and anterior plane); in the case of a small esophageal
stump, the anterior suture is perfomled by intemlpted stitches (Fig. 7 .3a, b).
hi both techniques , the anastomosis is always tested by injecting methylene
blue via the gastric tube .
T",'o drains are placed near the duodenal shimp and the EJA, respectively.

7.6 Advantages, Limitations and Outcomes of Robotic

Gastrectomy

7.6.1 Technical Aspects

Robotic technology can overcome most of the drawbacks of conventional

laparoscopy. It provides the surgeon with an advanced system for viewing and
66 A.(oratti et al.

manipulation, and the physiologic tremor is eliminated using a computerized

mechanical interface. The magnified , three-dimensional, high-definition
vision and the stability of the camera platfonu make the robotic console simi-
lar to a surgical microscope, enhancing the skill of surgeons in perfomung dif-
ficult dissections and suturing techniques [6 , 7]. Articulate endoscopic instru-
ments provide seven degrees of freedom to reproduce the movements of the
human hand inside the abdominal cavity, with coaxial alignment of the eyes,
hands, and tool tip image [8]. Furthemlore , the robotic console reduces
ergononuc discomfort , enabling the surgeon to maintain a comfortable posi-
tion for many hours if needed. The intrinsic advantages of the da Vinci®
Surgical System can be helpful in making easier lymph node dissection and
intracorporeal anastomosis .
During a radical gastrectomy, the operating field ranges from the first jejunal
loop to the celiac trunk, or esophageal hiatus in cases of total gastrectomy. The
nature of this operating field (particularly in obese or long-limbed patients) can
require more accessory ports and a switch between camera and surgical tools to
optinuze the working conditions. In robotic surgery, it is possible to lift up the
abdominal vvall ("tent effect"') using the laparoscopic gasless procedure . This
simple maneuver, perfonued by the camera amI and 30° endoscope , provides
good vision even with low pressure of pneumoperitoneum, gains some degrees
in the angle of vision and provides an excellent vievv up to the celiac tnmk and
esophagealluatus [6].

7.6.2 D2-Lymphadenectomy

Since there is a risk of understaging of patients diagnosed with early gastric

cancer at preoperative workup, surgery with D2-lymphadenectomy is consid-
ered the optimal option for resectable gastric cancer, for the therapeutic role
as well as for the prognostic significance of the extended lymphadenectomy
[7]. This is also our opinion and part of the policy followed in our in clinical
practice .
It is widely accepted that D2 lymph node dissection is the more critical part
of the minimally invasive gastrectomy procedure for gastric cancer. Although
laparoscopic D2-lymphadenectomy is feasible and safe, with similar results to
the open technique in tenus of average nUluber of harvested lymph nodes and
postoperative outcomes, the diffusion of this procedure has beeniinlited to only
a few advanced MIS centers. The anatomic complexity of the vascular struc-
tures, the technical limits of the conventionallaparoscopic instnuuentation, and
the lack of a steady image, can make this procedure quite complex even for nun-
inlally invasive well-trained surgeons.
The technical advantages offered with robotic surgery can help to standard-
ize nunimally invasive D2-lymphadenectomy and enable surgeons to perfoml
this procedure routinely in their clinical practice [7].
7 Gastrectomy for Cancer 67

The robotic system makes easier the dissection of difficult lymphatic areas,
namely stations 7-12a and 14v, \"hich represent the "hot point" in conventional
laparoscopy.
The removal of station 14v is controversial. Originally part of the D2-lym-
phadenectomy for tumors of the lower third, this station has since been exclud-
ed in the latest edition of Japanese Classification. However, the removal of sta-
tion 14v can still be beneficial in cases of macroscopic metastasis of lymph
nodes in station 6. Furthermore, if dissection of the infrapyloric area is started
from station 14v, a good exposure of the pancreas can be obtained before
approaching station 6 . This technique can reduce the amount of mistakes of dis-
section plane, particularly in obese patients. Another difficult area to dissect is
the splenic hilum. By using the robotic system, the surgeon can perform a cor-
rect spleen-preserving dissection thus reducing the likelihood of mistakes of
plane and the risk of bleeding [6, 7,9].
Additionally, the enhanced three-dimensional vision and the high precision
of the robotic movements allo\\' an optimal identification of vascular anomalies,
such as an accessory left hepatic artery coming from the left gastric artery, and
pemuts the dissection of the lymphatic tissue surrounding the main tnlllk.

7.6.3 Oncological Safety

Given the short follow-up times, the numbers of harvested lymph nodes and the
resection margin are used as indicators of oncological adequacy. Most authors
report a mean number of nodes superior to 30 that are in-line with the recom-
mended standard for conventional open D2-lymphadenectomy. In their recent
meta-analysis including a total of 7200 patients (663 , RAG; 1236, LG; 5301,
open gastrectomy (OG», Hyun et al. [10] reported that the number of retrieved
lymph nodes with RAG was sinular to that for LG and OG, even with a subgroup
analysis matched for the extent of lymphadenectomy and type of gastrectomy.
Likewise, in the meta-analysis from Xiong et al. [3] , there were no differences
observed in the number of nodes retrieved between the RAG and LG procedures.
The majority of studies reported free resection margins at pathological exam-
ination in 100% of cases following RAG [7, 9]. This likely reflects an accurate
preoperative selection of cases, with prevalence for early versus advanced
stages. In our experience, intraoperative endoscopy can be useful to confiml the
location of the gastric lesion and to evaluate the adjacent mucosa.
Currently, there is no significant data available in terms of long-tenn onco-
logical results and survival in robotic gastric surgery. The longest follow-up to
date was reported by Pugliese et al. [11], with a mean observation of 53 months.
According to their data, there are not significant differences in 5-year survival
between LG and RAG.
MIS plays an important role in the therapeutic strategy for advanced disease
offering a less aggressive procedure that can help to reduce the time between
68 A.(oratti et al.

surgery and postoperative chemotherapy. Moreover, faster recovery can increase

the number of patients able to receive adjuvant chemotherapy. Some authors
reported that all histologically-proven N+ patients who underwent RAG, started
adjuvant treatment without any surgery-related delay within 30 days of surgery
[7]. In this context, RAG can play an important role in allowing the surgeon to
reproduce routine D2-lymphadenectomy, to perform complex resections at other
organs (including the pancreas, liver, and colon) and to provide precise minimal-
ly invasive reconstruction. Multicenter, randomized, controlled trials and long-
tenn follow-up evaluation are needed to definitively establish the oncological
adequacy of RAG .

7.6.4 Digestive Restoration

In several studies , it has been reported that digestive restoration was performed
extracorporeally through the same mini-laparotomy used for specimen removal
[9, 10] . This hybrid-open technique ..vas used both in gastrojejunostomy and gas-
troduodenostomy following distal gastrectomy, as vveU as in esophagojejunosto-
my following total gastrectomy. This approach is possible for patients with a
very low BMI, indeed the technique of extracorporeal anastomosis is primarily
used by Eastern surgeons. In cases with high BMI, it is very difficult to perfornl
an extracorporeal anastomosis, unless an incision larger than that for a mini-
laparotomy is used . Other disadvantages of extracorporeal anastomosis are the
lack of appropriate vision and the excessive traction put on the viscera, which
make the application of stapling devices potentially difficult and dangerous.
This is why other authors described an intracorporeal digestive restoration using
a linear stapler for GJA and a circular stapler for EJA [1, 7]. Extracorporeal
anastomosis may negate the potential mininlally invasive surgical approach ,
especially for obese patients, and the intracorporeal techniques appear to be the
preferred solution. The robotic system, moreover, pemlits full hand-sewn
C"robot-sewn") technique of anastomosis . All reconstructions, including Roux-
en-Y jejunal limb, EJA, GJA, or even gastroduodenal anastomosis, can be fully
carried out by the intracorporeal robot-sewn method.
In our present clinical practice we always perfonll intracorporeal anastomo-
sis : mechanical side-to-side GJA after distal gastrectomy, and hand-sewn end-to-
side EJA after total gastrectomy. The hand-sewn anastomosis is achievable
thanks to the ability of the robotic system to provide the surgeon with the nec-
essary tools to perform precise sutures even in deep and narrow spaces .

7.6.5 Perioperative Outcomes

7.6.5.1 Hospital Stay

Most studies reported similar results for postoperative short-tenn outcomes after
7 Gastrectomy for Cancer 69

RAG compared with LG: no differences were found in time to start mobilization
and time to resume diet [6, 10] . The hospital stay is shorter in patients undergo-
ing RAG than in those having LAG, but such a difference is not statistically sig-
nificant [3 , 8]. Hospital stay for RAG is significantly shorter than OG in all
series [10].

7.6.5.2 Operative Time

The mean operating time is commonly longer in robotic surgery than in conven-
tionallaparoscopy or open surgery. This finding has been reported as the most
consistent in the meta-analysis from Hyun et a1. [10] . Only one series, exclud-
ing the procedures completed during the initial RAG leaming period, reported a
similar operating time for RAG and LG (234 vs. 220 min) [4] . Robotic surgery
needs additional senlp procedures, including preparing and docking, which often
require less than 20 minutes [10 , 11]. Both setup tinle and operative time
decrease with the progressive experience of the surgical team [1, 4 , 7] .
Compared with LAG, robotic surgery increases the shift from extracorpore-
al to intracorporeal anastomosis , which is known to be a more consuming time
technique. Furthermore , robotic surgery is typically associated with a more
meticulous dissection than conventionallaparoscopy, particularly along the ves-
sels and during the lymphadenectomy [6].

7.6.5.3 Blood Loss

The robotic platfoml is very helpful in reducing blood loss even in major and
complex surgical procedures.
First , it is due to the fact that the robotic system allows an extremely accu-
rate dissection, especially in the case of extended lymphadenectomies.
Furthenuore , in the case of major bleeding by vascular injury the robotic control
of hemostasis is much easier than in conventionallaparoscopy. In this sinlation,
the surgeon has direct control of the vision and he can use three surgical tools
for clanlPing and sunlring . Moreover, the surgeon also has an assistant who
maintains the operating field clean using sponge , suction, and irrigation . It is
impossible to reproduce these same working conditions during conventional
laparoscopy [6] . The articulation of the endowrist permits free ligation and
suturing in the narrow abdominal cavity with few limitations in the movement
of the instruments [2]. In a comparative study among OG, LG, and RAG, Kim
et a1. [5] reported that the estimated blood loss in the robotic group was signifi-
cantly lower than in the open and laparoscopic groups. The same result was
reported in the meta-analysis from Xiong et a1. [3].
A perfect dissection and a better control of bleeding can result in a reduction
of perioperative transfusions and better long-term oncological results [6].

7.6.5.4 Complications
In their series of 5839 patients (4542 OG, 861 LAG and 436 RAG) , Kim and
colleagues [12] found that overall rates of complications , reoperation and mor-
70 A.(oratti et al.

tality were similar between the three groups. Postoperative ileus and intestinal
obstmction, as well as intra-abdominal fluid collections and abscesses , occurred
more frequently after open surgery, while anastomotic leakage was significant-
ly more conmlon after minimally invasive approach (LG, 2.1 %; RAG, 2.3% ;
OG , 1.1 %; P = 0·017). The authors hypothesized that the higher rate of leaks in
LG and RAG may be associated with the limited tactile feedback or differences
in staple-line reinforcement. Indeed, almost all anastomoses were made using
staplers and the staple lines were always reinforced by over-sewing sutures dur-
ing OG , vvhereas reinforcement was not perfonned in laparoscopic and robotic
procedures .
In the meta-analyses from Hyun [10] and Xiong [3], the complication rate
and mortality rate does not differ significantly between RAG , LG and OG.
Conversion to open surgery is critical because converted patients have high-
er complication rates and worse oncological outcomes. The conversion rate does
not differ significantly between LG and RAG [3] .

7.6.6 Cost Analysis

Improvements in technology and widespread multidisciplinary use could lead to

lower charges , but prompt reduction of costs in the near future is harder to
achieve and it is certainly a big limit . A shorter hospital stay for LG and RAG
compared vvith OG could offset the increased operation costs.
Anyway, a detailed analysis of cost is still lacking.

7.7 Conclusions

The most convincing indications for robotic surgery are procedures that involve
a small, deep, fixed operating field or where MIS requires extreme accuracy,
fine dissection and endoscopic suturing [1]. Therefore , the major technical
advantages of the robot-assistance in gastric surgery may be appreciated during
lymph node dissection , bleeding control, intracorporeal reconstmction, enlarged
resections and complex reconstmctions . Finally, the learning curve and repro-
ducibility of RAG seem to be shorter and more feasible than with conventional
laparoscopy.
For these reasons , robotics has the potential to contribute to a standardization
and major diffusion of MIS for the treatment of gastric cancer, making it a rOll-
tine approach even in advanced stages . Hence , RAG could better integrate min-
imally invasive resection with neoadjuvant and adjuvant multimodal therapies .
Longer operation tinIe , higher costs and oncologic equivalency to its coun-
terparts are still unresolved issues , which need further development and investi-
gation.
7 Gastrectomy for Cancer 71

References

I. Giulianotti PC. Coratti A.Angelini M et al (2003) Robotics in general surgery: personal ex-
perience in a large community hospital . Arch Surg 138:777-784
Hashizurne M. Sugimachi K (2003) Robot-assisted gastric surgery. Surg Coo North Am
83: 1429-1444
3. Xiong B. Ma L. Zhang C (2012) Robotic versus !aparoseopic gastrectomy for gastric cancer:
a meta-analysis of short outcomes. Surg Onco! 21 :274-280
4. Hyun MH. Lee CH. Kwon YI et al (2013) Robot versus laparoscopic gastrectomy for cancer
by an experienced surgeon: comparisons of surgery. complications. and surgical stress . Ann
Surg OncoI20:1258-1265
5. Kim MC. Heo GU. lung GI (2010) Robotic gastrectomy for gastric cancer: surgical techniques
and clinical merits. Surg Endose 24:610-615
6. Coratti A.Annecchiarico M . Di Marino M et al (2013) Robot-assisted gastrectomy for gas-
tric cancer: current status and technical considerations . World J Surg 37:2771-2781
7. D ' Annibale A . Pende V, Pemazza G et al (2011) Full robotic gastrectomy with extended (D2)
lymphadenectomy for gastric cancer: surgical technique and preliminary results . J Surg Res
166:e113-120
8. Marano A, Hyung WJ (2012) Robotic gastrectomy: the current state of the art . J Gastric Can-
cer 12:63-72
9. Song J, Oh SJ, Kang WH et al (2009) Robot-assisted gastrectomy with lymph node dissec-
tion for gastric cancer: lessons learned from an initial 100 consecutive procedures. Ann Surg
249:927-932
10. Hyun MH, Lee CH . Kim HJ et al (2013) Systematic review and meta-analysis of robotic sur-
gery compared with conventionallaparoseopic and open resections for gastric carcinoma. Br
J Surg 100: 1566-1578
11 . Pugliese R , Maggioni D. Sansonna F et al (2010) Subtotal gastrectomy with D2 dissection
by minimally invasive surgery for distal adenocarcinoma of the stomach: results and 5-year
survival. Surg Endose 24:2594-2602
12. Kim KM,An IY, Kim ill et al (2012) Major early complications following open. laparoseop-
ic and robotic gastrectomy. Br J Surg 99:1681-1687
Robotic Subtotal Gastrectomy:
a Modified Korean Technique
8
Giuseppe Spinoglio, Giampaolo Formisano, Ferruccio Ravazzoni,
Francesca Pagliardi, and Alessandra Marano

8.1 Procedure Overview

The robotic approach for the treatment of gastric cancer (GC) has been initial-
ly adopted mainly in Asia , where tIus malignant disease is more conlllon than
in Westen! countries and it is diagnosed at earlier stages thanks to a screening
program. Among Asian countries, South Korea started to embrace the robotic
technique in 2005 and now it has become one of the leading countries in robot-
ic gastric cancer surgery. In this chapter vl'e present our experience of robotic
subtotal gastrectomy (RSTG) with D2 lymph node (LN) dissection for GC
where the step-by-step procedure is based mostly on the technique of Dr Woo
Jin Hyung [1].

8.2 Patient and Robot Positioning

The patient is secured in the supine position with both anns alongside the body
and the legs are closed; a nasogastric tube is inserted during the anesthesiolo-
gist's preparation. The table is then placed in a 15° reverse-Trendelenburg
position. The surgical cart is placed at the head side of the patient, the 1ll00utor
to the right side of the patient and the assistant stands to the left of the table
(Fig . 8.Ia) .

G_ Spinoglio ( i8l)
Department of General and Oncologic Surgery,
" Ss _Antonio e Biagio" Hospital,
Alessandria , Italy
e-mail: giuseppe _spinoglio@gmaiLcom

G _Spinoglio (Ed) , Robotic Surgery: C/lrrelll Applications and Nell' Trends, 73

Updates in Surgery
DOl: 10.1007/978-88-470-5714-2_8, © Springer-Verlag Italia 2015
74 G. Spinoglio et al.

. <D
/ 00
<D . 0
•
Camen
Assistant

<,\)\.. SU{

/
!Q.
~
~ ~ ~
~

Fig. 8.1 Subtotal gastrectomy. a Overhead view of the OR setup. b Trocar layout . (02014 Intui-
tive Surgical, Inc .)

8.3 Trocar Placement

A 12 nIDIHg pneumoperitoneum is achieved with a small incision at Palmer's

point in the left upper quadrant and a infraumbilical 12-I1IDI camera port, for the
30° down scope is introduced.
Under direct visualization. trocars are inserted as follows (Fig . 8.lb):
• one 8 nun robotic trocar (ann No.1 : Rl) 1 cm below the costal angle , as far
lateral as possible on the patient's left side, for the bipolar forceps, Hot
ShearsT)I (monopolar curved scissors), large needle driver, Hem-o-Iok® clip
applier. Port should be 1 cm above the level of the bowel when viewed inter-
nally from the scope;
• one 8 I1IDI robotic trocar (ann No.2: R2) 2-4 Col superior to wnbilicus, at the same
distance between the Instmment R3 and the canlera port, for the ultrasonic shears;
• one 8 mlll robotic trocar (ann No . 3: R3) 1 cm below the costal angle , as far
lateral as possible on the patient 's right side , for the ProGraspni forceps
(altematively Cadiere forceps). Port should be 1 cm above the level of the
bowel when viewed intemally from the scope;
• one 12 11Ull assistant's trocar, 1 cm superior to umbilicus, at the same dis-
tance between and 1-2 cm below a diagonal line from Instmment Rl and the
camera port on patient's left side, for suction/irrigation, clip/stapler applica-
tion or other maneuvers.
Rl and R2 trocar placement can be subject to minor adjustments according
to the patient's body habitus, for instance in the case of larger patients, both tro-
car should be placed more medially and the R2 trocar should be higher in order
8 Robotic Subtotal Gastrectomy:a Modified Korean Technique 7S

to achieve the correct angle with the ultrasonic shears to perfonn a complete LN
dissection of station No . Up.

8.4 Step-by-Step Review of Critical Elements of the

Procedure

8.4.1 Exploration, Liver Retraction and Tumor Detection

After the laparoscopic exploration of the abdominal cavity to exclude the pres-
ence of metastatic disease, the left lobe of the liver is retracted toward the
abdominal wall with a liver- suspension method [2].
The teclmique requires: two X-ray-detectable 5 x 5 cm gauze pads, one
90 cm 2-0 nylon monofilament with a 60 oml double straight taper needle and
two plastic surgical clips (Hem-o-lokQt, Weck; Teleflex Medical Europe Ltd) .
The gauze pads are folded in half, threaded VI'ith the 2-0 nylon suture, then both
straight needles, with the attached suture-threaded gauze pads, are introduced
into the abdominal cavity through the assistant's port .
One of the straight needles is brought out through the anterior abdominal wall,
directly anterior to the middle of the left lobe of the liver.
The nylon suture is then secured to the pars condensa of the hepatogastric liga-
ment with two Hem-o-Iok® clips, after having divided the pars flaccida up to the
right of the esophageal cms. The other straight needle is passed extemally through
the abdominal wall immediately to the right of the falcifornl ligament. While the
assistant slowly pulls upward on the two sutures, the two gauze pads are brought
together and stretched to cover the undersurface of the retracted liver. Finally, the
two external sutures are tied together to rest on the external abdominal wall.
Originally, in the case of small or undetectable GC, portable plain radiogra-
phy was perfornled to identify endoscopic metallic clips, applied just proximal
to the tumor, during the preoperative upper endoscopy [3] . Actually, we use an
ultrasound evaluation with a curved linear probe (ProARTTM Robotic
Transducer), which is introduced into the abdominal cavity through the assistant
port. Once the tumor location is identified, the patient-side cart is moved next to
the patient and the robot is docked, as previously described .

8.4.2 Left and Right Gastroepiploic Vessels Division

An omentectomy is perfonned using ultrasonic shears (R2) toward the lower pole
of the spleen where the left gastroepiploic vessels are sectioned at their roots.
Once entered into the lesser sac, coloepiploic detachment is continued toward the
pyloms and the right gastroepiploic vessels are identified and ligated with clips
(LN station No. 4sb, No. 4d). The dissection proceeds along the gastroduodenal
artery to where it springs from the common hepatic artery (CHA).
76 G. Spinoglio et al.

FIg. 8.2 Complete dissection oflymph node No. 12a around proper hepatic artery (PHA). The me-
dial side of portal vein (P V) is pictured

8.4.3 Hepatoduodenal Ligament Dissection and Duodenal

Transection

The lesser omentum is dissected and the right gastric artery is identified and
divided betvveen clips at its origin. The supra- and infrapyloric nodes (LN sta-
tion No. 5, No.6) are removed: in the case of a suspected metastatic LN at sta-
tion No. 6 , the dissection of LN station No. 14v might be of benefit to the
patient. The duodenum, after being circumferentially cleared, is transected 2 cm
distal to the pyloms using a 45 mm Endo-linear stapler inserted through the
assistant port . The removal of LN station No. 12a is then carried out (Fig. 8.2) .

8.4.4 Lymphadenectomy of the Supra pancreatic Area and Left

Gastric Artery Ligation

The dissection continues by ablation with ultrasonic shears of LN station No. 8a (Fig.
8.3) and No. 9; during this step the left gastric vein is exposed and divided. Then, the
left gastric artery is carefully transected at its root with clips and the soft tissues
around it are retrieved for LN station No.7 (Fig. 8.4). The splenic vessels are [wally
skeletonized with the removal of LN No. IIp.

8.4.5 Lesser Curvature Dissection and Proximal Gastric Resection

The retroperitoneal detachment of the stomach is completed along the lesser cur-
vature up to the right esophageal cms together with the retrieval of LN station
No . 3 and No. 1. Once the mobilization of the stomach is completed , the resec-
8 Robotic Subtotal Gastrectomy:a Modified Korean Technique 77

Fig. 8.3 Complete dissection of lymph node No. 8a around common hepatic artery (CHA). GOA,
gastroduodenal artery; RGA, right gastric artery

Fig, 8.4 Clipping of the left gastric artery (LGA) with removal of lymph nodes Nos . 7 and 9 . CHA,
common hepatic artery

tion is performed by the assistant using a 60 mm Endolinear stapler; the speci-

men is bagged intracorporeally and is placed on the right lobe of the liver.

8.4.6 Reconstruction

After the transection, a gastrotomy on the posterior wall of the stomach and then an
enterotomy 15-20 cm away from the Treitz ligament are perfomled by means of
ultrasonic dissection. A gastrojejunostomy is perfomled intracorporeally, using a
60 nUll Endolinear stapler; the COnltllOn entry hole for the anastomosis is closed
with interrupted 3/0 PDS sutures. The robot is undocked; a suction drain is posi-
78 G. Spinoglio et al.

tioned close to the duodenal stump and finally the specimen is removed through a
Pfannenstiel incision. The nasogastric tube is left in place and removed on POD I .

8.5 Advantages

The main advantages of our technique are described as follows:

• Use of ultrasonic shears in R2: even if this device is nonv.·risted compared
to other available robotic instruments and is generally controlled by the non-
dominant left hand of the surgeon, we believe that this technical difference
provides some potential advantages mainly during LN dissection including
station Nos. 6, 14v, 8a, 9, 7, 12a, and IIp .
The infrapyloric area and superior mesenteric vein (LN No. 6 and LN No. 14v)
are considered the 1110st frequent source of bleeding during surgery while the
suprapancreatic lymphatic tissues (LN station Nos . 8a, 9 , 7) are the second [4].
The dissection conducted with the ultrasonic shears around LN station No.6 ,
No. 12 and along the CRA from the right to the left-side of the patient is more
inttlitive and makes the lymphadenectomy better to be inlplemented. An ade-
quate hemostasis is also achieved, especially in advanced GC stages.
Indeed, during this phase , a good dissection plane can be followed along the
CHA: the ultrasonic shears , controlled by the surgeon's left hand , reach the
target anatomy tangentially from the patient's right side with a parallelism
between the instrument tip and the vessel.
An appropriate tension is provided by the instrument in R3, grasping the lymphat-
ic tissue and the dissection continues with the ultrasonic shears in R2: its mobil-
ity is not limited by the pancreatic head and body thanks to its working angle.
For LN station No. IIp, a dissection carried out in the aforementioned way
aids the surgeon to perform a more accurate LN removal and vessels dissec-
tion , minimizing the intraoperative bleeding .
• Liver retraction: utilizing a 2/0 prolene suture and a gauze pad as a "sling"
is a way to achieve complete exposure of the anterior surface of the hepato-
gastric ligament .
The instrument in R3, free for dynanlic use, can grasp and lift up the lym-
phatic tissue while the dissection of LN No . 8 and No. 12 is carried out by
instnuuents in RI and R2. The assistant port is also available for additional
maneuvers .
• Intraoperative identification of transection line: in the case of small or
undetectable GC , in order to avoid an intraoperative endoscopy, metal clips
are placed on the greater and lesser gastric curvature to delineate the location
of the transection when coordinated with the intemal clips placed via preop-
erative endoscopy. Originally, we used to perform this double check with an
intraoperative plain radiography; acttlally, we employ an intraoperative ultra-
sound assessment with a dedicated probe to detect the lesion, previously
marked with clips .
8 Robotic Subtotal Gastrectomy:a Modified Korean Technique 79

8.6 Personal Experience

From March 2011 to April 2014, 26 patients affected by histologically-proven early

and advanced GC, located in the distal stomach, lUlderwent RSTG \vith Dl-D2Iym-
phadenectomy. according to the recommendations of the Japanese Gastric Treatment
Guidelines and Classification [5-7]. All surgeries have been perfomled with the da
Vinci~' Si lID Surgical System. The pathologic stage classification of the tumor was
worked out according to AJCC Cancer Staging Manual-Seventh Edition [8].
All patient characteristics and perioperative outcomes are shown in Table
8.1. The console time averaged 190.3 ± 48.9 minutes (range : 150-350 minutes) .

Table 8.1 Experience of our Institution of Robotic Subtotal Gastrectomy for Cancer
Variable G group (0=26)
Age (Y). meoll ± D 67 .7 ± 10.6
Gender ( :J/F) n (%) 1719
BMI k glm 2), meall ± D 24 ± 3.8
o-morbidit ,II (%)
HypenensioniCOPD/CAOD/ 7 (_6.9)/3 (11.5)/2 (7.6)/
CVDlHistory of previous rumorJOther* 2 (7 .6)/2 (7 .6)/3 (115)
A score, II (%)
IIIIIIII 6 (23.1)/14 (53 .8)/6 (23.1)
Extent of lymph-node Iii tion , II (%)
DIID2 2 (7.6)/24 (92.3)
onsole tim e (min), meall ± D 190.3 ± 48.9
Intraoperati ve complications, II (%) 0(0)
iquid diet Illrt day), meall ± SD 2.9 ± l.6
Ho pital stay (days, meoll ± D 92 ±2.9
omplicalions 11(%)
onelPresent 19 (73.1)n (26 .9)
Hyperamylasemia/Prolonged ileus! Pu.eumonia 1 (3.8)12 (7 .6)/4 (15.3)
Thmor location , II (%)
middle third/lower third 7 (26.9)/19 (73 .1)
Hi tology t pe, n (%)
intestinal/diffuse/mixed type 11 (42.3)n (26.9)/8 (30.7)
Grading, TI (%)O/1I213 2 (7 .6)/3 (11.5)110 (38 .4)111 (423)
AJ C tage, II (%)
0/ W m/ ITA! lIB/ mAl IIIB 2 (7 .6)/4 (15.4)/4 (15 .4)/1 (3 .8)/5
(19 2 )13 (1l5)n (26.9)
egatiYe proximal margin, II (%) 26 (100)
umber of r trieved L , mean ± D 295 ± 12.6
GC, gastric cancer; 8MI, body mass index; COPD, chronic obstructive pulmonary disease;
CAOD, coronary artery obsbUctive disease; CVD, cerebrovascular disease; LN, lymph nodes.
*Other, co-morbidity includes inflammatory bowel disease , diabetes and lithiasis of gallbladder
80 G. Spinoglio et al.

No intraoperative complications were observed; we registered one case of con-

version (conversion rate 3.8%) due to a suspected infiltration of the diaphrag-
matic pillars.
Except for special contraindications , aU patients VI'ere managed according to
our fast track protocol: after a contrast swallow on postoperative day one , liquid
diet was started (mean ± SD, 2.9 ± 1.6 days) and the mean hospital stay was
9.2 ± 2.9 days. One ASA ill patient, affected by atherosclerotic cardiovascular
disease , died on postoperative day 12 as a result of a myocardial infarction
(3 .8% mortality) . Early postoperative complications occurred in 7 out of 26
(morbidity 26.9%): transient asymptomatic hyperamylasemia (1500 UIImL) ,
pneumonia, prolonged ileus occurred in one, two and four patients, respectively
and were all medically treated. The 30-day readmission rate was 11.5%: three
patients presented with abdominal fluid collection and so underwent ultrasound-
guided drainage with complete remission.
A Dl-Iymphadenectomy was performed in two cases of early GC (7 .7%);
D2-lymphadenectomy was carried out in all the other stages (92.3%). The mean
number of retrieved LN s was 29.5 ± 12 .6. Proximal resection margins were
tumor-free in all patients (100%). The mean follow-up time was 25 ± 10.8
months (range: 1-38 months) and was conducted on 22 out of 25 patients.

References
I. Hyung W, Woo Y, Noh S (2011) Robotic surgery for gastric cancer: a technical review. Jour-
nal of Robotic Surgery 5:241-249
2. Woo y , Obama K, Son TI et al (20 II) Minimizing hepatic trauma with a novel liver retrac-
tion method during robotic and laparoscopic gastric cancer surgery, a simple liver-suspension
with gauze-suture technique . Int J Med Robotics ComputAssist Surg 7:56
3. Kim HI , Hyung WJ , Lee CR et al (2011) Intraoperative portable abdominal radiograph for
tumor localization: a simple and accurate method for laparoscopic gastrectomy. Surg Endosc
25:958-963
4. Kim MC, Heo GU, Jung GJ (2010) Robotic gastrectomy for gastric cancer surgical techniques
and clinical merits . Surg Endosc 24:610-615
5. Japanese Gastric Cancer Association (1998) Japanese classification of gastric carcinoma - 2nd
English edition. Gastric Cancer 1: 10-24
6. Japanese Gastric Cancer Association (2011) Japanese classification of gastric carcinoma: 3rd
English edition. Gastric Cancer 14:101-112
7. Japanese Gastric Cancer Association (2011) Japanese gastric cancer treatment guidelines
2010 (ver. 3). Gastric Cancer 14: 113-123
8. Edge S8, Compton CC (2010) The American Joint Committee on Cancer: the 7th edition of
theAJCC cancer staging manual and the future ofTNM.Ann Surg OncoI17:1471-l474
 Part III
Hepatob iI iopa nc reatic Su rgery
Hepatic Resections
9
Alberto Patriti, Graziano Ceccarelli, and Luciano Casciola

9.1 Procedure Overview

Minimally invasive surgery of the liver (MIS) is growing worldwide . As many

as 1677 minimally invasive liver resections were reported in Italy between 1
January 1995 and 28 Febmary 2012 [1]. Meanwhile , the interest in robot-assist-
ed liver resections (RALR) is rising.
The indications for MIS are similar to those for open liver resections as
recently stated in the Louisville Statement Consensus Conference .
Laparoscopic liver resections (LLR) were initially indicated for benign and
peripherally located lesions [2] . In the last few years the number of laparoscop-
ic complex liver resections has increased and even major hepatectomies and
segmentectomies of the postero-superior (P-S) segments have been successful-
ly performed [3]. Recently, robotics has been introduced in general surgery with
the aim to overcome some of the linutations of traditional laparoscopy provid-
ing a greater maneuverability with a set of articulated instmments and a tri-
dimensional vision. Since the first reports in 2008, a lot of case series and com-
parative studies were published showing the feasibility of robot-assisted nunor
and major liver resections. Potential advantages of robot-assistance include
facilitating complex reconstmctions (i.e. , biliary and vascular anastomoses) and
parenchyma-preserving resections of lesions located in P-S segments .
Giulianotti et al . have demonstrated that robot-assisted major hepatectonues are
safe and feasible even vvhen a biliary reconstmction is required , such as in case
of hilar cholangiocarcinoma [4] . In a recent study by our institution we showed

A. Patriti (183)
Department of Surgery Division of General, Minimally Invasive, and Robotic Surgery,
"San Matteo degli Infermi" Hospital , Spoleto (PG)
e-mail: albertopatriti@gmail .com

G . Spinoglio (Ed) , Robotic Surgery: C/lrrelll Applications and Nell' Trends. 83

Updates in Surgery
DOl: 1O.l007/978-88-470-5714-2_9, © Springer-Verlag Italia 2015
84 A. Patriti et al.

the possibility given by the robot to preserve liver parenchyma even in the case
of tumor location in the P-S segments or close to a major liver vessel [5] . In the
present chapter, technical details of robot-assisted liver resection will be provid-
ed along vvith a discussion on the current clinical applications of robotics in
hepatobiliary surgery.

9.2 Operating Room Setup, Patient and Trocar Positioning

Robot docking and patient position are of paramount importance to easily

approach all the liver segments. When approaching anterior segments, segment
I (Spiegel lobe) and major hepatectomies a reversed Trendelenburg supine
patient position is Optinlal. The patient can be tilted to the left or to the right
according to the site of the helllihepatectolllY. The on-table surgeon stands
between the legs and the scmb nurse and instmlllents are positioned lateral to the
left leg. The trocars are generally positioned along a bowl-shaped line passing
through the umbilicus .
For parenchyma-preserving resections of lesions located in the right postero-
lateral sector (upper segment 6 and segment 7) , the patient is rotated on the left
flank in order to facilitate liver mobilization and inferior vena cava dissection.
The camera port and the left-sided trocars should be placed as close as possible
to the right costal margin , whereas the right trocar can be inserted in the inter-
costal space between the 10th and 11 th rib close to the scapular line . At this level
the risk to accidentally injury the lung is very low and a direct access to the pos-
tero-Iateral segments is provided.
For bilobar liver metastases vvith involvement of both anterior segments
and S7-8, t'""O options are equally effective: re-docking the robot and chang-
ing patient position according to the tumor location; and using a semi-left lat-
eral patient position with the robot over the patient head . The latter is preferred
in our institution since it does not require robot re-docking and changes of
patient position during surgery which can cause possible contamination of the
surgical field.

9.3 Ultrasound Exploration

Ultrasound exploration follows the same general mles of traditionallaparoscop-

ic liver surgery. The typical frequency range adopted for LIOUS is 5-10 MHz.
Access for the US probe to the peritoneal cavity is achieved through 10 or
11 llUll ports , which are usually the same ports used by the on-table surgeon for
suction/irrigation and retraction. The supramesocolic space is instilled with
saline solution until the space between the liver dome and the right diaphragm
is completely filled in order to better explore the bare area of S7-8 and the hepa-
9 Hepatic Resections 85

tocaval confluence. A first ultrasound exploration of the liver is performed

before the robot is docked , and any other maneuver on the liver has been per-
fomled, to avoid artifacts. This first exploration is intended to allow the surgical
staff to acquire a clear three-dimensional picture of liver vascular anatomy and
lesion location. The examination is usually performed by contact scanning using
the liquid film on the glissonian surface as a coupling agent. The hepatocaval
confluence is usually visualized with the probe introduced through a right port
and placed on S4a. Moving the probe between the diaphragm and the liver
dome , the right hepatic vein is then identified . Portal bifurcation and right hepat-
ic pedicles are visualized by positioning the transducer on S4b and moving it to
the right side . The left portal pedicles and left hepatic vein are better identified
from the left upper quadrant. Using the linear probe, exploration of the diaphrag-
matic margins of S7-8 is carried out placing the probe on the water surface cre-
ated in the right sub-diaphragmatic area. Finally, the transection plane is out-
lined on the liver capsule with monopolar diathermy. When the robot is docked
and resection begins , a continuous and meticulous ultrasound assessment of the
transection margin is imperative due to the lack of tactile feedback .

9.4 Basic Maneuvers of Liver Surgery

9.4.1 The Pringle Maneuver and the Inflow Control

The Pringle maneuver is the easier and safer way to control the inflow but its use
in laparoscopic surgery has been neglected for years. An ideal system for laparo-
scopic Pringle maneuver should be cost-effective , as user-friendly as to pemnt
intermittent inflow occlusion during parenchymal transection and guarantee a
fast vascular control in case of bleeding . The device for inflov.·· occlusion set in
our institution is composed of a 20 Fr chest tube, an umbilical tape and a plug
used for occlusion of the Foley catheter [6] .
The chest tube is inserted in the right upper abdominal quadrant and the
umbilical tape is passed around the hepatoduodenal ligament with the use of
an endowristed Cadiere forceps (Intuitive Surgical Inc ., Sunnyvale , CA) or an
articulated laparoscopic device (Endoflex) . The umbilical tape is then exteri-
orized through the chest tube with the use of a 5-n1111 laparoscopic forceps. The
chest tube is finally closed with the plug in order to avoid air loss . When
inflow occlusion is needed the on-table surgeon removes the plug and pulls the
umbilical tape . When the desired tape tension is achieved , the chest tube is
closed with the plug.
For major hepatectomies individual dissection and control of portal and arte-
rial pedicles is possible and greatly facilitated by endowristed instruments.
Dissection is carried out as in open surgery with scissors or hook and a bipolar
forceps (Fig . 9.1) .
86 A. Patriti et al.

