Keith Chae Kim

Editor

Robotics in
General Surgery

123
Robotics in General Surgery
Keith Chae Kim
Editor

Robotics in General
Surgery
Editor
Keith Chae Kim, M.D., F.A.C.S.
Metabolic Medicine and Surgery Institute
Florida Hospital Celebration Health
Celebration, FL, USA

ISBN 978-1-4614-8738-8 ISBN 978-1-4614-8739-5 (eBook)

DOI 10.1007/978-1-4614-8739-5
Springer New York Heidelberg Dordrecht London

Library of Congress Control Number: 2013949142

© Springer Science+Business Media New York 2014

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There are many people who have been instrumental in the
publication of this book and others who have been essential
in creating the circumstances that led me to embrace robotic
surgery. Thank you.

I dedicate this book to Ella, Alex, Jennifer, John, Cathy,

Sofia, and Young, and especially to my parents, Sun Tok Kim,
my mother, and Kwi Hyon Kim, my father, who have taught me
through their actions that hard work and perseverance
have no equal.
Preface

Robotic surgery will prove to be the most significant advance in surgery for
this generation of surgeons and the next few generations to come. The current
platform, the da Vinci system, is the product of an evolution from the US
Department of Defense’s efforts to produce telerobotic capabilities in order to
provide injured frontline soldiers with advanced surgical care from remote
locations to commercial efforts to provide enhanced dexterity to facilitate
complex surgeries while maintaining minimally invasive techniques. The
enhanced dexterity, based on an anthropomorphic model whereby the robotic
system is designed to mimic the human hand in its range and freedom of
movements, is fairly advanced and has allowed both average surgeons to
adopt minimally invasive techniques and skilled surgeons to push the enve-
lope in the complexity of minimally invasive procedures. The robotic
approach has permeated essentially every specialty in general surgery.
More importantly, however, the robotic platform has introduced two new
dynamics between the patient and the surgeon that will have a far greater
impact. First, the system is based on a master–slave relationship in which the
surgeon is remote from the patient and performs the operation by controlling
a patient cart slave that is docked to the patient. Second, the console repre-
sents a digital interface between the surgeon and the patient. In these aspects,
we are just starting to scratch the surface of the possibilities.
The master–slave configuration allows for telepresence as was dramati-
cally demonstrated by Professor Marescaux and colleagues in “Operation
Lindbergh,” a transatlantic cholecystectomy. This capability will not only
have a profound impact on providing sophisticated and complex care to
remote locations from a command center but will also dramatically facili-
tate professional education and collaborative surgery. Experts will be able
to have a global presence without having to leave their operating rooms and
will be able to demonstrate surgery as well as assist or take over surgeries
being performed in remote locations by linking their console to the remote
patient cart. Additionally, the master–slave platform will eventually allow
for the manipulation of wireless “slave” components that will form the
foundation of the future of endoscopy, interventional radiology, and natural
orifice interventions.
The digital interface, which allows for the collection and manipulation of
data that can be used for diagnostic or interventional purposes, represents an
even greater potential. Even in the relatively early stages, imaging technology

vii
viii Preface

is being used to identify structures and provide a road map to the surgical
anatomy in real time. The future will see the digital interface between patient
and surgeon evolve to facilitate image-guided surgery, computer-aided sur-
gery, as well as pre-performed surgery in simulation models that is repro-
duced by a computer-driven system on the actual patient.
This textbook, the first comprehensive overview of the role of robotic sur-
gery in general surgery, is intended as a “how-to” reference of robotically
performed procedures in general surgery. Additionally, in recognition of the
importance of understanding the evolution of robotic surgery thus far, and the
impact that it will have on the future of surgery, this book provides a histori-
cal perspective of robotic surgery as well as an overview of the emerging
technology and future robotic platforms.

Celebration, Florida, USA Keith Chae Kim, M.D., F.A.C.S.

Contents

Part I Overview of the Robotic System

1 History of Robotic Surgery .......................................................... 3

Haidar Abdul-Muhsin and Vipul Patel
2 Introduction to the Robotic System............................................. 9
Monika E. Hagen, Hubert Stein, and Myriam J. Curet
3 Overview of General Advantages, Limitations,
and Strategies ................................................................................ 17
Erik B. Wilson, Hossein Bagshahi, and Vicky D. Woodruff

Part II Surgical Techniques: Esophagus

4 Robotic Assisted Minimally Invasive Esophagectomy............... 25

Abbas E. Abbas and Mark R. Dylewski
5 Robotic Assisted Operations for Gastroesophageal Reflux....... 33
Daniel H. Dunn, Eric M. Johnson, Kourtney Kemp,
Robert Ganz, Sam Leon, and Nilanjana Banerji
6 Achalasia ........................................................................................ 55
Julia Samamé, Mark R. Dylewski, Angela Echeverria,
and Carlos A. Galvani

Part III Surgical Techniques: Thoracic

7 Complete Port-Access Robotic-Assisted Lobectomy

Utilizing Three-Arm Technique Without a Transthoracic
Utility Incision ............................................................................... 69
Mark R. Dylewski, Richard Lazzaro, and Abbas E. Abbas
8 Robotic Pulmonary Resection Using a Completely Portal
Four-Arm Technique .................................................................... 85
Robert James Cerfolio and Ayesha S. Bryant

ix
x Contents

Part IV Surgical Techniques: Stomach

9 Gastric Cancer: Partial, Subtotal, and Total

Gastrectomies/Lymph Node Dissection
for Gastric Malignancies .............................................................. 95
Woo Jin Hyung and Yanghee Woo

Part V Surgical Techniques: Bariatric

10 Robotic Roux-en-Y Gastric Bypass ............................................. 113

Erik B. Wilson, Hossein Bagshahi, and Vicky D. Woodruff
11 Robotic Sleeve Gastrectomy ......................................................... 121
Jorge Rabaza and Anthony M. Gonzalez
12 Robotic Biliopancreatic Diversion: Robot-Assisted (Hybrid)
Biliopancreatic Diversion with Duodenal Switch ....................... 133
Ranjan Sudan and Sean Lee

Part VI Surgical Techniques: Hepatobiliary/Pancreas

13 Robotic Pancreaticoduodenectomy (Whipple Procedure) ........ 145

Martin J. Dib, Tara Kent, and A. James Moser
14 Robotic Distal Pancreatectomy .................................................... 151
Anusak Yiengpruksawan
15 Robotic Hepatic Resections: Segmentectomy,
Lobectomy, Parenchymal Sparing............................................... 161
M. Shirin Sabbaghian, David L. Bartlett, and Allan Tsung

Part VII Surgical Techniques: Colon and Rectum

16 Robotic Right Colectomy: Four-Arm Technique ....................... 175

Gyu Seog Choi
17 Robotic Right Colectomy: Three-Arm Technique ..................... 187
Henry J. Lujan and Gustavo Plasencia
18 Robotic Left Colectomy ................................................................ 203
Eduardo Parra-Davila and Carlos M. Ortiz-Ortiz
19 Totally Robotic Low Anterior Resection..................................... 213
Jung Myun Kwak and Seon Hahn Kim
20 Robotic Hybrid Low Anterior Resection .................................... 227
Eric M. Haas and Rodrigo Pedraza
21 Robotic-Assisted Extralevator
Abdominoperineal Resection ....................................................... 241
Kang Hong Lee, Mehraneh D. Jafari, and Alessio Pigazzi
Contents xi

22 Robotic Single-Port Colorectal Surgery...................................... 249

Byung Soh Min, Sami Alasari, and Avanish Saklani
23 Robotic Transanal Surgery .......................................................... 261
Sam Atallah and Matthew Albert

Part VIII Surgical Techniques: Endocrine

24 Robotic Thyroidectomy and Radical Neck Dissection

Using a Gasless Transaxillary Approach .................................... 269
Jandee Lee and WoongYoun Chung
25 Robotic Adrenalectomy ................................................................ 293
Halit Eren Taskin and Eren Berber

Part IX Surgical Techniques: Solid Organ

26 Robot-Assisted Splenectomy ........................................................ 307

Luciano Casciola, Alberto Patriti, and Graziano Ceccarelli
27 Robotic Donor Nephrectomy and Robotic
Kidney Transplant ........................................................................ 313
Ivo G. Tzvetanov, Lorena Bejarano-Pineda, and José Oberholzer

Part X Surgical Techniques: Hernias

28 Robot-Assisted Ventral and Incisional Hernia Repair .............. 327

Brad Snyder

Part XI Surgical Techniques: Pediatric

29 Pediatric Robotic Surgery ............................................................ 339

John J. Meehan

Part XII Surgical Techniques: Microsurgery

30 Robotic-Assisted Microsurgery for Male Infertility

and Chronic Orchialgia ................................................................ 365
Jamin V. Brahmbhatt, Ahmet Gudeloglu, and Sijo J. Parekattil

Part XIII Education and Training

31 Developing a Curriculum for Residents and Fellows ................ 385

Brian Dunkin and Victor Wilcox
32 Challenges and Critical Elements of Setting
Up a Robotics Program ................................................................ 415
Randy Fagin
xii Contents

33 Professional Education: Telementoring

and Teleproctoring ........................................................................ 431
Monika E. Hagen and Myriam J. Curet

Part XIV Evolving Platforms

34 Single-Incision Platform ............................................................... 437

Giuseppe Spinoglio
35 TilePro ............................................................................................ 457
Woo Jin Hyung and Yanghee Woo
36 ICG Fluorescence .......................................................................... 461
Giuseppe Spinoglio

Part XV Future

37 Robotics and Remote Surgery: Next Step .................................. 479

Jacques Marescaux and Michele Diana
38 The Future of Robotic Platforms ................................................. 485
Mehran Anvari

Index ....................................................................................................... 499

Contributors

Abbas E. Abbas, M.D. Department of Surgery, Ochsner Clinic Foundation,

New Orleans, LA, USA
Haidar Abdul-Muhsin, M.D. Florida Hospital—Celebration Health,
Global Robotics Institute, Celebration, FL, USA
Sami Alasari, M.D. Department of Surgery, Yonsei University College of
Medicine, Seoul, South Korea
Matthew Albert, M.D., F.A.C.S., F.A.S.C.R.S. Center for Colon and Rectal
Surgery, Florida Hospital, Altamonte, FL, USA
Mehran Anvari, M.B.B.S., Ph.D., F.R.C.S., F.A.C.S. Department of
Surgery, McMaster University, Hamilton, ON, Canada
St. Joseph’s Healthcare Hamilton, Hamilton, ON, Canada
Sam Atallah, M.D., F.A.C.S., F.A.S.C.R.S. Center for Colon and Rectal
Surgery, Florida Hospital, Winter Park, FL, USA
Hossein Bagshahi, M.D. Department of Surgery, Harris Methodist Hospital,
Fort Worth, TX, USA
Reshape Bariatric and General Surgery of Fort Worth, Fort Worth, TX, USA
Nilanjana Banerji, Ph.D. Neuroscience and Spine Clinical Service Line,
Abbott Northwestern Hospital, Minneapolis, MN, USA
David L. Bartlett, M.D. Department of Surgery and Surgical Oncology,
University of Pittsburgh Medical Center, Pittsburgh, PA, USA
Lorena Bejarano-Pineda, M.D. Division of Transplantation, Department
of Surgery, University of Illinois Hospital and Health Sciences System,
Chicago, IL, USA
Eren Berber, M.D., F.A.C.S. Department of General Surgery, Cleveland
Clinic, Cleveland, OH, USA
Jamin V. Brahmbhatt, M.D. Department of Urology, Winter Haven
Hospital and University of Florida, Winter Haven, FL, USA
Ayesha S. Bryant, M.D., M.S.P.H. Division of Cardiothoracic Surgery,
University of Alabama at Birmingham, Birmingham, AL, USA

xiii
xiv Contributors

Luciano Casciola, M.D. Division of General, Minimally Invasive and

Robotic Surgery, Department of Surgery, San Matteo degli Infermi Hospital,
Spoleto, Italy
Graziano Ceccarelli, M.D. Division of General, Minimally Invasive and
Robotic Surgery, Department of Surgery, San Matteo degli Infermi Hospital,
Spoleto, Italy
Robert James Cerfolio, M.D., F.A.C.S., F.C.C.P. Division of Cardio-
thoracic Surgery, University of Alabama at Birmingham, Birmingham, AL,
USA
Gyu Seog Choi, M.D., Ph.D. Colorectal Cancer Center, Kyungpook
National University Medical Center, Daegu, South Korea
WoongYoun Chung, M.D., Ph.D. Department of Surgery, Yonsei University
College of Medicine, Seoul, South Korea
Myriam J. Curet, M.D. Intuitive Surgical International, Sunnyvale, CA,
USA
Department of Intuitive Surgery, Stanford University, Sunnyvale, CA, USA
Michele Diana, M.D. Department of Digestive and Endocrine Surgery,
IRCAD (Research Institute against Digestive Cancer), Strasbourg, France
Martin J. Dib, M.D. Department of Surgery, Beth Israel Deaconess Medical
Center, Boston, MA, USA
Brian Dunkin, M.D., F.A.C.S. Department of Surgery, The Methodist
Hospital, Houston, TX, USA
Daniel H. Dunn, M.D. Esophageal and Gastric Care Program, Virginia
Piper Cancer Institute, Abbott Northwestern Hospital, Minneapolis,
MN, USA
Mark R. Dylewski, M.D. Department of Cardiac Vascular and Thoracic
Surgery, Baptist Health of South Florida, Miami, FL, USA
Angela Echeverria, M.D. Department of Surgery, University of Arizona,
Tucson, AZ, USA
Randy Fagin, M.D. Texas Institute for Robotic Surgery, Hospital Corpora-
tion of America, Austin, TX, USA
Intuitive Surgical International, Sunnyvale, CA, USA
Carlos A. Galvani, M.D. Department of Surgery, University of Arizona,
Tucson, AZ, USA
Robert Ganz, M.D., F.A.S.G.E. Department of Gastroenterology, Abbott
Northwestern Hospital, Bloomington, MN, USA
Anthony M. Gonzalez, M.D. Bariatric Surgery, Baptist Health Medical
Group, Miami, FL, USA
Ahmet Gudeloglu, M.D. Department of Urology, Winter Haven Hospital
and University of Florida, Winter Haven, FL, USA
Contributors xv

Eric M. Haas, M.D. Division of Minimally Invasive Colon and Rectal

Surgery, Department of Surgery, The University of Texas Medical School at
Houston, Houston, TX, USA
Colorectal Surgical Associates, Ltd, LLP, Houston, TX, USA
Monika E. Hagen, M.D., M.B.A. Intuitive Surgical International, Sunnyvale,
CA, USA
Department of Digestive Surgery, University Hospital Geneva, Geneva,
Switzerland
Woo Jin Hyung, M.D., Ph.D. Department of Surgery, Yonsei University
College of Medicine, Seoul, Republic of Korea
Mehraneh D. Jafari, M.D. Department of Surgery, Irvine School of
Medicine, University of California, Orange, CA, USA
Eric M. Johnson, M.D. Department of Surgery, Abbott Northwestern
Hospital, Minneapolis, MN, USA
Kourtney Kemp, M.D. Specialists in General Surgery, Maple Grove
Hospital, Maple Grove, MN, USA
Tara Kent, M.D., F.A.C.S. Department of Surgery, Beth Israel Deaconess
Medical Center, Boston, MA, USA
Keith Chae Kim, M.D., F.A.C.S. Metabolic Medicine and Surgery Institute,
Florida Hospital Celebration Health, Celebration, FL, USA
Seon Hahn Kim, M.D. Ph.D. Department of Surgery, Korea University
Anam Hospital, Seoul, Republic of Korea
Jung Myun Kwak, M.D., Ph.D. Department of Surgery, Korea University
Anam Hospital, Seoul, Republic of Korea
Richard Lazzaro, M.D. North Shore LIJ Health System, Lenox Hill
Hospital, New York, NY, USA
Jandee Lee, M.D., Ph.D. Department of Surgery, Eulji University College
of Medicine, Seoul, South Korea
Kang Hong Lee, M.D., Ph.D. Department of Surgery, Hanyang University
College of Medicine, Seoul, South Korea
Sean Lee, M.D. Division of Metabolic and Weight Loss Surgery, Duke
University Medical Center, Durham, NC, USA
Sam Leon, M.D. Minnesota Gastroenterology, Minneapolis, MN, USA
Henry J. Lujan, M.D., F.A.C.S., F.A.S.C.R.S. Deparment of Surgery,
Jackson South Community Hospital, Miami, FL, USA
Jacques Marescaux, M.D., F.A.C.S., (Hon) F.R.C.S., (Hon) J.S.E.S.
Department of Digestive and Endocrine Surgery, IRCAD (Research Institute
against Digestive Cancer), Strasbourg, France
John J. Meehan, M.D., F.A.C.S. University of Washington School of
Medicine, Seattle Children’s Hospital, Seattle, WA, USA
xvi Contributors