Fig. 9.1 Hilar dissection for right hepatectomy. The right portal vein is encircled and exposed

9.4.2 Parenchymal Transection

T\\'o robotic devices are available for parenchymal transection. The Kelly
clamp-cmshing technique associated with an intemuttent Pringle maneuver is
considered the safer and more accurate method of parenchymal transection in
open liver surgery. The major advantages of the Kelly clamp-cmshing tech-
nique are the low costs and the ability to fragment the parenchyma, preserving
the vascular stmctures that can be ligated and divided or preserving according
to the resection plan . Using the endowristed PreCise™ bipolar forceps (Intuitive
Surgical Systems, Sunnyvale , CA , USA) the parenchyma can be easily frag-
mented exposing the inner vessels as in open surgery. The on-table surgeon
uses the forceps to perfonn the intermittent inflow occlusion, thereby allowing
the console surgeon to focus luslher attention only on the transection line . The
robotic clamp-cmshing technique allows parenchymal preservation even for
deeply located lesions, widening the indications for a minimally invasive
approach to lesions in the P-S segments and those located close to major liver
vessels. Hemostasis of small vessels is obtained with monopolar or bipolar
cautery. To secure larger vessels on the transection line, we use Hem-o-Iock®
clips or ligatures with Vicryl® and Prolene® . The hepatic veins (HVs) are usu-
ally divided with the laparoscopic linear stapler or sutured with Prolene® .
Biliostasis is assessed by observation and the bile leaks controlled with sutures
as in open surgery.
The hamlonic scalpel is the other device used to transect the liver. It can be
used to cut and coagulate the liver or, by taking advantage of ultrasonic dissec-
tion , using it to fragment the liver parenchyma exposing the underlying vessels.
The only drawback of this device is related to its four degrees of freedom mak-
ing it ideal for straight-line resections (left and right hepatectomies) but less
effective for parenchyma-preserving resections.
9 Hepatic Resections 87

9.4.3 Liver Retraction

For resections on anterior segments, left lateral sectionectomy included, some stay
sutures can be useful to retract the specimen using the fourth robotic ann or the
assistant grasper. A vessel-loop held by the fourth amI around the left lobe can be
used to stretch the parenchyma along the transection plane thus facilitating the
effect of the Kelly clamp-cmshing technique. For deeply located lesions or when
the tumor is close to a major vessel the "corkscrew technique" can be reproduced.
After identification of the lesion by inspection and intraoperative ultrasound,
Glisson's capsule is marked with electrocautery 1-2 cm away from the tumor mar-
gin. According to the location of the tumor the marked area is anchored by stitch-
es, with caution, in order to prevent the needle from entering the tumor. The suture
is held together by clips and upward traction is perfonned, facilitating the transec-
tion of the parenchyma and correct identification of vascular and biliary stmctures.
Parenchymal transection is perfonned with the monopolar shears for the first liver
layer (1 cm from the Glisson capsule) and then "vith the Kelly clamp-cmshing tech-
nique . For steady exposure of the parenchymal transection plane in major hepatec-
tomies, the "mbber band technique" can be used. Two sterile mbber bands are
introduced into the abdominal cavity. One end of each mbber band is anchored with
stay sutures at the right and left resection margins . The other end is pulled outside
using an EndoClose needle and fixed with appropriate tension.

9.5 Step-by-Step Review of Critical Elements of

Hemihepatectomies and Bisegmentectomies

9.S.1 Right Hepatectomy

The patient is placed in mild reverse Trendelenburg position, with semi-left lat-
eral decubihls and spread legs . The pneumoperitoneum is made using a Veress
needle in the left upper quadrant, maintaining a pressure of 12 mmHg . Four tro-
cars are placed for the robot, one in the right pararectal for the camera, two
8 mm trocars in the right flank and left pararectal, and another 8-nlll trocar for
the fourth arm in the left flank . Two additional lO-nl1ll trocars are inserted to be
used by the assistant (Fig. 9.2a). The OR setup in shown in Fig. 9.2b.
Cholecystectomy is completed and the hepatic hilum is dissected using the
monopolar hook in the right antI of the robot, and the bipolar forceps in the left.
The right hepatic artery is the first element to be sectioned between ligahues or
Hem-o-lock~' clips. The right portal vein is exposed , looped and sectioned
between Hem-o-lock® clips or 5-0 polypropylene suhlre .
The dissection and evaluation of the biliary tree requires special attention
because sectioning will be made either at this time or later during the procedure,
depending upon the location of the biliary bifurcation. Recent visualization tech-
nology with ICG (Indocyanine Green) fluorescence enables the evaluation of the
 A. Patriti et al.

FIg. 9.2 a Trocar disposition for right hepatectomy. b OR setup for right and left hepatectomy.
For left hepatectomy arm 3 is positioned on the opposite side . (© 2014 Intuitive Surgical, Inc .)

extrahepatic biliary tree without requiring any invasive procedure; this is due to
the physical characteristics of ICG , which allows for unique hepatic metabolism
and biliary excretion (Fig. 9.3) . The right liver is retracted to the left using the
fourth arm. The first step is to section the right triangular ligament, using the
hook. The liver is gently retracted to the left while dissection proceeds to the
bare area of the liver. At this point, the space behveen the vena cava and the liver
is dissected in a caudal-to-cephalad direction, sectioning between Hem-o-lock®
clips the accessory veins to segments 6 and 7. For a better hemostasis,
polypropylene 5-0 sutures can be applied on the side of the vena cava. A hepa-
tocaval dissection is then made up to the drainage of the RHV.
The ischemic delineation of the transection along Cantlie's line is marked
following the section of the vascular vessels of the right liver. The monopolar
hook can be used to mark this line and open the capsule of Glisson, although it
is not mandatory. Prior to starting the transection , two stay sutures at the tran-
section margins can be used for a better retraction. The transection is performed
using the hannonic scalpel , closing gradually as ultrasonic energy is applied.
The transection is performed in a caudal-to-cephalad direction. Once the vascu-
lar branches are crossing between right and left liver lobes, they are ligated or
secured with Hem-o-lock® clips. The surgical specimen is then extracted in an
endoscopic plastic bag , through a Pfannenstiel incision. The surgical hemostasis
and the trocars ' orifices are again evaluated and two closed Jackson-Pratt drains
are left in place.
9 Hepatic Resections 89

Fig. 9.3 leG fluorescence highlighting the extrahepatic biliary tree during a right hepatectomy

Fig. 9.4 Trocar disposition for left hepatecto-

./
my and left lateral sectionectomy. (© 2014
Intuitive Surgical. Inc.)

00
• •
o Camera Assi~ant
AssIstant

9.5.2 Left Hepatectomy

The patient is placed in mild reverse Trendelenburg position, vvith semi-right lateral
decubitus and with spread legs. Patient's anus are either tucked along the body to
avoid collision with robotic anus. The assistant stands in between the patient's legs.
The robot is docked directly over the head of the patient with two operating
amlS on the patient's right side.
A total of 5-6 ports are placed, replacing the specular shape of the trocar dis-
position of the right hepatectomy. Pneumoperitoneum is maintained at 12 mmHg
(Fig . 9 .4) .
Surgery starts with visual exploration of the abdomen, followed by contact
ultrasonography of the liver. As soon as resectability is confirmed, the left lobe
90 A. Patriti et al.

is freed from its surrounding peritoneal and diaphragmatic attachments . Next ,

the hepatoduodenalligament is exposed by retracting upward and cephalad , the
gallbladder is grasped with Cadiere forceps driven by robotic ann 3. Left hepat-
ic artery and portal vein are dissected and divided between ligatures, as previ-
ously described. After vascular isolation of the portal triad supplying the left
hepatic lobe, a vascular demarcation along the parenchymal transection plane
becomes evident.
Parenchymal transection is carried out using bipolar forceps or the harmon-
ic scalpel and monopolar curved scissors . During tllls phase , Cadiere forceps in
robotic arm 3 may be used to retract the specinlen, to allow optimal alignment
of the transection line \vith robotic scissors , or to control hemorrhage on the
remnant by compression.
HV s are sealed and divided intraparenchymally using an endoscopic stapler
arrned with a vascular cartridge. The stapler is usually inserted through the 12
mlll assistant's port since the alignment between the device and the target hepat-
ic vein is usually optimal
The specinlen is removed in an endoscopic bag through a Pfannestiel incision .
Before completing the operation the raw surface of the liver is carefully inspect-
ed . Bile leaks and bleeding sites are individually sealed by suture ligature. Two
closed Jackson-Pratt drains are placed near the transection surface of the liver.

9.5.3 Left Lateral Sectionectomy

The patient is placed in mild reverse Trendelenburg position, with right lateral
decubitus and with spread legs . Patient"s arms are either tucked along the body
to avoid collision \vith robotic anus. The assistant stands in between the
patient's legs. The robot is docked directly over the head of the patient. Trocar
disposition is the same as that used for left hepatectomy (Fig. 9.4) . We general-
ly encircle the liver pedicle for the Pringle maneuver in case of bleeding . A 2-0
stay suture is passed at the inferior border of segment 3 to retract the left later-
al section to the left. The Rex fossa is therefore exposed. The fa1cifonnligament
is transected sparing the round ligament. After opening of the bare area of the
hepatocaval confluence, the anterior and posterior layer of the left triangular lig-
anlent are sectioned with monopolar hook or scissors . Retracting the left lateral
section to the left allows the pedicle of segment 3 (P3) to be identified.
Sometimes a small bridge of parenchyma has to be separated before reaching the
pedicle (the so called hepatic bridge) . Liver transection is carried out with bipo-
lar forceps in the left hand and a mono polar scissor in the right hand.
Transection starts 5 mm to the left of the falcifonu ligament. The first portion of
liver parenchyma is transected to allow a complete exposition of P3. The small
arteries to S3 are identified and ligated with titanium clips or coagulated with
bipolar forceps. P3 is finally encircled using the bipolar forceps and secured
vvith Hem-o-lock® clips. After its transection parenchymal division is continued
9 Hepatic Resections 91

till reaching the portal pedicle of segment 2 (P2), which is clipped and divided
in the same way. The LHV is finally secured and divided "'ith a single fire of an
endovascular stapler. The specimen can be extracted through the umbilicus or a
Pfannenstiel incision. Two closed suction Jackson-Pratt drains are placed near
the transection surface of the liver.

9.6 Step-by-Step Review of Critical Elements of

Segmentectomies and Sub-segmentectomies

For segmentectomies and sub-segmentectomies, the patient positioning and tro-

car placement should be individualized according to the tumor location.
Pneumoperitoneum induction with the Verres needle can help to tailor trocar
position limiting the use of an umbilical port to the cases where it is really nec-
essary. Anatomical and nonanatomical liver resections of peripheral (segments
2,3 , 4b, 5, 6), superficial lesions is generally feasible and can be done with min-
imal morbidity and mortality rates . Pedicle clamping is optional or can be
applied only in the case of bleeding and liver division can be perfomled with all
the available transection devices. Generally three to fonr trocars disposed at the
level of the umbilical line are adequate . For lesions located in the postero-later-
al sector (upper segment 6, segments 7 and 8) the patient is rotated on the left
flank in order to facilitate liver mobilization and inferior vena cava dissection,
when necessary. The camera port and the left-sided trocars should be placed as
close as possible to the right costal margin, whereas the right trocar can be
inserted in the intercostal space between the 10th and 11 tb rib along the scapular
line (Fig. 9.5). Due to the higher risk of bleeding, intemlittent pedicle clamping

I Fig. 9.5 Trocar layout for segments 7 and 8.

(j)
I <D.
The patient is tilted on the left flank and the
right robotic trocar in inserted between the
10th and 11th rib. (© 2014 Inruitive Surgical .
• (j) O Inc .)

I •
Camera (
0
0
AssIstant AssI<tant

,,>S-- SlI{

is;
/
~ 90
P ~. ~
r-

I
92 A. Patriti et al.

is advisable when approaching P-S segments. Careful ultrasonographic explo-

ration with demarcation on the Glisson capsule of the right hepatic vein can
avoid major bleeding during parenchymal transection. For deeply located
lesions or when the tumor is close to a major vessel , even in case of lesions
located in the anterior segments, the "corkscrew technique"' can be useful. After
identification of the lesion by inspection and intraoperative ultrasound,
Glisson"s capsule is marked vvith electrocautery 1-2 cm away from the nlDlor
margin. According to the location of the nlDlOr the marked area is anchored by
stitches with caution in order to prevent the needle from entering the nUllor.
Metallic clips hold the sunue together and upward traction is performed, facili-
tating the transection of the parenchyma and correct identification of vascular
and biliary stmctures. The control of the surgical margin can be verified by
intraoperative ultrasonography during parenchymal transection. Generally,
small specimens can be extracted with an endoscopic bag through any port site,
otherwise enlarging the umbilical port or rarely a Pfannenstiel incision could be
necessary. Robot-assistance is particularly useful to perform parenchymal-pre-
serving resections especially in the P-S segments and when the tumor is in con-
tact with a portal branch or HV, and when both are close to the nUllor mass . In
fact, the endowristed instmments allow fine movements and complex transec-
tion planes reducing the discomfort coming from the use of rigid tools. The prin-
ciples of patient and trocar positions in conventional laparoscopic surgery are
applicable also for the robot-assisted approach. For liver surgery the robot is
docked over the patient's head.
All liver resections should be guided by the ultrasound performed by the on-
table surgeon. The console surgeon can view the ultrasound screen in picture-in-
picture modality directing the dissection plane, which appeared as an echogenic
line between the cut surfaces. Parenchyma is usually transected with the har-
monic scalpel for straight-line resections. The Kelly clamp-cmshing technique
with the endowristed PreCise™ bipolar forceps (Intuitive Surgical Systems,
Sunnyvale, CA, USA) is preferred for curved and angulated section lines and for
tumor dissection close to a major liver vessel. Hemostasis of small vessels is
obtained with monopolar or bipolar cautery. To secure larger vessels on the tran-
section line, we use Hem-o-Iock® clips or ligatures with Vicryl# or Prolene®.
The HVs are usually divided with the laparoscopic linear stapler or sunued vvith
Prolene#. Biliostasis is assessed by observation and the bile leaks controlled
with sutures as in open surgery.

9.7 Indications and Results of Robot-assistance

in Liver Surgery

To date, only a few reports have focused on robotics in liver surgery, the num-
ber of patients included is rather small and the majority of revie,,"s are carried
out on a retrospective basis [3, 5, 7]. Therefore there is still not good evidence
9 Hepatic Resections 93

of a superiority of robotics over standard laparoscopy. Potential advantages of

robot-assistance arising from these studies may include facilitating complex
reconstmctions (i.e., biliary and vascular anastomoses) and parenchyma-pre-
serving resections of lesions located in the P-S segments . Giulianotti et al. have
demonstrated that robot-assisted major hepatectomies are safe and feasible even
when a biliary reconstmction is required, such as in case of hilar cholangiocar-
cinoma [8]. However, there are no studies comparing the outcome of robot-
assisted and laparoscopic major hepatectomies. In a recent study by our institu-
tion , where every attempt is made for a parenchyma-preserving surgery, we
showed the possibility given by the robot to preserve liver parenchyma even in
the case of a tumor located in the P-S segments or close to a major liver vessel.
In a total of 23 cases, 9 patients (47 .8%) had liver nodules in the P-S segments,
in three cases the tumor was in connection with a portal branch, in two cases
with a hepatic vein and in one case with both vascular stmctures. Using robot-
ics we performed, even in complex cases, the same parenchyma-preserving
resections that we would have done in the open setting, thus avoiding carrying
out major hepatectomies [3]. When comparing the two minimally invasive tech-
niques, robotics allowed a more parenchymal preservation surgery in respect to
laparoscopy [5].
Even if randomized controlled studies are still missing , robotic assistance
could be attractive for those surgeons who want to perfoml a minimally invasive
parenchyma-preserving surgery even in the case of lesions close to main liver
vessels or located in segments 7, 8 or I . As there are not randomized studies
demonstrating the superiority of robotics over laparoscopy in major hepatec-
tomies and anterolateral segment resections, the two approaches can be consid-
ered analogous . There are some evidences that applications of robotics in major
hepatectomies could improve two phases of liver resection: hilar and hepatocav-
al confluence dissection [4]. This aspect gives the basis for prospective studies on
the application of the da Vinci® system for liver resections requiring a meticulous
vascular dissection and reconstmction. Nevertheless , if a program of robotic liver
surgery is planned, even resections in the anterior segments should be considered
in the first phase of the leaming curve in order to gain expertise and the P-S seg-
ments and complex major hepatectomies can be safely approached when all the
members of the staff are familiar with the robotic surgery features.

References
l. AJdrighetti L, Cipriani F, Ratti F et al (1013) The Italian experience in minimally invasive
surgery of the liver: A national survey. In: Calise F, Casciola L (eds) - Minimally invasive
surgery of the liver. Springer, Milan
Buell IF, Cherqui D, Geller DA et al (1009) The international position on laparoscopic liver
surgery: The Louisville Statement, 1008. Annals of Surgery 150:813-830
3. Casciola L, Patriti A , Ceccarelli G et al (10 II) Robot-assisted parenchymal-sparing liver sur-
gery including lesions located in the posterosuperior segments . Surg Endosc 25:3815-3814
94 A. Patriti et al.

4. Giulianotti PC, Coratti A , Sbrana P et al (2010) Robotic liver surgery: Results for 70 resec-
tions. Surgery 149:29-39
5. Troisi RI, Patriti A, Montalti R , Casciola L (2013) Robot assistance in liver surgery: a real
advantage over a fully laparoscopic approach? Results of a comparative bi-institutional analy-
sis. Int J Med Robot 9:160-166
6. Patriti A, Ceccarelli G , Bartoli A , Casciola L (2011) Extracorporeal Pringle maneuver in r0-
bot-assisted liver surgery. Surg Laparosc Endosc Percutan Tech 21 :e242-244
7. Tsung A , Geller DA , Sukato DC et al (2014) Robotic versus laparoscopic hepatectomy. An-
nals of Surgery 259 :549-555
8. Giulianotti PC , Sbrana P, Bianco PM, Addeo P (2010) Robot-assisted laparoscopic extended
right hepatectomy with biliary reconstruction. J Laparoendosc Adv Surg Tech A 20: 159-163
Biliary Tract Tumors
(Resection and Reconstruction)
10
Pier Cristoforo Giulianotti, Vivek Bindal, and Despoina Daskalaki

10.1 Classification

Bile duct tumors can be broadly classified into benign, premalignant and malig-
nant tumors as per the histologic findings, and into intrahepatic and extrahepat-
ic tumors based on their location [1]. Most of these tumors are malignant. Bile
duct adenoma is the most conmlon benign neoplasm of the bile ducts, though it
is rare. Premalignant bile duct tumors include biliary intraepithelial neoplasia
(BilIN) and intraductal papillary neoplasm of the bile duct (lPN-B).
Cholangiocarcinoma (CC) is the commonest primary malignancy of the bile
ducts [2]. It is predominantly adenocarcinoma (95% of cases), although other
histologic types including squamous cell carcinoma , small cell carcinoma and
sarcomas have been described.
CC can be classified as intrahepatic or peripheral, periliilar and distal
depending on their location. The distal CC, if resectable, is treated by pancre-
aticoduodenectomy (described in next chapter). Periliilar CC, also called
Klatskin tumor, accounts for 60% cases of extrahepatic CC [3]. It is a challeng-
ing situation, as it may require a formal hepatectomy with lymphadenectomy
and reconstruction. We shall elaborate on these details in the sections below.

10.2 Surgical Treatment

RO resection of the tumor offers the only possibility for long term survival and
has been regarded as the gold standard for the treatment of resectable disease.

P. C. Giulianoni ( :81)
Division of General, Minimally Invasive and Robotic Surgery,
University of lllinois, Chicago, IL, USA
e-mail: [email protected]

G. Spinoglio (Ed) , Robotic Surgery: Cllrrelll Applications and Nell' Trends. 9S

Updates in Surgery
DOl: lOJOO7/978-88-470-5714-2_1O,© Springer-Verlag Itaha 2015
96 P. C. Giulianotti et al.

For Klatskin tumor, which forms the majority of cases, this may include extend-
ed hepatectomy, combined with complete extrahepatic bile duct resection and
radical lymphadenectomy [4]. This aggressive surgical strategy has increased
the rate of curative resection and long term survival for the patients harboring
this disease [5]. There are many challenging technical complexities in this
approach like inflow control, inclusion of caudate lobe and reconstruction with
separate small caliber ducts. The feasibility and safety of laparoscopic tech-
niques in liver resections have been reported, especially for anterior and lateral
segments. However, the adoption of laparoscopy for biliary tumors has been
restricted due to technical limitations and oncologic concerns [6].
Robotic surgery may help overcome certain limitations of laparoscopy and
provide the minimally invasive advantage to these patients, who otherwise usu-
ally undergo extensive open surgery. The main challenges faced during these
procedures are right lobe mobilization, hepatic hilum dissection, control of
bleeding during parenchymal transection, and complex biliary reconstruction.
The robotic platform provides many advantages which have been already well
described. This helps the surgeon increase the precision of dissection while
facilitating suturing in difficult situations. It also provides him with the
ergonomic comfort in these long and challenging procedures so as to allow him
to work to his full potential.
In all these advanced procedures, it is important to understand that with the
use of a minimally invasive method, indications and patient selection for a pro-
cedure does not change. The fundamental principles of a safe R0 surgical resec-
tion and adequate lymphadenectomy should not be compromised. A low thresh-
old for conversion to an open procedure should be kept if the goals of the oper-
ation cannot be accomplished safely by using minimally invasive technique.

10.2.1. Preoperative Assessment of Patient

One has to assess these patients for their performance status and fitness for
major surgery that may include a partial hepatectomy. Chronic liver disease or
portal hypertension generally makes these patients bad candidates for surgery. If
there is any evidence of cholangitis, it should be treated with adequate drainage
and antibiotics before surgery [2].
The main goal of the surgery is R0 resection with free proximal and distal
margins, resection of tumor bed (including caudate lobe and vascular elements)
and adequate lymphadenectomy. A complete resection with histologically nega-
tive resection margins is a very important criterion for long term survival in
cholangiocarcinoma.
The criteria for unresectable disease are [7]:
• major comorbidities precluding safe surgery;
• metastatic disease;
10 Biliary Tract Tumors (Resection and Reconstruction) 97

• invasion of main portal vein or hepatic artery proximal to their bifurcation;

• bilateral invasion of portal vein or hepatic artery branches;
• bilateral involvement of hepatic ducts up to secondary radicles; and
• unilateral duct and/or vessel involvement with contralateral liver lobe
atrophy.
Some of these restrictions can be overcome by techniques like portal venous
embolization, which induces contralateral liver hypertrophy to increase the
future remnant liver volume.

10.3 Procedure Overview

10.3.1 Patient Positioning and Docking

Under general anaesthesia, the patient is placed in the supine position with part-
ed legs with approximately a 20° reverse-Trendelenburg tilt. The abdomen is
cleaned and draped and an orogastric tube and urinary catheter are inserted. The
assistant stands in between the legs. Pneumoperitoneum is achieved to 15mmHg
using a Veress needle at Palmer’s point. A 10/12mm trocar is placed in supraum-
bilical position (which is used as an assistant port in the operation). One optical
and three da Vinci® trocars are placed as follows (Fig. 10.1a):
• optical (12mm): in the right midclavicular line, approximately 10cm from
the assistant trocar, above the level of the umbilicus;
• R1: in the left midclavicular line approximately 10cm away from the assis-
tant trocar, above the level of umbilicus;
• R2: in right anterior axillary line, at least at 10cm from the optical trocar;
• R3: in left anterior axillary line, used for retraction purpose.
The port placement needs to be adjusted based on the body habitus of the
patient so as to prevent external arm collision and provide optimal exposure.
A diagnostic laparoscopy is done to look for any metastatic deposits or free
fluid. If a suspicious deposit is seen, it is biopsied and sent for frozen examina-
tion to rule out metastatic disease. Any free fluid is sent for cytology to look for
malignant cells. Intraoperative ultrasonography is performed to rule out any
undetected metastatic deposits in the liver.
The da Vinci® patient cart is brought from the head of the patient, and the
arms are docked to the placed ports. The third arm of the robot comes from the
left side of the patient. To start the procedure, a monopolar hook is taken in R1,
bipolar forceps in R2 and grasping forceps in R3. The assistant surgeon stands
in between the legs for complementary maneuvers (i.e., suction, stapling, retrac-
tion, and laparoscopic ultrasonography). A sample OR setup for right extended
hepatectomy for CC is depicted in Fig. 10.1b.
98 P. C. Giulianotti et al.

a b
Fig. 10.1 Robotic-assisted right extended hepatectomy. a Port position. SUL, spino-umbilical li-
ne; MCL, midclavicular line; 1, 2, 3 represent positions for robotic arm 1, 2 and 3 respectively. b
OR setup. (© 2014 Intuitive Surgical, Inc.)

10.3.2 Bile Duct Resection

Hepatic flexure of the colon is mobilized medially and caudally and a partial
Kocher maneuver is performed. Dissection is commenced at the hepatic hilum
while it is retracted using R3. If the gallbladder is in place, it is taken down
keeping the cystic duct attached to the common bile duct (CBD). Indocyanine
green fluorescence aids in the detection of CBD and any aberrant biliary anato-
my. The CBD is dissected and transected distally at the superior border of pan-
creas, and the distal stump is oversewn. The distal margin is sent for frozen sec-
tion, which if positive, calls for a pancreaticoduodenectomy with or without
liver resection, as per disease location, spread and performance status of the
patient. Now, the proximal bile duct is lifted up and dissection is continued to
separate the hepatic artery and portal vein from the bile duct. Starting at the
superior border of the pancreatic head, a lymphadenectomy along the common
hepatic artery is performed. The origin of gastroduodenal artery is exposed.
Generally, lymph node dissection in hepatoduodenal ligament is adequate. The
fat and lymph nodes are resected en bloc with the bile duct. At the hilum, right
and left hepatic ducts are dissected and encircled with vessel loops to aid in trac-
tion. If one can get proximal to the tumor, bile ducts are divided and margins are
sent for frozen section to confirm R0 resection.
In case of Bismuth type III tumors, an extended right or left hepatectomy along
with bile duct resection may be required for R0 resection. The detailed technique
of these procedures is described below in separate sections.
Vascular resection and reconstruction may be required in case of portal
venous or hepatic arterial involvement. This may be done only by experienced
10 Biliary Tract Tumors (Resection and Reconstruction) 99

surgeons and institutions with good perioperative results in such high risk pro-
cedures.

10.3.3 Reconstruction: Roux-en-Y Hepaticojejunostomy

For a Roux-en-Y hepaticojejunostomy, the attention is diverted to the submeso-

colic area in order to prepare the loop for reconstruction. A proximal jejunal loop
is divided using a stapler, and a jejunojejunostomy is performed with a laparo-
scopic stapler to create a Roux loop. The distal loop is then brought into the right
upper quadrant usually in a transmesocolic fashion. Here, an anastomosis
between the bile duct and the loop is performed in end-to-side fashion, using 4-
0, 5-0 or 6-0 PDS (Ethicon, Somerville NJ) depending on the diameter of the
bile duct. A ductoplasty may be required if the bile duct diameter is small. We
usually do a single layered anastomosis with half running layers of suture, one
for the posterior and one for the anterior wall. Few interrupted stitches may be
placed to reinforce the anastomosis. Sometimes, anterior layer has to be formed
by interrupted stitches, in case of small diameter or thin walled ducts (Fig. 10.2).
The possibility of doing microsurgical interrupted stitches is one of the main
advantages of using robot. In order to decrease the tension of the anastomosis,

Fig. 10.2 Interrupted stitches to perform the anterior layer of hepaticojejunostomy. The interrup-
ted sutures are held in position by clips. Use of robotic platform provides the distinct advantage of
ability to perform microsurgical interrupted stitches in a minimally invasive environment. HD, he-
patic duct
100 P. C. Giulianotti et al.

two stitches of Prolene 3-0 (Ethicon, Somerville, NJ, USA) are placed to fix the
jejunal loop to the hilum.
Use of fibrin glue may be considered at the end of the anastomosis. At the
end of the procedure, a drain may be left near the biliary anastomosis.

10.3.4 Extended Left Hepatectomy with Caudate Lobe Resection

Ports are placed as already described. A thorough diagnostic laparoscopy is

done along with ultrasonography of the liver to rule out metastatic disease. The
patient cart is docked and the operation starts by removing the gall bladder,
while keeping the cystic duct intact. Indocyanine green fluorescence is used to
identify the biliary anatomy and look for any variations. The CBD is complete-
ly dissected, tied and transected. The distal margin of CBD is sent for frozen
section and the stump is oversewn with PDS sutures. Lymphadenectomy is per-
formed along the hepatoduodenal ligament. The left hepatic artery is dissected,
and before transection with a stapler, confirmed by a clamping test which leads
to a change in color of the liver parenchyma on the left side. The left branch of
the portal vein is then dissected, ligated and divided (Fig. 10.3). Parenchymal
transection is done along the line of ischemia usually using ultrasonic shears.
HabibTM (a bipolar radiofrequency device) or cavitational ultrasonic surgical
aspirator (CUSA) may be used for parenchymal transection. Anterior and pos-

Fig. 10.3 Left branch of portal vein (PV) being ligated. The left hepatic artery (LHA) has been di-
vided and lifted up. One can see the gastroduodenal artery (GDA) and right hepatic artery (RHA)
10 Biliary Tract Tumors (Resection and Reconstruction) 101

terior branches of right hepatic duct are dissected, transected and margins are
sent for frozen section. The caudate lobe is dissected from the inferior vena
cava. The parenchymal transection is completed and hemostasis confirmed.
The reconstruction is done in a Roux-en-Y fashion. The Roux limb is created
by stapled jejunojejunostomy (as described in Sect. 10.3.3) and it is brought
cranially in a transmesocolic (sometimes retrogastric) fashion. Using 5-0 PDS,
the two right ducts are connected to each other. An opening made in the Roux
limb and a posterior layer of the anastomosis is performed using continuous
suturing. An interrupted anterior layer is thrown and a few stitches are placed
between liver and Roux limb so as to avoid undue tension on the anastomosis.
Fibrin glue is used over the anastomosis and the raw surface of transected liver
parenchyma. The specimen is retrieved in an Endobag usually through a
Pfannensteil incision.

10.3.5 Extended Right Hepatectomy

Initially, the hepatic flexure of the colon is mobilized, and a partial Kocher
maneuver is performed. Starting at the superior border of the pancreatic head,
a lymphadenectomy of the common hepatic artery is performed, using a
monopolar hook and bipolar forceps, to expose the origin of the gastroduode-
nal artery. The inferior aspect of segment IV is retracted upward by using the
third robotic arm, and the CBD is dissected and sectioned at the superior bor-
der of the pancreatic head. The distal stump of the CBD is sutured, and a
frozen section is sent to rule out neoplastic invasion. The right hepatic artery
is dissected and divided at its origin from the proper hepatic artery. The left
hepatic duct is transected at the left umbilical fissure and a frozen section is
sent at this level as well. Following this, the right portal vein is dissected and
divided between ligatures. The right liver lobe is mobilized from its peritoneal
attachments. This is done by sectioning the falciform ligament and the anteri-
or half of the coronary ligament, until the anterior side of the inferior vena
cava (IVC) and the right hepatic vein is reached. The hepatorenal ligament and
the right triangular ligament are divided by using a monopolar hook. The third
arm is used to retract the inferior aspect of the right liver lobe upward. In this
way, the right side of the IVC is exposed. The accessory hepatic vein is suture
ligated and the dissection proceeds until the inferior aspect of the right hepat-
ic vein is reached. After sectioning the bridge of parenchyma between seg-
ments IV and III, the parenchymal transection is carried out along the right
aspect of the falciform ligament, by harmonic scalpel, starting at the anterior
border of the liver. The recurrent vessels from the umbilical fissure to segment
IV, middle hepatic and right hepatic veins are divided using staplers. The
reconstruction is done as per the already described method. The specimen is
retrieved in an Endobag.
102 P. C. Giulianotti et al.

10.4 Palliative Surgery

A vast majority of patients with cholangiocarcinoma have a surgically unre-
sectable tumor at the time of diagnosis. The goal in these patients is palliation of
symptoms using interventions with least morbidity and maximal efficacy [8, 9].
For distal CC, usually endoscopic stenting is the preferred modality, while for
proximal CC, percutaneous methods with or without endoscopic interventions
are helpful. In a limited number of situations, a surgical biliary and/or digestive
bypass may be needed, but is associated with a high morbidity and mortality
when done by open approach [10]. With the use of surgical robotics, we can pro-
vide minimally invasive advantage to these patients with a low morbidity [11].

10.5 Liver Transplantation

Orthotopic liver transplantation, in combination with multimodality therapy, is
rarely an option in advanced tumors like those invading the portal vein, bilater-
al hepatic ducts and atrophic liver lobes. However, there are only a few studies
on liver transplantation as a modality for treatment of cholangiocarcinoma. Also,
because of the shortage of organs and poor outcomes, the indications of trans-
plant are very limited and it cannot be considered as a standard form of therapy.
In a few cases when transplant needs to be done, use of robotic platform can be
an option for living donor hepatectomy [12].

10.6 Postoperative Outcomes

Surgery for bile duct tumors is associated with significant postoperative morbid-
ity and mortality. The perioperative complications associated with the procedure
are bile leak, hemorrhage, cholangitis, liver abscess, hepatic failure, organ space
or superficial surgical site infections and respiratory complications.
Our experience included more than 150 cases of robotic hepaticojejunosto-
my for different indications, out of which 52.9% patients has had a previous
hepatobiliary procedure, either open or laparoscopic. There was a 3.9% bile leak
rate, 4% biliary stenosis rate and 3% cholangitis rate at 16.82±13.09 month fol-
low-up. The variables which significantly increased the risk of complications
after a minimally invasive bilioenteric anastomosis were iatrogenic bile duct
injury and duct diameter 5mm. These results are better placed than most of the
studies with open and laparoscopic hepaticojejunostomy.
As per the literature, less than 50% of patients with cholangiocarcinoma are
able to undergo a curative resection. The five-year survival rates are highly vari-
able, ranging from 8 to more than 50%. The factors which predict a better out-
come are negative margins on histopathology, no lymph nodal involvement,
concomitant liver resection, well-differentiated tumors, papillary tumors and
10 Biliary Tract Tumors (Resection and Reconstruction) 103

lack of perineural invasion [13]. In general, the best outcomes are in patients
who undergo R0 resection and this is the best predictor for five-year survival.

References
1. Joo I, Lee JM (2013) Imaging bile duct tumors: pathologic concepts, classification, and ear-
ly tumor detection. Abdominal Imaging 38:1334–1350
2. Jarnagin W, Winston C (2005) Hilar cholangiocarcinoma: diagnosis and staging. HPB
7:244–251
3. Lazaridis KN, Gores GJ (2005) Cholangiocarcinoma. Gastroenterology 128:1655
4. Giulianotti PC, Sbrana F, Fransesco BM, Addeo P (2010) Robot-assisted laparoscopic extend-
ed right hepatectomy with biliary reconstruction. J Laparoendosc Adv Surg Tech 20:159–163
5. Ito F, Agni R, Rettammell RJ et al (2008) Resection of hilar cholangiocarcinoma: Concomi-
tant liver resection decreases hepatic recurrence. Ann Surg 248:273–279
6. Simillis C, Constantinides VA, Tekkis PP et al (2007) Laparoscopic versus open hepatic re-
sections for benign and malignant neoplasms—a meta analysis. Surgery 141:203–211
7. Whang EE, Duxbury M, Rocha FG; Zinner MJ (2013). Cancer of the gall bladder and bile
ducts. In: Maingot R, Zinner M, Ashley SW, (eds.) Maingot’s abdominal operations, 12th edn.
McGraw-Hill Medical, New York
8. Date RS, Siriwardena AK (2005) Current status of laparoscopic biliary bypass in the man-
agement of non-resectable peri-ampullary cancer. Pancreatology 5:325–329
9. Smith AC, Dowsett JF, Russell RC et al (1994) Randomised trial of endoscopic stenting ver-
sus surgical bypass in malignant low bile duct obstruction. Lancet 344:1655–1660
10. Lesurtel M, Dehni N, Tiret E et al (2006) Palliative surgery for unresectable pancreatic and
periampullary cancer: a reappraisal. J Gastrointest Surg 10:286–291
11. Buchs NC, Addeo P, Bianco FM et al (2011) Robotic palliation for unresectable pancreatic
cancer and distal cholangiocarcinoma. Int J Med Robotics Comput Assist Surg 7:60–765
12. Giulianotti PC, Tzvetanov I, Jeon H et al (2009) Robot assisted right lobe donor hepatecto-
my. Transpl Int 25:e5–e9
13. Santibanes ED, Ardiles V (2012) High malignant biliary tract obstruction. In: Fischer JE, (ed.)
Fischer’s Mastery of Surgery. 6th ed. Lippincott Williams & Wilkins
Pancreatic Surgery for Cancer
11
Pier Cristoforo Giulianotti, Despoina Daskalaki,
and Francesco Mario Bianco

11.1 Introduction
Pancreatic cancer is the fourth leading cause of cancer-related death in the
United States, with more than 45,000 estimated new cases per year [1]. The only
potentially curative treatment is surgery, but unfortunately only 10–20% of
patients have a resectable disease at the time of diagnosis [2]. The most impor-
tant factors that can improve the oncologic outcome after surgery are an ade-
quate lymphadenectomy and a negative resection margin [3]. Even though the
overall morbidity and mortality rates after pancreatic surgery have been pro-
gressively decreasing over the past twenty years, pancreas-related complica-
tions are still a major concern.
The last major innovation in pancreatic surgery has been the introduction of
minimally invasive (MI) techniques [4–6]. Even though the rates of pancreatic
fistula and delayed gastric emptying have not been proven to be lower with the
MI approach, several other postoperative outcomes are in favor of these tech-
niques: less blood loss and transfusion, less wound infections, shorter hospital
stay, faster recovery and faster start of adjuvant treatment are all indisputable
advantages of MI surgery [7, 8].
The laparoscopic approach to the pancreas has proved to be feasible and safe
[9, 10]. However, while laparoscopic distal pancreatectomy has been widely
adopted even for malignant disease, laparoscopic pancreaticoduodenectomy
still remains relatively uncommon [11]. This is most likely due to the technical
complexity of this procedure and the steep learning curve.
The introduction of robotic technology more than a decade ago, has slowly

P. C. Giulianotti (
)
Division of General, Minimally Invasive and Robotic Surgery,
University of Illinois, Chicago, IL, USA
e-mail: [email protected]

G. Spinoglio (Ed), Robotic Surgery: Current Applications and New Trends, 105
Updates in Surgery
DOI: 10.1007/978-88-470-5714-2_11, © Springer-Verlag Italia 2015
106 P.C. Giulianotti et al.

but steadily revolutionized the field of MI surgery. Robot-assistance can over-

come the limits of laparoscopy (two-dimensional imaging, rigid instrumentation
and counter-intuitive movements) and expand the indications of the MI
approach. With the robotic assistance, surgeons can recreate the open technique
in a MI fashion, allowing for adequate oncologic resections. In a recent met-
analysis comparing robotic and open pancreatectomy [12], the authors conclud-
ed that robotic pancreatic resections are as efficient as open surgery not only for
benign, but also for malignant disease.

11.2 Operative Technique

Our experience with robotic pancreatic resections started more than ten years
ago and since then we have improved and standardized our technique. In our
experience, the main advantages of the robot can be mostly appreciated during
the uncinate process dissection, the lymphadenectomy and the reconstructive
phase, in the case of pancreaticoduodenectomies; and in the spleen preservation,
in the case of distal pancreatectomies [5, 6].

11.2.1 Step-by-Step Robotic Oncological

Pancreaticoduodenectomy (PD)

The patient is placed supine, in a reverse-Trendelenburg position, slightly tilted

to the left side. The robot is positioned at the patient’s head. The assistant sur-
geon is placed between the patient’s legs (Fig. 11.1).
We always start with a diagnostic laparoscopy, in order to exclude liver
metastases or carcinomatosis.
The robotic trocars are placed as follows (Fig. 11.2):
• 12-mm camera port: placed in the right pararectal area (this allows optimal expo-
sure of the superior mesenteric vein during the uncinate process dissection);
• 12-mm assistant port: placed in the periumbilical area;
• 8-mm port for the right robotic arm (R1): placed in the lower left hypochon-
driac region;
• 8-mm port for the left robotic arm (R2): placed medially in the right flank;
• 8-mm port for the fourth robotic arm (R3): placed laterally in the right flank
(the fourth robotic arm is mainly used for retraction and exposure of tissues)
when the patient body conformation is not too small;
• 5-mm assistant port: placed between the camera port and R2.
The procedure starts with the mobilization of the right colonic flexure. The
lesser sac is opened and explored, in order to assess any tumor infiltration. The
right colon is then mobilized up to the origin of the gastroepiploic vessels. The
duodenum is exposed and the superior mesenteric vein (SMV) is identified at the
root of the mesentery (evaluation of resectability).
11 Pancreatic Surgery for Cancer 107

Fig. 11.1 OR setting for

robotic pancreaticoduode-
nectomy. (©2014 Intuitive
Surgical, Inc.)