Byung Soh Min, M.D., Ph.D. Department of Surgery, Yonsei University

College of Medicine, Seoul, South Korea
A. James Moser, M.D., F.A.C.S. Institute for Hepatobiliary and Pancreatic
Cancer, Beth Israel Deaconess Medical Center, Boston, MA, USA
José Oberholzer, M.D. Division of Transplantation (MC 958), University
of Illinois Hospital and Health Sciences System, Chicago, IL, USA
Carlos M. Ortiz-Ortiz, M.D. Department of General Surgery, Florida
Hospital—Celebration, Celebration, FL, USA
Sijo J. Parekattil, M.D. Department of Urology, Winter Haven Hospital
and University of Florida, Winter Haven, FL, USA
Eduardo Parra-Davila, M.D., F.A.C.S., F.A.S.C.R.S. Departments of
General Surgery, Colorectal, Bariatric, Florida Hospital—Celebration,
Celebration, FL, USA
Vipul Patel, M.D. Florida Hospital—Celebration Health, Global Robotics
Institute, Celebration, FL, USA
Alberto Patriti, M.D., Ph.D. Division of General, Minimally Invasive and
Robotic Surgery, Department of Surgery, San Matteo degli Infermi Hospital,
Spoleto, Italy
Rodrigo Pedraza, M.D. Division of Minimally Invasive Colon and Rectal
Surgery, Department of Surgery, The University of Texas Medical School at
Houston, Houston, TX, USA
Colorectal Associates, Ltd, LLP, Houston, TX, USA
Alessio Pigazzi, M.D., Ph.D. Division of Colorectal Surgery, Department of
Surgery, Irvine Medical Center, University of California, Orange, CA, USA
Gustavo Plasencia, M.D., F.A.C.S., F.A.S.C.R.S. Department of Surgery,
Jackson South Community Hospital, Miami, FL, USA
Jorge Rabaza, M.D. South Miami Hospital, Baptist Health Medical Group,
Miami, FL, USA
M. Shirin Sabbaghian, M.D. Division of Surgical Oncology, Department
of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
Avanish Saklani, M.S., F.R.C.S. Colorectal Division, Surgical Oncology,
Tata Memorial Centre, Parel, Mumbai, India
Julia Samamé, M.D. Department of Surgery, University of Arizona, Tucson,
AZ, USA
Brad Snyder, M.D. Department of Surgery, Memorial Hermann Texas
Medical Center, Houston, TX, USA
Giuseppe Spinoglio, M.D. Department of General and Oncological Surgery,
City Hospital SS. Antonio e Biagio, Alessandria, Italy
Contributors xvii

Hubert Stein, DIPL.-ING, BMT Clinical Development Engineering,

Intuitive Surgical Inc., Sunnyvale, CA, USA
Ranjan Sudan, M.D. Department of Surgery, Duke University Medical
Center, Durham, NC, USA
Halit Eren Taskin, M.D. Endocrine Surgery Division, Cleveland Clinic,
Cleveland, OH, USA
Department of General Surgery, Cleveland Clinic, Cleveland, OH, USA
Allan Tsung, M.D. Division of Hepatobiliary and Pancreatic Surgery,
Department of Surgery, University of Pittsburgh Medical Center Liver Cancer
Center, Montefiore Hospital, Pittsburgh, PA, USA
Ivo G. Tzvetanov, M.D. Division of Transplantation, Department of
Surgery, University of Illinois Hospital and Health Sciences System,
Chicago, IL, USA
Victor Wilcox, M.D. Department of Surgery, Houston Methodist Hospital,
Houston, TX, USA
Erik B. Wilson, M.D. Department of Surgery, The University of Texas
Health Science Center, Houston, TX, USA
Yanghee Woo, M.D. Division of GI/Endocrine Surgery, Center for
Excellence in Gastric Cancer Care, Columbia University Medical Center,
New York, NY, USA
Department of Surgery, Columbia University College of Physicians and
Surgeons, New York, NY, USA
Department of Surgery, New York Presbyterian Hospital, New York, NY, USA
Vicky D. Woodruff, Ph.D. Department of Surgery, University of Texas
Health Science Center, Houston, TX, USA
Anusak Yiengpruksawan, M.D., F.A.C.S. Department of Surgery, The
Valley Minimally Invasive and Robotic Surgery Center, The Valley Hospital,
Ridgewood, NJ, USA
 Part I
Overview of the Robotic System
 History of Robotic Surgery
1
Haidar Abdul-Muhsin and Vipul Patel

came from his brother Joseph Capek who advised

Introduction him to use this term to describe these characters.
Ironically, 5 years earlier, when he wrote
Human dreams and fantasies to develop a “robot” “Opilec,” Joseph described the artificial people as
roots back deep in history, as old as ancient civi- “automats” and not robots.
lizations. History of robotic development is an Karel Capek in RUR wanted to warn against
interesting example of how a myth can transform the rapid growth of the modern world and thus
to reality, how fiction becomes the seeds of his- described the evolution of the robots with increas-
torical inventions and achievements that serves ing capabilities that eventually revolted against
humanity for decades. their human makers [1]. He envisioned that these
As we go through the history of robotic develop- robots would revolt 40 years after the time the
ment, we realize how difficult it is to attribute this play was created, which is nearly in the 1960s.
development to a certain person or a certain era. This coincided with the first appearance of the
This is not due to lack of historical resources but industrial robot later on. However, The Robots
because robot creation was the result of interaction described in Capek’s play were not robots, as we
of multiple civilizations, cultures, and sciences. know them now, a mechanical device that some-
“Robota” is a Czech term that described com- times resembles a human. They were not
pulsory work. In its original Czech, robota means machines, but rather live creatures that may be
forced labor of the kind that serfs had to perform mistaken for humans.
on their masters’ lands and is derived from the RUR quickly became famous and was influen-
term rab, meaning “slave.” Despite the existing tial early in the history of its publication. Two
debate in Czech literature regarding the first per- years after its first spread, it had been translated
son who invented this term, the most reliable ref- into 30 languages. This fact played a major role
erences point that this term appeared first when in the widespread popularity of this term.
Karel Capek used it in his play “Rossum’s Many years later Isaac Asimov, a science fic-
Universal Robot” (RUR) in 1921. It was used to tion writer, used the term “Robotics” to describe
describe the artificial people in his play. The idea the field of study of robotics in 1942. This usage
further popularized the use of this term and
resulted in the widespread of robots in subse-
H. Abdul-Muhsin, M.D. • V. Patel, M.D. (*) quent artistic works with multiple roles that var-
Florida Hospital–Celebration Health, Global ied from friendly roles to hostile or comedian
Robotics Institute, 410 Celebration Place, Suite 200,
ones [2]. Asimov outlined the three rules of
Celebration, FL 34747, USA
e-mail: [email protected]; robotics in his books Runaround and I, Robot
[email protected] that were published between 1938 and 1942.