Fig. 11.2 Trocar placement for robotic pancreaticoduode-

nectomy. (© 2014 Intuitive Surgical, Inc.)

A wide Kocher maneuver is performed and continued up to the left lateral

border of the aorta. The nodal tissue surrounding the portal vein, hepatic artery
and common bile duct (CBD) is dissected and sent for permanent pathology.
The next step is the hepatic hilum dissection. At this point, the gall bladder
is taken down (remains en bloc with the specimen by keeping the cystic duct
intact) and the CBD is dissected and isolated. The common hepatic artery is
identified, dissected and followed distally in order to identify the gastroduode-
nal artery that is then dissected, ligated and divided preferably in between
sutures. At this point, the CBD can be transected and its proximal margin sent to
pathology for frozen-section evaluation.
108 P.C. Giulianotti et al.

The pancreas is now exposed and the pancreatic neck is identified. The dis-
section continues along the inferior border of the pancreas in order to expose the
SMV. The retropancreatic tunnel can be created at this point, paying attention
not to disrupt any vascular branches.
Usually at this point we perform an intraoperative ultrasound in order to
localize the mass and assess its relationship to the vessels.
The duodenum (or the stomach, depending on the type of pancreaticoduo-
denectomy) is now transected, using an Endostapler. The jejunum is also divid-
ed using a stapler device, distal to the Treitz ligament. At this point, the jejunum
is retracted to the right, rotating the specimen. This maneuver facilitates expo-
sure of the SMV and artery.
The pancreas is now completely dissected. Prolene® sutures are placed at the
superior and inferior border of the pancreas as a way of anchoring and retract-
ing it, prior to division of the gland. The parenchyma is now divided using the
robotic ultrasonic shears (Intuitive Surgical, Sunnyvale, CA) being careful not
to occlude the duct. A plastic stent is placed in the main pancreatic duct and
secured with a stitch. The proximal margin of the pancreatic remnant is sent to
pathology for frozen-section analysis.
The next step is the uncinate process dissection. The pancreas is lifted
upward and rotated, facilitating the dissection from the SMV; the fourth robotic
arm facilitates the retraction. The dissection begins distally, following the SMV
upward (Fig. 11.3). The small jejunal branches are transected either with the
robotic ultrasonic shears or between sutures. The value of robotic technology is
particularly evident during this step of the procedure. The stability of the plat-
form and the magnified vision, together with the EndoWrist® instruments, allow
a precise dissection with minimal blood loss. Moreover, even in the case of
bleeding, suturing can be performed like in open surgery, with less technical dif-
ficulty compared to laparoscopy.
After confirmation of the negative resection margins, the reconstructive
phase of the operation can begin. In the case of a pylorus-preserving procedure,
we prefer performing a dunking transgastric pancreaticogastrostomy (PG) (Fig.
11.4). The PG is performed by making an anterior gastrotomy and then pulling
the pancreatic stump into the gastric cavity through a posterior gastrotomy. Once
the pancreas is well mobilized (for at least 2 inches) inside the stomach, the
sutures are placed and the anterior gastrotomy is closed with a running PDS
suture. Attention must be made to the accurate hemostasis of the gastric mucosa,
in order to avoid postoperative bleeding. The hepaticojejunostomy (HJ) and
duodenojejunostomy are performed with a single loop of jejunum, with running
PDS suture, or interrupted stitches in the case of a HJ with a small/normal CBD.
In the case of the classical Whipple, without preservation of the pylorus, the
jejunal loop is used for the pancreatic reconstruction. We usually prefer placing
two drains, one near the PG and one near the HJ.
11 Pancreatic Surgery for Cancer 109

Fig. 11.3 Uncinate process dissection. The dissection follows the superior mesenteric vein cau-
dal to cephalad. SMV, superior mesenteric vein; SMA, superior mesenteric artery; RPL, retropor-
tal lamina; PD, pancreatic duct

Fig. 11.4 Dunking transgastric pancreaticogastrostomy during the reconstructive phase of pancre-
aticoduodenectomy. An anterior gastrotomy is performed and the pancreatic stump is then pulled
into the gastric cavity through a posterior gastrotomy. PG, posterior gastrotomy; AG, anterior gas-
trotomy; PS, pancreatic stump
110 P.C. Giulianotti et al.

After the reconstruction is completed, accurate hemostasis is performed. The

specimen is placed in an Endobag and extracted through a Pfannenstiel incision,
or through a previous incision, if present.

11.2.2 Robotic Distal Splenopancreatectomy (DSP)

Facilitating splenic preservation in distal pancreatectomy (DP) is one of the

main advantages of using the robotic technique. But in case of pancreatic can-
cer, we require DSP for adequate lymphadenectomy to maintain the radical
nature of the procedure.
Laparoscopy already has a clear and established role in DSP. The use of the
robotic platform can be of benefit in the following steps of the procedure:
1. Better control of the vascular structures, especially when they are encased by
the tumor. This allows performing more complex resections in a MI way;
2. More precise lymphadenectomy;
3. Major ability in performing multiorgan resections en bloc, if required.

11.2.2.1 Step-by-Step Robotic Distal Splenopancreatectomy

The patient positioning, trocar placement and docking are similar to the robotic
PD. For this procedure, the 12mm camera port is placed periumbilically, along
the midline.
After a diagnostic laparoscopy, the procedure starts by dividing the gastro-
colic ligament and entering the lesser sac, paying attention to preserve the gas-
troepiploic artery. The stomach is retracted upward and the pancreas is exposed.
At this point, we perform an intraoperative ultrasound in order to localize the
lesion and its relationship to the vessels and surrounding organs.
The dissection starts at the pancreatic neck. The SMV, splenomesenteric con-
fluence and portal vein are identified and dissected. A retropancreatic tunnel is
now created and a Penrose drain is placed around the pancreatic neck for retrac-
tion purposes. The splenic vessels are isolated and dissected. The splenic artery
is ligated and divided first, followed by the splenic vein. In some cases, the
splenic vessels can be divided together using an Endostapler. The dissection con-
tinues proximal to distal, toward the tail of the pancreas, or vice-versa, depend-
ing on the location of the mass. The inferior border of the pancreas is dissected
from the mesocolon. The pancreatic gland is now mobilized and the parenchyma
is transected with the use of the robotic ultrasonic shears. The transection line of
the pancreatic stump is reinforced with prolene mattress sutures, being careful to
include the Wirsung duct in order to minimize the risk of a pancreatic leak. The
lateral attachments of the spleen are dissected and the whole specimen is
removed en bloc with the pancreas. A drain is placed near the pancreatic remnant.
Hemostasis is accurately checked. The specimen is placed in an Endobag and
extracted through a Pfannenstiel incision or through enlargement of a trocar site.
11 Pancreatic Surgery for Cancer 111

11.3 Innovations

11.3.1 Indocyanine Green Fluorescence (ICG)

We are currently using ICG fluorescence during all the hepatobiliopancreatic

procedures. In the case of robotic PD, we use ICG for biliary identification dur-
ing dissection of the hepatic hilum. During robotic DSP, ICG can be used for
identification of the vascular anatomy and even the vascular pattern of the pan-
creatic lesion. It is useful in identification of neuroendocrine tumors of the pan-
creas as well.

11.3.2 New instruments

A robotic EndoWrist® stapler is available in the market; this allows the surgeon
sitting at the console to control the device directly.
Integrated imaging is one of the most important innovations that will soon be
available. The robotic console could allow integration of preoperative imaging
that could be superimposed onto the intraoperative view and may even allow vir-
tual-reality options. This would be an important step toward better training of
robotic surgeons and patient safety.

11.4 Advantages, Limitations and Personal Experience

Pancreatic resections, especially pancreaticoduodenectomies, represent the most
challenging procedures in general surgery. The robotic approach can solve some
of the technical difficulties that are encountered during laparoscopic pancreatic
surgery. The features of the robot (EndoWrist® instruments, magnified vision,
stable platform, tremor filtering) allow meticulous dissection, even in narrow
operative fields and precise suturing (like in open surgery), which leads to better
and easier anastomosis and bleeding control. In the case of PD, the robotic
approach allows a fine dissection of the uncinate process, extensive lym-
phadenectomy and precise reconstruction. Moreover, vascular resection and
reconstruction is feasible, like in open surgery. In distal pancreatectomy, the
laparoscopic approach is currently the gold-standard for benign and borderline
malignant disease. The robotic technique allows a higher spleen preservation
rate, in the case of benign disease and multiorgan resection en bloc, if needed [6].
Even though long-term follow-up results are still lacking, the oncologic princi-
ples of open pancreatic resection can be followed with the robotic approach.
In a recent metanalysis comparing robotic to open pancreatic surgery, the
authors report that the overall complication rate is lower with the robot (absolute
risk reduction 12%). Robotic surgery also demonstrated to have a significantly
lower reoperation rate and lower positive margin rate [12]. These results are
112 P.C. Giulianotti et al.

encouraging and even though larger studies are needed, they open the way for
wider acceptance of robotic technology in the pancreatic field. It is important to
note that robotic pancreatic surgery should be performed by experienced robot-
ic, hepatopancreatobiliary surgeons. The initial learning curve of a robotic sur-
geon, should include simpler procedures and then be followed by more complex
operations, such as pancreatic resections.
Our experience with robotic pancreatic surgery started in 2000. Since then
115 cases of PD and 77 cases of DP, for different indications, have been per-
formed by a single surgeon, in two different centers (Grosseto, Italy and
Chicago, USA). The results of the series were presented in an oral communica-
tion at the 2013 Clinical Robotic Surgery Association Meeting (Washington
DC). Out of 114 PDs, 66 were standard Whipple procedures and 48 were
pylorus-preserving; the mean operative time was 443.5min (including the dock-
ing time), with a mean estimated blood loss of 343mL; the conversion-to-open
rate was 13% and the postoperative morbidity (Clavien III/IV) rate was 24.7%;
the mortality rate was 2.8%; the surgical indication was malignant disease in
70% of cases; a negative resection margin (R0) was achieved in more than 90%
of cases, with a mean of 19.4 lymph nodes retrieved.
Of the 77 DPs, 41 included splenectomy and 36 were spleen-preserving
(these last ones performed for benign disease); the intention-to-treat spleen-
preservation rate was 97%; the mean operative time was 236min (including the
docking time), with a median estimated blood loss of 100mL; the rate of clini-
cally significant postoperative pancreatic fistula, grade B according to the
ISGPF definition [13], was 12%; no grade C fistulas occurred in our series; the
conversion-to-open rate was 5% and the mortality was nil; surgery was per-
formed for malignant disease in 36% of the patients; the mean number of lymph
nodes harvested was 10.3, with a 90% negative resection margin.
We should mention at this point that opting for a robotic approach in pancre-
atic surgery also has some limitations, especially for the less experienced sur-
geons that have yet to learn how to troubleshoot the potential problems that
could arise by using the robotic system. The lack of tactile feedback represents
a drawback, especially at the beginning of the learning curve. With experience
though, the surgeon learns how to compensate by taking advantage of the excel-
lent vision that the robotic system provides. Another limitation is the difficulty
of performing multiquadrant surgery and the inability of changing the patient’s
position, once the robotic system is docked. This can be overcome by careful
preoperative planning of the robot setting and a correct placement of the robot-
ic trocars, in a way that collisions will be avoided. Also, all the advanced robot-
ic procedures require a trained team of assistant surgeon and scrub nurse. As the
main surgeon is separated from the patient while performing robotic surgery, the
assistant surgeon has to be trained enough to help in performing difficult tasks
and also to take care of any emergency situation that could arise during the pro-
cedure. The role of a trained scrub nurse and operating room technician is also
very important in streamlining the conduct of the procedure and preventing any
11 Pancreatic Surgery for Cancer 113

wastage of time and resources. Thus, team work is the key to success in
advanced robotic surgery.

References
1. Siegel R, Naishadham D, Jemal A (2013) Cancer statistics, 2013. CA: Cancer J Clin 63:11–30
2. Bilimoria KY, Bentrem DJ, Ko CY et al (2007) Validation of the 6th edition AJCC Pancreat-
ic Cancer Staging System: report from the National Cancer Database. Cancer 110:738–744
3. Konstantinidis IT, Warshaw AL, Allen JN et al (2013) Pancreatic ductal adenocarcinoma: is
there a survival difference for R1 resections versus locally advanced unresectable tumors? What
is a “true” R0 resection? Annals of Surgery 257:731–736
4. Venkat R, Edil BH, Schulick RD et al (2012) Laparoscopic distal pancreatectomy is associ-
ated with significantly less overall morbidity compared to the open technique: a systematic
review and meta-analysis. Annals of Surgery 255:1048–1059
5. Giulianotti PC, Sbrana F, Bianco FM et al (2010) Robot-assisted laparoscopic pancreatic sur-
gery: single-surgeon experience. Surgical Endoscopy 24:1646–1657
6. Milone L, Daskalaki D, Wang X, Giulianotti PC (2013) State of the art of robotic pancreatic
surgery. World J Surg 37:2761–2770
7. Kendrick ML (2012) Laparoscopic and robotic resection for pancreatic cancer. Cancer J
18:571–576
8. Kooby DA (2006) Laparoscopic surgery for cancer: historical, theoretical, and technical con-
siderations. Oncology (Williston Park) 20:917–927
9. Jayaraman S, Gonen M, Brennan MF et al (2010) Laparoscopic distal pancreatectomy: evo-
lution of a technique at a single institution. J Am Coll Surg 211:503–509
10. Kim SC, Song KB, Jung YS et al (2013) Short-term clinical outcomes for 100 consecutive
cases of laparoscopic pylorus-preserving pancreatoduodenectomy: improvement with surgi-
cal experience. Surgical Endoscopy 27:95–103
11. Subar D, Gobardhan PD, Gayet B (2014) Laparoscopic pancreatic surgery: An overview of
the literature and experiences of a single center. Best Pract Res Clin Gastroenterol 28:123–132
12. Zhang J, Wu WM, You L, Zhao YP (2013) Robotic versus open pancreatectomy: a system-
atic review and meta-analysis. Ann Surg Oncol 20:1774–1780
13. Bassi C, Dervenis C, Butturini G et al (2005) Postoperative pancreatic fistula: an internation-
al study group (ISGPF) definition. Surgery 138:8–13
 Part IV
Lower Gastrointestinal Surgery
Right Colectomy for Cancer:
Three-arm Technique 12
Domenico Garcea, Francesca Bazzocchi, and Andrea Avanzolini

12.1 Procedure Overview

The surgical use of robotic systems stems from a military medical research
effort. Since then it has been applied to several surgical specialties as the tech-
nological reply to overcome the inherent limitations of laparoscopy [1]. To date,
however, scientific evidence about the clinical advantages of robotic colonic
surgery over laparoscopy is still lacking.
Though the main benefits are expected to be demonstrated in low anterior
resections and different studies have been published [2], robotic right colecto-
my is an ideal procedure for starting the robotic learning curve: it could repre-
sent the operation used for training and is propaedeutic for other more complex
procedures.
The robotic system may have several potential advantages in performing right
colectomies since it facilitates:
• a more precise, meticulous dissection and lymphadenectomy along the supe-
rior mesenteric vein, especially in obese patients with short and heavy
mesentery or with voluminous lymph nodes;
• suturing and undertaking intracorporeal anastomosis;
• the extraction of the specimen through optimally located minimal incisions;
• an ergonomic operative position for increased comfort with reduction of
physical stress;
• less experienced surgeons to perform complex tasks with a minimally inva-
sive approach.

F. Bazzocchi (
)
General, Gastrointestinal, and Minimally Invasive Surgery Unit,
“G.B. Morgagni - L. Pierantoni” Hospital,
Forlì, Italy
e-mail: [email protected]

G. Spinoglio (Ed), Robotic Surgery: Current Applications and New Trends, 117
Updates in Surgery
DOI: 10.1007/978-88-470-5714-2_12, © Springer-Verlag Italia 2015
118 D. Garcea et al.

12.2 Patient Positioning

The patient is supine with the right side up and the arms alongside the body in
order to avoid neurological injury. Security devices, such as belts and shoulder
holders, guarantee body position during Trendelenburg and left-side tilting
movements.
The gastric tube and urinary catheter are placed; an intermittent mechanical
compression device is applied to both legs to prevent deep venous thrombosis.
Final positioning will be adjusted according to the operative field exposure
before docking.

12.3 Robot Positioning and Docking

The operative field can be identified as a triangle connecting the right costal
margin, right anterior superior iliac spine and the camera port. The patient cart
will be moved aligning the camera arm along the bisectrix of the camera port
angle (with the arrow on the second joint of the camera arm within the blue
marker).
After correct positioning of the camera arm is achieved, the cart can be
locked without any further changing of patient and operating table position
(Fig. 12.1).

12.4 Trocar Placement

We usually perform right colectomy with a three-arm technique. The ports are
placed as follows:
• camera port (C), 10–12 mm: on a transverse umbilical line, 3–5 cm left
paraumbilical;
• instrument arm 1 (R1), 8mm: on the left midclavicular line, 5cm below left
costal margin;
• instrument arm 2 (R2), 8mm: on the left midclavicular line, slightly above
the bisiliac line;
• assistant port, 10–12mm: placed 10cm lateral to the camera port (used for
stapling, ligation, retraction, suction and irrigation);
• assistant port, 5mm: on the midline 3–5cm below xiphoid process (used for
retraction, suction and irrigation) (Fig. 12.2).
The ports are inserted under direct vision once a pneumoperitoneum of
11mmHg is achieved by means of open laparoscopy and the abdominal cavity
is explored; port placement can be modified according to patient size and anato-
my. After port placement, the patient is placed in the Trendelenburg position
with a left tilt.
12 Right Colectomy for Cancer: Three-arm Technique 119

Fig. 12.1 OR setup (our

technique). (© 2014
Intuitive Surgical, Inc.)

Fig. 12.2 Trocar placement (our technique).

(© 2014 Intuitive Surgical, Inc.)

12.5 Step-by-Step Review of Critical Elements of the

Procedure
The procedure begins laparoscopically in order to identify a tattoo, perform
takedown of any adhesions and to rule out peritoneal or hepatic metastases. The
greater omentum and the small intestine are moved toward the left upper quad-
rant of the abdomen thus exposing the cecum and terminal ileum as well as the
120 D. Garcea et al.

axis of the superior mesenteric vein: it represents the target and horizon of the
operative field.
When the surgeon is sure about the feasibility of the procedure the robotic
cart is docked. A medial to lateral approach is used. Sometimes in obese patients
it is necessary to use a lateral to medial approach; an inferior to superior
approach has also been described [3]. In order to avoid intraoperative complica-
tions, proper tractions and countertractions should be exerted by robotic and
laparoscopic forceps to create an adequate exposure: the surgeon can better visu-
alize the vascular anatomy and its variations, can avoid ureteral injuries and can
execute a safe dissection along the correct planes without unnecessary bowel
manipulation. The technique is described step-by-step.

12.5.1 Gastrocolic Ligament Dissection

The gastrocolic ligament is put in tension, divided and then dissected up to the
right colic flexure so that the lesser sac and the duodenum are exposed. For neo-
plasms of the right colic flexure or proximal transverse colon, it is necessary to
extend the dissection of the gastrocolic ligament toward the distal transverse
colon, in order to facilitate the execution of the intracorporeal ileocolic anasto-
mosis in the right side of the abdomen without changing the robotic docking.
Moreover, in these neoplasms, it is mandatory to carry out the dissection of the
gastrocolic ligament along the greater curve of the stomach rather than along the
margin of the transverse colon, performing in this way the lymphadenectomy of
the right gastroepiploic vessels.

12.5.2 Section of the Ileocolic Pedicle and of the Right Branch of

the Middle Colic Pedicle

By retracting the mesocolon of the ascending colon anteriorly and laterally, it is

possible to identify and lift up the ileocolic pedicle so that the peritoneum on
each side is incised. The dissection is carried out along the avascular plane
between Gerota’s fascia posteriorly and Toldt’s fascia anteriorly, up to the third
and second duodenal portions, and the head of the pancreas superiorly and the
right iliac vessels inferiorly. In this manner, two windows beside the ileocolic
pedicle and lateral to the superior mesenteric vein are created. In this step, it is
necessary to visualize the right ureter and gonadal vessels in order to avoid
injuries. The ileocolic vein and artery and the right colic vessels (if present) are
isolated and sectioned between large Hem-o-lok® (violet) clips at their origin.
Now the assistant at the operating table lifts up the transverse colon with fenes-
trated forceps to visualize the middle colic pedicle and its branches. Depending
on the tumor location, the surgeon can isolate and divide between the clips, the
right branch, or the main trunk of the middle colic artery (Fig. 12.3).
12 Right Colectomy for Cancer: Three-arm Technique 121

Fig. 12.3 Exposure of the superior mesenteric vein during lymphadenectomy

12.5.3 Mobilization of Right Colon

We continue with a medial to lateral dissection in the previously referred avas-

cular plane. After cecum and ascending colon takedown is completed, the right
colic flexure is fully mobilized.

12.5.4 Transection of Transverse Colon and Ileum

The transverse mesocolon is divided from its root to the colonic wall for final
transection. The ileal mesentery is divided approximately 10–20 cm from the
ileocecal valve. Marginal arteries will need to be controlled with clips or
cautery. A linear articulated stapler with tri-staple technology is used by the
assistant at the operating table for the transection of the transverse colon and
ileum.

12.5.5 Intracorporeal Ileocolic Anastomosis

The ileum is approximated to the transverse colon in order to perform an intra-

corporeal isoperistaltic side-to-side anastomosis. With the use of the monopolar
hook, we create the enterotomies through which the jaws of a linear stapler are
inserted and fired. Now we put one stitch of suspension at the medial margin of
122 D. Garcea et al.

the mechanical suture and the bowel defect is closed with a two-layer running
suture with an absorbable self-locking thread. The mesenteric defect is then
closed with an absorbable suture.
The specimen extraction is carried out through a paraumbilical incision or a
sovrapubic minilaparotomy with plastic wound protection.

12.6 Advantages, Limitations and Relative Contraindications

(Personal Experience and Literature Outcomes)
The advantages of the robotic approach over standard laparoscopy are: a) a
shorter learning curve; b) major precision in carrying out intracorporeal anasto-
moses; and c) a more accurate lymphadenectomy and dissection of the ileocolic
and middle colic vessels, especially in obese patients or in patients with volumi-
nous lymph nodes. On the other hand robotic procedures are associated with a
significantly longer operative time, even if there are no differences in the esti-
mated blood loss and early complication rates [3–7].
However, different factors can influence the abovementioned results: a) an
intracorporeal anastomosis is usually performed in the robotic series and this is
a time consuming technique; b) most of the clinical trials comparing robotic and
laparoscopic outcomes have been performed by surgeons who had a greater
experience with laparoscopic surgery whilst they were at the beginning of their
robotic learning curve; c) for those surgeons who have skipped the laparoscop-
ic step, a longer learning curve is necessary to standardize the robotic approach.
According to Spinoglio et al. [8], however, mean operative time decreases as
team experience improves and other studies have demonstrated that robotic sur-
gery has a shorter learning curve than laparoscopy [7].
Certainly, the robotic system greatly enables less experienced surgeons to
perform an advanced minimally invasive procedure and permits a progressive
improvement of the entire surgical team’s skills. The robotic system may be a
valid tool in carrying out an intracorporeal anastomosis [5, 8], though it is per-
formed extracorporeally in some robotic series. [3, 9]. In our opinion, intracor-
poreal anastomosis avoids the risk of ileus caused by the mesenteric twisting
during the extraction of the bowel and allows the surgeon to choose the optimal
abdominal location to perform a small and cosmetic skin incision.
The robotic system improves the accuracy in vessel skeletonization and
makes lymphadenectomy along the superior mesenteric vein easier, especially in
the case of obese patients or voluminous lymph nodes. The mean number of
retrieved nodes, reported in the systematic review by Fung, is 22.2. In our series
(231 robotic colorectal resections), the mean number of harvested lymph nodes
in right colectomies (91 cases) was 24.7; though controversies exist on the real
value of higher lymph node counts, it may represent a measure of the quality of
care of the robotic technique. Leak rate and 30-day mortality were 0%. Despite
some skilled laparoscopic surgeons not recognizing the real value of the robotic
12 Right Colectomy for Cancer: Three-arm Technique 123

system in colectomies, we believe that the da Vinci® System may improve accu-
racy during lymphadenectomy and intracorporeal anastomosis. The high costs of
robotic surgery represent the main limitation to the widespread diffusion of this
technology. In order to reduce costs, we have chosen to use only three robotic
arms and no more than three robotic instruments (monopolar hook, Maryland
bipolar forceps, needle driver). Therefore, the approximate additional cost for a
right colectomy is 2250 USD.
In conclusion, the robotic system improves the performance of the surgeon
and allows to reproduce open procedures faithfully. Further studies comparing
clinical and cost-effectiveness outcomes with laparoscopy are required to better
assess the role of this technology in colorectal surgery.

References
1. Mirnezami AH, Mirnezami R, Venkatasubramanian AK et al (2010) Robotic colorectal sur-
gery: hype or new hope? A systematic review of robotics in colorectal surgery. Colorectal Dis
12:1084–1093
2. Antoniou SA, Antoniou GA, Koch OO et al (2012) Robot-assisted laparoscopic surgery of
the colon and rectum. Surg Endosc 26:1–11
3. Park SY, Choi GS, Park JS et al (2012) Robot-assisted right colectomy with lymphadenecto-
my and intracorporeal anastomosis for colon cancer: technical considerations. Surg Laparosc
Endosc Percutan Tech 22:271–276
4. de Souza AL, Prasad LM, Park JJ et al (2010) Robotic assistance in right hemicolectomy: is
there a role? Dis Colon Rectum 53:1000–1006
5. D’Annibale A, Pernazza G, Morpurgo E et al (2010) Robotic right colon resection: evalua-
tion of first 50 consecutive cases for malignant disease. Ann Surg Oncol 17:2856–2862
6. Rawlings AL, Woodland JH, Vegunta RK et al (2007) Robotic versus laparoscopic colecto-
my. Surg Endosc 21:1701–1708
7. Fung AKY, Aly EH (2013) Robotic colonic surgery: is it advisable to commence a new learn-
ing curve? Dis Colon Rectum 56:786–796
8. Spinoglio G, Summa M, Priora F et al (2008) Robotic colorectal surgery: first 50 cases ex-
perience. Dis Colon Rectum 51:1627–1632
9. Zimmern A, Prasad L, Desouza A et al (2010) Robotic colon and rectal surgery: a series of
131 cases. World J Surg 34:1954–1958
Right Colectomy with Complete Mesocolic
Excision: Four-arm Technique 13
Giuseppe Spinoglio, Alessandra Marano, Fabio Priora,
Ferruccio Ravazzoni, and Giampaolo Formisano

13.1 Introduction
Minimally invasive surgery is gaining worldwide acceptance in the treatment of
colonic cancer and the advantages over the traditional open approach are well
known [1–3]. Unfortunately, during recent decades, the outcomes of patients
after colon cancer resection have not improved to the same degree as for rectal
cancer, whose treatment with total mesorectal excision (TME) is universally
accepted as the standard of care. The complete mesocolic excision (CME), first
reported by Hohenberger and colleagues in 2008 [4], seems to produce better
long-term outcomes when compared to standard lymphadenectomy by follow-
ing the same embryological-based principles introduced by Heald for rectal can-
cer more than 20 years ago [5]. However, well-conducted randomized studies
are needed to confirm its efficacy.
Additionally, laparoscopic right colectomy with intracorporeal anastomosis
is still considered by some surgeons as one of the most difficult procedures to
perform [6] and radical lymphadenectomy with CME is technically challenging
when performed with conventional laparoscopic instruments.
To date and to the best of our knowledge, few reports analyzing the safety and
feasibility of laparoscopic CME for right-sided colonic malignancies exist in the
literature [7–14]. No studies have focused selectively on the robotic approach.
This chapter describes the technical approach to robotic CME in right colec-
tomy, including technical tips culminating from the author’s nearly 10-year
experience in robotic colonic surgery.

G. Spinoglio (
)
Department of General and Oncologic Surgery,
“Ss. Antonio e Biagio” Hospital,
Alessandria, Italy
e-mail: [email protected]

G. Spinoglio (Ed), Robotic Surgery: Current Applications and New Trends, 125
Updates in Surgery
DOI: 10.1007/978-88-470-5714-2_13, © Springer-Verlag Italia 2015
126 G. Spinoglio et al.

13.2 Procedure Overview

The concept of CME stems from the knowledge of the embryological process of
gut rotation and subsequent coalescence of fascial layers. The sharp dissection
of the visceral fascial layer from the parietal one, both constituting the Toldt’s
fascia, results in a complete mobilization of the entire mesocolon covered by an
intact visceral fascial layer on both sides: this allows the safe ligation of the sup-
plying vessels (ileocolic, right colic if present and right branches of middle colic
vessels) at their root. The procedure is full-robotic.

13.3 Patient Positioning

After induction of general anesthesia, a nasogastric tube and a urinary catheter
are put in place. Antithrombotic prophylaxis with compressive elastic stockings
is performed. The patient is placed on the operating room table in the supine
position, with arms along the body and legs closed. After port placement has
been completed, the table is placed in a Trendelenburg position with a slight
angle (5–10°) and with a left tilt (5–10°). This position allows the small bowel
to move aside under gravity and expose the right and transverse mesocolon. The
head plate is tilted down (10–15°) to avoid facial soft-tissue injury from the
robotic arm movement.

13.4 Trocar Placement

For optimal port placement, the superior mesenteric axis must be considered our
“target” organ for CME. Figure 13.1a shows our trocar layout.
• The camera port is placed in the mid point of the left spinoumbilical line.
This location in the left iliac fossa guarantees visualization of the entire right
quadrant of the abdomen and the course of superior mesenteric axis.
• R1 is positioned 2–3cm laterally to the left mid-clavicular line and 2–3cm
below the costal margin.
• R2 is placed on the midline and 2cm above the symphysis pubis. The R1 and
R2 trocars are used for dissection.
• R3 is located just below the xyphoid process and is used for retraction.
• The 15-mm assistant port is positioned between the camera port and R1 in
the left flank. This port is used for suction/irrigation, clipping, stapling and
additional retraction if necessary.
The distance between all ports should be at least 8cm. We strongly recom-
mend that the port locations are not changed and adapted according to the
patient’s body habitus. The umbilicus is always considered to be the midpoint
between the xyphoid process and the pubis.
13 Right Colectomy with Complete Mesocolic Excision: Four-arm Technique 127

a b
Fig. 13.1 Robotic right colectomy. a Trocar layout. b Overhead view of OR setup. (© 2014 Intui-
tive Surgical, Inc.)

13.5 Robot Positioning and Docking

The surgical cart is positioned at the patient’s right hemithorax level with a 45°
angle; the vision cart is on the right side of the surgical cart; and the robot arms
are docked to the trocars. Figure 13.1b shows an overhead view of the recom-
mended operating room setup for robotic right colectomy. The first assistant is
on the patient’s left side and the scrub nurse to the assistant’s left.

13.6 Step-by-Step Review of Critical Elements of the

Procedure
A 30° down endoscope is used. Monopolar curved scissors or a cautery hook are
placed on arm 1 for dissection. Bipolar forceps and fenestrated Cadiere forceps
are mounted on arm 2 and arm 3, respectively.

13.6.1 Step 1 – Mesocolic Exposure and Traction on the Superior

Mesenteric Axis

The first important step is to achieve exposure of the right and transverse meso-
colon. R2 and R3 trocars are used to keep the superior mesenteric axis in trac-
tion and the monopolar cautery hook/scissors in R1 are used for dissection.
128 G. Spinoglio et al.

13.6.2 Step 2 – Vascular Control with Complete Mesocolic Excision

(Medial-to-Lateral Approach)

We routinely perform CME with a medial-to-lateral approach, primary exposure

of the left anterior aspect of the superior mesenteric vein (SMV) and ligation of
the vessels at their roots, avoiding the need of colonic detachment or Kocker
maneuver as described by Hohenberger in open surgery. This strategy allows the
complete removal of both visceral fascia layers of the right mesocolon, progres-
sively exposing the root of the SMV in a caudal-to-cephalad direction.
The location of the camera port in the left iliac fossa guarantees visualiza-
tion of the entire right quadrant of the abdomen and the course of the superior
mesenteric axis, which is our “target” organ for CME. The trocar layout allows
arm movement to be maximized and external collisions to be minimized with-
out any difficulties in the far lateral and superior extension or the blind spots,
with complete respect of optimal working, azimuth and elevation angles. After
gentle cephalad traction on the transverse mesocolon, with the grasp in R3, the
ileocolic vessels are identified and lifted up with R2; the peritoneum is then
opened just below their prominence and along the left side of the anterior
aspect of the SMV. Ileocolic vessels, right colic vessels (if present), right colic
veins at their confluence with the Henle’s sinus and the right branch of the mid-
dle colic artery can be easily and safely ligated at their roots along the right bor-
der of the superior mesenteric axis and at the Henle sinus (Fig. 13.2). Both the
robotic clip applier (Hem-o-lok®, Weck) and the laparoscopic one (through the
assistant port) can be used.

Fig. 13.2 Final view of the operative field after complete mesocolic excision. MCA, middle colic
artery; SMV, superior mesenteric vein; MCV, middle colic vein; RGEV, right gastroepiploic vein;
ARCV, accessory right colic vein; AIPDV, anterior inferior pancreaticoduodenal vein
13 Right Colectomy with Complete Mesocolic Excision: Four-arm Technique 129

A CME is performed by sharp dissection, exposing the duodenum and the

pancreatic head. The right gonadal vessels and the right ureter are identified and
preserved retroperitoneally. Cephalad dissection continues with the transverse
mesocolic division from its root to the colon, which is transected with a linear
stapler. When the hepatic flexure or the proximal transverse colon are involved
(T3/T4/N+ tumors), en bloc resection of the right gastroepiploic lymphovascu-
lar chain is also performed close to the greater curvature of the stomach. The
ileal mesentery is sectioned at the selected point with both monopolar and bipo-
lar cautery devices and the skeletonized ileum is transected with a linear stapler.
Both ileal and colonic stumps are evaluated for perfusion with ICG-NIR fluores-
cence imaging system and sectioned in a well-vascularized area. Complete
coloparietal detachment is then performed; the specimen is inserted in a 15-mm
Endobag, which is introduced through the assistant port and is subsequently
placed in the right upper quadrant.

13.6.3 Step 3 – Ileocolic Intracorporeal Anastomosis and Specimen

Extraction

The transverse colon and the ileum are approximated to choose the correct
enterotomy sites, but no stay sutures are placed since they are not useful, in our
opinion. Monopolar curved scissors in R1 are used to create enterotomies on the
antimesenteric border of the ileum and the free taenia of the transverse colon.
The monopolar device in R1 is then replaced with a needle driver. A 60-mm lin-
ear stapler is introduced through the assistant port to perform an isoperistaltic
anastomosis and the enterotomies are subsequently closed with a robotically
hand-sewn double-layer running suture (using absorbable monofilament barbed
knotless sutures; V-Loc™, Covidien). The mesenteric defect is also closed with
a continuous suture to prevent internal hernias.
The specimen is then extracted into a plastic bag through a mini-Pfannenstiel
incision performed at the suprapubic port site, avoiding any squeezing. The
advantages of intracorporeal anastomosis are minimal colonic mobilization, lim-
ited chance for bowel and anastomotic twisting, and also the possibility to
choose the specimen extraction site (according to the patient’s history of prior
abdominal surgery).

13.6.4 Step 4 – Wound Closure and Abdominal Re-exploration

Once the specimen is removed, the mini-laparotomy incision is closed and the
pneumoperitoneum re-established for a final check of the operative field. No
drain is routinely left in place. The trocars are removed under direct vision and
all the sites greater than 8mm in diameter are closed with absorbable sutures at
the fascial level.
130 G. Spinoglio et al.

13.7 Advantages, Limitations and Relative Contraindications

(Personal Experience and Literature Outcomes)
According to the retrospective and prospective published studies, robot-assisted
right colectomy for cancer is technically safe and feasible and short-term post-
operative outcomes are comparable to those of conventional laparoscopic sur-
gery. Therefore, robotic assistance is not recommended by some authors [15] for
right colectomy because of the higher costs involved, although experience with
the robotic technique demonstrated considerably lower conversion rates, rang-
ing from 0 to 4% [15–21], compared with 16.7–25% for laparoscopic colonic
resections [1–3].

Table 13.1 Perioperative outcomes and pathological characteristics of robotic vs. laparoscopic
right colectomy for cancer with complete mesocolic excision
RRC LRC p value
(101 pts) (101 pts)
Operating room time (min)
Mean (SD) 279 (80) 236 (68) p<0.001†
Range 135–540 95–465
Conversion rate
n (%) 0 (0) 7 (6.9) p=0.014§
Length of stay
Mean (SD) 7.9 (5.2) 7.9 (3.5) p=0.948†
Range 4–37 4–19
Time to return of bowel function (days)
Mean (SD) 1.9 (1) 1.8 (0.8) p=0.563†
Range 1–7 1–4
Oral re-intake (days)
Mean (SD) 1.3 (1.1) 1.1 (0.5) p=0.150†
Range 1–9 1–4
Harvested lymph nodes (n)
Mean (SD) 28.2 (10.6) 30.4 (13.1) p=0.188†
Range 13–66 12–74
Specimen length (cm)
Mean (SD) 35.2 (9.9) 36.2 (10.8) p=0.489†
Range 21–70 20–88
AJCC staging (n) p=0.088‡
I 21 26
II 38 28
III 37 33
IV 5 14
Values are expressed as mean (SD=standard deviation) or n (%). RRC, robotic right colectomy;
LRC, laparoscopic right colectomy; AJCC, American Joint Committee on Cancer; †Student’s t
test; ‡Pearson’s chi-squared test; §Fisher’s exact test
13 Right Colectomy with Complete Mesocolic Excision: Four-arm Technique 131

Table 13.2 Comparison of oncological outcomes

Study 3-Y 3-Y 3-Y 3-Y 5-Y 5-Y 5-Y 5-Y 5-Y OSin
[Reference] DFS CRS OS LR DFS CRS OS LR conver-
ted pts
CLASSICC [1] 66.8%§ – 67.8%§ 8.4% 56.4%§ – 57.9%§ 10.1%§ 49.6%§
COLOR [2] 74.2%§ – 81.8%§ – 66.5%§ – 73.8%§ 8%§ –
COST [3] 83%§ – 85%§ – 80.2%§ – 77.1%§ – –
Hohenberger – – – – – 89.1%† – 3.6%† –
et al. [4]
Our series 87.1%§ 90.5%§ 86%§ 3.9%§ – – – – –
91.1%‡ 93.7%‡ 91.2%‡ 1.9%‡
DFS, disease-free survival; CRS, cancer-related survival; OS, overall survival; LR, locl recurrence;
§ laparoscopicseries; ‡ robotic series; † open series

To date, however, no robotic series directly addresses the issue of CME for
right-sided colonic malignancies.
We recently conducted a retrospective analysis on prospectively collected
data of 101 patients who underwent robotic right colectomy with CME at our
institution between October 2005 and November 2013. The results of a consec-
utive contemporary series of 101 standard laparoscopic resections carried out
with the same operative technique have been retrospectively analyzed. The
groups were comparable in terms of baseline characteristics and we found only
two statistically significant differences: the robotic series showed a lower con-
version rate (0% vs. 6.9%; p=0.014) but longer operative times (279 min. vs.
236 min.; p <0.001) than the laparoscopic one (Table 13.1), thus confirming
results from previously published studies. Anastomotic leak rate (1%) and reop-
eration rate (2%) were equal in both groups, as well as minor complication rates.
The 3-year disease-free, cancer related and overall survival were 91.1%, 93.7%
and 91.2% in the robotic group, respectively, and 87.1%, 90.5% and 86% in the
laparoscopic series, respectively. Though encouraging and superior to the 3-year
results from previous randomized studies (from 67.8% to 84.2%) [1–3], at least
a 5-year follow-up is required (Table 13.2).
Robotic right colectomy with CME is feasible and safe. The inherent prop-
erties of the robotic system might eventually lessen the technical difficulties of
vascular control, extended lymphadenectomy and intracorporeal anastomosis
during right colonic resections, but longer operating room times are required.
Nevertheless, scientific evidence about the clinical advantages of both the
robotic approach and CME, if compared to laparoscopy and standard lym-
phadenectomy, is still insufficient at present to recommend their adoption in
routine practice.
132 G. Spinoglio et al.