K.C. Kim (ed.), Robotics in General Surgery, DOI 10.1007/978-1-4614-8739-5_1, 3

© Springer Science+Business Media New York 2014
4 H. Abdul-Muhsin and V. Patel

These rules were: mechanical bird that was made of wood and
1. A robot may not injure a human being. could fly by propelling steam. One century later
2. A robot must obey orders given by humans (250 BC), Ctesibius of Alexandria designed the
except when doing so conflicts with the first “clepsydra” which meant the water thief in
law. Greek. Clepsydra was a water clock with move-
3. A robot must protect its own existence as long able figures on it. Initially this water clock was
as this does not conflict with the first and sec- used as a timer only and was later on modified
ond laws. into an ordinary clock. This was followed by the
These literary sources led our imagination to landmark efforts of Heron of Alexandria (10–70
build stereotypes for robots. However, in order to AD) who made numerous innovations in the field
study history of robots, we need to define what do of automata. He made the first vending machine
we mean by “robot” from the scientific point of and he utilized his steam-driven engine, as known
view. as aeolipile, to make many machines including
The first scientific definition of the robot did one that was supposed to speak.
not appear until lately in 1972 when the Robot The Arabic Muslim inventor, Al Jazari
Institute of America set a definition for the robot (1136–1206), designed and constructed several
which was “A reprogrammable, multifunctional automatic machines and invented the first pro-
manipulator designed to move materials, parts, grammable robot. For entertainment purposes, he
tools, or specialized devices through various pro- made a “robotic band,” a boat with automated
grammed motions for the performance of a vari- humanoid musicians.
ety of tasks.” The sketches of Leonardo da Vinci that were
Looking at history with this meaning in mind, discovered in the 1950s demonstrated the first
we can find that human trials to build a “robot” record of a humanoid robot design and showed a
extend into the deepest roots of human civiliza- presentation of a mechanical knight. This work
tions and represent a continuum of developments could possibly present an extension of his famous
that led to the current status of robotics. anatomical study of human body proportions in
his Vitruvian man sketches. This inspired the cur-
rent surgical robot makers to name their robot
Robots in Ancient History after this genius Italian architect and inventor.
Da Vinci ideas inspired Gianello Torriano
One of the first known automated machines ever who created a robotic mandolin-playing lady in
built was in 1300 BC, when Amenhotep made the 1540. This was followed by many European
statue of king Memnon that was able to produce innovators like Jacques Vaucanson 1738
sounds. In Ancient China (1023–957 BC), Yan (the creator of the loom) who constructed a
Shi (engineer) presented King Mu of Zhou with a mechanical duck that could eat, drink, move its
life-size, human-shaped mechanical figure. In the wings, and digest grains. Pierre Jaquet-Droz
fifth century BC, King-shu Tse in China designed made the first android in 1772. He made a child
a flying magpie and a horse that was able to jump. robot and called it the writer. This robot was
One century afterward, Aristotle looked at able to write complete phrases. It was program-
automation from a philosophical point of view. In mable to make movements to draw each letter
his famous “politics” book, he mentioned that “if of the alphabet. This allowed it to write what-
every tool, when ordered, or even of its own ever the user wants. In collaboration with his
accord, could do the work that befits it then there son, Henri-Louis, he developed two other
would be no need either of apprentices for the androids using the same principle. The first one
master workers or slaves for the lords.” In this could draw and the second one could play
description, he imagined the future role of auto- different musical pieces. It actually could play
mation and robotics. musical instruments like a flute.
In the fourth century (428–347 BC), the Greek In 1801, Joseph Jacquard modified the loom
mathematician Archytas of Tarentum designed a by making it automatic by following a set of
1 History of Robotic Surgery 5

preordered commands. These commands were in has extended into many other countries that
the form of holes punched into cardboard. started production of their own robots.
Several years later (1978) PUMA
(Programmable Universal Machine for
History of Robotic Technology Assembly) was developed by Victor Scheinman
in Surgery at Unimation. This device utilized electric motors
and was a smaller version of the Unimate robot.
The development of contemporary robots was It had more variable usages and multitasking
mainly driven by the need for “telepresence.” abilities. This by itself resulted in more spread of
Telepresence is a term used to describe the sensa- the robot. This spread reached fields beyond
tion that a person is in one location while being in industry including medicine.
another. It was needed to let automated machines In the strict sense of the word, the robotic sys-
perform certain tasks in hazardous or unwanted tems currently used in surgery are not actually
environments for human being and probably in a robots but remote performers that use end effec-
more accurate method. tors or instruments. The systems capable of per-
This was first made possible in 1951 when forming such tasks are called “telemanipulators”
Raymond Goertz, while working for the Atomic and it works using the master–slave style. These
Energy Commission, designed the first teleoper- master–slave systems do not perform tasks auto-
ated master–slave manipulator in order to handle matically but obey orders through the voice or
hazardous radioactive materials. This presented hand of the surgeon.
the first example for successful implementation PUMA was used for the first time in 1985 in
of telepresence. the field of medicine when it was used to direct a
Inspired by the science fiction stories of Isaac needle to undergo a brain CT-guided biopsy [3].
Asimov, George Devol, and Joseph Engelberger This stereotactic brain biopsy achieved an accu-
developed the first commercial robot. They estab- racy of 0.05 mm. With this accuracy of execu-
lished a company and called it Universal tion, this first robot-assisted surgical procedure
Automation. They were successful in producing paved the road for robot-assisted surgery. Soon
a programmable robot that can replace a human afterward, it was used to resect an astrocytoma of
worker. Their first robot was called “Unimate” the thalamus.
and was produced in 1961. The Unimate robot The fixed anatomical landmarks in neurosur-
was able to store commands and had six degrees gery and orthopedic surgery facilitated the quick
of freedom. It was able to precisely conduct use and distribution of the robot-assisted tech-
potentially hazardous tasks like handling molten niques. This robot was developed to become the
die casting and perform spot welding. This robot prototype of “NeuroMate” that is currently FDA
was used for the first time by General Motors to approved (1999).
work in their car assembly. This highlighted the The first robot-assisted surgical procedure
past need for telepresence where the machine was performed in 1983 with the use of
was used for potentially dangerous chores that “Arthrobot,” which was designed to assist in
were previously performed by humans. orthopedic procedures. In 1988 the “ROBODOC”
The Unimate presented a huge commercial production of integrated surgical systems was
success. For manufacturers it performed repeti- used in total hip arthroplasty to allow precise
tive tasks with a great degree of precision, no preoperative planning [4]. This robot is com-
fatigue, and without need for human labor. It sim- puter guided to precisely drill the femoral head
ply meant less spending. After many years of to insert the hip replacement prosthesis. This
success, the company was acquired by approach gained FDA approval in August 2008
Westinghouse and continued production until after multiple clinical trials [5–7]. Similar
today. The usage of this robot has diffused into designs have been used in knee replacement sur-
many other factories and resulted in widespread gery using the “ACROBOT” and temporal bone
use of robots since its introduction. Moreover, it surgery “RX-130.”
6 H. Abdul-Muhsin and V. Patel

In 1988 at Imperial College in London, a completely operated by a surgeon. This indirectly

group of researchers started the first application meant the usage of telemanipulation in
of robot in urology with the PUMA to aid in per- laparoscopy.
forming one of the most commonly performed Despite the fact that the concept of laparos-
urological procedures, transurethral resection of copy dates back to more than a decade ago
the prostate [8]. (G Kelling 1901 and HC Jacobaeus in 1911), this
The successor for this robot was the surgeon- approach was not deemed possible until after
assistant robot for prostatectomy “SARP.” This 1969 when Smith and Boyle invented the charge
was motorized rather than using the manual coupling device. This new technology allowed
frame in the previous robot. It was used success- the conversion of light into an analog signal that
fully on 1991 in London, UK. This was perhaps can be transmitted into a digital image. This new
the world’s first robotic surgery on the prostate. technique not only allowed laparoscopic inter-
Further development on “SARP” led to the cre- vention but was also a key step toward telepres-
ation of “PROBOT,” “URobot,” and “SPUD,” ence through the interposition of a technological
which are abbreviation for prostate robot, urol- interface.
ogy robot, and Surgeon Programmable Urological In the 1980s the National Aeronautics and
Device, respectively. Space Administration (NASA) joined with the
The PROBOT worked through a computer- Ames Research Center to start the development
generated 3D image of the prostate. Once the sur- of a head-mounted virtual reality display to allow
geon determines the boundaries of resection area users to immerse themselves in large data sets
using this 3D model, the system starts using these that were transmitted from aerospace missions.
data to calculate the area of resection and exe- This resulted in the head-mounted display
cutes the procedure without further intervention (HMD) that immersed the user in a 3D virtual
from the surgeon. This system had four degrees environment using tiny television monitors
of freedom and rapidly rotating blade [9, 10]. attached to a helmet. This was developed by
Despite the initial encouraging result with Michael McGreevy and Stephen Ellis and later
PUMA, Westinghouse stopped the manufactur- was enhanced by the addition of a 3D audio by
ing of this device secondary to concerns of safety Scott Fischer (computer scientist). By coupling
during surgery. this technology with the data glove that was orig-
The SARP and PROBOT devices (from inally developed by Jaron Lanier, they allowed
Imperial College, London) were further devel- the users to see their own interaction with the vir-
oped to develop the URobot in 1991. This device tual world [13, 14].
was utilized for multiple purposes including In parallel Dr. Joseph Rosen, a plastic surgeon
transurethral HIFU (high-intensity focused ultra- at Stanford University, began to experiment with
sound), brachytherapy, needle prostate biopsy, Philip Green from Stanford Research Institute
and laser resection of the prostate [11, 12]. (SRI) to develop a dexterity- enhancing surgical
Collaboration with Dornier Asia Medical telemanipulator.
Systems led to the creation of the SPUD device Joe Rosen and Scott Fischer later produced
(Surgeon Programmable Urological Device). the idea of telepresence surgery. Their vision was
to design a surgical system that could be used to
perform remote surgical operations in space that
Robotics in Visceral Surgery could be achieved by combining HMD at NASA
and the robotic telepresence system at SRI.
The mobility of the visceral organs in visceral Many of the initially designed features of
surgery presented an obstacle toward the use of a Green’s Telepresence System were at the time
programmable device to achieve a certain surgical unworkable from an engineering standpoint [15].
task. The main place where robots could play a The HMD was subsequently replaced with moni-
part was when used as a telemanipulator that are tors, and the data gloves were replaced with
1 History of Robotic Surgery 7

handles for controllers at the surgeon’s console. control the movements of the camera during
Since the imperative at this time was for space laparoscopic surgery and provided 7 degrees of
and/or military application for acute surgical freedom of movement [17]. Originally the
care, the end effectors were substantially similar AESOP was manipulated by hand or foot con-
to open surgical instruments. By 1989, Richard trols, but the later version was capable of utiliz-
Satava, a military surgeon, joined this team. ing voice commands and incorporated voice
While Jacques Perrisat of Bordeaux was pre- control of endoscopic and OR room lights
senting on the technique of laparoscopic cholecys- (HERMES) [18].
tectomy at the Society of American Gastrointestinal Wang became interested in complete robotic
and Endoscopic Surgeons (SAGES) in Atlanta, the surgery and obtained DARPA funding to develop
team of investigators began to consider developing a modular robotic system to be integrated with
a system that could be applied to minimally inva- AESOP. HERMES was the integrated operating
sive laparoscopic surgery. room control system that allowed the complete
Satava looked for further funding and pre- integration of Computer Motion’s robotic system
sented a videotape of a bowel anastomosis using [19]. In 2001, Computer Motion, the ZEUS
the telepresence surgery system to the Association robotic system, developed a device combining
of Military Surgeons of the United States. The both the AESOP and HERMES. This was a mas-
results of demonstrating this technology resulted ter–slave configuration that allowed the surgeon
in a Defense Advanced Research Projects Agency to control a robotic slave device that was docked
(DARPA) grant for further investigation and to the patient remotely from a console.
development in July of 1992. In addition, Satava The ZEUS robotic system, similar to the
became the program manager for Advanced AESOP, had an endoscope holder arm that was
Biomedical Technologies to aid funding of tech- voice controlled, along with two other operating
nologically advanced projects. By 1995, the arms that provided four degrees of freedom and
robotic system had progressed to a prototype were able to hold a variety of instruments. These
mounted into an armored vehicle (the Bradley instruments were manipulated with joysticks
557A) that could “virtually” take the surgeon to from the surgeon console. The computer system
the front lines and immediately render surgical that interfaced the surgeon console with the oper-
care to the wounded, called MEDFAST (Medical ating robotic arms allowed filtration of surgeon
Forward Area Surgical Team) [15]. tremor and scaling of movements by a factor of
Vascular surgeon Jon Bowersox performed 2–10. The surgical field was visualized through a
the first telesurgery experiment, an ex vivo intes- regular 2D screen or through polarized glasses
tinal anastomosis using this system for demon- with a different axis for each eye that allowed for
stration. This was later developed to be used for 3D images [20]. This system was used for the
vascular anastomosis [16]. This demonstrated the first time in a full laparoscopic procedure for fal-
delicate ability of this system. lopian tube anastomosis at the Cleveland Clinic
in 1998 [21]. One year later, it was used for coro-
nary bypass by Reichenspurner [22].
ZEUS In 2001, in a dramatic demonstration of telep-
resence surgery, Jacques Marescaux utilized this
In 1993, Yulyn Wang developed a software for platform to perform a robot-assisted cholecystec-
control of motion of robotic systems and founded tomy on a patient in Strasbourg, France, who was
a company called Computer Motion. Wang suc- separated from the surgeon in New York by
ceeded in developing the first FDA-approved 4000 km [23]. This procedure was nicknamed
robotic device for use in laparoscopic surgery. “Operation Lindberg” and lasted for 54 min and
The system, Automated Endoscopic System for had no technical complications.
Optimal Positioning (AESOP), consisted of a In almost a parallel path, another group in
table-mounted articulating arm that was used to California, using as the foundation the early
8 H. Abdul-Muhsin and V. Patel

works funded by the US Department of Defense 10. Paul HA, Bargar WL, Mittlestadt B, et al. Development
of a surgical robot for total hip arthroplasty. Clin
on telerobotic surgery, as well as licensed
Orthop Relat Res. 1992;285:57.
technologies from MIT, IBM, and SRI, set about 11. Ho G, Ng WS, Teo MY. Experimental study of trans-
to develop a surgical robotic system for civilian urethral robotic laser resection of the prostate using
use. In 1995 Intuitive Surgical International was the laser Trode lightguide. J Biomed Opt. 2001;6:
244–51.
founded, and this group was eventually able to
12. Ho G, Ng WS, Teo MY, Kwoh CK, Cheng WS.
develop the first FDA-approved fully robotic Computer- assisted transurethral laser resection of the
system for use in minimally invasive surgery, prostate (CALRP): theoretical and experimental
which remains today as the only system in use in motion plan. IEEE Trans Biomed Eng. 2001;48(10):
1125–33.
minimally invasive general surgery.
13. Patel V. Robotic urologic surgery. 1st ed. London:
Springer; 2007.
14. Sackier JM, Wang Y. Robotically assisted laparo-
scopic surgery: from concept to development. Surg
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15. Parekattil SJ, Moran ME. Robotic instrumentation:
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robots: from science fiction to surgical robotics. Green PS. Vascular applications of telepresence sur-
J Robot Surg. 2007;1:113–8. gery: initial feasibility studies in swine. J Vasc Surg.
3. Kwoh YS, Hou J, Jonekheere EA, Hayall S. A robot 1996;23(2):281–7.
with improved absolute positioning accuracy for CT 17. Unger SW, Unger HM, Bass RT. AESOP robotic arm.
guided stereotactic brain surgery. IEEE Trans Biomed Surg Endosc. 1994;8:1131.
Eng. 1988;35:153. 18. Oddsdottir M, Birgison G. AESOP: a voice-controlled
4. Cowley G. Introducing “Robodoc”. A robot finds his camera holder. In: Ballantyne GH, Marescaux J,
calling in the operating room. Newsweek. 1992; 120:86. Giulianotti PC, editors. Primer of robotic and telero-
5. Nishihara S, Sugano N, Nishii T, Tanaka H, Nakamura botic surgery. Philadelphia, PA: Lippincott Williams
N, Yoshikawa H, Ochi T. Clinical accuracy evaluation and Wilkins; 2004. p. 35–41.
of femoral canal preparation using the ROBODOC 19. Wang YSJ. Robotically enhanced surgery: from con-
system. J Orthop Sci. 2004;9(5):452–61. cept to development. Surg Endosc. 1996;8:63–6.
6. Honl M, Dierk O, Gauck C. Comparison of robotic- 20. Kalan S, Chauhan S, Coelho RF, et al. History of
assisted and manual implantation of a primary total robotic surgery. JRS. 2010;4(3):141–7.
hip replacement. A prospective study. J Bone Joint 21. Falcone T, Goldberg J, Garcia-Ruiz A, Margossian H,
Surg Am. 2003;85(A(8)):1470–8. Stevens L. Full robotic for laparoscopic tubal anasto-
7. Zipper SG, Puschmann H. Nerve injuries after com- mosis: a case report. J Laparoendosc Adv Surg Tech
puter assisted hip replacement: case series with 29 A. 1999;9:107–13.
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402. German. of the voice-controlled and computer-assisted surgi-
8. Harris SJ, Arambula-Cosio F, Mei Q, et al. The cal system ZEUS for endoscopic coronary artery
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9. Davies BL, Hibberd RD, Coptcoat MJ, Wickman 23. Marescaux J, Leroy J, Rubino F, et al. Transcontinental
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 Introduction to the Robotic
System 2
Monika E. Hagen, Hubert Stein,
and Myriam J. Curet