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Left Colectomy and Segmental
Resections for Cancer 14
Paolo Pietro Bianchi, Igor Monsellato, and Wanda Petz

14.1 Introduction
One of the goals of surgical oncology is to attempt to reduce the invasiveness
of surgery while maintaining or further improving the outcomes of traditional
open surgery. Therefore minimally invasive techniques have been applied to
oncologic surgery since the end of 90s, on the basis of the good clinical results
obtained by laparoscopic surgery in some benign diseases. The diffusion of
laparoscopic colonic surgery has increased in recent years thanks to specific
educational and training programs, but mainly in academic and high-volume
hospitals [1]. The most frequently-performed procedures are the less difficult,
such as sigmoidectomy for benign diseases and right colectomies with extra-
corporeal anastomosis [2]. Despite the improvement of technology some dis-
advantages of standard laparoscopy are still present, such as poor ergonomics,
the difficulty to perform intracorporeal sutures and the problem of the assistant
being able to hold the camera stable. Robotic surgery is an emerging technique
that seems to overcome some difficulties of the standard laparoscopic
approach, and its use in colorectal cancer is increasing quickly [3]. In this
chapter, the technical details of robotic left colectomy and segmental colonic
resections are reported.

P. P. Bianchi (
)
Minimally Invasive Surgery Unit, European Institute of Oncology,
Milan, Italy
e-mail: [email protected]

G. Spinoglio (Ed), Robotic Surgery: Current Applications and New Trends, 133
Updates in Surgery
DOI: 10.1007/978-88-470-5714-2_14, © Springer-Verlag Italia 2015
134 P. P. Bianchi et al.

14.2 Left Colectomy

14.2.1 Patient Positioning and Docking

The patient is placed in a supine position with arms alongside the trunk and legs
abducted. A slight Trendelenburg position and a right tilt are maintained in order
to expose the operative field from the ileal loops. The procedure starts with the
insertion of the Veress needle in the left hypochondrium through which a 12-
mmHg pneumoperitoneum is induced. A 12-mm standard laparoscopic trocar is
placed 2 cm right of the midline along an ideal line passing through the left
anterosuperior iliac spine and right hypochondrium. The procedure is performed
with a five-trocar technique: three 8-mm robotic trocars and two 12-mm stan-
dard laparoscopic trocars (Fig. 14.1a). The robotic cart approaches the operative
table from the left side of the patient and the robotic arms are connected to the
trocars, starting from the camera. Arm 1 is connected to the trocar in the right
iliac fossa, arm 3 is connected to the trocar in the right hypochondrium, arm 2 is
connected to the trocar in left iliac fossa (Fig. 14.1b). The initial instrument
positions are configured as follows: the robotic monopolar hook/scissors are
mounted on arm 1, the robotic grasper on arm 2 and the robotic bipolar grasper
on arm 3.

14.2.2 Step-by-Step Review of Critical Elements of the Procedure

14.2.2.1 Left Colectomy and Sigmoidectomy

A laparoscopic exploration of the abdominal cavity and an intraoperative ultra-
sonography of the liver are systematically carried out in order to complete the
staging of the disease. The laparoscopic exploration can be performed with the
robotic camera or with a standard laparoscope. The standard laparoscope has the
advantage of easy manoeuvrability compared to the manual use of the robotic
camera, particularly when some adhesions must be removed before the full
placement of the trocars. The site of the tumor is localized and the surgical pro-
cedure is usually planned with a complete mobilization of the splenic flexure.

14.2.2.2 Splenic Flexure Mobilization

The inferior mesenteric vein (IMV) is individuated at the level of the inferior
border of the pancreas and a left retromesocolic dissection is carried out. A sta-
ble retraction of the left mesocolon is provided by the robotic grasper on arm 2,
enhancing the saliency of the IMV. The bipolar grasper on arm 3 lifts the vein
up and an incision in the peritoneum is performed below the vein by the robot-
ic monopolar hook or scissors on arm 1; the virtual avascular plane between the
two folds of the Toldt’s fascia is opened. A sharp dissection is carried out in a
medial-to-lateral way along the avascular plane. The root of the transverse
mesocolon, exposed by the assistant by a laparoscopic grasper, is sectioned by
14 Left Colectomy and Segmental Resections for Cancer 135

a b

Fig. 14.1 Robotic left colectomy/splenic flefure resection. a Trocar positioning. 1, monopolar
robotic cautery device (hook or scissors); 2, robotic grasper (Cadiere forceps); 3, robotic bipolar
grasper. b OR setup. (© 2014 Intuitive Surgical, Inc.)

the robotic monopolar hook on arm 1; the bipolar grasper on arm 3 helps this
surgical step by granting a stable tension on the root. This maneuver allows the
opening of the lesser sac, anterior to the pancreas (Fig. 14.2a). The IMV is freed
from the peritoneal envelope by the robotic monopolar hook on arm 1 and sec-
tioned between clips positioned by the assistant or by a robotic clip applier on
arm 1. Medial dissection is carried out to the end of the pancreatic tail; a gauze
may be positioned under the left mesocolon as a marker of the plane of dissec-
tion. Thereafter, the descending colon is retracted medially by the robotic
grasper on arm 1 and by the assistant with a grasper. Lateral mobilization of the
descending colon is achieved by the dissection of the parietocolic ligament per-
formed by the robotic monopolar hook on arm 2. During this step, robotic arm
3 is not utilized. The left colon is then freed laterally in the caudocranial path-
way up to the splenic flexure. The phrenocolic and splenocolic ligament, as well
as the sustentaculum lienis, are sectioned by the robotic monopolar hook on arm
1 and bipolar coagulation. The robotic grasper on arm 3 gently retracts the
spleen laterally with a gauze. Complete mobilization of the splenic flexure is
obtained by dissection of the coloepiploic ligament. Then the transverse colon is
retracted inferiorly by the grasper on arm 1 and by the assistant; the bipolar
grasper on arm 3 lifts the coloepiploic ligament cranially, which is dissected by
the robotic scissors on arm 2.

14.2.2.3 Inferior Mesenteric Artery Dissection with Locoregional

Lymphadenectomy
The assistant pulls upward the dissected IMV with a grasper, while the arch of
the inferior mesenteric artery (IMA) is lifted up and downward by the bipolar
136 P. P. Bianchi et al.

a b

c Fig. 14.2 Left colectomy/splenic flexure resection.

a Opening of the lesser sac and dissection of the
transverse mesocolon root. b Exposure of the infe-
rior mesenteric artery; arm 1, robotic monopolar
hook; arm 2, robotic grasper (outside the operating
field); arm 3, robotic bipolar grasper; assistant, la-
paroscopic grasper keeping inferior mesenteric
vein stump (outside the operating field). c Lym-
phadenectomy at the origin of the inferior mesen-
teric artery; arm 1, robotic monopolar hook; arm 2,
robotic grasper (outside the operating field); arm 3
robotic bipolar grasper; assistant, laparoscopic
grasper keeping inferior mesenteric vein stump
(outside the operating field)

grasper on arm 3, enhancing the shape of the IMA (Fig. 14.2b). The angle
between the IMA and the aorta is opened. This maneuver helps the surgeon to
identify the paraaortic nerves, which lie over the preaortic plane, the surgical
field is clear because of the stable retraction of the IMA by the locked robotic
grasper. A careful dissection of the IMA and a locoregional lymphadenectomy is
carried out preserving the paraortic nerves and the superior hypogastric plexus.
This step is performed with the robotic monopolar hook on arm 1 and bipolar
grasper on arm 3, which work synergically. The articulated tip of the robotic
monopolar hook facilitates dissection of the IMA, which is freed by the sur-
rounding lymphatic tissue, providing an optimal locoregional lymphadenectomy
(Fig. 14.2c). As for the IMV, the IMA is isolated between clips positioned by the
assistant or by robotic clip applier and then sectioned by the robotic scissors on
arm 1 or by the assistant.

14.2.2.4 Distal Transection of the Colon

The site of distal transection is localized about 3cm below the promontory, the
proximal rectum is retracted superiorly and laterally by the robotic grasper (arm
2) and the wall of the rectum is cleaned with bipolar coagulation of the superi-
14 Left Colectomy and Segmental Resections for Cancer 137

or mesorectal fat. The proximal rectum is sectioned with a linear stapler con-
trolled by the assistant. This step can also be performed by a robotic stapler on
arm 1, if available. The anastomosis is fashioned according to the Knight &
Griffen technique. A minilaparotomy is created in the left iliac fossa or supra-
pubically. The descending colon is extracted through the protected incision and
transected proximally. The anvil of a circular stapler is inserted into the colon
stump and fixed by a manual purse-string suture. The colon is then reintroduced
into the abdomen and the minilaparotomy is closed. A laparoscopy is carried
out to perform the transanal end-to-end mechanical colorectal anastomosis.
During this step the robot is undocked, but not deactivated, as it could be use-
ful to perform additional sutures in the case of weak anastomosis.

14.3 Splenic Flexure Resection

14.3.1 Procedure Overview

Splenic flexure resection is a challenging procedure in minimally invasive sur-

gery, both for anatomical and technical aspects [4]. The splenic flexure (SF) is
joined strictly to the spleen by means of the splenocolic ligament and susten-
taculum lienis. This anatomical connection requires colic manipulation to be
performed gently in order to avoid any trauma or bleeding of the spleen, which
is associated to an increased risk of postoperative morbidity. Moreover, there
are some anatomical variables of the SF, such as the so-called “high” or
“bulky” splenic flexure, which are demanding both in laparoscopic and in open
surgery. Another challenging technical aspect in SF resection is vessel and
lymph node dissection. Vascular supply to the SF is carried out by the left colic
artery, originating from the IMA, and the middle colic artery, originating from
the superior mesenteric artery (SMA). Individuation of the two vessels is con-
sidered technically difficult in traditional laparoscopy and depends on the sur-
geon’s experience [5]. Lymphadenectomy involves all the nodes around these
vessels and care should be taken in manipulating the transverse mesocolon dur-
ing dissection around the middle colic vein to avoid venous bleeding. The
anastomosis when performed intracorporeally is another demanding step,
which requires extensive experience in minimally invasive surgery. Robotic
assistance is helpful because it provides a stable three-dimensional vision of
the anatomy, a fine vascular dissection and an easy fashioning of the intracor-
poreal anastomosis.

14.3.2 Patient Positioning and Docking

The patient is placed in the supine position with arms alongside the trunk. A
slight anti-Trendelenburg position with a 10° right tilt are maintained in order to
138 P. P. Bianchi et al.

expose the operative field from the ileal loops. The positioning of trocars, OR
setup, and instruments are the same as for coloctomy (Fig. 14.1a, b).

14.3.3 Step-by-Step Review of Critical Elements of the Procedure

14.3.3.1 Splenic Flexure Mobilization

The procedure starts with the dissection of the IMV and IMA and identifica-
tion of the left colic vein (LCV) and artery (LCA). The stable retraction of the
left mesocolon provided by the robotic grasper on arm 2 and by an assistant
grasper makes it easy to identify the origin of the IMA and then that of the
LCA. Even though it is possible to section only the ascending branch of the
LCA, it is preferable to section the entire artery, as the arterial vascular sup-
ply for the remnant descending colon and of the sigmoid is granted by the sig-
moid vessels, i.e., branches of the IMA. In anatomic favorable patients, IMV
can be preserved by dissecting and sectioning only the LCV, otherwise the
IMV is dissected and sectioned as described in the left colectomy procedure.
Left colic vessels are clipped by the assistant or by the robotic clip applier and
sectioned by the assistant or by the robotic scissors on arm 1. After vascular
dissection the descending colon and the splenic flexure are completely mobi-
lized following the same steps described in left colectomy. The mobilization
of the left colon is performed up to the sigmoid loop, as far as possible, in
order to avoid any tension of the anastomosis. At this step, robotic arm 2 is
not utilized.

14.3.3.2 Dissection of the Left Branch of the Middle Colic Vessels and
Locoregional Lymphadenectomy
During this phase robotic arm 2 is turned upward and the robotic grasper main-
tains the distal transverse colon retracted, exposing the transverse mesocolon
and facilitating vascular dissection. The assistant pulls the transverse colon
upward providing tension on the root of the transverse colon. The identification
of the middle colic vessels (MCV) starts at the level of the origin from the supe-
rior mesenteric axis near the inferior margin of the pancreas. The bipolar grasper
on arm 3 provides a stable tension of the middle colic vessels and a precise iso-
lation of the left branch of the MCV is performed by the robotic electrocautery
hook on arm 1. The vessels are clipped by the assistant or by the robotic clip
applier and sectioned by the robotic scissors on arm 1.

14.3.3.3 Transection of the Transverse and Descending Colon and

Anastomosis
Once the SF has been mobilized and vascular dissection has been performed, the
transverse colon and the left colon are transected by the assistant with a laparo-
14 Left Colectomy and Segmental Resections for Cancer 139

scopic linear stapler. The use of both laparoscopic and robotic instruments per-
mits a wider angle of motion and allows an easy transection of both the descend-
ing and transverse colon. After transection a stitch is placed to join together the
colonic stumps; the wide articulation of the tip of the robotic needle-holder
facilitates the intraoperative knotting, reproducing precise movements as in
open surgery (Fig. 14.3a). The robotic bipolar gasper on arm 3 holds the
descending colon stump while a colotomy is performed at the level of the tenia,
with the robotic monopolar hook on arm 1. Then the assistant holds the trans-
verse colon stump and a second incision is perfomed at the level of the tenia of
the transverse colon stump, again with the robotic monopolar hook on arm 1.
The laparoscopic linear stapler is introduced by the assistant through the trocar
in the right flank and the surgeon at the console helps the introduction of the two
branches of the stapler inside the colonic stumps with the robotic grasper on arm
1 and 3. A colo-colic side-to-side mechanical anastomosis is then performed
(Fig. 14.3b). The vascular perfusion of the site of the colic transection can be
evaluated by the use of indocyanine fluorescence and near-infrared image, if
available, in order to reduce the risk of an ischemic anastomotic damage [6]
(Fig. 14.3c). Thereafter, the entry hole of the stapler is closed by two running
sutures starting from the opposite angles. The robotic grasper on arm 2 pulls the
tail of the upper suture up favoring a stable position of the anastomosis, thus
facilitating the closure of the defect. The first running suture is performed from
the inferior angle upward. The tail of the upper suture and the inferior suture are
tied together. After completing the first layer, the second suture is performed
from the upper angle downward. As for the first layer, the upper suture is tied
with the tail of the inferior suture; the wide articulation of the robotic needle-
holder facilitates knot-tying (Fig. 14.3d). Then the robot is disconnected from
the patient and a suprapubic minilaparotomy is performed through which the
specimen is extracted inside a bag and with the placement of a wound protector.

14.4 Transverse Colon Resection

14.4.1 Patient Positioning and Docking

The patient is placed in anti-Trendelenburg position with the arms along the
trunk and the legs abducted with a slight tilt to the right, which allows the small
bowel to roll off the operative field (Fig. 14.4a).
The procedure starts with the insertion of the Veress needle in the left
hypochondrium through which a 12-mmHg pneumoperitoneum is induced. A
12-mm standard laparoscopic trocar is placed 2cm right of the midline along an
ideal line passing through the left anterosuperior iliac spine and the right
hypochondrium. The procedure is performed with a five-trocar technique: three
8-mm robotic trocars and two 12-mm laparoscopic trocars. Three 8-mm trocars
140 P. P. Bianchi et al.

a b

d
Fig. 14.3 Splenic flexure resection. a Approach of the transverse and descending colonic stumps
by a stitch. b Fashioning of a side-to-side colo-colonic anastomosis by linear stapler. c Evaluation
of colo-colonic anastomosis perfusion by fluorescence and near-infrared imaging. d Robotic su-
ture of the service hole, after stapler colo-colonic side-to-side anastomosis

are placed in the left and right hypochondrium, and in the right flank, respective-
ly. A 12-mm trocar is placed in the left flank for the assistant. The robotic cart
approaches the operative table from the patient’s head and the robotic arms are
14 Left Colectomy and Segmental Resections for Cancer 141

a b
Fig. 14.4 Robotic transverse colonic resection. a OR setup. b Trocar positions. 1, monopolar
robotic cautery device (hook or scissors); 2, robotic grasper (Cadiere forceps); 3, robotic bipolar
grasper. (© 2014 Intuitive Surgical, Inc.)

connected to the trocars, starting from the camera. Arm 1 is connected to the tro-
car in the left hypochondrium, arm 2 is connected to the trocar in the right
hypochondrium, while arm 3 is connected to the trocar in the right flank (Fig.
14.4b). The initial instrument positions are configured as follows: the monopo-
lar hook/scissors are mounted on arm 1, the robotic grasper on arm 2 and the
robotic bipolar grasper on arm 3.

14.4.1.1 Dissection of the Middle Colic Vessels and Locoregional

Lymphadenectomy
The greater omentum is pulled up by the surgeon with the robotic graspers on arms
1 and 2, helped by the assistant with a laparoscopic grasper, to expose the trans-
verse colon and to identify the correct site of the tumor. The transverse colon is
pulled up by the robotic grasper on arm 2, thus enhancing the middle colic vessels
and exposing the ligament of Treitz and the root of the transverse colon. The latter
is incised by the robotic monopolar hook on arm 1 at the origin of the main trunk
of the middle colic vessels toward the end of the pancreatic tail. The lesser sac is
opened. The bipolar grasper on arm 3 gently provides a stable tension on the ves-
sels, facilitating the dissection and locoregional lymphadenectomy. The robotic
monopolar hook on arm 1 allows circumferential isolation of the main trunk of the
middle colic vein, which is clipped by the assistant or by the robotic clip applier
and sectioned by the assistant or by the robotic scissors on arm 1. Dissection of the
transverse mesocolon continues in a medial-to-lateral pathway. The robotic grasper
on arm 2 grants a stable tension on the transverse colon and mesocolon; the robot-
142 P. P. Bianchi et al.

ic bipolar grasper on arm 3 pulls up the mesocolon while the robotic monopolar
hook or scissors on arm 1 perform a dissection of the transverse mesocolon from
the posterior peritoneal layer toward the right colic flexure. Dissection of the trans-
verse mesocolon is now achieved, resembling a V-shape with the base on the trans-
verse colon, which is now pulled down.

14.4.1.2 Mobilization of the Left and Right Colic Flexures and of the
Transverse Colon
The assistant provides a medial retraction of the proximal part of the descend-
ing colon and of the splenic flexure, as well as the bipolar grasper on arm 2,
while the parietocolic ligament is sectioned by the robotic monopolar hook up
to the left colic flexure. The phrenocolic and splenocolic ligament, as well as the
sustentaculum lienis, are sectioned by a robotic monopolar hook on arm 1. The
assistant now pulls the transverse colon down with a grasper, while the robotic
bipolar grasper on arm 2 lifts up the proximal side of the gastrocolic ligament.
The ligament is then dissected below the gastroepiploic vessels by the robotic
monopolar hook on arm 1 up to the right flexure. The right colon is then retract-
ed medially by the assistant by a laparoscopic grasper and by the robotic grasper
on arm 3, allowing the dissection of the right parietocolic ligament, performed
by the robotic monopolar hook on arm 2. Total mobilization of both the right and
left colic flexures and of the transverse colon is completed without changing the
docking of the robot.

14.4.1.3 Transection of the Transverse Colon and Anastomosis

The assistant transects the transverse colon with a laparoscopic linear stapler on
both left and right side. The right and the left colon are joined by the robotic
graspers on arms 1 and 2. Both the two colonic stumps are opened at the distal
part by robotic scissors on arm 1 and an intracorporeal colo-colonic end-to-end
anastomosis is performed with a double running suture (Fig. 14.5). The robotic
grasper on arm 3 holds the right colon and the assistant holds the left colon with
a grasper during this step. The articulation of the tip of the robotic needle-hold-
ers is an advantage in fashioning intracorporeal manual end-to-end anastomoses,
as well as the three-dimensional view provided by the robotic system.

14.4.2 Advantages, Limitations and Relative Contraindications

The first robot-assisted colectomy was reported by Weber et al. in 2002 [6].
Since then several reports on robotic colorectal surgery have been published, but
originating mainly from single-center experiences. In Table 14.1, the results are
reported of the studies with more than 10 cases of robotic colonic resections. In
all of these studies the main significant data was that robotic surgery resulted in
a lower percentage of conversion to open surgery, compared to the laparoscopic
14 Left Colectomy and Segmental Resections for Cancer 143

Fig. 14.5 Robotic transverse colonic resection. Robotic sewing end-to-end colo-colonic anasto-
mosis

groups. Regarding short-term clinical and oncologic outcomes, no significant

differences were found between laparoscopy and robotic surgery (Table 14.1)
[7–15]. Advantages of robotic assistance in mobilizing the left colic flexure have
been reported [11]. In the case of a high splenic flexure, the focused three-
dimensional vision allows the correct identification of the flexure borders and its
relation to the spleen, while a gentle traction on the spleen is granted by the
robotic arm, avoiding the risk of splenic rupture or laceration. The improved
dexterity of the instruments favors a precise tissue dissection and facilitates the
intracorporeal fashioning of the anastomosis. The operative time was longer
than those of laparoscopy, especially, in the first experiences, ranging from 162
to 383minutes. Most of the authors reported that the docking/setup time was the
main cause of longer operative time, beside the time spent for the learning curve,
which has been demonstrated, however, to be shorter than the laparoscopic tech-
nique. Multiquadrant procedures have been claimed to be challenging if per-
formed by robotic assistance, but if a redocking of the robot was necessary in the
early experiences, to date, several multiquadrant surgeries have been carried out
by switching one or more robotic arms without the need to redock the robot,
with a reduction in the overall operative time.
One of the main concerns about robotic technology is the high cost of the
purchase and maintenance of the equipment. Baek et al. [16] showed increased
costs in robotic rectal resection compared to those in the standard laparoscopic
procedure, with a significantly lower hospital profit in the robotic group.
Another emerging problem is the appropriate use of the technology by low-
volume centers/surgeons, in fact a higher number of complications are reported
Table 14.1 Published and personal series on robotic colonic surgery with more than 10 cases
144

Year Study Type of study Total No. Mean Postoperative Conversion Mortality Type of
[Reference] of patients operative complications n (%) n (%) procedure
time (min) n (%)
2004 D’Annibale [7] Comparative 53 240 4 0 0 17 LC, 11 SC
2006 DeNoto [8] Case Series 11 197 2 1 0 11 SC
2006 Rawlings [9] Case Series 30 225 6 2 (LPT) 0 13 SC
2008 Soravia [10] Case Series 40 162 3 5 (3 LPS, 2 LPT) 0 28 SC
2008 Spinoglio [11] Comparative 50 383 7 2 (1 LPS, 1 LPT) 0 10 LC
2009 Luca [12] Case Series 55 290 12 0 0 27 LC
2011 Huettner [13] Case Series 102 229.7 19 0 0 43 SC
2011 Patel [14] Comparative 30 247 4 0 0 23 SC
2013 Helvind [15] Comparative 101 243 22 5 1 12 LC, 34 SC
2013 Bianchi Case Series 31 270 2 0 0 11 LC, 6 SF, 1
(unpublished TCR, 13 SC
data)
Total 503 248 81 (16) 15 (2.9) 1 (0.2) 66 LC, 150 SC
LC, left colectomies; SC, sigmoidectomies; TCR, transverse colon resection; LPT, laparotomy; LPS, laparoscopy; SF, splenic flexure resection
P. P. Bianchi et al.
14 Left Colectomy and Segmental Resections for Cancer 145

by Keller et al. [17] in the low volume users when compared to middle- and
high-volume centers and surgeons.
Although the results available on robotic surgery are still few, robotic assis-
tance seems to reduce the percentage of conversions to open surgery among
expert surgeons and is promising as a method to attenuate the learning curve of
more difficult procedures, such as segmental and splenic flexure resections with
intracorporeal anastomosis. At the moment, the robotic system has higher costs
than laparoscopy and its use should be planned within the remit of a clearly-
defined educational program, preferably in a hospital conducting middle/high
volumes of minimally invasive surgery and colorectal procedures, in order to
avoid an increase in complication rates.

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1. Kang CY, Halabi WJ, Luo R et al (2012) Laparoscopic colorectal surgery. A better look to
the latest trends. Arch Surg 147:724–731
2. The Surgical Care and Outcomes Assessment Program (SCOAP) Collaborative, Kwon S,
Billingham R, Farrokhi E, Florence M, Herzig D, Horvath K, Rogers T, Steele S, Symons,
Thirlby S, Whiteford M, Flum D (2012) Adoption of laparoscopy for elective colorectal re-
section: a report from surgical care and outcomes assessment program. J Am Coll Surg
214:909–918
3. Bianchi PP, Pigazzi A, Choi GS (2014) Clinical Robotic Surgery Association Fifth Worldwide
Congress, Washington DC, 3–5 October 2013: Robotic Colorectal Surgery. Ecancermed-
icalscience 8:385
4. Schlachta CM, Mamazza J, Poulin EC (2007) Are transverse colon cancers suitable for la-
paroscopic resection? Surg Endosc 21:396–399
5. Kim HJ, Lee IK, Lee YS et al (2009) A comparative study on the short-term clinicopatholog-
ic outcomes of laparoscopic surgery versus conventional open surgery for transverse colon
cancer. Surg Endosc 23:1812–1817
6. Weber PA, Merola S, Wasielevski A, Ballantyne GH (2002) Telerobotic-assisted laparoscop-
ic right and sigmoid colectomies for benign disease. Dis Colon Rectum 45:1689–1694
7. D’Annibale A, Morpurgo E, Fiscon V et al (2004) Robotic and laparoscopic surgery for
treatment of colorectal diseases. Dis Colon Rectum 47:2162–2168
8. DeNoto G, Rubach E, Ravikumar TS (2006) A standardized technique for robotically performed
sigmoid colectomy. J Laparoendosc Adv Surg Tech A. 16:551–556
9. Rawlings AL, Woodland JH, Crawford DL (2006) Telerobotic surgery for right and sigmoid
colectomies: 30 consecutive cases. Surg Endosc 20:1713–1718
10. Soravia C, Schwieger I, Witzig JA et al (2008) Laparoscopic robotic-assisted gastrointestinal
surgery: the Geneva experience. J Robotic Surg 1:291–295
11. Spinoglio G, Summa M, Priora F et al (2008) Robotic colorectal surgery: first 50 cases ex-
perience. Dis Colon Rectum 51:1627–1632
12. Luca F, Cenciarelli S, Valvo M et al (2009) Full robotic left colon and rectal cancer resection:
technique and early outcome. Ann Surg Oncol 16:1274–1278
13. Huettner F, Pacheco PE, Doubet JL et al (2011) One hundred and two consecutive robotic-
assisted minimally invasive colectomies—an outcome and technical update. J Gastrointest Surg
15:1195–1204
14. Patel CB, Ragupathi M, Ramos-Valadez DI, Haas EM (2011) A three-arm (laparoscopic, hand-
assisted, and robotic) matched-case analysis of intraoperative and postoperative outcomes in
minimally invasive colorectal surgery. Dis Colon Rectum 54:144–150
146 P. P. Bianchi et al.

15. Helvind NM, Eriksen JR, Mogensen A et al (2013) No differences in short-term morbidity
and mortality after robot-assisted laparoscopic versus laparoscopic resection for colonic can-
cer: a case-control study of 263 patients. Surg Endosc 27:2575–2580
16. Baek SJ, Kim SH, Cho JS et al (2012) Robotic versus conventional laparoscopic surgery for
rectal cancer: a cost analysis from a single institute in Korea. World J Surg 36:2722–2729
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tal surgery by provider volume. J Am Coll Surg 217:1063–1069
Hybrid Robotic Technique for
Rectal Cancer: Low Anterior Resection 15
and Perineal Resection

Timothy F. Feldmann, Raul M. Bosio, and Alessio Pigazzi

15.1 Introduction
Colorectal cancer is the third most commonly diagnosed cancer with over 1.4
million new cases each year [1]. As surgical technology has evolved so has the
treatment for this disease. Rectal cancer resection is complicated by the anatom-
ic configuration of the pelvis and the proximity of these tumors to the anus.
Evolving optics have allowed for the increased use of laparoscopy to allow for
better visualization during pelvic surgery however its use was not implemented
initially. Both the technical challenge of laparoscopic rectal surgery and the
concern over oncological outcome have made its widespread adoption limited.
As more surgeons gain comfort with advanced laparoscopic techniques the only
concern is of the oncologic benefit [2–4]. The Conventional vs. Laparoscopic-
Assisted Surgery in Colorectal Cancer (CLASICC) trial examined oncologic
outcomes between laparoscopic and open rectal resections. Laparoscopic resec-
tion was associated with a higher rate of positive circumferential margin; how-
ever this did not translate into an increase in local recurrence when compared to
the open procedures [5]. Long-term follow-up from the CLASICC trial has con-
tinued to provide support for the safe use of laparoscopy in colon and rectal can-
cer. The overall survival at 5 years after a low anterior resection was 56.7% in
the open group and 62.8% in the laparoscopic one; abdominal perineal resection
showed similar results with an overall survival of 41.8% in open cases and
53.2% in laparoscopic cases [6]. The Colorectal cancer Laparoscopic or Open
Resection (COLOR II) trial has also advanced the use of laparoscopy and
helped to show similarity in the completeness of mesorectal resection with a

A. Pigazzi (
)
Department of Surgery, University of California Irvine,
Irvine, CA, USA
e-mail: [email protected]

G. Spinoglio (Ed), Robotic Surgery: Current Applications and New Trends, 147
Updates in Surgery
DOI: 10.1007/978-88-470-5714-2_15, © Springer-Verlag Italia 2015
148 T. F. Feldmann et al.

10% rate of positive circumferential resection margin independent of the tech-

nique when specimens from patients randomly assigned to laparoscopy or open
resection were analyzed [7].
Robotic surgery is still an evolving field but multiple factors make its use in
rectal surgery appealing. The bony confines of the pelvis can lead to many dif-
ficulties including the inability to visualize structures or perform standard
maneuvers used frequently in other body cavities. Patient factors such as obesi-
ty, large tumors, or a narrow male pelvis can make resection complex. The
robotic platform allows for improved visualization especially as a result of the
three-dimensional optics. Furthermore, surgical precision in these locations can
be enhanced with the “wrist–like” functions that provide multiple degrees of
freedom in instrument movement thus facilitating dissection. Robotic rectal
resections have tended toward lower conversion rates than similar laparoscopic
cases. Conversion rates from laparoscopic series have ranged from 1–17% but
usually falling in the 10–15% range [10]. Results from previously published
series show robotic resection to be feasible with adequate mesorectal excision
[8–10]. Further randomized studies such as the Robotic versus Laparoscopic
Resection for Rectal cancer (ROLARR) trial are underway to examine the use of
robotics in an oncologic setting with a primary endpoint of determining conver-
sion rates, as well as secondary endpoints regarding completeness of the
mesorectal resection, genitourinary function and oncologic adequacy.

15.2 Procedures Overview

Rectal cancer resections at our institution are now commonly undertaken with a
hybrid laparoscopic and robotic approach. The procedure is initiated with
laparoscopic mobilization of the left colon, usually with takedown of the splenic
flexure. This portion of the procedure can be accomplished robotically but we
feel that this does not allow for the most effective use of resources, as operating
room time may be prolonged when compared to performing this part of the oper-
ation laparoscopically. Laparoscopy allows for table positioning changes which
may aid in the dissection of the descending colon and takedown of the splenic
flexure. Single docking robotic procedures are feasible [11, 12] however they
may not place the trocars in ideal positions for difficult pelvic dissection or be
used on every patient. With surgeons unfamiliar with this technique, it may lead
to repeated robotic docking procedures which increase operative time. It must
also be stressed that prolonged Trendelenburg positioning is undesirable as it has
been associated with several potential adverse consequences including lower
extremity compartment syndrome and blindness. Following mobilization of the
left colon and division of the inferior mesenteric artery (IMA) and vein (IMV),
the robotic platform is docked and proctectomy is undertaken. Depending on the
15 Hybrid Robotic Technique for Rectal Cancer: Low Anterior Resection and Perineal Resection 149

patient’s factors (i.e., incontinence) and tumor location, low anterior or abdom-
inal perineal resection can be completed after total mesorectal excision has been
performed. The robot is then undocked and the perineal or reconstructive por-
tion of the operation may be accomplished. We outline the basic steps in our
approach below.

15.3 Patient Selection and Preoperative Factors

The operating surgeon must be prepared for multiple challenges based on each
patient he or she encounters. Preoperative discussion of the possible outcomes
including type of procedure, the possibility of conversion, and surgical risks
must be undertaken. Early discussions about temporary or permanent ostomy
placement and future rectal function will allow patients to better understand the
changes that they may undergo. Tumor location and staging is essential;
endorectal ultrasound and/or pelvic MRI should be considered as part of the
staging studies. Preoperative chemoradiation is indicated for lymph node posi-
tive disease and/or selected T3 or higher disease. We advocate the surgeon to
perform his or her own evaluation with either digital rectal exam or endoscopy
(flexible or rigid). This can help identify unforeseen technical challenges, such
as the need for a partial or total trans-sphincteric resection, and can assist in
operative planning.

15.4 OR Setup and Patient Positioning

Preoperative setup of the operating theater will help with facilitating an easy
transition from laparoscopy to robotic surgery. The patient should be positioned
in the center of the room on the operating table. The patient will need to be in a
modified lithotomy position in a movable stirrup with adequate padding of the
extremities. The right arm must be tucked at side to allow room for the operat-
ing surgeon; we prefer to tuck both arms at side during these operations to pro-
vide more space. We recommend the use of high density foam that is strapped to
the operating room table to prevent the patient from sliding during steep posi-
tioning. A strap across the chest is also needed to prevent lateral sliding. Ideally
a room with multiple integrated monitors should be available with a monitor
placed on each side of the operating table. The laparoscopic equipment along
with electrocautery devices and suction should be positioned at the patient’s left
shoulder. The scrub technician and instrument table will be set back off the
patient’s right side and right shoulder. The robotic equipment and tower should
be to the side of the patient’s right leg. The robot itself should be sterilely draped
and available to be docked at the patient’s left hip. The robotic console can be
placed at the surgeon’s preference (Fig. 15.1).
150 T. F. Feldmann et al.

Fig. 15.1 OR setup for hybrid

robotic rectal resection. (© 2014
Intuitive Surgical, Inc.)

15.5 Port Placement

The abdomen is then entered in the surgeon’s standard fashion for laparoscopy.
We prefer a single small incision at Palmer’s point in the left upper quadrant.
The abdomen is insufflated through a Veress needle to 15mmHg and an initial
12-mm camera port is placed. This should ideally be placed halfway between the
xyphoid and the pubic symphysis in the midline. Preference should be given to
lower placement at about 20cm above the pubis in patients with longer torsos.
This allows for better visualization deep in the pelvis without disturbance from
the sacrum. After camera placement the robotic and assistant trocars are then
placed under direct vision.
Anatomic landmarks are then identified and marked with a surgical marker.
The right and left anterior superior iliac spines (ASIS) are identified. An oblique
line should be drawn from the camera port to each ASIS bilaterally. This will
create two equal sides of a triangle. The port for arm 1 on the robot (R1) should
be placed at least 8–10cm (four finger breadths) away from the camera port on
the line connecting the camera port to the right-sided ASIS. This port can be kept
closer to the midline to allow for dissection within the pelvis without losing
mobility on the pelvic sidewall. A 12-mm trocar should be placed to allow for
future placement of a laparoscopic stapling device if needed. If robotic stapling
technique is used, a 15-mm trocar is placed instead. When docking the robot, an
8-mm robotic trocar is placed within this trocar (trocar in trocar technique) to
15 Hybrid Robotic Technique for Rectal Cancer: Low Anterior Resection and Perineal Resection 151

Fig. 15.2 Placement of ports: an oblique

line should be drawn from the camera port
to each ASIS bilaterally. The R1-port is
placed at least 8–10cm (four finger widths)
away from the camera port on the line
previously described. R2-port is in a mirror
position to R1, on the left. R3 is placed
8–10cm (four finger widths) lateral to R2.
Two 5mm laparoscopic assistant ports are
placed as shown. (© 2014 Intuitive Surgi-
cal, Inc.)

allow for docking of the robotic arm.

Robotic arm 2 (R2) is placed in an identical fashion on the left side of the
abdomen. The line connecting the camera port and the left ASIS should be used
as a guide to place this port and as with the first port it should be located at least
8–10cm away from the camera port. An 8-mm robotic port is placed at this site.
Robotic arm 3 (R3) is also placed along the left side of the abdomen. The site
is chosen directly lateral to R2 at least 8–10cm away. This will be located above
the left ASIS and not on the previously made guidance line. Another 8-mm
robotic port is placed at this location.
R2 and R3 are not necessary during the laparoscopic portion of the procedure but
can allow for extra access points for retraction and dissection if placed at this time.
Two laparoscopic assistant ports are then placed, which will be used for both
portions of the procedure. The first laparoscopic port (L1) is placed in the right
abdomen. Positioning should be approximately 10–12 cm lateral to the camera
port and a similar distance superior to the R1 port. The second laparoscopic port
is placed just off of the midline (either right or left) high in the epigastric region.
This should be at least 8–10cm away from all other laparoscopic ports (Fig. 15.2).

15.6 Laparoscopic Mobilization of the Left Colon and Splenic

Flexure
After visual inspection of the abdomen, attention is turned to the left colon. A
medial-to-lateral approach is used to mobilize this region. Either the inferior
152 T. F. Feldmann et al.