perform coronary anastomosis during cardiac

Historical Overview revascularization (as of July 2012).
The design of the da Vinci® is the result of a long
The da Vinci® Surgical System (Intuitive Surgical developmental process which integrated many
Inc., Sunnyvale, CA, USA) is currently the most ideas and technologies to produce a functional
frequently used computer-enhanced endoscopic system. Much of the early work on telerobotic sur-
instrument control system capable of laparo- gery was funded by the US Department of Defense,
scopic surgery. The US Food and Drug with the aim of providing injured soldiers with a
Administration (FDA) has cleared this system for frontline surgical suite controlled by surgeons oper-
use in urological surgical procedures, general ating from a safe remote location. Although at the
laparoscopic surgical procedures, gynecologic time this proved impractical with the technology
laparoscopic surgical procedures, transoral oto- available, several prototypes showed promise and
laryngology surgical procedures restricted to Intuitive Surgical International was founded in
benign and malignant tumors classified as T1 and 1995 to license and develop this technology for
T2, general thoracoscopic surgical procedures, civilian use. The ultimate goal of the company was
and thoracoscopically assisted cardiotomy proce- to produce a reliable, intuitive system which would
dures. Additionally, the system is approved to be deliver the benefits of minimally invasive surgery
employed with adjunctive mediastinotomy to to patients while preserving the benefits of open
surgery to surgeons. The goal was to enable many
M.E. Hagen, M.D., M.B.A. difficult surgeries (such as cardiac surgery) to be
Intuitive Surgical International, Sunnyvale, CA, USA performed through small incisions and also achieve
Department of Digestive Surgery, University Hospital better results for procedures already performed
Geneva, 14, rue Gabrielle-Perret-Gentil, Geneva through ports. The technology specifically aimed
1211, Switzerland to address port-access limitations in dexterity, intu-
e-mail: [email protected]
itiveness, visualization, and ergonomics through
H. Stein, DIPL.-ING. B.M.T. advances in telepresence and stereoscopic capture
Clinical Development Engineering, Intuitive Surgical
Inc., 1266 Kifer Road, Sunnyvale, CA 94107, USA
as well as display.
e-mail: [email protected] After securing venture capital, the relevant
M.J. Curet, M.D. (*)
technologies were licensed from MIT, IBM, and
Intuitive Surgical International, Sunnyvale, CA, USA SRI International and a team of engineers set to
Department of Surgery, Stanford University School
work on producing a prototype. Initial efforts
of Medicine, Stanford, CA, USA using off-the-shelf and custom-built components
e-mail: [email protected] that were passed on from SRI yielded a device

K.C. Kim (ed.), Robotics in General Surgery, DOI 10.1007/978-1-4614-8739-5_2, 9

© Springer Science+Business Media New York 2014
10 M.E. Hagen et al.

called “Lenny,” which was used in animal trials to are designed to meet or exceed the way the
inform further design. These trials clearly demon- human hand and arms work. For instance, the
strated the promise of seven-degrees-of-freedom EndoWrist® instrument wrist will run out of
manipulators as well as the need for a mobile ability to flex when the user’s wrist is most
patient-side manipulator platform. The next major flexed. In addition, the systems are designed to
design iteration was called “Mona,” and featured offer hand–eye alignment which means that the
exchangeable sterile components, which allowed EndoWrist instruments move in the same way
human trials to proceed in 1997. The experience with respect to the camera as the hands of the
gleaned from these trials enabled the design to be surgeon move with respect to the surgeon’s eye.
refined further into the first generation “da The orientations of the instrument tips mimic the
Vinci®” Surgical System platform that is still in surgeon’s hand alignment inside the master con-
use today. In December 1998, the first commer- troller joysticks. These two properties establish a
cial version was delivered to the Leipzig strong sense of eye-hand coordination and natu-
University Heart Center in Germany. ral, intuitive motion, promulgating the illusion
Further product developments were delayed that the robotic instruments are his/her fingers.
due to a legal battle with Computer Motion Inc. The EndoWrist instruments that are inserted into
(Santa Barbara, CA, USA) over intellectual prop- the patient move around a fixed point in the body
erty rights. In 2003, Intuitive Surgical Inc. merged wall that is established by a mechanical remote
with Computer Motion Inc., and their Zeus telep- center concept. This enables the system to
resence system, which was the competitive prod- maneuver instruments and endoscopes into and
uct to the da Vinci Surgical System, was within the surgical site while exerting minimal
discontinued. Refinement of the original da Vinci force on the patient’s body wall.
design continued with the addition of a fourth Three different commercial models currently
manipulator arm and expansion of the instrument exist: the da Vinci Standard System represents
families. These changes were fully integrated the first generation of the da Vinci® Surgical
into the simplified and streamlined “da Vinci® S” System and was marketed in Europe in late 1998.
model, which takes less time to set up and has This model is no longer commercialized, but it is
improved range of motion manipulators; the lat- still in use and being supported by Intuitive
est product iteration is the “da Vinci® Si” Surgical. The next generation of da Vinci®
(released in 2009), which features improvements Surgical Systems is the da Vinci® S which offers
to the vision and control system and ergonomic a newer and slimmer robotic arm design that
improvements and allows two surgeons to share facilitates the surgical cart setup and enables a
control of manipulators (dual-console mode). greater reach within the abdomen when com-
This allows all four manipulators to be controlled pared to the earlier version. It also contains a
simultaneously during complex operations and superior vision system with HD, a streamlined
greatly improves the training paradigm for user interface and some other soft- and hardware
computer-enhanced surgery. innovations. The most current model is the da
Vinci® Si Surgical System which was launched
in April 2009. The da Vinci® Si introduces sev-
System Overview eral enabling features, including dual-console
capability (two surgical consoles can be attached
The da Vinci® Surgical System is built following to a single surgical cart) to support training
an anthropomorphic principle or a humanoid and collaboration during minimally invasive
concept. That means that the motion capabilities surgery (for details, see Chap. 33), enhanced
of the system are designed to mimic those of its high-definition 3D vision, improved ergonom-
human operator. The mechanical components of ics, an updated user interface for streamlined
the system have physical limitations of reach and setup and OR turnover, and extensibility for digital
range of motion. Whenever possible, these limits OR integration.
2 Introduction to the Robotic System 11

Fig. 2.1 The da Vinci® Surgical System with its main components (courtesy of Intuitive Surgical, Inc.)

Fig. 2.2 Range of motion of robotic instruments (courtesy of Intuitive Surgical, Inc.)

All above-mentioned systems have three greater than the human hand and with intui-
major components: the surgeon’s console, the tive control (Fig. 2.2)
surgical cart, and the vision cart (Fig. 2.1). • Software features such as tremor elimination
The shared core technology of all systems and optional motion scaling up to 3:1
offers the following distinguished features: The following description of the main da
• Physical separation of the surgeon from the Vinci® components are based on the da Vinci® Si
patient by operating at a console rather than at Surgical System.
the patient’s side
• A three-dimensional stereoscopic image (HD
for the S and Si model) with up to ten times The da Vinci® Surgical System:
magnification The Surgical Console
• Wrist action of the robotic instruments pro-
viding seven degrees of freedom (compared The surgical console is the workplace of the
with five degrees of freedom for standard robotic surgeon and contains the following core
laparoscopic instruments), a range of motion elements: master controllers, stereo viewer,
12 M.E. Hagen et al.

which decouple the master from control of its

instrument to allow for ergonomic repositioning
of the master controllers during surgery. Research
on learning curves has indicated that appropri-
ately frequent use of master clutching appears to
be a crucial part of mastering the da Vinci
Surgical System as it results in workspace and
ergonomic optimization.
The stereo viewer provides the video image to
the surgeon including the image of the surgical
site and extended system information. With the
head in the viewer, the surgeon can view the 3D
image in full-screen mode or can choose to swap
to TilePro™ mode, which displays the 3D image
along with up to two auxiliary images. Icons and
text messages are overlaid on the video to pro-
vide extended information to the surgeon. The
system provides 2-way audio communications
with the patient cart operator by a microphone
located under the viewport and a pair of speakers
located in the headrest.
The touchpad is the main control interface at
the Surgeon Console for system functions. The
touchpad home screen provides system status,
including instrument arm selection, and control
selections. In dual-console mode, the surgeon
Fig. 2.3 Master controllers (courtesy of Intuitive
Surgical, Inc.)
can use the touchpad to assign robotic arm con-
trol between the two consoles. The center of the
touchpad provides three quick setting buttons
touchpad for preference and feature selection, indicating settings for scope angle, zoom level,
left-side pod for ergonomic controls, right-side and motion scaling.
pod for power and emergency stop, and a foot- The left-side pod provides the ergonomic
switch panel for operative mode selection and adjustment controls for the Surgeon Console.
energy actuation. Choosing the correct ergonomic setup is par-
The master controllers (Fig. 2.3) or masters ticularly important in order to avoid unneces-
are the joysticks of the robotic surgeon. Two sary physical strain during the surgical
fingers of each hand are placed inside the procedure and time should be taken to do so
Velcro straps to control the movements of the before the actual procedure starts. The right-
patient cart instruments. side pod provides Power and Emergency Stop
The masters are built essentially like a human buttons (Fig. 2.4).
arm, with a wrist portion (orienting platform) and The footswitch panel (Fig. 2.5) is located at
the elbow/shoulder joints for positioning. The the base of the console directly beneath the sur-
wrist portion orients the instrument tip in the sur- geon and provides the interface for various system
gical environment. The elbow and shoulder joints functions without removing the head from the
move the instrument to the appropriate location stereo viewer.
in the surgical field and can be scaled to a 3:1 The footswitch panel features two groups of
(fine), 2:1 (normal), or 1.5:1 (quick) ratio. The footswitches. The three switches on the left
master controllers also possess finger clutches, control system function such as camera control,
2 Introduction to the Robotic System 13