Fig. 15.3 Dissection plane beneath the inferior mesenteric vein. The pancreas is visible at the left
edge of the picture. The inferior mesenteric artery will be found as dissection is carried toward the
right edge of the picture

mesenteric vein (IMV) or the inferior mesenteric artery (IMA) can be isolated
first and patient positioning should be changed as needed to allow for visualiza-
tion. We find that identification of the IMV near the ligament of Treitz allows for
development of the appropriate plane between the mesocolon and the retroperi-
toneum. The vein is identified lateral to the ligament of Treitz and the peri-
toneum below it is incised. Blunt dissection is carried laterally and inferiorly
until the IMA is encountered. This dissection plane will be bordered anteriorly
by the IMV and colonic mesentery, posteriorly by the retroperitoneum, superior-
ly by the pancreas, and inferiorly by the takeoff of the IMA (Fig. 15.3).
Dissection is carried out within this space. Care should be taken if the dissection
plane is continued superiorly as the natural dissection plane will continue under-
neath the pancreas. If this course is chosen then the surgeon will need to “step
up” over the pancreas to avoid injury to the splenic vessels. Dissection over the
pancreas can be accomplished later and therefore we recommend that blunt dis-
section be continued laterally and inferiorly until the IMA is reached.
Mobilization of the splenic flexure will be completed once the lateral attach-
ments have been divided. The IMV can be ligated at any point during the dissec-
tion through a variety of means (clips, staplers, bipolar cautery devices). Traction
must be avoided on the vein and earlier division can avoid an avulsion injury.
Once the superior aspect of the IMA is identified, the sigmoid colon is grasped
and retracted toward the anterior abdominal wall. The superior rectal artery
should be seen coursing through the mesenteric plane. Opening the peritoneum
underlying this pedicle will allow for blunt dissection of the mesocolon once
15 Hybrid Robotic Technique for Rectal Cancer: Low Anterior Resection and Perineal Resection 153

Fig. 15.4 Dissection plane beneath the superior hemorrhoidal artery. To the left of the picture is
the pedicle of the inferior mesenteric artery. The ureter is coursing directly through the middle of
the retroperitoneal plane

again. This dissection is again taken laterally and identification of the ureter and
gonadal vessels is paramount. These structures should be kept on the retroperi-
toneal side of the dissection. Visualization of the psoas muscle tendon often
implies a “deep” dissection and the ureter may have been swept into the tissue of
the mesocolon. Once this plane has been fully developed it should expose the
origin of the IMA and its branch point into the left colic and superior rectal
artery. This dissection plane will now be bordered superiorly by the IMA pedi-
cle, inferiorly by the mesorectum, anteriorly by the superior rectal artery and
mesocolon, and posteriorly by the retroperitoneum (Fig. 15.4). The ureter and
gonadal vessels travel in a crania-caudal direction within this area of the
retroperitoneum. In order to allow optimal mobilization of the left colon, as well
as to provide appropriate oncologic resection, the IMA should be taken at its ori-
gin. A classic view in the shape of a “T” should be seen at this point (Fig. 15.5).
The IMA will be the body of the T with the left colic artery as the left branch and
the superior rectal artery as the right branch. These structures should be free of
the retroperitoneum so that the ureter is not taken with the artery. Just as with the
IMV, the IMA can be taken using the surgeon’s preferred method.
Once the mesocolon has been dissected from the medial side, the lateral
colonic attachments must be taken down. The white line of Toldt is incised and
carried superiorly toward the splenic flexure. The omental attachments to the
descending colon should be taken as well. Dissection can continue from this
direction or it may also be approached from the transverse colon. This allows
mobilization of the omentum off of the colon and then entrance into the lesser
154 T. F. Feldmann et al.

Fig. 15.5 Classic view of “T”. The inferior mesenteric artery branches into the left colic (left
side) and the superior hemorrhoidal artery (right side). Both previous dissection planes can be
visualized

sac. The colon is retracted toward the midline and the splenocolic ligament is
taken down to allow for full mobilization of the flexure. This step will ensure
adequate colonic length to construct a tension free anastomosis once the resec-
tion is completed. After the mobilization is completed the patient is prepared for
docking of the robot.

15.7 Robotic Rectal Resection

Prior to docking, the patient must be placed in the appropriate position. Once the
robot is in place, rotation of the table is not possible. The patient should be
placed in the Trendelenburg position with the left side up. This will allow the
small bowel to fall out of the pelvis and not interfere with the rectal dissection.
If adhesions are present and are fixing the small bowel to the lateral pelvic wall,
the surgeon should divide them prior to docking to avoid small bowel injury by
the robotic arms. An 8-mm trocar should be placed inside the 12mm R1 port to
prepare for docking. The robot is brought in from the patient’s left side. Aligning
the central column, with the ASIS and right shoulder should allow for optimal
docking and adequate spacing between robotic arms. The robotic arms are then
docked and a 0° camera is placed through the camera port. The remaining robot-
ic instruments are then inserted under direct visualization and directed toward
the pelvis. A typical instruments setup is as follows:
15 Hybrid Robotic Technique for Rectal Cancer: Low Anterior Resection and Perineal Resection 155

• R1 – monopolar scissors
• R2 – bipolar fenestrated grasper
• R3 – ProGraspTM grasper
• L1 – suction irrigation device
• L2 – locking grasper (i.e., Davis & Geck)
The laparoscopic instruments will be used by the assistant, who will stay at
the patient’s right side. The operating surgeon should now proceed to the robot-
ic console. The assistant should grasp the upper rectum with the locking grasper
to allow for retraction throughout this part of the procedure.
Dissection of the mesorectum is then undertaken. Care should be taken to
stay in the avascular plane that exists between the endopelvic visceral fascia and
endopelvic parietal fascia. This will help to avoid the hypogastric nerve plexus
and sacral venous plexus located deep in the parietal layer within the presacral
space. R2 is used during this portion to provide upward traction on the mesorec-
tum while the assistant places countertraction with the suction device when able.
This allows for dissection to be carried out in the avascular plane posteriorly.
Frequent repositioning of R2 to maintain adequate countertraction will allow the
dissection plane to be continued to the level of the pelvic floor and for the later-
al stalks to be identified. R2 should be used with the wrist joint in an L shape to
allow for a larger surface area of retraction. The lateral stalks are then subse-
quently taken and dissection is carried onto the anterior surface of the rectum.
Here the vagina or the seminal vesicles and prostate are dissected free and pro-
tected. R3 should be used as a static retractor to move these structures anterior-
ly using a similar wrist configuration as used previously with R2. As the middle
rectal vessels are encountered they can be taken with bipolar cautery. The auto-
nomic nerves lie laterally on the pelvic sidewalls and should be kept free of the
dissection plane. The mesorectal excision continues downward in a cylindrical
fashion until past the level of the lesion. If no margin is feasible then dissection
should be carried as far as possible to allow for an easier perineal dissection. As
the plane below the mesorectum is reached (bare rectum area) further dissection
will lead to the intersphincteric plane. If a margin is obtainable, the rectum is
divided using a 45-mm stapler in either an anterior-posterior or right-to-left
fashion. Ideally, one or two loads are required. Once the rectum is free it is
grasped with the locking grasper at the site of the staple line and the robot can
be removed.

15.8 Anastomosis and Reconstruction

If a distal margin is obtained then the specimen must be extracted.
• Abdominal extraction: If the rectum has been divided under robotic visual-
ization then our preferred extraction site is through a mini Pfannenstiel inci-
sion. This is performed in a muscle sparing fashion and a wound protector is
then placed. The specimen is brought out and transected extracorporeally. A
156 T. F. Feldmann et al.

purse-string suture is placed in the remaining portion and an anvil inserted.

This is then returned to the abdomen and the Pfannenstiel incision is closed
in multiple layers. If desired, certain wound protectors allow for reinsuffla-
tion of the abdomen without the need to close the incision. This allows for
prompt reentry should the need arise. A standard end-to-end anastomosis
(EEA) is then performed. If adequate colonic length is present, a colonic J-
pouch can be constructed.
• Transanal extraction: In selected cases, consideration can be taken for
transanal extraction. If an intersphincteric approach is planned, we usually
perform this part of the operation first with the patient in the prone position.
The rectum is divided circumferentially and then the suture closed to avoid
spillage. Dissection is continued in the posterior plane toward the lower coc-
cyx. A sponge is then placed in this location and will be encountered during
the abdominal portion of the procedure. A decision to proceed with a
transanal extraction can also be made after the robotic portion has been com-
pleted. In this case, the rectum is divided transanally after placement of a
LonestarTM retractor. A hand-sewn coloanal anastomosis can then be per-
formed.
• A circular anastomosis can also be created if enough distal rectum is present.
A purse-string suture is placed and an anvil inserted in the proximal colon
and then it is returned to the abdomen. A second purse-string is then created
in the distal rectum and secured around the pin of the EEA circular stapler.
An end-to-end or colonic J-pouch to distal rectal anastomosis is then con-
structed under laparoscopic guidance.
It is our standard practice to perform a leak test with a flexible endoscope
after any pelvic anastomosis. This allows for both air testing as well as visuali-
zation of the site. In selected cases, fluorescein angiography is performed to
ensure adequate blood supply. If there is concern over the connection there must
be consideration for the anastomosis to be undertaken again. We also perform a
diverting ileostomy in all high-risk patients or those with an anastomosis within
7–8 cm of the anal verge. The R1 port site is enlarged and a loop of ileum is
brought out with laparoscopic assistance. A pelvic drain may be placed through
any of the other port sites in the lower abdomen if the surgeon desires. The
laparoscopic ports are closed and the ileostomy is matured in standard Brooke
fashion.

15.9 Perineal Resection

Once mobilization of the colon is completed, the bowel is divided intracorpore-

ally using Endostaplers. It is important to have adequate mobilization so that the
colon can be divided in such a fashion that the origin of the IMA is included in
15 Hybrid Robotic Technique for Rectal Cancer: Low Anterior Resection and Perineal Resection 157

the specimen side and an end colostomy can be constructed without tension.
Once the abdominal portion of the procedure is completed, and the focus shifts
to the perineal resection, two options are available from a patient positioning
standpoint. The choice can be made based on surgeon preference; however loca-
tion of the tumor may assist in decision making. Tumors located in the posteri-
or portion of the rectum may be more easily approached from the lithotomy
position while anterior or lateral lesions may be more amenable to prone posi-
tioning.
• If a decision is made to continue the operation in the lithotomy position. The
legs are raised and a perineal incision outside the external sphincters is per-
formed circumferentially. Dissection is carried superiorly and the levator ani
divided. Starting the dissection posteriorly, toward the coccyx, allows for
discovery of the superior plane of dissection. The rectum is then cleared cir-
cumferentially. Once free, the specimen can be extracted through the perineal
incision. Closure of the perineal wound can then be performed, ideally in
multiple layers. If preferred, tissue flaps, such as a vertical rectus abdominus
myocutaneous (VRAM) flap, gluteal flap, or a gracilis flap can be transposed
for reinforcement. The defect is closed and an end colostomy is brought out
laparoscopically. The R2 port can be upsized into a permanent colostomy site
with maturation in standard fashion after the laparoscopic sites are closed.
• The second option involves repositioning into the prone position for the per-
ineal resection. Some studies would suggest this provides a better circumfer-
ential resection margin as opposed to lithotomy [13, 14]. In this case, and as
mentioned above, laparoscopic or robotic stapling is used to transect the
colon at the desired location and is then brought out through the R2 site as
an end colostomy prior to changing to a prone position. Ports are then
removed and the incisions closed and dressed prior to maturation of the
colostomy. After the abdominal portion is complete the patient is then repo-
sitioned into a prone jackknife position. Again a circumferential incision is
made outside the level of the external sphincter and dissection is carried
down in an extralevator fashion until the dissection planes are joined. The
specimen can then be extracted and the wound closed as per the surgeon’s
preference.

15.10 Conclusions
Robotic platforms have created new opportunities for rectal surgery. Through
our experience we have found a hybrid laparoscopic and robotic approach that
is safe, feasible, and efficacious. This technique allows us to tailor our approach
for each patient and the location of the tumor. As technology moves forward and
further research emerges, robotic rectal cancer surgery will allow for excellent
cosmetic, oncologic, and overall outcomes.
158 T. F. Feldmann et al.

References
1. Ferlay J, Soerjomataram I, Ervik M, Dikshit R, Eser S, Mathers C, Rebelo M, Parkin DM,
Forman D, Bray F. GLOBOCAN 2012, Cancer Incidence and Mortality Worldwide: IARC
CancerBase No. 11 [Internet]. Lyon, France: International Agency for Research on Cancer;
2013. Available from: http://globocan.iarc.fr, accessed on 3/20/14
2. Clinical Outcomes of Surgical Therapy Study Group (2004) A comparison of laparoscopical-
ly assisted and open colectomy for colon cancer. N Engl J Med 350:2050–2059
3. Colon Cancer Laparoscopic or Open Resection Study Group, Buunen M, Veldkamp R, Hop
WC, Kuhry E, Jeekel J et al (2009) Survival after laparoscopic surgery versus open surgery
for colon cancer: long-term outcome of a randomised clinical trial. Lancet Oncol 10:44–52
4. Veldkamp R, Kuhry E, Hop WC et al (2005) Laparoscopic surgery versus open surgery for
colon cancer: short-term outcomes of a randomised trial. Lancet Oncol 6:477–484
5. Jayne DG, Guillou PJ, Thorpe H et al (2007) Randomized trial of laparoscopic-assisted re-
section of colorectal carcinoma: 3-year results of the UK MRC CLASICC Trial Group. J Clin
Oncol 25:306–308
6. Jayne DG, Thorpe HC, Copeland J et al (2010) Five-year follow-up of the Medical Research
Council CLASICC trial of laparoscopically assisted versus open surgery for colorectal can-
cer. Br J Surg 97:1638–1645
7. van der Pas MH, Haglind E, Cuesta MA et al (2013) Laparoscopic versus open surgery for
rectal cancer (COLOR II): short-term outcomes of a randomized, phase 3 trial. Lancet Oncol
14:210–218
8. Baik SH, Ko YT, Kang CM et al (2008) Robotic tumor-specific mesorectal excision of rec-
tal cancer: short-term outcome of a pilot randomized trial. Surg Endosc 22:1601–1608
9. Pigazzi A, Ellenhorn JD, Ballantyne GH, Paz IB (2006) Robotic-assisted laparoscopic low
anterior resection with total mesorectal excision for rectal cancer. Surg Endosc 20:1521–1525
10. Dalton RS, Smart NJ, Edwards TJ et al (2012) Short-term outcomes of the prone perineal ap-
proach for extra-levator abdomino-perineal excision (elAPE). Surgeon 10:342–346
11. Bianchi PP, Luca F, Petz W et al (2013) The role of the robotic technique in minimally inva-
sive surgery in rectal cancer. Ecancermedicalscience 7:357
12. Obias V, Sanchez C, Nam A et al (2011) Totally robotic single-position ‘flip’ arm technique
for splenic flexure mobilizations and low anterior resections. Int J Med Robot 7:123–126
13. Hellan M, Stein H, Pigazzi A (2009) Totally robotic low anterior resection with total mesorec-
tal excision and splenic flexure mobilization. Surg Endosc 23:447–451
14. Stelzner S, Hellmich G, Schubert C et al (2011) Short-term outcome of extra-levator ab-
dominoperineal excision for rectal cancer. Int J Colorectal Dis 26:919–925
Full-robotic Technique
for Rectal Cancer 16
Giuseppe Spinoglio, Giampaolo Formisano, Luca Matteo Lenti,
Fabio Melandro, and Alessandra Marano

16.1 Introduction
Since the first robotic total mesorectal excision (TME) was reported in 2006 [1],
two main methods for robotic rectal surgery, hybrid versus totally robotic tech-
nique, have been described.
In the hybrid technique [2, 3], the surgeon performs a splenic flexure mobi-
lization laparoscopically and in almost all cases the vascular handling, while the
robotic approach is reserved for pelvic dissection. Among the totally robotic
procedures, there are the single and dual docking strategies with several sub-
types, according to redocking of robotic arms and reorientation of the robotic
cart (or patient table) during surgery [4–8].
Since the introduction of the da Vinci® Si™ system at our institution in 2010,
we have developed a full-robotic single-docking technique for rectal anterior
resection with TME. In this chapter we outline each step of our surgical strate-
gy; the indications have already been discussed in Chapter 15.

16.2 Procedure Overview

The key steps for robotic rectal anterior resection (R-RAR) with TME are as
follows:
1. Splenic flexure takedown
2. Primary vascular control, medial-to-lateral mobilization of descending
colon/sigmoid and section of the mesocolon

G. Spinoglio (
)
Department of General and Oncologic Surgery,
“Ss. Antonio e Biagio” Hospital,
Alessandria, Italy
e-mail: [email protected]

G. Spinoglio (Ed), Robotic Surgery: Current Applications and New Trends, 159
Updates in Surgery
DOI: 10.1007/978-88-470-5714-2_16, © Springer-Verlag Italia 2015
160 G. Spinoglio et al.

3. TME and rectal resection

4. Specimen removal and anastomosis
Our technique for RAR is so-called “single-docking” because it does not
involve a change of the position of the robotic cart, but only of the robotic arms
(except for robotic arm 1), during the above-mentioned surgical steps. The initial
exposure and the anastomosis fashioning are usually performed laparoscopically.

16.3 Patient Positioning

After the induction of general anesthesia, the patient is placed supine in a mod-
ified lithotomy position. Legs are abducted with flexed knees (the left leg is less
abducted compared to the right one so as not to interfere with the robotic arms)
and are positioned in adjustable stirrups; arms are alongside the body. The
patient is carefully secured with shoulder supports on both sides of the neck and
with a safety band on the chest to prevent sliding.
The preparation is concluded by the insertion of a Foley catheter and an oro-
gastric tube and by the application of a body warmer and a compression device
for deep venous thrombosis prophylaxis. Antibiotics are injected according to
the guidelines.

16.4 OR Setup
First assistant is on the patient’s right side. The scrub nurse is at the lower right
side of the table and the assistant’s monitor is located at the patient’s left shoul-
der. The cart is placed at the patient’s left side and is docked from the left lower
quadrant over the left hip, at approximately 45° to the perpendicular to the
patient (Fig. 16.1).

16.5 Trocar Placement

A 12-mmHg pneumoperitoneum is achieved with a Veress needle and ports are
introduced as follows:
• one 12-mm laparoscopic trocar for the 30° down endoscope through an inci-
sion 1–2 cm lateral and 3 cm above the umbilicus;
• one 8-mm robotic trocar (robotic arm 1, R1) on the right lower quadrant at
the intersection between spino umbilical line (SUL) and the midclavicular
line (MCL);
• one 8-mm robotic port robotic arm 2/3, R2/R3) in the right upper quadrant,
slightly lateral to the right MCL, 3–4 cm below the 12th rib;
• one 8-mm robotic port robotic arm 2/3, R2/R3) in the left upper quadrant,
7–8 cm below the 12th rib and 5 cm lateral to the midline;
16 Full-robotic Technique for Rectal Cancer 161

Fig. 16.1 OR setup for full-robo-

tic single-docking rectal anterior
resection. (© 2014 Intuitive
Surgical, Inc.)

• one 8-mm robotic port (robotic arm 2, R2) in the left lower quadrant, 2 cm
lateral to the MCL and 16–18 cm to the pelvis;
• one 12-mm laparoscopic port, in the right flank area, 2 cm lateral to the
MCL.

16.6 Robot Positioning and Docking

Once the camera port is inserted, an assessment of the entire abdomen is per-
formed and all trocar are placed at their optimal sites. The greater omentum and
the small bowel loops are retracted out of the pelvic area into the right upper
quadrant by means of laparoscopic graspers inserted through the robotic ports.
If present, adhesions are freed.
At this time, the patient is placed in a 25° Trendelenburg position with a 20°
right tilt. The robotic cart is brought into the left lower quadrant.
In order to define the correct position of the robotic cart, we need to pinpoint
the best position for the camera arm. To adjust the positioning correctly, the fol-
lowing steps are as carried out:
1. Align the camera arm with the center column
2. Position setup joint 2 in the “sweet spot” by placing the blue arrow on the
camera arm in the middle of the blue bar located on the camera arm setup
joint
3. Move the cart to the patient so that a straight line passes through the center
162 G. Spinoglio et al.

column, the camera arm, the left anterior superior iliac spine and the camera
trocar
4. When the camera arm joins the camera trocar, the robotic cart is in the cor-
rect position and does not require further adjustments.
This method of positioning and docking the robot is the best one for the TME
step that is the core for the whole surgery.
Next, the patient is placed in a 15° reverse-Trendelenburg position and tilted
completely to the right side. Robotic arms are now docked to the trocar.

16.7 Step-by-Step Review of Critical Elements of the

Procedure

16.7.1 Step 1: Splenic Flexure Takedown

• The patient is placed in a 15° reverse-Trendelenburg position tilted down on

the right side.
• Only robotic arm 1 and 2 are docked to minimize external collision (Fig.
16.2):
- R1: Hot Shears™ (monopolar curved scissors) or cautery hook
- R2: Bipolar forceps
• The assistant port is used for tissue retraction, suction/irrigation or clipping
of vessels
The splenic flexure takedown can be performed in two ways:

Fig. 16.2 Trocar layout for splenic flexure

takedown (Step 1). (© 2014 Intuitive
Surgical, Inc.)
16 Full-robotic Technique for Rectal Cancer 163

Fig. 16.3 Splenic flexure takedown from top-to-bottom

1. From top-to-bottom
The assistant grasps the omentum and pulls it down while the robotic instrument
in R2 lifts the stomach up. The gastrocolic ligament is incised in its more
translucent portion (the so-called Bouchet’s area): a section from the right to the
left side of the patient is progressively carried out considering the inferior
splenic pole as a landmark. Once the gastrocolic ligament is sectioned, the pos-
terior peritoneal layer of the lesser sac is incised 1 cm caudal to the inferior bor-
der of the pancreas in order to expose the Gerota’s fascia.
The tranverse mesocolon is separated from the inferior border of the pan-
creas and the dissection proceeds in order to fully mobilize the splenic flexure
and a portion of the descending colon, separating the Gerota’s fascia from the
Toldt’s one or the two layers of the Toldt’s fascia (Fig. 16.3).
2. From bottom-to-top (after primary vascular control step)
After having pulled up the greater omentum, the transverse mesocolon is opened
from its inferior aspect just above the body of the pancreas to enter the lesser
sac. Dissection of the transverse mesocolon continues toward the distal trans-
verse colon and the base of the descending colon. The omentum, attached to the
transverse colon, is then dissected in the avascular plane, beginning from the
middle third of the transverse colon: the renocolic and splenocolic ligaments are
divided and the splenic flexure is fully mobilized.
Our standardized technique involves the splenic flexure takedown from the
top to the bottom for the following reasons:
• This strategy allows easy access to the avascular plane between the Toldt and
Gerota’s fascia (or the two layers of the Toldt’s fascia) since the largest space
between these two layers is at the level of the inferior border of the pancreas.
164 G. Spinoglio et al.

We believe that a dissection starting from this area is easier than the other
one;
• In the case of the splenic flexure being in a high position, its takedown is eas-
ier to perform (also when an adhesiolysis is needed) and is safer since the
spleen is always under visual control;
• The anatomical plane created after the splenic flexure mobilization from the
top to the bottom makes the dissection easy to be implemented after the divi-
sion of the inferior mesenteric vein (IMV).

16.7.2 Step 2 - Primary Vascular Control, Medial-to-Lateral

Mobilization of Descending Colon/Sigmoid, Section of the
Mesocolon

• The patient is placed in a steep Trendelenburg position with the right side
down.
• The arm setup is shown in Fig. 16.4:
- R1: Hot Shears™ (monopolar curved scissors) or cautery hook, Hem-o-
lok® clip applier
- R2: ProGrasp™ forceps
- R3: Bipolar forceps
• The assistant port is used for tissue retraction, suction/irrigation or clipping
of vessels.

Fig. 16.4 Trocar layout for primary vascu-

lar control, medial-to-lateral mobilization
and section of the mesocolon (Step 2).
(© 2014 Intuitive Surgical, Inc.)
16 Full-robotic Technique for Rectal Cancer 165

Transverse mesocolon is pulled up to expose the Treitz angle. The IMV is

identified and divided close to the inferior border of the pancreas: the IMV tran-
section allows easy entry into the space created during the splenic flexure mobi-
lization and so the dissection can be carried out downward.
The sigmoid colon and upper rectum are lifted anteriorly and laterally by the
assistant grasper and the robotic instrument in R2 to expose the base of the sig-
moid mesocolon and the upper mesorectum. The peritoneum is then incised at
the level of the sacral promontory with the Hot Shears™ in R1 and the inferior
mesenteric artery (IMA) is identified, dissected at its origin and divided with
Hem-o-lok® clips (Weck Teleflex Medical Europe Ltd).
A medial-to-lateral dissection is carried out posteriorly to the superior rec-
tal artery thus joining the previous superior dissection below the IMV, until all
the left colon is separated from the retroperitoneum preserving the left gonadal
vessels and the left ureter. Lateral detachment is implemented along the white
line of Toldt and continues cephalad to the middle portion of the descending
colon while the sigmoid colon is retracted medially by the assistant. The dis-
section is extended inferiorly up to the psoas muscle where the ureter crosses
the iliac vessels.
A complete intracorporeal division of the proximal mesocolon is also per-
formed up to the chosen transection point in the left colon: the assessment of
bowel stump perfusion will be carried out with the indocyanine green (ICG) flu-
orescence imaging system (see Chapter 19).

16.7.3 Step 3 - TME and Rectal Resection

• The patient positioning is the same as in step 2.

• The arm layout is shown in Fig. 16.5.
- R1: Hot Shears™ (monopolar curved scissors) or cautery hook, Hem-o-
lok® clip applier
- R2: ProGrasp™ forceps
- R3: Bipolar forceps
• The assistant uses both ports in the right flank for tissue retraction, suc-
tion/irrigation, clipping of vessels and stapler introduction in order to maxi-
mize the assistance.
TME is carried out according to Heald’s principles [9] and this step has been
already described in detail by Pigazzi et al. in Chapter 15, with the only differ-
ence being that, in our surgical strategy, instruments armed in R1 and R3 are the
operative ones while R2 is used to expose the anatomical field (Fig. 16.6).
Additionally, we routinely perform an assessment of the bowel perfusion
with the ICG fluorescence imaging system (see Chapter 19), before rectal resec-
tion (Fig. 16.7). At the end of this step, the robotic system is undocked if the
anastomosis is fashioned laparoscopically.
166 G. Spinoglio et al.

Fig. 16.5 Trocar layout for total mesorectal

excision and rectal resection (Step 3).
(© 2014 Intuitive Surgical, Inc.)

a b

Fig. 16.6 Total mesorectal excision. a Posterior aspect. b Lateral aspect

a b

Fig. 16.7 White light (a) and NIR-fluorescent view (b) of rectal transection
16 Full-robotic Technique for Rectal Cancer 167

16.7.4 Step 4 - Specimen Removal and Anastomosis

The diseased colorectal segment is extracted through a nearly 5 cm suprapubic

Pfannenstiel incision, protected with a wound shield. The proximal colon is tran-
sected, the anvil is inserted into the proximal stump and the colon is dropped
back into the abdomen. The Pfannenstiel incision is closed and pneumoperi-
toneum is re-established.
An end-to-end or side-to-end circular stapled anastomosis is fashioned intra-
corporeally or a handsewn coloanal anastomosis is used after intersphincteric
resection. A diverting ileostomy is selectively fashioned in cases of incomplete
donuts, preoperative radiation, coloanal anastomosis and ultralow RAR. Finally,
the trocar are removed under direct vision, a drain is placed and laparoscopic
fascial sites are closed as usual.

16.8 Advantages and Limitations of Full-robotic Technique

for Rectal Cancer

The technical advantages of the da Vinci® four-arms system encouraged our

team to develop a new surgical setting to exploit, as best, the robotic technolo-
gy. Thus, after our first experience with the first-generation da Vinci® system
[10], we have adopted a standardized setup for RAR with TME, a full-robotic
single-docking technique and we trained each member of our group. Two funda-
mental steps are necessary: the tailoring of port placement after induction of
pneumoperitoneum, and testing of the movement of the arms before introduction
of the instruments, in order to adjust the positioning of the elbow of the arms and
to facilitate their movement without conflicts.
Our strategy, also described with some variations by other authors [5, 8, 11,
12], offers potential distinct advantages in comparison with the multiple stage
and hybrid technique. We believe that the fixed position of the robotic cart
decreases the overall operating time and makes the surgery more on-going and
coordinated, making use of the benefits of robotic technology. All abdominal
quadrants can be reached easily by the robotic arms with correct port placement;
moreover, the splenic flexure takedown can be implemented effortlessly, in par-
ticular in the case of its high positioning as previously described.
Potential criticisms of the full-robotic procedure such as higher cost, a longer
operative time and a higher learning curve than those related to the hybrid tech-
nique are commonly reported [13], even if our personal feeling and experience
are different. Indeed, as already reported by other authors [5], if we exclude the
time for the robotic setup and disengagement, the operating time of our robotic
series (341 min) is similar to that of our laparoscopic series (unpublished data)
and is acceptable compared with that of the hybrid technique, which ranges from
217–383 minutes [2, 3].
168 G. Spinoglio et al.

Table 16.1 Our personal experience of full-robotic single-docking anterior resection

Variable Robotic group (n=114)
Sex, M/F 68/46
Age (years), mean ± SD, (range) 67.6±10 (37–86)
BMI (kg/m²), mean ± SD(range) 25.1±3.1 (18–32)
ASA 1/2/3/4 12/76/26/0
AJCC staging 0/1/2/3/4 n, (%) 18(16)/30(26)/25(22)/31(27)/10(9)
Upper/mild/inferior rectum n 46/24/44
Neoadjuvant chemoradiotherapy n, (%) 59 (51.8)
Anastomosis n, (%)
Knight-Griffen 91 (80)
Coloanal 23 (20)
Ileostomy n, (%) 90 (78.9)
Conversion n, (%)
Total /to open/to laparoscopy 5(4.4)/4 (3.5)/1(0.9)
Operative time (min), mean ± SD, (range) 341± 98.6 (175–723)
First flatus (days), mean ± SD (range) 1.5± 0.9 (1–6)
Oral re-intake (days) mean ± SD, (range) 1.3±0.8 (1–5)
Complicationsa n, (%)
Total number /I-II /III-IV 17(14.9)/9(7.9)b/8(7)c
LOS (days) mean ± SD,(range) 9.9 ± 6.1 (4–40)
Retrieved LNs (n)mean ±SD 20.1± 8
Specimen length (cm) mean ±SD,(range) 23.4 ± 7.7 (11–78)
Size tumor (cm) mean ±SD, (range) 2.9 ±1.9 (0.3–10)
Distal resection margin (cm) mean ±SD, (range) 3.7±2.3 (0.5–12)
CRM positivity n, (%) 4(3.5)
LOS, length of stay; LN, lymph node; CRM, circumferential resection margin. aAccording to
Clavien-Dindo Classification; b4 urinary retentions, 2 prolonged ileus, 2 pneumonias, 1 anasto-
motic fistula conservatively treated; c3 bowel obstructions, 1 descending colon ischemia, 1 anas-
tomotic leakage, 1 ureteral injury, 1 parastomal hernia repair, 1 anastomotic bleeding

Our personal experience includes 114 RAR with TME performed from March
2010 to May 2014. The patient demographic and perioperative data are shown in
Table 16.1. The procedure has been successfully performed in 109 out of 114
patients (conversion rate: 4.4%) with a mean operative time of 341 ± 98.6 min-
utes (range: 175–723 minutes, including loop ileostomy fashioning).
No intraoperative complications were observed. Bowel continuity was
restored with transanal stapled end-to-end or end-to-side anastomosis in 91
patients and with manual coloanal anastomosis for ultralow anterior resections
in 23 patients. A diverting loop ileostomy was matured in 90 patients (78.9%).
No positive distal resection margin was reported and the number of harvest-
ed lymph nodes was 20.1 ± 8. Four specimens (3.5%) showed circumferential
16 Full-robotic Technique for Rectal Cancer 169

resection margin (CRM) involvement (defined as a CRM 1 mm); in three

patients, who underwent neoadjuvant radiotherapy, the evaluation of the
mesorectum quality showed a Grade 3 – Good. In the last patient, who did not
receive a preoperative radiotherapy, the specimen showed a T4N0 at the final his-
tological evaluation.
All patients were submitted to a perioperative fast-track program. Recovery
of bowel function, oral re-intake and length of stay was on day 1.5 ± 0.9 (range:
1–6), 1.3 ± 0.8 (range: 1–5) and 9.9 ± 6.2 days (range: 4–40 days), respective-
ly. The overall complication rate on the basis of the Clavien-Dindo classifica-
tions was 14%.

References
1. Pigazzi A, Ellenhorn JD, Ballantyne GH et al (2006) Robotic-assisted laparoscopic low an-
terior resection with total mesorectal excision for rectal cancer. Surg Endosc 20:1521–1525
2. Hellan M, Anderson C, Ellenhorn JD et al (2007) Short-term outcomes after robotic-assisted
total mesorectal excision for rectal cancer. Ann Surg Oncol 14:3168–3173
3. Baik SH, Lee WJ, Rha KH et al (2008) Robotic total mesorectal excision for rectal cancer
using four robotic arms. Surg Endosc 22:792–797
4. Hellan M, Stein H, Pigazzi A (2009) Totally robotic low anterior resection with total mesorec-
tal excision and splenic flexure mobilization. Surg Endosc 23:447–451
5. Choi DJ, Kim SH, Lee PJ et al (2009) Single-stage totally robotic dissection for rectal can-
cer surgery: technique and short-term outcome in 50 consecutive patients. Dis Colon Rectum
52:1824–1830
6. Park YA, Kim JM, Kim SA et al (2010) Totally robotic surgery for rectal cancer: from splenic
flexure to pelvic floor in one setup. Surg Endosc 24:715–720
7. Obias V, Sanchez C, Nam A et al (2011) Totally robotic single-position ‘flip’ arm technique
for splenic flexure mobilizations and low anterior resections. Int J Med Robot 7:123–126
8. Bianchi PP, Ceriani C, Locatelli A et al (2010) Robotic versus laparoscopic total mesorectal
excision for rectal cancer: a comparative analysis of oncological safety and short-term out-
comes. Surg Endosc 24:2888–2894
9. Heald RJ (1988) The ‘Holy Plane’ of rectal surgery. J Royal Soc Med 81:503–508
10. Spinoglio G, Summa M, Priora F et al (2008) Robotic colorectal surgery: first 50 cases ex-
perience. Dis Colon Rectum 51:1627–1632
11. Kim SH, Kwak JM (2013) Robotic total mesorectal excision: operative technique and review
of the literature. Tech Coloproctol 17 Suppl 1:S47–53
12. D’annibale A, Pernazza G, Monsellato I et al (2013) Total mesorectal excision: a comparison
of oncological and functional outcomes between robotic and laparoscopic surgery for rectal
cancer. Surg Endosc 27:1887–1895
13. Alasari S, Min BS (2012) Robotic colorectal surgery: a systematic review. ISRN Surg
2012:293894
Robotic Surgery for Complicated
Diverticulitis 17
Giuseppe Spinoglio, Giampaolo Formisano, Francesca Pagliardi,
Ferruccio Ravazzoni, and Alessandra Marano

17.1 Introduction
The severity of complicated diverticulitis includes a broad spectrum of diseases
and is classified according to the Hinchey classification system [1]:
• Stage I: pericolic abscess, confined to the mesentery of the colon, usually
responsive to conservative management, with a radiological drainage in the
case of an abscess larger than 5 cm;
• Stage II: distant abscess amenable to percutaneous drainage (Stage IIa) or
complex and multiple abscesses with or without a digestive fistula (Stage IIb);
• Stage III: diffuse purulent peritonitis;
• Stage IV: diffuse fecal peritonitis;
Hinchey Stage I and II are amenable to laparoscopic lavage-drainage, when
percutaneous drainage has failed or in the case of clinical deterioration, which
may spare the patient from major emergency colorectal surgery or postpone an
elective delayed resection. Hinchey III diverticulitis represents a controversial
stage: a broad spectrum of surgical options is considered, which range from a
lavage-drainage to a major resection. An ongoing randomized trial (LADIES,
NTR2037) is expected to provide further recommendations [2, 3]. In the case of
Hinchey Stage IV, sigmoid resection with a primary anastomosis with or with-
out a diverting loop ileostomy can be performed [3]; however this stage repre-
sents the major indication for Hartmann’s procedure [2].
The laparoscopic approach for colorectal resection has been shown to be
feasible and safe in an emergency setting if performed by experienced surgeons

G. Spinoglio (
)
Department of General and Oncologic Surgery,
“Ss. Antonio e Biagio” Hospital,
Alessandria, Italy
e-mail: [email protected]

G. Spinoglio (Ed), Robotic Surgery: Current Applications and New Trends, 171
Updates in Surgery
DOI: 10.1007/978-88-470-5714-2_17, © Springer-Verlag Italia 2015
172 G. Spinoglio et al.

[4, 5] but to date, due to the weak evidence, no recommendation can be made.
In elective settings, this minimally invasive technique provides a reduction in
postoperative pain, systemic analgesia requirements, hospital stay, overall post-
operative morbidity, total hospital cost and improved quality of life [6, 7].
However, the laparoscopic management is associated with a conversion rate of
up to 65% due to the presence of bulky mesenteric tissue and ill-defined planes
of dissection [8].
The robotic technique has been recently applied to the treatment of compli-
cated diverticular diseases in elective settings. Thanks to its technology, the da
Vinci® application seems to be promising and might overcome some limitations
of the laparoscopic approach. This chapter deals with our experience of robotic
delayed sigmoidectomy for complicated diverticulitis.

17.2 Procedure Overview

17.2.1 Patient and Trocar Positioning, OR Setup, and Docking

The details for this procedure are the same as those for our personal technique
for rectal anterior resection (See Chapter 16).

17.2.2 Critical Elements of the Procedure

The key steps for our technique of single-docking full-robotic sigmoidectomy

are listed as follows:
1. Splenic flexure takedown
2. Vascular control
3. Medial-to-lateral mobilization of descending colon/sigmoid
4. Final mobilization of sigmoid/upper rectum and distal resection
5. Specimen removal and anastomosis
This strategy is similar to that which we follow for single docking robotic
anterior resection with some obvious differences related to the oncologic
aspects. However, it is worth explaining in more detail certain issues of each
step.

17.2.2.1 Step 1 - Splenic Flexure Takedown

We routinely mobilize the splenic flexure in order to prevent any further ten-
sion. In fact, Western patients have a higher incidence of diverticulitis com-
pared to the Eastern ones; moreover, they have a relatively short sigmoid colon
so that the mobilization of left colon splenic flexure is a routine procedure in
most cases.
17 Robotic Surgery for Complicated Diverticulitis 173

Fig. 17.1 Pericolic

abscess involving a
small bowel loop

Fig. 17.2 Blunt

dissection of the small
bowel loop involved
in the inflammatory
process

17.2.2.2 Step 2 - Vascular Control

Two vascular ligation options can be considered during a delayed sigmoidecto-
my: a central one and a peripheral one.
Indeed, complicated diverticulitis can be characterized by the presence of
intense inflammatory processes (Figs. 17.1 and 17.2) and by the involvement of
the mesosigmoid and of the left ureteral posterior plane. If this occurs, the infe-
rior mesenteric artery (IMA) division at its origin, preserving the hypogastric
nerve plexus, can be recommended since it is easier and safer to perform com-
pared to a more distal ligation. Following this strategy, a gentle dissection in the
avascular retroperitoneal plane between Gerota’s and Toldt’s fascia can be pro-
gressively implemented, even if abscesses or adhesions are still present. The
peripheral ligation, in this particular case, would be associated with a high risk
of directly enter into the inflammatory process, losing the anatomical landmarks
and eventually causing ureteral and vascular injuries.
174 G. Spinoglio et al.

Otherwise, in the case of less inflammatory settings or when abscesses are

located in other sites such as in the pelvis, the section of the sigmoid arteries at
their origin, preserving the superior hemorrhoidal artery has to be considered in
order to guarantee a better rectal stump perfusion.

17.2.2.3 Step 3 - Medial-to-Lateral Mobilization of Descending

Colon/Sigmoid
A medial-to-lateral dissection should be carried out until the left colon is sepa-
rated from the retroperitoneum to avoid initial dissection into the inflammatory
process and to facilitate the identification and preservation of the left gonadal
vessels and the left ureter. As we routinely performed, the complete intracorpo-
real division of the proximal mesocolon is carried out to the chosen transection
point in the left/sigmoid colon.

17.2.2.4 Step 4 - Final Mobilization of Sigmoid/Upper Rectum

and Distal Resection
Following our standardized technique, the colonic mobilization proceeds down
to the sacral promontory until the upper rectum is completely freed. At this level,
the overlying peritoneum is laterally incised while the limit of the anterior dis-
section is represented by the absence of the anterior tenia on the rectal segment,
close to the peritoneal reflection. During this step, the sequelae of the inflamma-
tory process that may involve other organs, such as small bowel, bladder, uterus
and especially left adnexa, are also treated.
Once the mobilization is completed, the mesorectum is dissected and the rec-
tum, selected for distal stapler location, is skeletonized. The rectum is thus
divided using an articulating linear endostapler via the assistant port, after hav-
ing assessed the bowel perfusion with the indocyanine green fluorescence imag-
ing system (see Chapter 19).

17.2.2.5 Step 5 - Anastomosis

An end-to-end or side-to-end circular stapled anastomosis, according to the sur-
geon’s preference and the anatomical setting, is performed intracorporeally, usu-
ally without a temporary loop ileostomy since the anastomosis is fashioned at a
safe colonic segment.

17.3 Advantages, Review of the Literature and Personal

Outcomes
In recent decades, the surgical management of complicated diverticulitis is
quickly moving toward less invasive procedures than previously. Even though a
strong specific recommendation is not yet present [3], the laparoscopic approach
for colonic resection can be adopted and to date the published literature reports
potential benefits of this technique to improve patient outcomes. However, in the
17 Robotic Surgery for Complicated Diverticulitis 175

case of significant inflammatory diverticular masses, the limits of visualization

and dissection related to the laparoscopic approach have been associated with a
significant conversion rate [9, 10] that consequently reduced the benefits of min-
imally invasive surgery [11].
The robotic technology, benefiting from its intrinsic technical advantages,
has been recently applied for the treatment of complicated diverticular disease.
It is worth specifying that at present the available data are poor. However,
excluding case reports, the first experience of robotic sigmoidectomy for com-
plicated diverticulitis was reported in 2011 [8]: data on nine enrolled patients
showed no conversion and promising outcomes in terms of length of hospital
stay (4.2 ± 4 days).
Recently, a study comparing laparoscopic (55 patients) versus robotic (20
patients) left colectomy for colovesical fistula was published [10]. The robotic
group had shorter hospital stays, a lower complication rate and no conversions
compared to the laparoscopic group (0% vs. 14.55%, p =0.001). Even consider-
ing the small robotic sample size, the authors conclude that the advantages of
robotic surgery might be of clinical significance in complicated, “high-risk-of-
conversion” cases, such as fistulized diverticular disease.
In unpublished series, 25 robotic delayed sigmoidectomies with primary
anastomosis have been performed at our institution. Demographic data, disease
stratification and perioperative outcomes are shown in Table 17.1. There were
neither intraoperative complications nor conversions to the open or laparoscop-
ic approach; the mean hospital stay was 6.5 days (range = 3–13) and 3 out of 25
patients (12%) presented with a minor complication that was medically treated.
A retrospective analysis was conducted on prospectively collected data of a
series of 46 patients whom underwent delayed laparoscopic sigmoidectomy for

Table 17.1 Personal experience of robotic delayed sigmoidectomy for complicated diverticulitis
Variable Robotic sigmoidectomy group, n=25 pts
Sex (F/M) 11/14
Mean age, yrs (range) 60 (32–85)
Mean BMI, kg/m2 (range) 27.3 (18.7–33)
Hinchey I, n(%) 10 (40%)
Hinchey II, n(%) 14 (56%)
Stenosis, n(%) 1 (4%)
Conversion rate %, (n) 0% (0/25)
Central/peripheral vascular ligation (n) 16/9
Mean OT, min (range) 327 (200–515)
Mean LOS, days (range) 6.6 (3–13)
Intraoperative complications rate % 0%
Postoperative complications rate %, (n) 12% (3/25); 1 perianastomotic collection;
1 pulmonary embolism; 1 proctorrhage
OT, operative time; LOS, length of stay
176 G. Spinoglio et al.

complicated diverticulitis; this group was comparable to the robotic one in terms
of demographic characteristics and Hinchey disease stratification. A statistically
significant reduction in conversion rate (0% vs. 17.4%, p =0.027) was observed
in favor of the robotic group, with comparable operating room times (282 min
vs. 255 min; p =0.167). No statistically significant differences were observed
regarding hospital stay or 30-day postoperative morbidity between the compared
groups.
Our results support the robotic approach as a safe and effective tool in max-
imizing the advantages of minimally invasive surgery in the management of
complicated diverticular diseases. The 3DHD vision and the Endowristed tech-
nology make the robotic approach particularly useful during surgery performed
in these settings. The dissection of hard and severely inflamed tissue in the
abdomen (and also in a narrow pelvis) and the identification of the proper plane
are likely to be the areas that benefit from this technology mainly.

References
1. Hinchey EJ, Schaal PG, Richards GK (1978) Treatment of perforated diverticular disease of
the colon. Adv Surg 12:85–109
2. Mutter D, Marescaux J (2013) Appendicitis/diverticulitis: minimally invasive surgery. Dig Dis
31:76–82
3. Agresta F, Ansaloni L, Baiocchi GL et al (2012) Laparoscopic approach to acute abdomen
from the Consensus Development Conference of the Societa Italiana di Chirurgia Endoscop-
ica e nuove tecnologie (SICE), Associazione Chirurghi Ospedalieri Italiani (ACOI), Societa
Italiana di Chirurgia (SIC), Societa Italiana di Chirurgia d’Urgenza e del Trauma (SICUT),
Societa Italiana di Chirurgia nell’Ospedalita Privata (SICOP), and the European Association
for Endoscopic Surgery (EAES). Surg Endosc 26:2134–2164
4. Zdichavsky M, Granderath FA, Blumenstock G et al (2010) Acute laparoscopic intervention
for diverticular disease (AIDD): a feasible approach. Langenbecks Arch Surg 395:41–48
5. Cirocchi R, Cochetti G, Randolph J et al (2014) Laparoscopic treatment of colovesical fistu-
las due to complicated colonic diverticular disease: a systematic review. Tech Coloproctol
doi:10.1007/s10151-014-1157-5
6. Klarenbeek BR, Veenhof AA, Bergamaschi R et al (2009) Laparoscopic sigmoid resection for
diverticulitis decreases major morbidity rates: a randomized control trial: short-term results
of the Sigma Trial. Ann Surg 249:39–44
7. Alves A, Panis Y, Slim K et al (2005) French multicentre prospective observational study of
laparoscopic versus open colectomy for sigmoid diverticular disease. Br J Surg 92:1520–1525
8. Ragupathi M, Ramos-Valadez DI, Patel CB et al (2011) Robotic-assisted laparoscopic sur-
gery for recurrent diverticulitis: experience in consecutive cases and a review of the litera-
ture. Surg Endosc 25:199–206
9. Purkayastha S, Constantinides VA, Tekkis PP et al (2006) Laparoscopic vs. open surgery for
diverticular disease: a meta-analysis of nonrandomized studies. Dis Colon Rectum 49:446–463
10. Maciel V, Lujan HJ, Plasencia G et al (2014) Diverticular disease complicated with colovesi-
cal fistula: laparoscopic versus robotic management. Int Surg 99:203–210
11. Guillou PJ, Quirke P, Thorpe H et al (2005) Short-term endpoints of conventional versus la-
paroscopic-assisted surgery in patients with colorectal cancer (MRC CLASICC trial): multi-
centre, randomised controlled trial. Lancet 365:1718–1726
 Part V
New Technologies in Robotic Platform
Single-Site™ Surgery
18
Giuseppe Spinoglio, Giampaolo Formisano,
Luca Matteo Lenti, Fabio Priora, and Alessandra Marano

18.1 Introduction
The Single-Site™ platform was primarily designed to work in a narrow opera-
tive field and with a specific anatomical target. To date, the most consistent pub-
lished experiences are regarding the use of this technology to perform cholecys-
tectomy [1–9] but, recently, it has been applied in other fields of general surgery
[10–12]. This chapter will focus on its current application in performing chole-
cystectomy and right colectomy.

18.2 Single-Site™ Robotic Cholecystectomy (SSRC)

18.2.1 Patient and Robot Positioning

Under general anesthesia, the patient is secured in a supine position with both
arms tucked at sides. The robotic cart should approach the patient at 45° (from
perpendicular) over the right shoulder ensuring that the target anatomy is in-line
with the center column, umbilicus and arrow on the port. The assistant and the
scrub nurse are positioned at the patient’s left side and at the patient’s feet,
respectively; the main assistant monitor is located at the right of the patient in
the line of vision of the assistant (Fig. 18.1a).

G. Spinoglio (
)
Department of General and Oncologic Surgery,
“Ss. Antonio e Biagio” Hospital,
Alessandria, Italy
e-mail: [email protected]

G. Spinoglio (Ed), Robotic Surgery: Current Applications and New Trends, 179
Updates in Surgery
DOI: 10.1007/978-88-470-5714-2_18, © Springer-Verlag Italia 2015
180 G. Spinoglio et al.

a b
Fig. 18.1 a Overhead views of OR setup for Single-Site™ robotic cholecystectomy and Single-
Site TM robotic right colectomy. b Single-Site™ port placement for cholecystectomy. (© 2014
Intuitive Surgical, Inc.)

18.2.2 Single-Site™ Placement and Docking

Access to the peritoneal cavity is gained through a nearly 2.5 cm midline

intraumbilical incision extended to the fascia and by means of transection of the
umbilical stalk if necessary (Fig. 18.1b). In order to exclude the presence of
adhesions, a digital exploration of the abdominal cavity is recommended and so
it is suggested to slightly enlarge the fascial incision.
Subsequently, the Single-Site™ port, folded by the clamp technique or
unfolded, is lubricated with a sterile solution, and is introduced with an atrau-
matic clamp just above its lower rim into the abdomen with a downward motion
while countertraction is provided by retractors within the single incision. The
right position of the port is achieved when the top port flanges lay flat against
the abdominal wall and the arrow marking on the port is aligned with the theo-
retical anatomical target (gallbladder).
A 12-mmHg pneumoperitoneum is instilled and the 30° downscope and the
accessory cannula are inserted. The table is placed at the minimum angle of
reverse-Trendelenburg (10–15°) and is rolled to the left side (5°) for better expo-
sure of the gallbladder. Diagnostic laparoscopy is so performed.
The assistant grasps and retracts the fundus of the gallbladder with a laparo-
scopic grasper to expose the infundibulum: this step is crucial to assess port
alignment, to ensure an adequate working space for the cannulae and finally to
choose the most appropriate length of these. The laparoscopic grasper, the endo-
scope and the accessory cannula are then removed. The patient cart is brought at
18 Single-Site™ Surgery 181

a 45° angle over the right shoulder ensuring that the target anatomy is in-line
with the center column, umbilicus and arrow on the port.
For SSRC, only robotic arm 1 (R1) and arm 2 (R2) are used in addition to the
camera arm:
• the camera arm has to be in line with the center of the column and bent at an
angle of 45° (sweet spot);
• R1 is placed to the left of the patient and its instruments reach the surgical
field from the right: Cadiere forceps (alternatively crocodile or Maryland
grasper);
• R2 is placed to the right of the patient and its instruments reach the surgical
field from the left: monopolar cautery with hook tip, Hem-o-lok® clip appli-
er, curved scissors, suction/irrigator;
• accessory port: laparoscopic grasper.
It is worth pointing out that one of the main innovations is that the da Vinci®
software restores the correct hand/instrument correlation: the surgeon uses the
right hand to drive the instrument visualized on the right side of the operative
screen, even if the instrument comes from the left and vice versa.
The endoscope is reinserted vertically; under direct vision the lubricated
curved cannulae are inserted by sight to avoid visceral injury, in order that they
cross inside the port keeping the remote center at the level of the abdominal
wall. Then, the robot is docked.

18.2.3 Operative Technique

At the patient’s bedside, the assistant grasps the fundus of the gallbladder and
lifts up and toward the patient’s right shoulder to expose the hepatoduodenal lig-
ament. At the console, the da Vinci® software has automatically associated the
surgeon’s hand to the ipsilateral instrument tip: the surgeon retracts the scope,
moves it under the grasper, and pushes it toward the gallbladder while the assis-
tant lifts the grasper (and therefore the fundus of the gallbladder) upward.
Finally, the surgeon can easily retract the gallbladder infundibulum laterally to
open the Calot’s triangle, as in multitrocar laparoscopy.
Dissection begins and follows the traditional steps until the critical view of
safety is achieved. The peritoneum, close to the gallbladder neck, is incised with
the monopolar hook by gentle dissection of the peritoneal elements. The cystic
duct and artery are identified and skeletonized (Fig. 18.2). The ligation is per-
formed with Hem-o-lok® ML clips (clip applier in R2) and the division is per-
formed with curved scissors (R2).
The dissection of the gallbladder from the liver bed is carried out using the
Cadiere forceps (R1) and monopolar cautery hook (R2). During this last step,
the scope is repositioned above the grasper to lift the liver and expose the surgi-
cal field. Before completion of the dissection of the gallbladder from the liver,
it is important to inspect the gallbladder bed and ducts for evidence of bleeding
182 G. Spinoglio et al.

a b

Fig. 18.2 Final view of cystic duct and cystic artery after Calot’s dissection in white light (a) and
near-infrared fluorescent (b) view. CD, cystic duct; CA, cystic artery; CHD, common hepatic
duct; CBD, common bile duct

or bile leak: if required, the suction/irrigation instrument is inserted in R2 and

later replaced with the previous energy instrument.
After complete dissection of the gallbladder from the liver bed, a lubricat-
ed 10-mm accessory cannula for the extraction bag replaces the 5-mm one.
The gallbladder is then placed inside the retrieval bag and removed along with
the Single-Site™ port after all instruments and cannulae have been withdrawn.
The fascia is closed with absorbable suture, the umbilicus is restored to its
physiological position and the skin is reapproximated with a running subcutic-
ular closure.
When indicated, an intraoperative cholangiography can be performed using a
percutaneous laparoscopic cholangiography set. The catheter is inserted percu-
taneously in the right upper quadrant, under visualization, and grasped by means
of the robotic instruments per standard technique. During the procedure, the
endoscope and all Single-Site™ instruments are removed, robotic cart is
undocked from patient and the curved cannulae (left in port) are retracted back
until an exposure of about 3 cm below the remote center is achieved.
At the end of the cholangiography, the robot is redocked. The balloon
catheter is removed by sight. Finally, the surgery is completed as usual.
Another innovative tool is represented by the fluorescent cholangiography
that can be routinely performed, during the surgery, to visualize in “real time”
the biliary tree (see Chapter 19).

18.3 Discussion

18.3.1 Advantages

The robotic Single-Site™ platform offers distinct advantages:

• the lateral traction of the infundibulum, that is essential to open Calot’s tri-
angle and to reach the “critical view of safety” [13], is guaranteed;
18 Single-Site™ Surgery 183

• the correct triangulation of the target anatomy is restored by the rigid can-
nulae, crossing at the monoport and the robotic arm collisions are mini-
mized;
• the bedside-assistant port enables dynamic retraction to perform a safe dis-
section;
• any internal clashing with other instruments are avoided because of the
placement of the robotic camera in the middle of the curved cannulae zone
(instead of being parallel as in SILS);
• the same-sided hand-eye control of the instruments is maintained by the da
Vinci® intuitive software: “what is right is right and vice versa”;
• the added benefits of the stable 3DHD view, the precision, the better
ergonomic comfort and the intraoperative dynamic fluorescent cholangiogra-
phy increase the safety and make the surgery easy to perform.

18.3.2 Limitations

The main drawbacks of the Single-Site™ system are:

• the absence of the EndoWrist® technology at the flexible instrument tips;
• the reduced intracorporeal range of motion of the robotic instruments;
• the interaction between the assistant instrument and the scope: since the
assistant cannula can only be parallel to the camera one, it is very important
to consider the close relationship between these two tools and especially that
the assistant instrument can be moved by the camera controlled by the sur-
geon at the console.

18.3.3 Outcomes Overview

The most consistent experiences of SSRC are reported in Table 18.1. Nine arti-
cles evaluating over 600 SSRC with Single-Site™ kit have been published
between 2011 and January 2014 [1–9]. Based on available data, the approach is
safe and feasible and has been easily adopted by surgeons mainly of American
and European origin.
SSRC was successfully carried out not only in the case of symptomatic
cholelithiasis but also for cholecystitis with a conversion rate of about 3.8%. The
mean length of hospital stay, derived from seven articles, was 30.2 hours and
few early or late major complications have been reported. It is worth saying that
no bile duct injuries occurred in any of the above mentioned papers.
Our single institutional experience consists of 151 patients whom underwent
SSRC for symptomatic cholelithiasis (n = 139, 92%), cholecystitis (n = 8, 5.3%)
and gallbladder polyposis (n = 4, 2.7%) from July 2011 to May 2014. The mean
total operative time was 70.7 minutes; no conversions occurred and no addition-
al port was required. With a mean hospital stay of 1.2 days, no major intraoper-
184 G. Spinoglio et al.

ative or early postoperative complications occurred, including bile duct injuries.

At a mean follow-up of 26.3 months, two incisional hernias (1.3 %) were
observed (Table 18.2).

18.4 Single-Site™ Robotic Right Colectomy (SSRRC)

18.4.1 Patient and Robot Positioning

The patient is placed in a partial Trendelenburg supine position with a slight roll
to the left and the cart is on the patient’s right shoulder. The assistant is at the
patient’s left side and the scrub nurse at the patient’s feet. The main assistant
monitor is located at the patient’s right side (Fig. 18.1).

18.4.2 Single-Site™ Placement and Docking

The Single-Site™ port, grasped with an atraumatic clamp, is introduced through

a nearly 2.5 cm left paramedian transverse sovrapubic incision (Fig. 18.3) and a
12-mmHg pneumoperitoneum is established. The 8.5-mm cannula for the 3DHD
scope is lubricated and inserted; under direct vision, the other two robotic
curved cannulae and the accessory cannula for the assistant are introduced as
well. For right colectomy, our usual instruments are:
• R1: Cadiere grasper
• R2 : Curved scissors or alternatively monopolar cautery with hook tip, Hem-
o-lok® clip applier, suction/irrigator, bipolar Maryland and curved needle
driver (recently put on the market)
• Accessory port: laparoscopic grasper.

18.4.3 Step-by-Step Review of Single-Site™ Robotic Right

Colectomy with Intracorporeal Anastomosis

The first surgical step is represented by the lateral retraction of the last ileocol-
ic loop with the Cadiere grasper tenting up the ileocolic vessels; then, in order
to create a window under these, the peritoneum is opened with the cautery hook
to visualize the duodenum. The ileocolic vessels are clipped, sectioned (Fig.
18.5) and following the superior mesenteric vein (SMV) left anterior surface
upward, the right branches of the middle colic vessels are clipped and sectioned
too, as a result of the cephalad traction of the transverse mesocolon with the
assistant’s laparoscopic grasper. A medial-to-lateral colonic mobilization is per-
formed in the avascular plane between Gerota’s and Toldt’s fasciae keeping the
right ureter and the gonadic vessels down.
For malignant diseases, a complete mesocolic excision (CME), according to
the principles of Hohenberger et al. [14], is carried out as we usually perform in
Table 18.1 Single-Site™ robotic cholecystectomy (SSRC): major clinical series of at least 25 cases
Study Study No. of Preoperative Age, years; Docking; console; Conversion; Incision, LOS, Major early;
[Reference] design patients diagnosis BMI, kg/m2; total time, min. adding port; cm hours late complica-
(F/M) ASA score, (mean, SD) n (%) (mean) (mean) tions, n (%)
(mean, SD)
Konstantinidis Case series 45 36 choleli- 47 ± 12; 28.8 ± 4; 5.8 ± 1.56; 43 ± 21.98; 0(0); 3(6.7) 2 23.8 1(2.2); 0; 1
[1] (2012, (22/23) thiasis; 1.48 ± 1 84.5 ± 25.5 hemorrhage
18 Single-Site™ Surgery

Greece) 5 cholecystitis;
4 other1
Pietrabissa Prospective 100 100 53.4 ± 12.9; 13 ± 6; 32 ± 13; 2 to OC(2); 0 2 - 0; –
[2] (2012, observational (71/29) cholelithiasis 24.4 ± 3.7; – 71 ± 19
Italy)
Spinoglio [3] Retrospective 25 23 cholelithiasis; 54.2 (19–78)*; 5.2 ± 1.1; 22.3 ± 10.9; 0; 0 2.5 26.4 0;0
(2012, Italy) comparativea (20/5) 2 other1 23.7(16.5–32.4)*; – 62.7 ± 16.6 p
Angus [4] Case series 55 37 cholelithiasis; 46.01± 4.25; 11.34±3.74; 0; 0 2 - 0;0
(2013, USA) (34/21) 18 other3 26.57± 4.25; – 28.74±11.04;
61.84±14.66
Gonzalez [5] Retrospective 166 127 cholelithiasis; 51.6 ± 15.9; – ; – ; 63.0 ± 25.2 p 0; 3(1.8) 2.5 28.8 2(1.2); 0; 2
(2013, USA) comparativeb (131/35) 20 cholecystitis; 29.4 ± 6.2; intrabdominal
19 other1,2,3 1.84 ± 0.73 abscesses
Spinoglio [6] Case series 45 45 cholelithiasis 48(23–76)*; – ; 24.1 (7.3–59.3)*; 0; 0 - 26.4 0; –
(2013, Italy) (33/12) 24.7(19–43)*; – 67(35–110)*
Uras [7] Case series 36 36 cholelithiasis 40.1(21–64)*; 9.8 (4–30)*; 0; 1(2.7) 2.5 24 0; 1(2.7); 1
(2013, (31/5) –;– 24.9 (7–60)*;
Turkey) 61.8 (34–110)* incisional hernia

(cont.) 
185
Table 18.1 (continued)
186

Study Study No. of Preoperative Age, years; Docking; console; Conversion; Incision, LOS, Major early;
[Reference] design patients diagnosis BMI, kg/m2; total time, min. adding port; cm hours late complica-
(F/M) ASA score, (mean, SD) n (%) (mean) (mean) tions, n (%)
(mean, SD)
Vidovszky [8] Prospective 95 80 cholelithiasis; 45.2 ± 16.1; 4.9 ± 3.0; 7 (6 to LC, 1 2.5 24 4(4.2); 0; 3
(2013, USA) cohort study (68/27) 8 cholecystitis; 30.1 ± 7.1; – 39.1 ± 15.3; to OC, 8.4)/ 0 (84%pts) residual CBD
7 other1,3,4 88.63 ± 32.0 lithiasis,
1 biloma
Morel [9] Case series 82 82 cholelithiasis 48.74 ± 13.23; 6.60 ± 7.58; 50.90 ± 1 to OC(1.2); 2.93 58.1 1(1.2); 1(1.2);
(2014, (72/28) 26.33 ± 4.18; 23.25; 91.05 ±29.92 2(2.4) 1 duodenal
Switzerland) 1.73 ± 0.54 lesion/1
incisional
hernia
aSSRC vs. Single-Incision Laparoscopic Cholecystectomy (SILC); bSSRC vs. SILC vs. SPIDER approach; 1 gallbladder polyps; 2 biliary pancreatitis; 3 biliary dyskinesia;
4 Recurrent pyogenic cholangitis; *median(range); p Value with statistical significance between compared group; CBD, common bile duct; OC, open cholecystectomy; LC,
laparoscopic cholecystectomy; LOS, length of stay
G. Spinoglio et al.
18 Single-Site™ Surgery 187

Table 18.2 Demographics and perioperative outcomes of our series of Single-Site™ robotic
cholecystectomy
Variable Total No. of patients, n=151
Sex, n (F/M) 109/38
Age, years (mean ± SD) 49.4 ± 14.0
BMI, kg/m2
mean ± SD 24.5 ± 4.2
<25, n (%) 89 (58.9)
25–29.9, n (%) 46 (30.5)
>30, n (%) 16 (10.6)
Previous major abdominal surgery, n (%) 54 (37.2)
Preoperative diagnosis
Symptomatic cholelithiasis, n (%) 139 (92)
Cholecystitits, n (%) 8 (5.3)
Gallbladder polyps, n (%) 4 (2.7)
Total operative time, min (mean ± SD) 70.7 ± 24.8
Conversion/adding ports, n (%) 0 (0)
IOC, n (%) 1 (0.7)
Major intraoperative complication, n (%) 0 (0)
Major early postoperative complication, n (%) 0 (0)
LOS (mean ± SD) 1.17 ± 0.5
Mean follow-up, months 26.3
IOC, intraoperative cholangiography; LOS, length of stay

Fig. 18.3 Single-Site™ port placement

for right colectomy. (© 2014 Intuitive
Surgical, Inc.)
188 G. Spinoglio et al.

Fig. 18.5 Skeletonization and division of ileocolic vessels at their root. ICA, ileocolic artery; ICV,
ileocolic vein; SMA, superior mesenteric artery; SMV, superior mesenteric vein

our laparoscopic or robotic multiport standardized technique. The segment of

transverse colon chosen for the section is skeletonized and the gastrocolic liga-
ment and the omentum are divided. The hepatic flexure is then mobilized and the
detachment of the right colon is completed by the dissection of the right peri-
toneal groove. Finally, the segment of the terminal ileum is as well identified
and prepared.
In order to perform an intracorporeal anastomosis and to insert the specimen
into a 15 mm Endobag, we placed a 15-mm trocar on the right side of the single
port, just enlarging the previous skin incision.
The ileum and the transverse colon are approximated side-to-side by a 3–0
absorbable monofilament suture, placed at their antimesenteric side. An entero-
tomy and a colotomy are made at the antimesenteric border. The two bowel
stumps are vertically aligned with a traction on the stay suture in order to insert
a 60 mm long flexible stapler (Echelon Flex™ Endopath®, blue cartridge) and to
perform a side-to-side anisoperistaltic anastomosis.
Finally, the ileum and the transverse colon are mechanically transected
with two stapler applications, including the remaining enterotomies (Fig.
18.6). Then, the specimen, inserted into an Endobag, is extracted through a
Pfannenstiel minilaparotomy, resulting from the single port and 15-mm trocar
incisions. Fascia and skin are sutured in standard fashion. Fluorescence imag-
ing with indocyanine green (ICG), integrated into the da Vinci® system, can
be used to verify bowel stump perfusion before bowel transaction (see
Chapter 19).
18 Single-Site™ Surgery 189

Fig. 18.6 The ileum and the transverse colon are mechanically transected with two stapler appli-
cations, including the remaining enterotomies, after having performed the side-to-side anisoperi-
staltic anastomosis

18.5 Discussion

18.5.1 Advantages

The robotic Single-Site™ platform provides some benefits in performing right

colectomy compared to SILS:
• the correct triangulation is restored and internal and external instrument col-
lision is minimized thanks to the curvature of the cannulae that increases the
distance between the instrument tips allowing each to reach the target anato-
my in a convergent way;
• the intuitive control is re-established by the da Vinci® software that automat-
ically associates the surgeon’s hands to the ipsilateral instrument tips;
• the stable 3D vision, the absence of tremor together with the recent introduc-
tion of new robotic Single-Site™ instruments (curved needle driver and bipo-
lar Maryland) potentially allow performing a more accurate lymphadenecto-
my, an easier dissection and intracorporeal anastomosis compared to SILS.
In our opinion, the insertion of the monoport in the left transverse sovrapu-
bic area rather than around or through the umbilicus provides a correct vision of
the SMV, along all its length and on the left side: the entire medial to lateral dis-
section and an adequate CME can be easily performed. Furthermore, the left
sovrapubic port insertion combines a good visualization of the superior mesen-
190 G. Spinoglio et al.

teric axis with the Pfannenstiel minilaparotomy. The extraction of the specimen
through this incision is carried out in order to obtain an improved cosmesis, a
decreased pain and a lower rate of incisional hernia compared to median supra
and infraumbilical laparotomy.
Fluorescence imaging with indocyanine green (ICG), integrated into the da
Vinci® system, can also be used to verify bowel stump perfusion before bowel
transection.

18.5.2 Limitations

The main drawbacks of the Single-Site™ system are as follows:

• the absence of the EndoWrist® technology at the flexible instrument tips: the
desired release of an Endowristed Single-Site™ needle driver in the near
future could facilitate this procedure;
• in the case of intracorporeal anastomosis, the stapler for the bowel transec-
tion has to be introduced into the abdomen through an additional laparoscop-
ic port: although this issue makes the single-incision technique lose its theo-
retical principle, its own value is preserved since the additional trocar is
inserted into the same slightly enlarged skin incision used for specimen
extraction.

18.5.3 Outcomes Overview

Up to date, one case of SSRRC has been published [11]. It was in a patient
affected by a malignant polyp of the caecum and both resection and anastomo-
sis have been carried out extracorporeally. The authors reported about the safe-
ty and feasibility of this procedure underlying the main technical benefits of this
system.
Our experience consists of three full SSRRC with the robotic monoport
inserted through a left sovrapubic transverse incision [12]. Overall SSRRC oper-
ative time was 218.3 ± 75.9 min. A side-to-side anisoperistaltic anastomosis was
fashioned intracorporeally in two out of three cases. All patients were discharged
within 5 days from surgery; oncological principles have been satisfied in both
two candidates affected by colon cancer.

References
1. Konstantinidis KM, Hirides P, Hirides S et al (2012) Cholecystectomy using a novel Single-
Site® robotic platform: early experience from 45 consecutive cases. Surg Endosc 26:2687–2694
2. Pietrabissa A, Sbrana F, Morelli L et al (2012) Overcoming the challenges of single-incision
cholecystectomy with robotic single-site technology. Arch Surg (Chicago, Ill: 1960)
147:709–714
18 Single-Site™ Surgery 191

3. Spinoglio G, Lenti LM, Maglione V et al (2012) Single-site robotic cholecystectomy (SSRC)

versus single-incision laparoscopic cholecystectomy (SILC): comparison of learning curves.
First European experience. Surgical endoscopy 26:1648–1655
4. Angus AA, Sahi SL, McIntosh BB (2014) Learning curve and early clinical outcomes for a
robotic surgery novice performing robotic single site cholecystectomy. Int J Med Robot
10:203–207
5. Gonzalez AM, Rabaza JR, Donkor C et al (2013) Single-incision cholecystectomy: a com-
parative study of standard laparoscopic, robotic, and SPIDER platforms. Surg Endosc
27:4524–4531
6. Spinoglio G, Priora F, Bianchi PP et al (2013) Real-time near-infrared (NIR) fluorescent cholan-
giography in single-site robotic cholecystectomy (SSRC): a single-institutional prospective
study. Surg Endosc 27:2156–2162
7. Uras C, Böler DE, Erguner I, Hamzaoglu I (2013) Robotic single port cholecystectomy (R-
LESS-C): Experience in 36 patients. Asian J Surg 37:115–119
8. Vidovszky TJ, Carr AD, Farinholt GN et al (2013) Single-site robotic cholecystectomy in a
broadly inclusive patient population: A prospective study. Ann Surg 260:134–141
9. Morel P, Buchs NC, Iranmanesh P et al (2014) Robotic single-site cholecystectomy. J Hepa-
tobiliary Pancreat Sci 21:18–25
10. Corcione F, Bracale U, Pirozzi F et al (2014) Robotic single-access splenectomy using the
Da Vinci Single-Site(R) platform: a case report. Int J Med Robot 10:103–106
11. Morelli L, Guadagni S, Caprili G et al (2013) Robotic right colectomy using the Da Vinci Sin-
gle-Site® platform: case report. Int J Med Robot 9:258–261
12. Spinoglio G, Lenti LM, Ravazzoni F et al (2014) Evaluation of technical feasibility and safe-
ty of Single-Site™ robotic right colectomy: three case reports. Int J Med Robot. DOI:
10.1002/rcs.1609
13. Strasberg SM, Brunt LM (2012) Rationale and use of the critical view of safety in laparoscop-
ic cholecystectomy. J Am Coll Surg 211:132–138
14. Hohenberger W, Weber K, Matzel K et al (2009) Standardized surgery for colonic cancer: com-
plete mesocolic excision and central ligation–technical notes and outcome. Colorectal Dis
11:354–364
ICG Fluorescence: Current and Future
Applications 19
Giuseppe Spinoglio, Alessandra Marano, Luca Matteo Lenti,
Fabio Priora, and Giampaolo Formisano

19.1 Introduction
The imaging technique based on indocyanine green (ICG) fluorescence has been
widely used for more than forty years, especially to study blood flow and micro-
circulation. This method was first applied in general surgery to perform sentinel
lymph node (SLN) biopsies in patients affected by breast and colorectal cancer.
In 2010, a near-infrared (NIR) laser light system was integrated with the da
Vinci® Si™ HD robotic system (Intuitive Surgical Inc., Sunnyvale, CA, USA).
This imaging system is able to provide both white light and near-infrared light
images through dedicated endoscopic illuminators and filters by simply press-
ing a pedal on the surgical console, thus allowing real-time fluorescence-guid-
ed surgery. There are many fields of application of ICG fluorescence in robotic
general surgery, some experimental and still evolving, that include:
• intraoperative (IO) fluorescent cholangiography to assess biliary anatomy;
• evaluation of bowel stump perfusion;
• lymph node (LN) mapping and the SLN biopsy in colorectal cancer surgery;
• colorectal tattoing.
In this chapter, we describe our nearly 3-year experience with fluorescence-
guided robotic general surgery.

G. Spinoglio (
)
Department of General and Oncologic Surgery,
“Ss. Antonio e Biagio” Hospital,
Alessandria, Italy
e-mail: [email protected]

G. Spinoglio (Ed), Robotic Surgery: Current Applications and New Trends, 193
Updates in Surgery
DOI: 10.1007/978-88-470-5714-2_19, © Springer-Verlag Italia 2015
194 G. Spinoglio et al.

19.2 Fluorescent Cholangiography (FC) during Single-Site

Robotic Cholecystectomy

19.2.1 Procedure Overview

Bile duct injury (BDI) is a rare but serious and feared complication of cholecystec-
tomy and in the current era of laparoscopy the incidence of these lesions increased
to 0.2–0.5% [1] when compared to open surgery (0.1–0.2%) [2]. Moreover, single-
incision laparoscopic cholecystectomies may be associated with an even higher rate
of BDI (0.7–0.8%) [3] due to the loss of the linchpins of conventional laparoscopy,
such as triangulation and respect of optimal working angles. A “misperception” of
the biliary anatomy is considered the primary cause of BDI rather than the lack of
skill or knowledge and the use of a routinely intraoperative cholangiography (IOC)
has been emphasized recently [4]. While recognizing the importance of IOC, it has
several disadvantages, such as the interruption of the regular workflow with
increased operative time, requirement for a multidisciplinary team and equipment,
patient and staff exposure to radiation and the necessity to cannulate the cystic duct.
Moreover, it provides static images that are often difficult to interpret. As already
mentioned by some authors, there is a need for a “simpler method of locating the
course of the ductal system during the operation, something simpler than cholan-
giography or ultrasonography” [5].
Single-Site™ robotic cholecystectomy (SSRC) certainly allows easier and safer
surgical procedures than single-incision laparoscopy to be performed by overcom-
ing its inherent technical limitations; however, the difficulty in visualizing the bil-
iary structures can still remain. The use of the da Vinci® NIR-fluorescence imaging
system could be a valid solution to allow real-time view of the anatomy of the
extrahepatic biliary tract and a time-efficient dissection of Calot’s triangle, thus fur-
ther increasing safety during single-site surgery.

19.2.2 Technique

A dose of 2.5mg of ICG is injected intravenously during induction of general anes-

thesia, about 30–45 minutes before surgery. If fluorescence is not detected after
60minutes, an additional dose of 2.5mg ICG can be administered. The SSRC pro-
cedure has already been described in detail in Chapter 18. Once the exposure of
Calot’s triangle is achieved, the imaging system is switched to fluorescence mode
for an initial attempt to identify the biliary anatomy (Fig. 19.1). Subsequently, the
dissection of Calot’s triangle is performed as usual according to the principles of
the “critical view of safety” of Strasberg, alternately switching from white to NIR
light and allowing visualization of the fluorescent bile ducts in real time. In this
way, the surgeon can follow a road map for a safe dissection of the cystic duct and
the cystic artery (Fig. 19.2), especially in the presence of accessory structures
and/or anatomical variations. The cystic duct may be clipped under fluorescence
before sectioning, especially if it is very short and if there are problems in the bil-
19 ICG Fluorescence: Current and Future Applications 195

a b

Fig. 19.1 White light (a) and near-infrared view (b) of biliary anatomy prior to Calot’s dissection.
CD, cystic duct; CBD, common bile duct; CHD, common hepatic duct; RHD, right hepatic duct

a b

Fig. 19.2 White light (a) and near-infrared view (b) of biliary anatomy after Calot’s dissection.
CD, cystic duct; CA, cystic artery; CBD, common bile duct; CHD, common hepatic duct; RHD,
right hepatic duct; LHD, left hepatic duct

iary confluence. If there are concerns with the vascular anatomy, it is possible to
proceed with a further injection of 2.5mg of ICG: after 10–20seconds, hepatic and
cystic arteries can be visualized to avoid any damage to both main and anomalous
branches, especially the branch to the sixth hepatic segment. During the detachment
of the gallbladder from the liver bed, the use of fluorescence is useful to define the
limit between the gallbladder and liver bed (especially in cases of a thin or intra-
hepatic gallbladder) and to visualize any aberrant Luschka ducts. At the end of the
procedure, a final fluorescent view of the operative field may be prudent.

19.2.3 Advantages, Limitations and Relative Contraindications

(Personal Experience and Literature Outcomes)

19.2.3.1 Advantages
The advantages of FC over standard IOC are numerous:
• no interruption of the regular workflow: the surgeon operates both in white and
fluorescent light;
196 G. Spinoglio et al.

• real-time interpretation of the images, in contrast to the traditional IOC that pro-
vides static information;
• control of the cystic duct section with a clear distinction of its confluence with
the common bile duct;
• real-time detection of any aberrant Luschka ducts and bile leaks;
• identification of the vascular anatomy of the hepatic and cystic arteries, if nec-
essary.

19.2.3.2 Limitations
The main limitations of FC are obesity and inflammation since fluorescent NIR light
has a limited tissue penetration (5–10mm). The ability of NIR light to reach deep-
er, inflamed and edematous tissues must be further investigated. Moreover, the capa-
bility of this method to recognize common bile duct stones or other obstructions is
low and, of course, IOC remains the best method to assess choledocholithiasis.

19.2.3.3 Personal Experience and Literature Outcomes

FC during SSRC allows safe real-time evaluation of the biliary tract anatomy and
is an additional helpful tool to prevent BDI during the procedure. First Ishizawa
and then Buchs demonstrated the technical feasibility of this approach during mul-
tiport laparoscopic cholecystectomy [6], SILC [7] and SSRC [8]; also our initial
experience has already been published [9]. Recently, Daskalaki et al. [10] reported
their series of 184 robotic cholecystectomy (112 multiport and 72 Single-Site™):
ICG fluorescence allowed visualization of at least one biliary structure in 99% of
cases (182/184 patients), with promising results even in the setting of acute chole-
cystitis and obesity (BMI >30).
From July 2011 to May 2014, 120 patients (31 male / 89 female) underwent
SSRC with FC for symptomatic cholelithiasis and gallbladder polyposis. Eight out
of 120 patients suffered from acute cholecystitis (6.6%); the mean age was 48 ys
and the mean BMI was 24.7kg/m2; the mean operative time and mean console time
were 71 and 30 minutes, respectively. No statistically significant differences in
operative times between standard SSRC (our previous experience) and SSRC with
FC were observed, thus confirming that no additional time is needed. There were
no conversions, BDIs, intra- or postoperative complications or adverse events; the
mean hospital stay was 1.2 days. At a medium follow-up of 21 months, no patients
presented with an incisional hernia.
Calot’s dissection is defined as the skeletonization to at least 1cm of the cys-
tic duct and artery [9]. The rates of visualization of the cystic duct , the common
hepatic duct and the common bile duct were 95%, 76.6 %, 79.2 % prior to
Calot’s dissection, respectively, and 99.2%, 92.5%, 96.6% after Calot’s dissec-
tion, respectively. At least one biliary structure was visualized in 100% of cases
after Calot’s dissection, and in 116 out of 120 patients (96.6%) before Calot’s
dissection (Table 19.1). Our results are comparable to those reported by the
more consistent series regarding the application of FC during conventional
laparoscopic cholecystectomy [6].
19 ICG Fluorescence: Current and Future Applications 197

Table 19.1 Visualization of fluorescent biliary ducts prior to and after Calot’s dissection
No. of visualization/total procedures %
Before Calot’s dissection
Cystic duct 114/120 95
CHD 92/120 76.6
CBD 95/120 79.2
At least one duct 116/120 96.6
After Calot’s dissection
Cystic duct 119/120 99.2
CHD 111/120 92.5
CBD 116/120 96.6
At least one duct 120/120 100
CHD, common hepatic duct; CBD, common bile duct

We can conclude that FC is a simple, fast, safe and effective procedure. It allows
clear real-time identification of extrahepatic biliary anatomy in almost all patients,
thus implementing the well-known advantages of SSRC over the traditional single-
incision laparoscopic approach.