The da Vinci® Surgical System:

The Patient Cart

The patient cart (Fig. 2.6) is the operative compo-

nent of the da Vinci Si System, and its primary
function is to support the instrument arms and
camera arm. It contains five main components:
the setup joints, instrument arms, camera arm,
EndoWrist instruments, and an endoscope.
The setup joints enable movements of the
instrument and the camera arm to position them
for sterile draping and docking of the system to
Fig. 2.4 Left-side and right-side pod (courtesy of the patient. Clutch buttons are used by the patient-
Intuitive Surgical, Inc.) side assistants to free the setup joints, which is
applied in some cases to readjust instrument arms
if needed during the procedure. To help ensure
patient safety, any actions of the patient cart oper-
ator will always preclude simultaneous telepres-
ence actions from the Surgeon Console operator.
While the instrument arms hold the EndoWrist
instruments, the camera arm holds the endoscope
during surgery. As described above, all arms can
be controlled within their range of motion by the
surgeon from the surgical console. The setup is
performed by the bedside assistant using the
clutch buttons to release the setup joints.
EndoWrist instruments are installed onto the
instrument arms after the system is docked to
ports that are inserted into the patient. Most
instruments offer 7 degrees of freedom and ±90
Fig. 2.5 Food switch panel (courtesy of Intuitive degrees of articulation in the wrist. The arsenal
Surgical, Inc.) of instruments includes advanced energy instru-
ments (monopolar cautery shears, hooks, spatulas,

master clutch, and arm swap. The four pedals

on the right side of the footswitch panel are
used for energy activation and are arranged as
a left pair of pedals and a right pair of pedals.
Cautery, ultrasonic shears, suction/irrigation,
and other advanced instrumentation are avail-
able for control.
The da Vinci® Si Surgical console can be aug-
mented for training by attaching the da Vinci®
simulator to its back. For details see Chap. x:
simulation. Additionally, up to two surgical con-
soles can be attached to a single surgical cart for
dual-console surgery, which is particularly useful
for teaching purposes. Fig. 2.6 Patient cart (courtesy of Intuitive Surgical, Inc.)
14 M.E. Hagen et al.

bipolar shears, bipolar graspers, Harmonic™

ACE, PK™ dissecting forceps, and laser), differ- The da Vinci® Surgical System:
ent types of forceps, needle drivers, retractors, The Vision Cart
and other specialized instruments such as clip
appliers, probe graspers, and cardiac stabilizers. The vision cart (Fig. 2.7) houses the system’s
The most common instruments have a diameter central processing and vision equipment. It includes
of 8 mm. A selection of 5 mm instruments is a 24″ touch screen monitor used to control sys-
available for use with smaller access ports. tem settings and view the surgical image.
Most instruments contain the following It also provides adjustable shelves for optional
elements: ancillary surgical equipment such as insufflators
• A tip that represents the appropriate end effector and electrosurgical generators. The da Vinci® Si
for a specific surgical task such as different type core on the vision cart is the system’s central con-
of graspers, dissectors, cautery tips, and scalpels nection point where all system, auxiliary equip-
• An articulating wrist designed to mimic the ment, and audiovisual connections are routed.
wrist of the human hand (some instruments The core also is the “brain” of the system where
are not wristed as required by the underlying all computer calculations are processed to control
technology, such as the Harmonic™ ACE
which is a long ultrasonic horn that cannot be
bent)
• A shaft that represents the rotating “arm” of
the instrument and through which the motive
force is transferred from the robotic arms to
the wrist tips
• Release levers which are the mechanism for
removal of the instrument
• An instrument housing which is the portion of
the instrument that engages with the sterile
adapter of the instrument arm
The EndoWrist instruments are reposable,
which means that the main component needs to
be replaced after a certain number of surgeries.
The da Vinci® Si HD Vision System uses a
12 mm or 8.5 mm 3D rod lens endoscope with
either a straight (0°) or angled (30°) tip. Light
from the illuminator is sent down the shaft of the
endoscope via fiber optics and projected onto the
surgical site. The video image of the surgical site
captured by the endoscope is sent back through
the left and right channels to the camera head.
The camera head connects to the camera control
unit, as well as the illuminator. In keeping with
the anthropomorphic principle, the endoscope
contains two separate optical chains and focusing
elements, and the camera head contains two sep-
arate cameras. When displayed on two monitors
to the left and right eye of the surgeon, a true and
natural 3D image is recreated. Fig. 2.7 Vision cart (courtesy of Intuitive Surgical, Inc.)
2 Introduction to the Robotic System 15

the motions of the instruments inside the body. of an exciting journey that might change the
An integrated illuminator on the vision cart pro- surgical landscape sustainably. New robotic
vides lighting for the surgical field. A camera platforms for the use in surgical specialties will
control unit on the vision cart is connected to the emerge down the line and distinct new features
camera and controls the acquisition and process- will enable more procedures to be performed
ing of the image from the camera. with the help of computer-enhanced systems.
Further technology adopted into currently exist-
ing or new robotic platforms will evolve and
Conclusion transform these systems into surgical cockpits
that hold the promise of becoming the central
The da Vinci Surgical System is a success story workstation of surgical care. Integrated diag-
of visionary concepts brought into wide clinical nostics and real-time imaging will enhance
adoption to improve clinical outcomes through training, diagnostic assessment, and therapeutic
the interdisciplinary work of many different treatment in unforeseen new ways for the bene-
specialties. However, this is just the beginning fit of many patients in the years to come.
 Overview of General Advantages,
Limitations, and Strategies 3
Erik B. Wilson, Hossein Bagshahi,
and Vicky D. Woodruff

For centuries surgical technique remained rela- now enjoys a presence in cardiology, electrophysi-
tively unchanged despite an improved understand- ology, neurology, gynecology, urology, bariatric,
ing of medicine. Only 30 years ago, the general pediatrics, orthopedics, and radiosurgery. This
surgeon’s work spanned the abdomen, chest, neck, introduction reviews general advantages and limi-
and soft tissues, but in the late 1980s, minimally tations related to technical and clinical aspects,
invasive surgery (MIS) segmented general surgery strategies of robotics, and the future of robotics.
into sub-specializations and challenged the gen-
eral surgeon to learn new skill sets to take advan-
tage of the innovative tech tools. More recently, Technical Advantages of Robotics
the explosion of robotic technology is poised to
repeat further segmentation and challenges the In general, the development of robotic surgery
surgeon to adopt an even more advanced skill set with Intuitive Surgical’s da Vinci platform has
to keep pace with more advanced technology that successfully built on the advantages of laparo-
overcomes obstacles as rapidly as they are encoun- scopic surgery and overcome its fundamental
tered [1]. This is especially so for single incision limitations allowing completion of complex and
or no incision procedures. Robotic technology advanced surgical procedures with increased pre-
cision in a minimally invasive approach [2–4].
Technical advantages of robotics are plenteous
E.B. Wilson, M.D. (*) and embrace mechanical improvements, surgery
Department of Surgery, The University of Texas via telecommunication systems, and safe simula-
Health Science Center, 6431 Fannin Street tion systems that allow skill training prior to
MSB4.162, Houston, TX 77030, USA
actual human procedures.
e-mail: [email protected]
Improved mechanical advantages include
H. Bagshahi, M.D.
enhanced stabilized three-dimensional stereo-
Department of Surgery, Harris Methodist Hospital,
of Fort Worth, 800 Fifth Avenue, Suite 404, scopic vision of the operative field, boost visual
Fort Worth, TX 76104, USA sharpness, and depth perception beyond the stan-
Reshape Bariatric and General Surgery dard laparoscopic monitor. Additionally, the abil-
of Fort Worth, 800 Fifth Avenue, Suite 404, ity to digitally zoom without sacrificing clarity
Fort Worth, TX 76104, USA provides greater confidence in preciseness of sur-
e-mail: [email protected]
gical dissection and reconstruction. The increased
V.D. Woodruff, B.A., B.S., Ph.D. maneuverability of articulating wrist instruments
Department of Surgery, University of Texas Health
created additional degrees of freedom from five
Science Center, 6431 Fannin Street, Suite 4.294,
Houston, TX 77030, USA movements to seven, improving the surgeons’
e-mail: [email protected] dexterity and allowing greater precision in the

K.C. Kim (ed.), Robotics in General Surgery, DOI 10.1007/978-1-4614-8739-5_3, 17

© Springer Science+Business Media New York 2014
18 E.B. Wilson et al.