19.3 Evaluation of Bowel Stump Perfusion

19.3.1 Procedure Overview

The anastomotic leakage is one of the most feared complications in colorectal sur-
gery occurring in 1.2–19.2% of all operations, with rates reaching 39% for rectal
cancer cases requiring low or ultralow anastomosis.
The underlying pathogenic mechanism has not yet been fully clarified and is
thought to be a multifactorial problem: adequate exposure and access, correct sur-
gical technique and gentle handling of the bowel, adequate hemostasis, absence of
tension at anastomosis, avoidance of fecal contamination and approximation of
well-vascularized bowel are all cornerstones to safely performing an intestinal
anastomosis and have historically been considered as “good practice” by the surgi-
cal community.
Besides technical aspects, adequate bowel perfusion is certainly the main factor
in ensuring the integrity of an anastomosis: it has been traditionally based on sub-
jective parameters such as the presence of active bleeding from the section line,
pulsatility of the mesenteric vessels, as well as peristalsis and the lack of discol-
oration of bowel segments. The clinical judgment alone, however, could represent
an inaccurate method to evaluate the risk of anastomotic leakage, with limited pre-
dictive accuracy [11].
Though many different solutions have been proposed [12–14], the da Vinci®
NIR-fluorescence imaging system represents the latest innovation in the field: it
198 G. Spinoglio et al.

a b

Fig. 19.3 White light (a) and near-infrared view (b) for evaluation of bowel stump perfusion

can be used to assess in real time both macroscopic vascular anatomy and perfu-
sion of intestinal stumps thus supporting surgeons in choosing the correct section
point during colorectal resections. Moreover, it can be extremely useful in nonstan-
dardized colonic procedures (i.e., transverse colon, splenic flexure), since vascular
abnormalities can strongly impair blood supply.

19.3.2 Technique

Surgery is performed with the da Vinci® Si™ HD surgical system according to the
usual technique of vascular control and mesenteric division to prepare the intestinal
segments. Afterward, the optimal transection line is evaluated by the surgeon with
white light and a dose of 0.1 mg/kg of ICG is administered intravenously: after
approximately 15–30seconds, the surgeon switches to fluorescent vision (Fig. 19.3).
If the site chosen for the section does not appear to be sufficiently perfused, the sec-
tion line may be revised and the stapler can be moved to a more proximal/distal
location according to the best fluorescence point reflected. In case of doubt, the test
can be repeated after waiting for a few minutes to allow the dye to washout.
However, depending on the tissue, the green fluorescent intensity appears different
and at different times.
Regarding the colonic stumps, the vessels of the epiploic appendices and
mesentery turn green first, then the green spreads across the intestinal wall. The
antimesenteric border of the descending and transverse colon is always a little
paler, because the vascularization of the tenia is less intense due to the thickness of
muscle tissue. The perfused segments gradually become green until they assume a
bright green color, in contrast with the gray segments that are not well vascularized.
Further checks may be carried out before and after performing the anastomosis.
With regard to the rectal stump, the pelvic wall turns green first (as does the
uterus in women), because it is highly vascularized. After a few seconds, the rectal
stump colors up allowing the assessment of perfusion at the selected point. The
ends of the section lines of the rectum in a Knight-Griffen anastomosis or of the
colon in a laterolateral anastomosis are often referred to as critical points of leak-
19 ICG Fluorescence: Current and Future Applications 199

age for their potential minor irroration: particular attention should be paid to their
perfusion.

19.3.3 Advantages, Limitations and Relative Contraindications

(Personal Experience and Literature Outcomes)

19.3.3.1 Advantages
Visual inspection and caution are often sufficient to choose a well-vascularized
intestinal stump for anastomosis, especially for experienced surgeons. However
there are difficult cases, both for patient conditions (such as obesity, diabetes,
inflammatory disease, etc) and for the type of anastomosis (i.e., ultralow anterior
rectal resection, splenic flexure resection, right colectomy), in which the evaluation
of perfusion is important, even if only as confirmation, especially in the presence of
a thick mesocolon and short mesentery. Moreover, this application might clearly be
useful during minimally invasive surgery where there is a loss of tactile feedback.

19.3.3.2 Limitations
A limitation of this method can be represented by the fluorescence of the peri-
toneum due to an accidental spillage in the course of injection for tattoo or LN map-
ping. In this case, it may be difficult to appreciate the fluorescence of the stump tied
to the perfusion, as distinct from the one linked to impregnation of the tissue.
Unfortunately, at present it remains a linear-graded result that requires subjec-
tive interpretation as to the cutoff point between sufficient and insufficient perfu-
sion. However, in our opinion, there is a very clear visible cutoff in fluorescence
mode between not perfused and perfused bowel during the first seconds after ICG
administration. Quantitative real-time analysis of the fluorescence image would be
desirable but is currently not available on the robotic system.

19.3.3.3 Personal Experience and Literature Outcomes

The first study to use fluorescence imaging for colorectal surgery was published in
2010 [12] with interesting results. This retrospective study compared 201 patients
with laser fluorescence angiography (LFA) to a control group. The authors report-
ed an overall reduction of revision due to anastomotic leaks by 4% in the LFA
group (3.5% LFA vs. 7.5% control). In 13.9% of patients, the use of LFA resulted
in a change in the initially planned transection line.
To date, only limited clinical data can be found in the literature regarding bowel
perfusion assessment using the da Vinci® NIR-fluorescence imaging system.
Jafari et al. [15] have recently analyzed the effectiveness of fluorescence in
reducing the rate of anastomotic leak after robotic-assisted low anterior resection
(LAR) for rectal cancer in a retrospective case-control study. They compared LAR
with and without fluorescence imaging and reported a change in the proximal tran-
section point in 3 out of 16 patients (19%) and a reduced leak rate of 6% when com-
pared to 18% for the control group.
200 G. Spinoglio et al.

Promising outcomes have also been reported by Bae et al. [16] in three case
reports. The authors applied the ICG fluorescence during robotic LAR for cancer
to better demark the ischemic area in the distal rectum so that the surgeon was
helped to define the distal resection margin.
A prospective multicenter study [17] has recently evaluated the impact of fluo-
rescence imaging on visualization of perfusion and subsequent change of transection
point during left-sided robotic colorectal surgery. Fluorescence imaging was applied
on 40 patients and resulted in a change of the proximal transection location in 40%
(16/40) of the candidates: two patients (5%) with a change in transection line devel-
oped an anastomotic leak at postoperative days 15 and 40. The authors concluded
that fluorescence imaging during colorectal procedures provides important addition-
al information about bowel perfusion at the transection site; this may eventually help
to decrease leaks caused by hypoperfusion.
From September 2011 to May 2014, we have performed bowel stump evalua-
tion with fluorescence imaging system in 128 full-robotic multiport colorectal
resections for benign and malignant diseases (unpublished data), which included:
51 right colectomies, 39 low and ultralow anterior rectal resections, 32 left colec-
tomies and 6 splenic flexure resections. We routinely choose the transection line,
after mesenteric section and bowel preparation, according to intestinal perfusion as
shown by fluorescence imaging system. There were no intraoperative or anesthetic
complications associated with the injection of ICG dye and the fluorescence bowel
assessment was easily accomplished in real-time in 100% of cases with no addi-
tional operative time.
We registered one case of anastomotic leak (0.8%) in a 78-year-old obese male
patient affected by sigmoid cancer. He presented a Grade C anastomotic leakage on
postoperative day 4 and therefore he underwent emergency laparoscopic surgery
with toilette and endoscopic clip placement.
To conclude, considering both promising published outcomes and our large
experience, ICG fluorescence imaging is an effective and not time-consuming
method to evaluate bowel stump perfusion. Whether this will eventually translate
into decreased leakage rates, if compared to standard subjective parameters,
remains to be definitively proven by large and well-conducted randomized trials.
Integrated software to quantify the fluorescent signal could be useful.

19.4 Sentinel Lymph Node (SLN) Biopsy in Colon Cancer

19.4.1 Procedure Overview

The concept of the SLN biopsy is based on the premise that drainage from a solid
organ tumor occurs in an orderly and near linear manner via lymphatics to region-
al LNs. Identification of SLNs during surgery through dedicated tracers would
identify the “proper nodes” for pathologic examination. The promise of an accurate
nodal staging with reduced surgical trauma and morbidity pushed the development
19 ICG Fluorescence: Current and Future Applications 201

Fig. 19.4 Intraoperative subserosal injection of indocyanine green for sentinel lymph node biop-
sy for caecal cancer

of the SLN biopsy for melanoma and breast cancer in 1992 and 1994, respectively.
When compared with breast cancer or melanoma, however, SLN biopsy in
colon cancer is used primarily for improving the accuracy of staging since typical-
ly it does not determine a more limited surgical resection, which remains clearly
investigational because of the still high rate of false-negative SLNs.
Therefore, although its clinical value in colon cancer is far from being fully
established, the aim is to upstage tumors (stage I and II) by providing the patholo-
gist with one to three lymph nodes for detailed immunohistochemical evaluation. A
reliable sentinel node harvesting technique may eventually alter the management in
colon cancer treatment (i.e., adjuvant chemotherapy) where nodal micrometastases
or isolated tumor cells would remain undetected by conventional pathological
examination.

19.4.2 Technique

The dye (1.5–2.5mg) is injected intraoperatively into the subserosa, by the inser-
tion, through the assistant trocar, of a butterfly infusion set (Fig. 19.4). About
10–20minutes after the injection, from one to three fluorescent LNs are displayed
(Fig. 19.5). SLNs are removed selectively with a “berry picking” technique or
marked with clips for ex vivo identification: each SLN will be stained with H&E
and if no metastases are identified, the pathologist will select from each SLN a
superficial, intermediate and deep section, respectively, that will be immunostained
for cytokeratin (AE-1/AE-3).
Removed tissues are labeled according to anatomical location and sent separate-
ly for pathological evaluation.
202 G. Spinoglio et al.

a b

Fig. 19.5 Near-infrared view of sentinel lymph nodes (a). Final white light view of clipped sen-
tinel lymph nodes (b)

19.4.3 Discussion

Published results on identifying SLNs in CRC with radioguided or blue-dye injec-

tion show variable success rates ranging from 58% to 100%. Consequently, there is
ample room for investigation.
The feasibility of NIR-fluorescence SLN identification during open and laparo-
scopic colonic resections has already been demonstrated by some studies [18–22],
with a detection rate ranging from 88.5% to 100%. This technique with a robotic
fluorescent imaging system was first investigated for gynecological cancers in both
preclinical and clinical settings, reporting a SLN detection rate of 95% [23].
To the best of our knowledge, no published reports exist about ICG SLN biopsy in
robotic colonic surgery.
To date, we have performed 14 SLN biopsies at our institution for stage I and
II colonic cancer, by using the da Vinci® NIR-fluorescence imaging system. The
overall detection rate (number of successful attempts to retrieve LNs/number of
attempts to retrieve LNs) was 92.8%. No aberrant lymphatic drainage was
observed, unlike previous studies have reported [19, 24].
Our preliminary experience showed some shortcomings. The subserosal butter-
fly needle injection for SLN biopsy can be difficult and often remains too superfi-
cial and spreads the dye into the peritoneum. An important caveat in the removal of
fluorescent LN with the “berry picking” technique is to gently manipulate them
since, even without fractures, the dye can easily spread staining the robotic forceps
and, consequently, the surrounding tissues. Additionally, the dose of the dye was
progressively reduced over time: this can help surgeons to improve the accuracy of
detection.
Recently, a study protocol for SLN identification using the robotic NIR fluores-
cent imaging system has been approved by the Ethical Committee of our institu-
tion. The objectives of the study are to establish the feasibility and accuracy of this
method in “real-time” identification of SLN in patients affected by stage I/II colon
cancer and to histologically evaluate by immunohistochemistry the SLN harvested
for micrometastasis. Further studies should then highlight the prognostic signifi-
cance of upstaging and consequences for adjuvant therapy in this subgroup of
patients; a Dutch randomized prospective trial is currently recruiting patients
(EnRoute Trial – ClinicalTrials.gov Identifier: NCT01097265).
19 ICG Fluorescence: Current and Future Applications 203

19.5 Lymph Node (LN) Mapping in Rectal Cancer

19.5.1 Procedure Overview

The prognosis and quality of life of patients affected by colorectal cancer depends
on the extent of the tumor (i.e., stage), its biological features (i.e., differentiation
grade) and characteristics of onset. Complete surgical removal with en-bloc region-
al lymphadenectomy is pivotal for patient oncological outcomes and correct stag-
ing. Nevertheless, concerns about lymphatic spread in rectal cancer still exist.
Examples of involved nodal basins, which are not usually removed through a
standard lymphadenectomy, are represented by lateral pelvic and periaortic LNs in
rectal cancer, that typically have a variable drainage pattern. Although more radical
surgical treatments (such as lateral pelvic lymphadenectomy in Japan) have been
advocated over the years, surgical oncology is evolving toward less aggressive
approaches: in this scenario, LN mapping with ICG might be considered a valid
tool in performing a “tailored” surgery, eventually changing the operative strategy
by performing an extended but selective lymphadenectomy according to the lym-
phatic migration of the fluorescent dye. The aim of LN mapping in rectal cancer is
to potentially improve the staging process without higher morbidity figures if com-
pared to standard resections.

19.5.2 Technique

From 1.5 to 2.5mg of ICG solution are injected endoscopically around the tumor
in the submucosa from 3 to 24 hours before surgery. Within 10–15 minutes, it
reaches the first LN, one or two hours later it reaches the regional LNs where it
remains for about 24–48hours. Operating in NIR light, the LNs, from where the
ICG has been drained, are highlighted during dissection. The LNs are removed en
bloc if present in typical sites, whilst they are removed with a “berry picking” tech-
nique when present in unusual locations after LN mapping (i.e., periaortic, pericav-
al and lateral pelvic nodes, Fig. 19.6).

19.5.3 Discussion

To date, no studies about ICG lymph node mapping in robotic rectal surgery have
been reported.
We have performed 19 LN mappings for rectal cancer, at our institution, to eval-
uate the feasibility of using the da Vinci® NIR-fluorescence imaging system. The
overall detection rate was 78.9%. LN mapping was not successful in 4 out of 19
patients: two patients underwent preoperative radiochemotheraphy, which could
compromise the detection rate by obliteration of lymphatic channels or by scleros-
ing of LNs draining the primary tumor. An overdose of ICG was administered in
204 G. Spinoglio et al.

a b

Fig. 19.6 White light (a) and near-infrared view (b) of interaortocaval lymph nodes following
submucosal indocyanine green injection for rectal cancer

the remaining two cases, making the surgical field appear completely green in the
fluorescent view.
Important caveats in LN mapping are the same as for the SLN biopsy, and
include gentle manipulation of fluorescent LNs to avoid inadvertent staining of the
surrounding tissues and ICG dose.
The ICG fluorescence imaging system during robotic colorectal surgery is a
novel and challenging procedure: it may represent an additional tool to perform LN
mapping and SLN biopsies. Our experience is still at a feasibility stage and we hope
that our on-going study on SLN biopsy could provide useful information.

19.6 Colorectal Tattooing

To date, Indian ink is the most common agent used for perioperative colorectal
tumor localization in the case of small or flat lesions. However, the use of this tat-
tooing agent has been associated with complications [25, 26]. Therefore, some
authors have proposed the use of ICG for endoscopic tattooing and have demon-
strated the feasibility of the technique without adverse events [27].
A preoperative endoscopic tattooing with a dose of 2.5 mg ICG can be per-
formed in order to identify, in real time, the tumor during robotic colorectal resec-
tions.
The use of ICG fluorescent imaging may be safe and useful for perioperative
colorectal tumor localization; nevertheless, the peritumoral injection of the ICG
before the surgery may cause an excessive or inadequate diffusion of the fluores-
cent dye around the tumor, spreading the ICG inside the abdominal cavity.

References
1. Connor S, Garden OJ (2006) Bile duct injury in the era of laparoscopic cholecystectomy. Brit
J Surg 93:158–168
19 ICG Fluorescence: Current and Future Applications 205

2. Rowe CK, Franco FB, Barbosa JA et al (2012) A novel method of evaluating ureteropelvic
junction obstruction: dynamic near infrared fluorescence imaging compared to standard
modalities to assess urinary obstruction in a Swine model. J Urol 188:1978–1985
3. Joseph M, Phillips MR, Farrell TM, Rupp CC (2012) Single incision laparoscopic cholecys-
tectomy is associated with a higher bile duct injury rate: a review and a word of caution. Ann
Surg 256:1–6
4. Berci G, Hunter J, Morgenstern L et al (2013) Laparoscopic cholecystectomy: first, do no harm;
second, take care of bile duct stones. Surgical endoscopy 27:1051–1054
5. Way LW, Stewart L, Gantert W et al (2003) Causes and prevention of laparoscopic bile duct
injuries: analysis of 252 cases from a human factors and cognitive psychology perspective.
Ann Surg 237:460–469
6. Ishizawa T, Bandai Y, Ijichi M (2010) Fluorescent cholangiography illuminating the biliary
tree during laparoscopic cholecystectomy. Brit J Surg 97:1369–1377
7. Ishizawa T, Kaneko J, Inoue Y et al (2011) Application of fluorescent cholangiography to sin-
gle-incision laparoscopic cholecystectomy. Surg Endosc 25:2631–2636
8. Buchs NC, Hagen ME, Pugin F et al (2012) Intra-operative fluorescent cholangiography us-
ing indocyanin green during robotic single site cholecystectomy. Int J Med Robot Comput As-
sist Surg 8:436–440
9. Spinoglio G, Priora F, Bianchi PP et al (2013) Real-time near-infrared (NIR) fluorescent cholan-
giography in single-site robotic cholecystectomy (SSRC): a single-institutional prospective
study. Surg Endosc 27:2156–2162
10. Daskalaki D, Fernandes E, Wang X et al (2014) Indocyanine Green (ICG) fluorescent cholan-
giography during robotic cholecystectomy: results of 184 consecutive cases in a single insti-
tution. Surg Innov. doi: 10.1177/1553350614524839
11. Karliczek A, Harlaar NJ, Zeebregts CJ (2009) Surgeons lack predictive accuracy for anasto-
motic leakage in gastrointestinal surgery. Int J Colorectal Dis 24:569–576
12. Kudszus S, Roesel C, Schachtrupp A, Hoer JJ (2010) Intraoperative laser fluorescence angiog-
raphy in colorectal surgery: a noninvasive analysis to reduce the rate of anastomotic leakage.
Langenbeck’s Arch Surgery 395:1025–1030
13. Sherwinter DA, Gallagher J, Donkar T (2013) Intra-operative transanal near infrared imag-
ing of colorectal anastomotic perfusion: a feasibility study. Colorectal Dis 15:91–96
14. Ris F, Hompes R, Cunningham C et al(2014)Near-infrared (NIR) perfusion angiography in
minimally invasive colorectal surgery. Surg Endosc 28:2221-2226
15. Jafari MD, Lee KH, Halabi WJ et al (2013) The use of indocyanine green fluorescence to as-
sess anastomotic perfusion during robotic assisted laparoscopic rectal surgery. Surg Endosc
27:3003–3008
16. Bae SU, Baek SJ, Hur H et al (2013) Intraoperative near infrared fluorescence imaging in ro-
botic low anterior resection: three case reports. Yonsei Med J 54:1066–1069
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imaging on the location of bowel transection during robotic left-sided colorectal surgery. Surg
Endosc 28:1695–1702
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sy using fluorescence navigation with indocyanine green. Int J Colorectal Dis 27:319–224
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cancer using infrared ray laparoscopy. Anticancer Res 26:2307–2311
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206 G. Spinoglio et al.

23. Jewell EL, Huang JJ, Abu-Rustum N et al (2014) Detection of sentinel lymph nodes in min-
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ternative to India ink for endoscopic marking. Surg Endosc 23:347–351
 Part VI
Miscellany
Splenectomy and Hemisplenectomy
20
Giuseppe Spinoglio, Alessandra Marano,
Luca Matteo Lenti, Francesca Pagliardi,
and Giampaolo Formisano

20.1 Splenectomy

20.1.1 Procedure Overview

Minimally invasive splenectomy has become an established standard of care in

general surgery for nontraumatic splenic lesions. Since laparoscopic splenecto-
my was first reported in 1991 by Delaitre et al. [1], subsequent literature has
clearly shown that this approach dramatically improves short-term periopera-
tive outcomes and provides enhanced cosmesis [2].
However, standard laparoscopy has some drawbacks, including an unstable
two-dimensional vision and rigid instrumentation: these inherent limitations
could make the procedure difficult to perform in the case of massive
splenomegaly and fragile parenchyma.
The robotic system, thanks to its technological advantages, may potentially be
a valid tool in performing splenectomy in these challenging situations [3, 4].
Moreover, the meticulous hilar dissection achieved with endowristed instruments
may allow to easily perform partial splenectomies as well [3, 5, 6].

20.1.2 Patient and Robot Positioning

The patient is positioned in a right-lateral supine position (left side up by

approximately 60–70°) and legs closed. Arms are secured with belts and appro-
priate supports to avoid injuries. The operating table is then flexed, lowering the

G. Spinoglio (
)
Department of General and Oncologic Surgery, “Ss. Antonio e Biagio” Hospital,
Alessandria, Italy
e-mail: [email protected]

G. Spinoglio (Ed), Robotic Surgery: Current Applications and New Trends, 209
Updates in Surgery
DOI: 10.1007/978-88-470-5714-2_20, © Springer-Verlag Italia 2015
210 G. Spinoglio et al.

legs and the thorax, with the umbilicus above the pivoting point of the table.
This position widens the space between the costal margin and anterior superior
iliac spine for introducing trocars. A mild reverse-Trendelenburg tilt is applied
to improve exposure of the operative field.
The robot is brought to the table from the left shoulder with a 45° angle and
docked (Fig. 20.1a).

20.1.3 Trocar placement

Five trocars are placed after induction of 12 mmHg pneumoperitoneum by the

Veress needle. A 12-mm camera port is introduced in the middle point between
the left costal margin and the umbilicus; a 30° downscope is used.
Under direct visualization, trocars are inserted as follows (Fig. 20.1b):
• One 8-mm robotic trocar (R1) is placed on the transverse umbilical line,
5–6 cm left paraumbilical, for Hot Shears™ (monopolar curved scissors),
cautery hook or robotic clip applier. We do not routinely use an ultrasonic
scalpel in case of splenectomy;
• One 8-mm robotic trocar (R2) is placed in the epigastric area, 2–3 cm left
paramedian, for bipolar forceps. Harmonic scissors are mounted on R2 for
parenchymal transection during hemisplenectomy;
• One 8-mm robotic trocar (R3) in the left flank for the ProGrasp™ forceps or
Cadiere forceps, used for upward traction on the splenic parenchyma or
downward traction on the left colonic flexure to achieve exposure;
• One 15-mm assistant's trocar is placed between R1 and R3 for suction/irriga-
tion, clip application (if necessary) or other maneuvers to achieve optimal
exposure of the splenic hilum.
A thorough inspection of the peritoneal cavity for gross pathology and acces-
sory spleen is performed. If identified, the accessory spleen should be removed.

a b
Fig. 20.1 Splenectomy and hemisplenectomy. a OR setup. b Trocar layout. (© 2014 Intuitive
Surgical, Inc.)
20 Splenectomy and Hemisplenectomy 211

20.1.4 Step-by-Step Review of Critical Elements of the Procedure

20.1.4.1 Step 1 - Access to the Lesser Sac and Splenic Hilum Exposure
Robotic Splenectomy (RS) is performed with an anterior approach (i.e., vessel divi-
sion without a posterior mobilization of the spleen). The stomach is retracted medi-
ally by the assistant’s grasper and a gentle and constant lateral traction on the spleen
is applied with the fenestrated grasper in R3. Gastrocolic and gastrosplenic liga-
ments, within which short gastric vessels lie, are opened with the bipolar forceps in
R2 and the cautery hook/monopolar scissors in R1; clips may be applied if required.
There are two vascular patterns of the splenic pedicle: the magistral type, in
which the main splenic artery enters the splenic hilum as a compact structure
without branching; and the distributed type, which is the most common pattern,
in which multiple arterial branches arise from the main splenic artery 2–3 cm
from the hilum. Indeed, two or three lobar arteries can be found in the majority
of cases (86% and 12%, respectively) [7].

20.1. 4.2 Step 2 - Vascular Dissection

This step of the operation is carried out with the cautery hook in R1 and bipolar
forceps in R2. The monopolar scissors, clip applier and large needle driver can
be mounted on R1 when necessary.
The pancreatic tail is exposed and the splenic artery may be thus easily iden-
tified along its superior border. The splenic artery is dissected circumferentially
and passed under with a loop as distally as possible for vascular inflow control.
The splenic artery can be ligated or clipped along its main trunk (Fig. 20.2) but,
if it gives off long lobar or segmental branches, they can be dissected separate-
ly and divided between self-locking nonabsorbable clips.
Finally, the splenic vein is dissected (Fig. 20.3), ligated and divided. It is impor-
tant that the length of the prepared vessels is optimal to allow both double proximal
and a distal ligature: an important advantage provided by the robotic system is the
possibility to easily and safely ligate splenic vessels with traditional knots, if
required. Venous branches usually overlay arterial vessels at the splenic hilum: if
this dissection is challenging, the main trunk of the splenic artery can be clipped thus
reducing splenic vascular inflow and allowing a safer control of the splenic vein.

20.1.4.3 Step 3 - Spleen Mobilization

The spleen is pulled cranially and laterally with the grasper in R3, while the assis-
tant gently stretches the Gerota’s fascia caudally with the suction/irrigator to
maintain the operative field clean. The cautery hook in R1 and bipolar forceps in
R2 are used to dissect the posterior attachments in a caudal-to-cephalad direction.
Care should be taken to avoid any parenchymal fracture in neoplastic diseases.

20.1.4.4 Step 4 - Specimen Extraction

An endobag is inserted through the assistant trocar for specimen extraction and
the robot is undocked. The spleen is removed for morcellation by slightly
212 G. Spinoglio et al.

Fig. 20.2 Dissection of the main trunk of the splenic artery

Fig. 20.3 After arterial control, the vein is fully dissected and divided

enlarging a trocar site, otherwise through a Pfannenstiel laparotomy if larger

specimens cannot be morcellated because of the underlying pathology. After a
final laparoscopic check of the operative field, a suction drain is routinely left in
place and trocars are removed under direct vision.

20.2 Hemisplenectomy

20.2.1 Procedure Overview

The value in performing partial splenectomy for selected benign diseases has been
well demonstrated in preserving the immune function, particularly in young patients.
20 Splenectomy and Hemisplenectomy 213

The robotic assisted approach may be the most indicated for hemisplenectomy
because it theoretically allows a more meticulous dissection of small arterial branch-
es if compared to laparoscopy. However, to date, different studies have shown
laparoscopic partial splenectomy to be feasible and safe with good clinical results
[8–16] and only few robotic series have directly addressed this issue [3, 5, 6].

20.2.2 Step-by-Step Review of Critical Elements of the Procedure

Patient and robot positioning, trocar placement and splenic hilum exposure are
the same as previously described for total splenectomy, except for an extensive
division of the more cranial short gastric vessels in the case of lesions located at
the lower pole of the spleen.
The splenic artery is dissected first and passed under with a loop as distally
as possible for bleeding control, if necessary, during hilar and parenchymal dis-
section. The hilar dissection is then undertaken and all arterial branches are
identified and progressively dissected free, depending on the vascular pattern.
Any arterial or venous branches to be preserved are identified, while the other
vessels are clipped proximally and distally or ligated with absorbable sutures
(Fig. 20.4). The cautery hook in R1 guarantees for precise dissection of even
small branches of the splenic vessels.
The demarcation line is then identified in white light or through the integrat-
ed fluorescence imaging system after the intravenous administration of
0.1 mg/kg of indocyanine green (ICG); also arterial vascular branching can be
assessed in real-time during the procedure. The spleen is divided using the

Fig. 20.4 Dissection and ligation of the inferior lobar artery during hemisplenectomy. The demar-
cation line is clearly visible
214 G. Spinoglio et al.

Fig. 20.5 Final view after hemisplenectomy. An absorbable fibrin sealant patch is applied on the
transected splenic parenchyma

Harmonic scalpel on R2 or the bipolar forceps and retrieved in an endobag.

During this step, small median vessels (subsegmental arteries and veins or their
branches) may be encountered, gently skeletonized and selectively clipped as a
result of the technological features of the robotic system. Hemostasis of the
remaining splenic parenchyma can be refined through bipolar coagulation or
dedicated hemostatic materials (Fig. 20.5). A suction drain is routinely left in
place, robot is undocked and trocars are removed.

20.3 Advantages and Personal Experience

Minimally invasive splenectomy is considered a well-accepted approach for a vari-
ety of conditions, including auto-immune or congenital hematological disorders,
lymphoproliferative diseases, focal lesions, cysts, abscesses and tuberculosis.
To date, comparative studies did not show any significant advantages of RS
over standard laparoscopy. From a technical point of view, the choice of whether
to use the robotic or laparoscopic approach for the hilar dissection should be
considered on a case-by-case basis and is dependent on various factors, includ-
ing anatomy of the pancreatic tail, anatomy of the splenic vessels, and volume
and consistency of the spleen.
It seems reasonable to advocate a laparoscopic approach in the case of a
small and compact spleen associated with a short pancreatic tail, allowing for
safe stapling of the pedicle.
However, the endowristed instruments together with the magnified 3DHD
vision may give advantageous results in the case of (3, 4, 6):
• multiple and short arterial and venous branches of the splenic vessels;
• bulky or “intrasplenic” pancreatic tail;
20 Splenectomy and Hemisplenectomy 215

• fragile parenchyma and huge spleen volume, which is the main predictor for
conversion to open surgery in the case of laparoscopic splenectomy;
• previous radiotherapy with extensive fibrosis and adhesions;
• hemisplenectomy, for selective small vessel ligation, parenchymal transec-
tion and parenchymal sparing.
In the case of hemisplenectomy, different methods of parenchymal transec-
tion can be used [6]; however, we do not routinely oversew the remaining
splenic parenchyma with pledgets as described by other authors [3]. Moreover,
Vasilescu et al. [6] have demonstrated lower blood loss and vascular dissection
time during robotic subtotal splenectomy if compared to the laparoscopic
approach.
To date, we performed 15 total splenectomies and 5 hemisplenectomies.
There were 9 men (45%) and 11 (55%) women, with a mean age of 45.2 years.
Indications for surgery with total splenectomies included hematological disor-
ders (8 pts), lymphoproloferative diseases (5 pts) and voluminous cysts (2 pts);
the mean spleen size for total splenectomy was 13.2 cm. Hemisplenectomies
were performed for benign focal lesions. The mean operative times were
229 min and 260 min for total and partial splenectomy, respectively. Overall,
there were no conversions to open surgery and no intraoperative complications
or major postoperative complications were observed.
In conclusion, our series and previous studies report RS as safe and feasible;
it provides a valid alternative to laparoscopic splenectomy, especially in more
challenging cases and during hemisplenectomy.

References
1. Delaitre B, Maignien B (1991) Splenectomy by the laparoscopic approach. Report of a case.
Presse Med 20:2263
2. Gamme G, Birch DW, Karmali S (2013) Minimally invasive splenectomy: an update and re-
view. Can J Surg 56:280–285
3. Giulianotti PC, Buchs NC, Addeo P (2011) Robot-assisted partial and total splenectomy. Int
J Med Robot Comput Assist Surg 7:482–488
4. Gelmini R, Franzoni C, Spaziani A (2011) Laparoscopic splenectomy: conventional versus
robotic approach–a comparative study. J Laparoendosc Adv Surg Tech A 21:393–398
5. Vasilescu C, Tudor S, Popa M (2010) Robotic partial splenectomy for hydatid cyst of the spleen.
Langenbeck’s Arch Surg 395:1169–1174
6. Vasilescu C, Stanciulea O, Tudor S (2012) Laparoscopic versus robotic subtotal splenecto-
my in hereditary spherocytosis. Potential advantages and limits of an expensive approach. Surg
Endosc 26:2802–2809
7. Liu DL, Xia S, Xu W et al (1996) Anatomy of vasculature of 850 spleen specimens and its
application in partial splenectomy. Surgery 119:27–33
8. Seims AD, Breckler FD, Hardacker KD, Rescorla FJ (2013) Partial vs total splenectomy in
children with hereditary spherocytosis. Surgery 154:849–853
9. Zhang Y, Chen XM, Sun DL, Yang C (2014) Treatment of hemolymphangioma of the spleen
by laparoscopic partial splenectomy: a case report. W J Surg Oncol 12:60
10. Slater BJ, Chan FP, Davis K, Dutta S (2010) Institutional experience with laparoscopic par-
tial splenectomy for hereditary spherocytosis. J Ped Surg 45:1682–1686
216 G. Spinoglio et al.

11. Morinis J, Dutta S, Blanchette V et al (2008) Laparoscopic partial vs total splenectomy in chil-
dren with hereditary spherocytosis. J Ped Surg 43:1649–1652
12. Hery G, Becmeur F, Mefat L et al (2008) Laparoscopic partial splenectomy: indications and
results of a multicenter retrospective study. Surg Endosc 22:45–49
13. Breitenstein S, Scholz T, Schafer M (2007) Laparoscopic partial splenectomy. J Am Coll Surg
204:179–181
14. Uranues S, Grossman D, Ludwig L, Bergamaschi R (2007) Laparoscopic partial splenecto-
my. Surg Endosc 21:57–60
15. Rescorla FJ, West KW, Engum SA, Grosfeld JL (2007) Laparoscopic splenic procedures in
children: experience in 231 children. Ann Surg 246:683–687
16. Dutta S, Price VE, Blanchette V, Langer JC (2006) A laparoscopic approach to partial splenec-
tomy for children with hereditary spherocytosis. Surg Endosc 20:1719–1724
Transperitoneal Adrenalectomy
21
Giuseppe Spinoglio, Alessandra Marano,
Ferruccio Ravazzoni, Francesca Pagliardi,
and Giampaolo Formisano

21.1 Procedure Overview

Laparoscopic transperitoneal adrenalectomy was first reported in 1992 by
Gagner et al. [1]. During the last decade, it has largely replaced the open
approach as the standard of care for adrenal gland removal, especially for
benign tumors, given the well-known advantages of minimally invasive surgery.
Nevertheless, laparoscopy is recognized as associated with a steep learning
curve and has some technical constraints. Robotic surgery can potentially pro-
vide a solution to these drawbacks.
In 1999, Piazza et al. [2] described the first robotic adrenalectomy case
series using the AESOP 2000, which was the commercially available robotic
platform in Europe at that time. With the introduction of the da Vinci® system
(Intuitive Surgical, Sunnyvale, CA, USA), different series of robotic adrenalec-
tomy have been reported [3–13], showing the safety and feasibility of the pro-
cedure as well as potential advantages over laparoscopy because of its unique
technological features. The first report of robotic transperitoneal adrenalectomy
with the da Vinci® system dates back to the 2001 [14].
In 1996, Walz et al. [15] first described a posterior retroperitoneoscopic
approach for adrenal masses: though comparative studies of transperitoneal and
retroperitoneal laparoscopic adrenalectomy demonstrate heterogeneous results,
retroperitoneal techniques may offer less postoperative pain, faster recovery and
an easier bleeding control by simply increasing the CO2 pressure up to
28 mmHg in a confined space. Disadvantages include the smaller working
space, and the requirement for the surgeon to learn a new “reverse angle”

G. Spinoglio (
)
Department of General and Oncologic Surgery, “Ss. Antonio e Biagio” Hospital,
Alessandria, Italy
e-mail: [email protected]

G. Spinoglio (Ed), Robotic Surgery: Current Applications and New Trends, 217
Updates in Surgery
DOI: 10.1007/978-88-470-5714-2_21, © Springer-Verlag Italia 2015
218 G. Spinoglio et al.

anatomic perspective. In 2010, the robotic posterior approach was also reported
by Berber et al. [16].
In this chapter, we will focus on the robotic lateral transperitoneal approach
for adrenal gland tumors.

21.2 Patient and Robot Positioning

After administration of general anesthesia, the patient is placed in a lateral right
or left decubitus position, according to the side of the tumor, with legs closed.
Arms are secured with belts and appropriate supports to avoid injuries. The
operating table is then flexed, lowering the legs and the thorax, with the umbili-
cus above the pivoting point of the table. A mild reverse-Trendelenburg tilt is
applied to improve exposure of the operative field.
The robot is brought to the table from the shoulder with a 45° angle and is
docked (Fig. 21.1).

21.3 Trocar Placement

For left adrenalectomy, five trocars are placed after induction of 12 mmHg pneu-
moperitoneum by the Veress needle in the left subcostal space. A 12-mm camera
port is introduced in the middle point between the left costal margin and the
umbilicus. A 30° downscope is used.
Under direct visualization, trocars are inserted as follows (Fig. 21.2):

Fig. 21.1 OR setup for left adrenalec-

tomy. For right adrenalectomy the cart
is brought to the table from the opposi-
te side. (© 2014 Intuitive Surgical,
Inc.)
21 Transperitoneal Adrenalectomy 219

Fig. 21.2 Trocar layout for left

adrenalectomy. (© 2014 Intuitive
Surgical, Inc.)

Fig. 21.3 Trocar layout for right

adrenalectomy. (© 2014 Intuitive
Surgical, Inc.)

• One 8-mm robotic trocar (R1) is placed in the left flank for Hot Shears™
(monopolar curved scissors), cautery hook or robotic clip applier. We do not
routinely use an ultrasonic scalpel;
• One 8-mm robotic trocar (R2) is placed in the epigastric area, 2–3 cm left
paramedian, for bipolar forceps;
• One 8-mm robotic trocar (R3) is placed cranially to R2, a few centimeters
below the xyphoid process, for the ProGrasp™ forceps or Cadiere forceps;
they are used for traction on the adrenal gland or on the splenic parenchyma
along with the pancreatic tail;
• One 12-mm assistant’s trocar is placed between R1 and the camera ports for
suction/irrigation, clip application (if necessary) or other maneuvers to
achieve optimal exposure of the adrenal gland.
Trocars are placed in a mirror image for right-sided adrenal masses, with R1
in the epigastric area and R2 in the right flank (Fig. 21.3).
We perform a totally robotic approach, though a hybrid technique with
laparoscopic mobilization of the liver or of the splenopancreatic block has been
described.
220 G. Spinoglio et al.

21.4 Step-by-Step Review of Critical Elements of the

Procedure

21.4.1 Right Adrenalectomy

It is not necessary to divide the triangular and coronary ligaments with the robot-
ic approach, whilst this maneuver is required in laparoscopic surgery. The liver
is retracted upward with the fenestrated grasper in R3 and the inferior caval vein
(ICV) is identified.
The peritoneum and the Gerota’s fascia are opened along the right border of
the ICV; the dissection is continued upward along the inferior surface of the liver
and then counterclockwise to gain access to the right margin of the superior renal
pole. Once the peritoneum has been incised, the liver can be further mobilized
and pulled cranially with the grasp in R3 without any risk of capsular tears
because of the stable and constant traction exerted by the robotic instruments.
The inferior part of the right border of the caval vein and the superior aspect
of the right renal vein are fully exposed to gain access to the posterior muscular
plane. We separate the adipose capsule from the posterior abdominal wall open-
ing a wide dihedral angle that represents our first working space and allows the
control of the right middle adrenal vein more easily and safely, as a result of an
anterior and posterior access. If present, upper polar renal arteries must be iden-
tified and preserved. Attention should be paid to a small accessory hepatic vein
(Fig. 21.4).The middle adrenal vein is dissected and clipped with laparoscopic
or robotic nonabsorbable self-locking clips (Hem-o-lok®, Weck-Teleflex Europe
Ltd.) and divided (Fig. 21.5). This maneuver is a crucial step of the operation,
especially in the case of a large and short adrenal vein: the robotic clip applier
should be used in these situations because of the advantages offered by the
EndoWrist® technology.

Fig. 21.4 An accessory hepatic vein (AHV), crossing the upper pole of the adrenal gland is clipped
and divided. ICV, inferior caval vein
21 Transperitoneal Adrenalectomy 221

Fig. 21.5 Medial dissection during right adrenalectomy. MAV, middle adrenal vein; ICV, inferior
caval vein; AHV, accessory hepatic vein

Other small venous or arterial branches are usually controlled with bipolar
energy and are divided. The adrenal gland is dissected completely free along with
the surrounding epinephric fat, with complete respect for oncological principles.
The robot is undocked and the lesion is removed in a specimen retrieval bag
by slightly enlarging a trocar site. A suprapubic minilaparotomy can be per-
formed in the case of larger masses.

21.4.2 Left Adrenalectomy

The Toldt’s white line is incised starting from the proximal descending colon in
a caudal-to-cephalad direction, thus gaining access to the avascular plane and
exposing the lateral aspect of the Gerota’s fascia. The peritoneum is incised up
to the greater curvature of the stomach behind the spleen by the division of the
splenophrenic ligament; the dissection is carried out progressively upward and
the splenopancreatic block, together with the splenic flexure, is fully mobilized
and can be retracted medially to expose the adrenal gland.
The Gerota’s fascia is then incised along the medial aspect of the adrenal
gland thus entering into the epinephric fat. The left renal vein is identified as a
landmark for medial dissection and isolation of the middle adrenal vein, paying
great attention not to damage the spermatic vessels, as well as the underlying
renal artery. If present, upper polar renal arteries must be identified and pre-
served. The middle adrenal vein is dissected free and clipped with laparoscopic
or robotic nonabsorbable self-locking clips (Hem-o-lok®, Weck-Teleflex Europe
Ltd.) and divided. A small superior adrenal artery, arising from the inferior
phrenic artery, may be found; it can be controlled with bipolar energy or clips.
Once the specimen is completely freed, the procedure continues as already
described.
222 G. Spinoglio et al.

21.5 Advantages, Limitations and Relative Contraindications

(Personal Experience and Literature Outcomes)
To date, there is not indisputable proof that robotic adrenalectomy is superior to
laparoscopic adrenalectomy, both with the transabdominal and posterior
retroperitoneal approach. Although there are several case reports describing the
laparoscopic techniques, robotic adrenalectomy is, to date, the subject of a still
limited number of studies in the literature.
The only available randomized prospective trial comparing laparoscopic
approach to the robotic counterpart was reported by Morino et al. [12] in 2004.
There were 20 patients randomized to either the laparoscopic or robotic approach.
The operative time was longer in the robotic group (169 vs. 115 min) and conver-
sion to laparoscopy was required in 40% of patients in the robotic group. The mor-
bidity rate (20% vs. 0%) and the costs ($3.467 vs. $2,737) were significantly high-
er in the robotic series. The authors concluded that laparoscopic adrenalectomy
was superior to robotic adrenalectomy in terms of feasibility, morbidity and costs.
However, this study has a small patient sample and neither the power of the study
nor the randomization method are described in detail. Additionally, the procedures
were conducted at the beginning of the learning curve with the old three-arm da
Vinci® System: an updated high-quality evaluation should be considered.
In a prospective study of 100 patients who underwent robotic transperitoneal
unilateral adrenalectomy, Brunaud et al. [8] achieved no mortality and a 10%
morbidity rate. Their conversion rates were 4% to laparoscopy and 1% to open
surgery. The mean operative time was 99 min, which decreased by 1 min for
every 10 cases: surgeon’s experience, first assistant’s level, and tumor size were
found to be independent predictors of operative time. The cost of the robotic
procedure was 2.3 times more than the lateral transperitoneal laparoscopic
adrenalectomy (€4,102 vs. €1,799). Despite its costs, Brunaud et al. and asso-
ciates suggested that the robotic procedure was preferable owing to better vision
quality and surgeon comfort.
Adrenalectomy in obese patients may be challenging due to the difficult
exposure. However, though Brunaud et al. [17] and Giulianotti et al. [10] have
shown that the robotic approach may be a valid option for patients with a BMI
of 30 kg/m2, results from Aksoy et al. [5] have suggested that the robotic
approach does not provide significant benefits because of the difficulties in
maintaining adequate exposure and dissection. Postoperative outcomes and
operative times were similar between the laparoscopic and the robotic group.
Karabulut et al. [18] have recently published their comparative study of robot-
ic vs laparoscopic adrenalectomy, both with transperitoneal and posterior approach.
Operative time was comparable between the two groups with both the transperi-
toneal and posterior approach. However, the robotic procedures were more favor-
able because of a lower morbidity and shorter hospital stay over the laparoscopic
counterpart. Once experience has been gained, robotic posterior adrenalectomy
could shorten the operative time compared to the laparoscopic posterior approach.
21 Transperitoneal Adrenalectomy 223

The same group compared the robotic vs. standard laparoscopic technique in
the surgical treatment of large adrenal tumors >5 cm [3]. The operative time and
conversion rate were lower in the robotic group (159 min vs. 187 min, and 4%
vs. 11%, respectively). Additionally, the length of hospital stay was shorter in the
robotic vs. laparoscopic group (1.4 vs. 1.9 days). These results suggest that the
robotic platform could potentially facilitate the resection of large adrenal tumors.
An additional benefit of the robotic approach may be glimpsed in partial
adrenalectomy for patients requiring bilateral adrenalectomy and therefore life-
long steroid supplementation. Few cases, however, have been reported in the lit-
erature [19–21].
Recently, a metanalysis has been published by Brandao et al. [22] to critical-
ly analyze the available evidence of studies comparing laparoscopic and robotic
adrenalectomy. Studies with both the transperitoneal and posterior approach
have been included. Authors showed that the robot-assisted adrenalectomy can
be performed safely and effectively with operative times and complication rates
similar to laparoscopic adrenalectomy and it can provide the potential advantage
of a shorter hospital stay and less blood loss.
To date, we have performed 14 robotic adrenalectomy (unpublished data),
mainly for right-sided adrenal tumors (12 out of 14). The indications for surgery
were five nonfunctional adenomas, four pheochromocytomas, three metastasis
and two Cushing syndromes. Mean BMI was 25 kg/m2. The mean tumor size
was 5.2 cm and the mean operative time was 180 min. Neither intraoperative nor
early postoperative complications were recorded, and there were no conversions
to laparoscopic or open surgery.
Our experience, even though limited, confirms the feasibility and safety of
robotic adrenalectomy with the transperitoneal approach. The technological
properties of the da Vinci® system strongly improve the dissection during adre-
nal surgery, especially in the case of large right-sided tumors (>6 cm) posterior
to the caval vein. The stable platform and the EndoWrist™ technology also
enables the surgeon to safely control and divide large and short right adrenal
veins at the caval confluence.
Future studies involving larger case series and randomized trials with ade-
quate power will determine the exact role of robotics in adrenal surgery with
both the anterior and posterior approach. Moreover, the experience with mini-
mally invasive surgery is limited and therefore controversial in the case of
malignant lesions.

References
1. Gagner M, Lacroix A, Bolte E (1992) Laparoscopic adrenalectomy in Cushing’s syndrome
and pheochromocytoma. N Engl J Med 327:1033
2. Piazza L, Caragliano P, Scardilli M et al (1999) Laparoscopic robot-assisted right adrenalec-
tomy and left ovariectomy (case reports). Chirurgia Italiana 51:465–466
224 G. Spinoglio et al.

3. Agcaoglu O, Aliyev S, Karabulut K et al (2012) Robotic versus laparoscopic resection of large

adrenal tumors. Ann Surg Oncol 19:2288–2294
4. Agcaoglu O, Aliyev S, Karabulut K et al (2012) Robotic vs. laparoscopic posterior retroperi-
toneal adrenalectomy. Arch Surg 147:272–275
5. Aksoy E, Taskin HE, Aliyev S et al (2013) Robotic versus laparoscopic adrenalectomy in obese
patients. Surg Endosc 27:1233–1236
6. Aliyev S, Karabulut K, Agcaoglu O et al (2013) Robotic versus laparoscopic adrenalectomy
for pheochromocytoma. Ann Surg Oncol 20:4190–4194
7. Brandao LF, Autorino R, Zargar H et al (2014) Robot-assisted laparoscopic adrenalectomy:
step-by-step technique and comparative outcomes. Eur Urol. doi: 10.1016/j.eururo.2014.04.003
8. Brunaud L, Ayav A, Zarnegar R et al (2008) Prospective evaluation of 100 robotic-assisted
unilateral adrenalectomies. Surgery 144:995–1001
9. D’Annibale A, Lucandri G, Monsellato I et al (2012) Robotic adrenalectomy: technical as-
pects, early results and learning curve. Int J Med Robot Comput Assist Surg 8:483–490
10. Giulianotti PC, Buchs NC, Addeo P et al (2011) Robot-assisted adrenalectomy: a technical
option for the surgeon? Int J Med Robot Comput Assist Surg 7:27–32
11. Ludwig AT, Wagner KR, Lowry PS (2010) Robot-assisted posterior retroperitoneoscopic
adrenalectomy. J Endourol 24:1307–1314
12. Morino M, Beninca G, Giraudo G et al (2004) Robot-assisted vs. laparoscopic adrenalecto-
my: a prospective randomized controlled trial. Surg Endosc 18:1742–1746
13. Pineda-Solis K, Medina-Franco H, Heslin MJ (2013) Robotic versus laparoscopic adrenalec-
tomy: a comparative study in a high-volume center. Surg Endosc 27:599–602
14. Horgan S, Vanuno D (2001) Robots in laparoscopic surgery. J Laparoendosc Adv Surg Tech
A 11:415–519
15. Walz MK, Peitgen K, Hoermann R et al (1996) Posterior retroperitoneoscopy as a new min-
imally invasive approach for adrenalectomy: results of 30 adrenalectomies in 27 patients. World
J Surg 20:769–774
16. Berber E, Mitchell J, Milas M, Siperstein A (2010) Robotic posterior retroperitoneal adrena-
lectomy: operative technique. Arch Surg 145:781–784
17. Brunaud L, Bresler L, Ayav A et al (2008) Robotic-assisted adrenalectomy: what advantages
compared to lateral transperitoneal laparoscopic adrenalectomy? Am J Surg 195:433–438
18. Karabulut K, Agcaoglu O, Aliyev S (2012) Comparison of intraoperative time use and peri-
operative outcomes for robotic versus laparoscopic adrenalectomy. Surgery 151:537–542
19. Asher KP, Gupta GN, Boris RS et al (2011) Robot-assisted laparoscopic partial adrenalecto-
my for pheochromocytoma: the National Cancer Institute technique. Eur Urol 60:118–124
20. Boris RS, Gupta G, Linehan WM et al (2011) Robot-assisted laparoscopic partial adrenalec-
tomy: initial experience. Urology 77:775–780
21. St Julien J, Ball D, Schulick R (2006) Robot-assisted cortical-sparing adrenalectomy in a pa-
tient with Von Hippel-Lindau disease and bilateral pheochromocytomas separated by 9 years.
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a systematic review and meta-analysis. Eur Urol 65:1154–1161
Robotic-assisted Organ Transplantation
22
Raquel Garcia-Roca, Ivo Tzvetanov, Hoonbaen Jeon,
Jose Oberholzer, and Enrico Benedetti

22.1 Introduction

The da Vinci® Robotic Surgical System (Intuitive Surgical, Sunnyvale, CA) is

the only robotic system approved by the Food and Drugs Administration (FDA)
for use in humans. It offers several advantages over laparoscopic surgery, such
as: efficient microsuturing through the ports, three-dimensional high-definition
view, and wristed instruments with seven degrees of freedom. However, the
greatest limitations of the current robotic system are high cost and lack of hap-
tic feedback.
The da Vinci® surgical system has enabled surgeons to complete complex
major surgical procedures in a minimally invasive fashion expanding into those
fields of surgery that were never considered before. Robotic surgery has been
successfully used in kidney transplantation [1, 2], and in a lesser proportion in
pancreas transplantation [3] and donor hepatectomy for living donor liver trans-
plantation [4].

22.2 Living Donor Robotic-assisted Nephrectomy

Living donation is an elective procedure compared to deceased donation. This
offers the advantage of having kidney grafts of excellent quality and the option
to perform the procedure when the recipient is in optimal condition. In addition,
wait time until transplantation and dialysis duration can be minimized. The
main obstacle for living donation is the exposure of a healthy individual to the

R. Garcia-Roca (
)
Department of Surgery, Division of Transplantation, University of Illinois Hospital and Health
Sciences System, Chicago, IL, USA
e-mail: [email protected]

G. Spinoglio (Ed), Robotic Surgery: Current Applications and New Trends, 225
Updates in Surgery
DOI: 10.1007/978-88-470-5714-2_22, © Springer-Verlag Italia 2015
226 R. Garcia-Roca et al.

inherent risk of a surgical intervention without a direct health benefit. The avail-
ability of a minimally invasive, laparoscopic surgical technique greatly
enhanced living donation rates by reducing postoperative pain, achieving faster
recovery and minimizing the surgical incisions. The da Vinci® Surgical System
has been used in living donor nephrectomy as a logical extension of the widely
adapted laparoscopic approach. To date there are no randomized trials compar-
ing robotic versus laparoscopic donor nephrectomy. Intuitively, with the expand-
ed range of movements, it simplifies complicated procedures in the presence of
multiple renal arteries or other vascular anomalies. The first worldwide transab-
dominal hand-assisted robotic donor nephrectomy was performed successfully
at the University of Illinois at Chicago Hospital in 2000 [5]. Since then, our
institution has performed over 800 robotic donor nephrectomies with excellent
outcomes.
Potential donors are evaluated by a multidisciplinary transplant team, which
includes a surgeon, pharmacist, social worker, nutritionist, financial counselor
and nurse coordinator. The medical screening involves assessment of immuno-
logic compatibility, the renal function and the current medical status of the
patient to exclude conditions that can be transmitted to the recipient or jeopard-
ize the donor health. The decision regarding which kidney to be harvested is
based on the function and anatomy of the kidneys determined by a 3D recon-
struction from an abdominal CT scan with arterial contrast. Usually the left kid-
ney is procured, due to its favorable anatomy (longer left renal vein) and the
lower complexity of the left nephrectomy, even in the presence of multiple arter-
ies on that side.

22.2.1 Step-by-Step Review of Surgical Procedure

For a left nephrectomy, the patient is rolled into the right lateral decubitus posi-
tion with a cushioned beanbag and axillary roll, and the table is flexed. The
patient should be secured to the operative table, because any instability after
docking the robotic system could jeopardize the safety. The table should be in
the Trendelenburg position to avoid injury of the arm and shoulder from the left
robotic arm (Fig. 22.1a).

22.2.1.1 Step 1 - Incision and Trocar Placement

Robotic-assisted donor nephrectomy is a transabdominal procedure through four
laparoscopic-robotic ports. Additionally, a 7-cm access incision, longitudinal or
transverse, is required in the lower abdomen for extraction of the kidney. In our
practice the assistant’s hand, previously wrapped with protective, sterile
IobandTM (3M, USA) around the wrist and forearm is inserted directly through
the incision. This maneuver does not interfere with the maintenance of pneu-
moperitoneum and, according to our observation, significantly decreases the
incidence of wound infections.
22 Robotic-assisted Organ Transplantation 227

a b
Fig. 22.1 Living donor nephrectomy. a OR setup. b Trocar placement. (© 2014 Intuitive Surgical,
Inc.)

The kidney to be harvested is palpated to identify the position of the hilum.

Under hand control from inside the abdomen, a 12-mm laparoscopic port is
placed above the umbilicus, close to the midline, at the level of the renal hilum.
This port is required for the 30° robotic camera system. To achieve good triangu-
lations, the two 8-mm robotic working ports are placed along the left mid clavic-
ular line. They are located proximal and distal, 10 to 12 cm apart from camera
port. Last, 12-mm port is placed in left lower quadrant to assist with suction, clip-
ping, stapling, and cutting (Fig. 22.1b). The robotic system is docked and inte-
grated to the ports and pneumoperitoneum is achieved. To obtain additional
working space, the robotic arms are used to give additional lift on the ports.

22.2.1.2 Step 2 - Exposure of the Retroperitoneum and Identification

of the Ureter
The assisting surgeon medially retracts the descending colon; the lateral peri-
toneal attachments are divided with cautery, exposing the left paracolic gutter
and fully mobilizing the sigmoid colon. The splenocolic ligament is transected
and the anterior surface of the left kidney is exposed following the plane
between the mesentery of the left colon and the Gerota’s fascia. Dissection in
this plane permits a bloodless exposure even in cases with significant intraab-
dominal adiposity.
In the lower quadrant, the assisting surgeon retracts the mobilized left colon
medially; the ureter is circumferentially dissected and mobilized distally to the
point where it crosses the iliac vessels. Minimal dissection is advised to preserve
its blood supply. A short Penrose drain is secured with laparoscopic Hem-o-lok®
around the ureter allowing atraumatic retraction by the assisting surgeon. With
lateral light retraction of the ureter, the posterior and inferior aspects of the kid-
ney are mobilized.

22.2.1.3 Step 3 - Identification of Renal Hilum

The gonadal vein is identified medial to the ureter and dissected toward its junc-
tion with the left renal vein where it is transected between two robotic Hem-o-
228 R. Garcia-Roca et al.

a b c

Fig. 22.2 a Anterior dissection of the artery. b Posterior exposure of the artery and transection
of lymphatic tissue. c The left robotic arm gently retracts the artery to facilitate introduction
of the stapling device. RV, renal vein; RA, renal artery

lok® clips. Along the upper border of the renal vein, the left adrenal vein is also
dissected and transected between robotic clips. In most of the cases at least one
lumbar vein will be joining the left renal vein and should be similarly transect-
ed. In these cases the articulating skills of the robotic system and the 3D vision
give significant advantage over conventional laparoscopic instruments.
In the dissection plane between the upper pole of the kidney and the adrenal
gland lies the adrenal artery, which originates from the left renal artery and
should be divided between clips whenever present. The upper pole of the kidney
is then fully mobilized close to the renal capsule, leaving behind Gerota’s fascia
and fat. With the kidney in the anatomical position, the artery can be found just
behind the renal vein, the lymphatic tissue surrounding the artery is transected
with the hook forceps.
The previously mobilized ureter is clipped with two robotic Hem-o-lok® clips
at the pelvic rim and sharply transected proximal to them. The posterior attach-
ments of the kidney are divided with the help of the assisting surgeon, exposing
the renal hilum posteriorly. At this point the orientation of the kidney should be
maintained anatomical avoiding twisting of the vessels. This could potentially
result in ischemia of the kidney, or worse, intimal dissection of the renal artery.
Additionally, the robotic surgeon may injure the renal artery if the anatomy is dis-
torted due to torsion. With the kidney in the medial position, the ganglionic and
lymphatic tissue surrounding the renal artery needs to be transected. The vessel
needs to be circumferentially dissected at the level of its origin from the aorta
(Fig. 22.2). If multiple arteries are present, every vessel has to be dissected free
as described. If a lower polar artery, originating from distal abdominal aorta, is
present, this vessel needs to be identified and exposed carefully, because its unin-
tentional injury would deprive the ureter from blood supply.

22.2.1.4 Step 4 - Vascular Exclusion and Kidney Graft Extraction

As the kidney is now completely dissected, the surgeon at the console is pre-
pared with a robotic clip on the right arm. The assistant surgeon maintains the
mobilization of the kidney medially, exposing the renal artery posteriorly.
22 Robotic-assisted Organ Transplantation 229

Intravenous heparin (5000 IU) is administered to avoid parenchymal thrombosis

after arterial occlusion. The second assistant surgeon advances the Endo TATM
stapler, with vascular load, through the 12-mm left lower quadrant port and the
renal artery is stapled on its origin from the aorta. Utilization of a Endo TATM
stapler allows the additional length of the artery to facilitate the implantation of
the graft. After checking the proper deployment of the stapling line, the robotic
clip is placed to enhance hemostasis. The artery is sharply divided with robotic
scissors at least 3–4mm distal from the stapler line. If multiple arteries are pres-
ent, they are sequentially stapled and transected in a similar fashion.
The kidney is now placed in an anatomical position and the renal vein
exposed. The operating surgeon exercises gentle lift and traction to the hilum,
thus straightening the vein. The vessel is divided with an Endo-GIATM vascular
stapler, inserted by the second assist surgeon through the left lower quadrant
assisting port. Care should be taken not to engage previously placed plastic clips
into the stapler line.
The kidney graft is rapidly removed from the abdominal cavity and placed in
a container with cold solution with the temperature below 4° C, the staple line in
the renal vein is transected and the kidney is flushed with cold preservation solu-
tion through the renal artery.
The abdominal cavity is inspected for bleeding. The arterial and venous
stumps are visualized, and the condition of the stapler line is verified. The field
should be cautiously examined for the presence of lymphatic leak, which, if
present, can be controlled with suture ligation. The robotic system is disengaged
and the ports removed. Closure of the 12-mm port sides is not mandatory, but is
recommended. The 7-cm assist incision is closed in layers anatomically. Skin
incisions are closed cosmetically.

22.2.1.5 Special Considerations

Right donor nephrectomy: The anatomical features of the right kidney make it
less preferred for harvesting, mostly because the shorter length and greater
fragility of the right renal vein. The right renal artery is commonly found direct-
ly posterior to the short right renal vein, requiring increased intraoperative
manipulation raising the potential for vasospasm and iatrogenic vascular injury.
The main indication for harvesting the right kidney is the presence of anatomi-
cal defects compatible with transplantation in the right kidney or significant dif-
ference in function between both kidneys. For robotic-assisted right donor
nephrectomy the patient is placed in a left decubitus position and the robotic
tower docks from the right side of the patient. The 7-cm incision is performed in
the same way, while the port sites are placed in mirror image locations.
Occasionally, one additional port is placed in the left upper quadrant for liver
retraction. After medial mobilization of the right colon, the ureter is identified
and the IVC is exposed. Following the gonadal vein the dissection continues
superiorly to the renal vein. Additional Kocher maneuver may be necessary to
fully expose the IVC. The right renal vein is identified and circumferentially dis-
230 R. Garcia-Roca et al.

sected free. The renal artery is localized after posterior mobilization and medial
retraction of the kidney. The right renal artery may bifurcate behind the vena
cava; ligation of lumbar veins may become necessary to medially rotate the IVC
adequately exposing the renal artery. The rest of the procedure follows the same
steps as described for left nephrectomy.
Multiple vessels: The transplant team at our institution prefers to remove the
left kidney even in the presence of multiple arteries. In the hands of experienced
surgeons, reconstruction of multiple vessels has similar outcomes in terms of graft
function and risk of graft loss [6]. The surgeon needs to evaluate the 3D reconstruc-
tions of the computerized tomography to visualize the relationship between the
arteries and renal vein. Lower polar arteries should be preserved in every case, as
they are the sole blood supply of the ureter. Upper polar arteries may be sacrificed
if they are small and do not feed to a large portion of the renal parenchyma. This
can only be assessed once the kidney is removed and flushed in the back table
through the main renal artery, as it will demarcate the area dependent on the upper
polar artery better. Vascular reconstruction is necessary if the area is significant.
Arteries need to be fully dissected individually; this is better done from the
posterior aspect of the kidney. The arterial occlusion is performed in a similar
fashion as when there is a single artery, they are sequentially clipped and tran-
sected from the lower polar to the upper one.
Retroaortic and circumaortic renal vein: The reported incidence of cir-
cumaortic and retroaortic left renal vein is 9 to 14%, this common variant has
been considered a relative contraindication for left donor nephrectomy due to
the potential for inadvertent venous injury. Evaluation of the renal anatomy pre-
operatively via computerized tomography and 3D reconstructions provides
superior details of the renal vascular anatomy including the location, size and
spatial interrelationship of the renal, adrenal, gonadal, and lumbar veins.
Left donor nephrectomy was efficaciously performed in the presence of left
renal venous anomaly, with surgical outcomes comparable to patients with a nor-
mal left renal vein. Importantly, the warm ischemia time and harvested length of
the left renal artery and vein were similar [7]. The two components of the cir-
cumaortic renal vein are meticulously dissected. In most situations, the posteri-
or component of the circumaortic renal vein can be safely ligated, similar to a
larger lumbar vein.
In the presence of a retroaortic renal vein, the aorta limits the posterior dis-
section and the vein will be significantly shortened. This should not compromise
the transplant procedure and in our experience, it has never required backbench
repair or extension patch prior to implantation.

22.3 Robotic Kidney Transplantation

We consider the robotic-assisted surgical approach to be applicable to all med-
ically suitable patients with a body mass index (BMI) >30 kg/m2. In the United
22 Robotic-assisted Organ Transplantation 231

States, obesity is a common comorbidity among waitlisted patients, causing

increased waiting times for kidney transplantation compared to nonobese candi-
dates. Presumably, due to more technically demanding case and increased surgi-
cal complication rates compromising graft outcomes.
Recent studies suggest that a BMI >30 kg/m2 is an independent risk factor
for surgical site infection (SSI), which is directly correlated to decreased graft
survival [8]. However, obese recipients who avoid SSI have similar outcomes to
nonobese recipients [9], thus, we draw the conclusion that in order to obtain sim-
ilar outcomes in obese recipients, we need to devise a technique that minimizes
incision to dramatically reduce the risk of infection.
The experience acquired using the robotic system for different procedures
was essential in the development of the robotic-assisted kidney transplant pro-
cedure. One of the goals with this new surgical approach was to offer a similar
opportunity to obese patients with end-stage renal disease to access kidney
transplantation as leaner patients at similar complication risk, by reducing SSI
risk and in turn, optimizing graft outcomes. Robotic kidney transplantation uses
a 7-cm incision located in the upper abdomen in addition to the access robotic-
laparoscopic ports. The location of the incision in the epigastric area is more
favorable, as the thickness of the subcutaneous tissue is lower and the length of
the incision is significantly reduced. In addition, the epigastrium is generally
more visible to patients and less likely to remain moist due to sweat. These are
contributing factors to a lower infection rate in this location.
Over the last four years at the University of Illinois at Chicago Hospital, we
performed over 80 kidney transplants on obese recipients using the da Vinci®
robotic surgical system. Initial results showed the advantages and feasibility of
the robotic-assisted procedure [10].

22.3.1 Step-by-Step Review of the Surgical Technique

22.3.1.1 Step 1 - Graft Preparation

Backbench preparation for robotic implantation has some specific steps, regard-
less of the kidney graft originating from a living or deceased donor. The purpose
is to facilitate orientation of the organ and minimize bleeding after the implan-
tation. The adipose capsule is meticulously ligated with 3-0 silk during excision.
The renal vein and artery are dissected toward the hilum and marked for orien-
tation, depending on the site of implantation, right or left. Lastly, the ureter is
appropriately shortened, vessels ligated and the end is spatulated.

22.3.1.2 Step 2 - Patient Positioning and Trocar Placement

The patient will be in the Trendelenburg position during most of the surgical
procedure; to assure safety, they should be secured by using shoulder block and
tape over the hips to avoid sliding of the patient during the operation. In larger
patients, we have been using a beanbag to add additional support, as they might
232 R. Garcia-Roca et al.

be wider than the operating table. After proper preparation and draping, a 7-cm
midline incision approximately 5cm below the xyphoid process is made for the
placement of the hand access device.
Port placement can be done under direct laparoscopic visualization through
a 5-mm port inserted through the epigastric incision. The position of the laparo-
scopic ports are as follows:
• A 12-mm long laparoscopic port for the 30° robotic scope is inserted just
above the umbilicus;
• Two 7-mm robotic ports are inserted triangulating to the target vessels in the
pelvis, one is placed in the right flank and the other in the left lower quad-
rant (or mirror image in the case of left implantation);
• Another 12-mm assistant laparoscopic long port is placed to the left of the
camera one (Fig. 22.3a).
The patient is placed in a 45° Trendelenburg position and the table is rotated
to the left (for implantation to the right external iliac vessels). This positioning
uses gravity to retract the bowels away from the surgical field. The robot system
is docked into position parallel to the patient’s right leg and slightly diagonal to
the body (Fig. 22.3b).

22.3.1.3 Step 3 - Vascular Exposure

The right colon is mobilized medially exposing the right external iliac vessels
and ureter. The iliac vessels are dissected free and lymphatic tissue is excised.
In order to facilitate the exposure and the dissection around the external iliac
vein, the vessel loop is used to retract the artery upward and it may be fixed to
the abdominal wall with a Hem-o-lok® clip, maintaining exposure during vascu-
lar anastomosis. Another vessel loop is placed around the iliac vein to allow the
dissection on the posterior surface of the vein; the loop serves as a handle for
retraction (Fig. 22.4). Any collateral vessels found during the dissection will
need to be suture ligated with Prolene 5-0 and transected.

a b
Fig. 22.3 Kidney transplantation in obese patients. a Trocar placement. b OR setup.
(© 2014 Intuitive Surgical. Inc.)
22 Robotic-assisted Organ Transplantation 233

a b

Fig. 22.4 Dissection of the iliac vein: (a) using vessel loop for retraction; (b) application of
robotic vascular clamps on the iliac vein

22.3.1.4 Step 4 - Graft Implantation and Reperfusion

Once the external iliac vessels are dissected completely free, two robotic bulldog
clamps are used to clamp the external iliac vein. Robotic Potts scissors are used
to create a venotomy to about 15-mm in length. For the vascular anastomosis we
use a double needle Gore-Tex 5-0 suture, this needs to be prepared beforehand,
measure length at twelve centimeters and knotted in the middle leaving each nee-
dle at equal length. Kidney graft is inserted in the abdominal cavity by the assist-
ing surgeon making sure the ureters is positioned toward the pelvis and the ves-
sels facing those of the recipient, the vascular markings prepared earlier will now
be useful to find the proper orientation. Veno-venous anastomosis is completed in
an end-to-side fashion with running sutures (Fig. 22.5). If needed, interrupted
stitches of 5-0 Prolene are used to reinforce the anastomosis.
The external iliac artery is then clamped between double robotic bulldogs
and an oval-shaped window is made in the anterior wall of the artery using
robotic scissors. The arterial anastomosis is completed in an end-to-side fashion
with 12-cm double needle 6-0 Gore-Tex suture with a knot in the middle pre-
pared similar to the one used for the venous anastomosis (Fig. 22.6).
Once the reconstruction is completed venous clamps are removed first, fol-
lowed by immediate removal of the arterial clamps. The reperfusion of the organ
and hemostasis are additionally verified and bleeding points secured with 6-0
Prolene suture. At this point the pressure of the pneumoperitoneum is decreased
to minimize possible negative effect of high intraabdominal pressure on the graft
perfusion.

22.3.1.5 Step 5 - Neocystoureterostomy

The bladder is distended with diluted methylene blue solution in order to facili-
tate its identification; this can be possible by infusion on the third port of the
Foley catheter. The ureter is anastomosed to the bladder mucosa with running 5-
0 Monocryl sutures, and the bladder muscular layer is approximated with inter-
rupted 3-0 Vicryl sutures to create an antireflux mechanism. Utilization of a
ureteral stent is optional.
234 R. Garcia-Roca et al.

a b c

Fig. 22.5 a Placing corner stitch, 5-0 Gore-Tex 12-cm double needle tied ends. b Posterior
wall running suture. c Completion of anastomosis

a b c

Fig. 22.6 a Corner stitch made with 6-0 Gore-Tex. b Posterior wall with running suture. c
Followed with anterior wall running suture

At the end of the procedure the minilaparotomy is closed with running 0

PDS and the two 12-mm port sites are closed laparoscopic visualization with 0
Vicryl suture.

22.3.2 Discussion

In the last four years, we have used this technique and performed more than 80
robotic-assisted kidney transplants in obese recipients. We include any patient
with a BMI >30kg/m2, without an upper limit. The mean BMI of the group was
45kg/m2. We have not observed any SSI within the first 30 post-transplant days.
High immunologic risk or multiple previous surgeries were not considered con-
traindications for the procedure. The only exclusion criteria were severe athero-
sclerosis in the iliac vessels of the recipient or in the graft vessels of kidney
coming from a deceased donor. To evaluate our initial hypothesis of improving
wound complications with the robotic approach, we performed a case-control
study comparing our first 28 robotic-assisted kidney transplants to a matched
retrospective cohort of obese recipients who underwent kidney transplantation
22 Robotic-assisted Organ Transplantation 235

by open technique. We observed no wound complications occurring in the sam-

ple of robotic-assisted kidney transplanted obese recipients as compared to 28%
in the control group, and up to 40% in previous published studies [9]. In addi-
tion to the proven advantages of minimally invasive surgery, such as early mobi-
lization and patient satisfaction, we have observed excellent graft function pos-
sibly related to the minimization of wound complications [10].
Based on the experience in our institution, we can state that the robotic-
assisted kidney transplantation for obese recipients is a safe and effective proce-
dure. By achieving excellent kidney graft function and minimizing surgical
complications this surgical technique gives the opportunity to the disadvantaged
group of obese patients with ESRD to have more realistic access to transplanta-
tion. A surgeon attempting this procedure requires the expertise in robotic sur-
gery including advanced vascular suture techniques.

22.4 Application in Pancreas Transplantation

Despite the advantages in surgical technique, pancreas transplantation has the
highest rate of surgical complications among solid organ transplantation.
Therefore, the introduction of innovating surgical techniques to achieve a reduc-
tion of post-transplant morbidity in these patients is needed.
Living donor pancreas transplantation is seldom used due to the morbidity of
the procedure, some think the increased risk of complications, such as pancre-
atitis, leak and diabetes due to low islet mass results in excess morbidity to the
donor [11]. Distal pancreatectomy in the presence of pathology carries a mor-
bimortality rate, this might be an unacceptable risk for most surgeons to take in
healthy individuals. Nevertheless, living donor pancreatectomy has been per-
formed in the past, using open surgical approach in most cases [12], with prom-
ising outcomes for the recipient. If we could minimize the morbidity to the
donor, it may become a more popular approach to treat diabetes outside the
deceased donor list. The only case reported worldwide of robotic distal pancre-
atectomy and nephrectomy for living donor transplantation was performed in
2006 at the University of Illinois at Chicago.
Nephrectomy was completed first as previously described. Subsequently, the
patient required repositioning to a supine position, and the procedure continued
laparoscopically in order to takedown the gastrocolic ligament and retract the
stomach to ensure a good exposure of the pancreas. The gastroepiploic pedicle
was handled carefully to preserve the left gastroepiploic artery as the sole sup-
ply to the spleen. The short gastric vessels were spared as well.
The da Vinci® Surgical System was again brought to the field from the
patient’s head. The splenic artery and vein were isolated and divided close to the
hilum in the extrapancreatic portion at the tail of the pancreas. The spleen
remained viable after vascular division. The body and tail of the pancreas is
mobilized medially to expose the celiac trunk. At the neck of the pancreas, dis-
236 R. Garcia-Roca et al.

section of the splenic vein is performed at the confluence with the mesenteric
vein. The splenic artery was dissected from the celiac trunk.
The parenchymal transection was performed at the junction between the
body and the head of the pancreas with a robotic UltraCision device. After sys-
temic heparinization, the splenic artery was stapled at the take-off with a TA vas-
cular stapler and then sharply divided with a robotic scissor. Finally the splenic
vein was divided with a GIA vascular stapler and the pancreas immediately
retrieved through the midline incision.
During the recipient’s operation, the renal graft was anastomosed to the left
external iliac vessels and the pancreas graft to the right external iliac artery and
vein. The exocrine secretions were drained to the bladder via pancreaticocys-
tostomy. The allografts became functional immediately on transplantation into
the recipient.
The potential postoperative complications for the donor include pancreatitis,
pancreatic leak, pseudocyst formation and splenic infarction. But a more devas-
tating long-term complication is the development of diabetes in the donor. In
2005, Tan et al. [11] reported their first initial experience with five hand-assist-
ed laparoscopic donor pancreatectomies. The donor and recipient survival rate
was 100% at up to 3 years of follow-up. None of these donors have had compli-
cations or required antidiabetic medications. More recent publications acknowl-
edge the risk of diabetes in the donor but support the procedure in selected cases
of highly-sensitized recipients, owing to long waiting times for deceased pan-
creas donors [12].
In reference to the future of minimally invasive pancreas transplantation,
Boggi et al. reported the first three whole pancreas transplants performed with
the assistance of the da Vinci® Surgical System [3]. The mean warm and cold
ischemia times were 30 minutes and 7.3 hours, respectively. Hemorrhage that
required intervention occurred in the third pancreas graft; however, it was con-
trolled successfully using the robotic system. None of the recipients needed
blood transfusions. Their experience proves the feasibility of robotic-assisted
laparoscopic surgery in pancreas transplantation. However, further studies are
necessary and larger series for it to become an alternative approach to the con-
ventional open technique.

22.5 Application in Liver Transplantation

Living donation for liver transplantation offers excellent results with minimal
complication to the donor. The procedure is complex and results in long inci-
sions and prolonged hospital stay for them. Recently, complete laparoscopic left
and right donor hepatectomy have been reported [13, 14]. The goal is to improve
recovery and cosmetic results on the donors without compromising on the safe-
ty. There are many barriers before the standardization of such procedures but in
selected cases, it is a valid and feasible option. Our institution is a major refer-
22 Robotic-assisted Organ Transplantation 237

ral center for robotic liver procedures, such experience in combination with liv-
ing donation expertise made possible the first robotic right donor hepatectomy.
Our first case was conducted in a 53-year-old healthy man, donating the right
lobe to his brother who had hepatocellular carcinoma, which was complicating
his hepatitis C cirrhosis [4]. The entire procedure was performed using the da
Vinci® Robotic Surgical System. After the laparoscopic trocars were placed and
the robotic system was installed, a cholecystectomy was performed. The hepat-
ic artery and the right portal vein were dissected free, followed by isolation and
transection of the right hepatic duct. The right lobe was completely mobilized
exposing the retrohepatic cava upward from the caudate lobe. Consequently,
parenchyma transection was performed with the robotic Harmonic scalpel while
preserving vascularization of the lobe. The vascular transsection was performed
using Endo-GIATM vascular stapler, first to the right hepatic artery, then the right
portal vein and lastly the right hepatic vein. The graft was rapidly removed
through a lower abdominal incision. The operative time was approximately
8 hours, with an estimated blood loss of 350 mL and no transfusion require-
ments. His postoperative course was uneventful and he was discharged home on
the fifth postoperative day.
Besides facilitating the vascular and biliary dissection, the robotic technolo-
gy also offers the possibility of identifying biliary structures using Indocyanine
Green, minimizing dissection around the biliary tree, and thus reducing the
chances of ischemic injury of the biliary anastomosis [13]. The lower incision
provides better pulmonary care and minimizes analgesic requirements, thus
facilitating early mobilization. This incision decreases the pain and risk of pul-
monary complications associated with an upper midline incision. However, liv-
ing donor hepatectomy should only be undertaken by experienced surgical
teams, due to the significant morbidity and mortality associated to this proce-
dure for donor and recipient.

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