Fig. 3.1 Freedom of (a) movement and (b) instrumentation

Fig. 3.2 (a) White light and (b) fluorescent imaging

surgical field, which more closely mimics open lantic surgery via telerobotic presence was a cho-
surgery (Fig. 3.1a, b). Coupled with this technol- lecystectomy performed by robot in Strasbourg,
ogy, hand stabilization eliminates surgeon tremor France, by surgeons in New York, NY [7, 8]. Since
and allows for refinement of scaled movements. then, many telerobotic operations have been per-
This gives the surgeon the capability of adjust- formed allowing surgeons to operate where their
ing the degree of precision of his or her motions skills are needed without being in the direct pres-
from bold to very fine. One of the newest addi- ence of the patient. Proponents of telerobotic sur-
tions to the platform is a new integrated fluores- gery tout the beneficial delivery of surgical care in
cence imaging capability that provides real-time, medically underserved areas [9, 10]. However, the
image-guided identification of key anatomical cost of a surgical robot (>$1 million) is beyond the
landmarks using near-infrared technology financial ability of many medically underserved
(Fig. 3.2a, b). This allows the surgeon to visual- areas, but when finances are not limiting, robotic
ize the end perfusion of the tissue of interest. surgery presents the potential for delivering surgi-
Linking the robot to a telecommunication cal care to patients who have no direct access to a
device creates two new revolutionary applications. surgeon [11, 12]. In telementoring, two surgeons
The SOCRATES system achieves a “telepres- located a distance away “share” the view of the
ence” surgery with “telerobotic” and “telementor- surgical field and control the robotic system, com-
ing” capability [5, 6]. In a telerobotic procedure, municating via microphones. This system has
the surgeon, operating from a console miles away advantages for teaching surgical skills to fellows,
from the slave robot, guides the procedure via junior surgeons, and advanced medical students all
fiber-optic cable. In 2001, the first major transat- around the world by expert colleagues [13–15].
3 Overview of General Advantages, Limitations, and Strategies 19

A robotic simulation system provides a Technical and clinical advantages of robotics

medium for anyone to acquire or refine their sur- have been well documented, and safety has been
gical skills, thus reducing the learning curve and substantially established with many series of
surgical error [5]. Utilizing the 3D, virtual reality cases reporting favorable outcomes [20–23].
of the simulator, visual simulations, and soft Robotic technology is expected to play an increas-
tissue models recreate the textures of human tis- ingly important role in the future of surgery.
sues through forced feedback haptics [15, 16].
Image-guided simulations of the anatomy of the
actual patient allow for practice of planned recon- Limitations in Robotics: Technical
structions prior to the actual procedure [17–19]. and Clinical
Since all surgical movements in both simulation
sessions and actual surgery are automatically Technical limitations form the drawback for the
captured as objective precise data measurements majority of resistance to robotic surgery. Near the
by the robotic system, they can be utilized as a top of the list is the decreased tactile feedback
means for establishing surgical proficiency crite- sense. It remains that the robot is still a self-
ria, measuring quality improvement in surgical powered, computer-controlled device not
skill; provide hospitals quality measures on sur- intended to act independently from human sur-
geons; and as best practice for educational geons or to replace them [1, 3, 11]. Although true
instruction. In due course, simulation training “feel” of tissues has yet to be realized, there are
may be integrated into surgical course work and some crude haptics that occur if the instruments
licensing of surgeons to provide an objective bump or hit each other (usually due to poor trocar
means for assessment of surgical effectiveness. placement or planning), transmitting a tactile
sensation back to the surgeon’s console finger
apparatus. Otherwise, the surgeon must maintain
Clinical Advantages visual contact through the monitor to guide the
instrumentation and ensure appropriate and safe
Clinical advantages for robotic surgery touch the manipulation is preserved. It has been our experi-
patient, the surgical institution, and the health- ence that with time working with the robot, it
care insurer. Due to greater precision, smaller may become possible for visual cues to become
incisions, lack of fatigue during extended opera- so strong a faux tactile sensation can be realized.
tive procedures, reduction of blood loss, less The size of the available robotic instruments
pain, quicker healing time, and a reduction of becomes a real limitation in certain surgical spe-
complications, benefits such as reduced duration cialties. For example, the trocar and instrument
of hospital stays, transfusions, and use of pain size in relation to the pediatric patient may prevent
medications are common. Patients undergoing its advantage in this population. In otorhinolaryn-
robotic procedures typically return to normal gology and head and neck surgery, this small area
activity faster and experience very low mortality of accessibility also limits the use of robotics.
and morbidity events [1]. The advantage of mul- More minor technical limitations include the
tiple robotic arms that do not become fatigued, bulkyness of the robot, extended time to set it up
hold instruments steady, and provide constant in position for activity, and difficulty traversing
strength in holding selected tissue opens greater wide fields. While bulkyness may be a valid issue
surgical opportunity to the morbidly obese patient in a small operating space, the time to set up can
or patient with difficult anatomy (usually due to through practice be reduced to less than 5 min.
scaring or altered anatomy from prior abdominal Traversing multiple quadrants has been addressed
surgeries) and allows multiple teams of surgeons through alternate positioning of the robot at the
to seamlessly and effortlessly transition during head of the patient and a specific five or six trocar
extended procedures, making wider range of pro- placement system that avoids patient reposition-
cedures more realistic. ing (cite book1).
20 E.B. Wilson et al.

While a hybrid laparoscopic and robotic approach

Clinical Limitations has been suggested, nothing can substitute time
logged on the simulator or the actual robot [1].
Although rapidly overcoming technical limitations, However, the majority of hospitals, fellowships,
robotic surgical technology has yet to achieve its and residency programs in the USA do not provide
full potential due to substantial clinical limitations. formal training in robotic surgery skills. This glar-
Undoubtedly, the greatest clinical limitation is the ing deficit of development in surgical technology
cost of the robot system. Two studies comparing needs to be addressed as robotics is likely to
robotic procedures with conventional operations reshape the way we practice surgery.
showed that although the absolute cost for robotic A review of residency programs in the USA
operations was higher, the major part of the shows an inadequate emphasis on training in
increased cost was attributed to the initial cost of robotic surgery [11]. A 2002 survey reported
purchasing the robot [24, 25]. Coming in at over $2 23 % of surgical program directors have plans to
million, $500–$1,500/case in disposable costs, incorporate robotics into their programs [26].
maintenance cost upward to $100,000/year, and Sadly, the same survey group also reported that
robotic instruments limited to a fixed number of although 57 % of surgical residents indicated a
uses (unrelated to instrument wear), the cumulative high interest in robotic surgery, 80 % did not have
cost is prohibitive to most healthcare organizations. a robotic training program at their institution
Even in the USA, surgical robots are chiefly limited [27]. Currently, individual hospitals bear the bur-
in availability to hospital systems and large aca- den of ensuring competency to perform robotic
demic centers. Factors such as more wide spread procedures. There is a glaring need for standard-
acceptance, decreased operative times, complica- ized credentials to be developed and required to
tions, and hospital stay will contribute to the obtain robotic surgical privileges.
cost-effectiveness. Conversely, further technical In conjunction with training, documentation
advances may at first drive prices even higher. and publishing of clinical randomized controlled
Although there is research and development cur- trials comparing robotic-assisted procedures with
rently underway to develop indefinitely reusable laparoscopic or open techniques are needed to
instruments, until then the robot remains a major inform data-driven decisions for the surgeon,
capital expense to the bottom line. It has been hospital administrator, and medical education
estimated that the sum of these costs each year is institutions in regard to cost, training, and clinical
approximately 10 % of the capital acquisition cost effectiveness of robotics.
[24, 25]. The cost factor also becomes prohibitive to Robotic surgery, while still in a relatively early
the spread of telerobotic technology to underserved stage, is on a continuous journey that will have sub-
areas that need it most. Studies to determine the cost stantial implications for the future of surgery. This
over time vs. reduction of morbidities and mortali- emerging technology allows surgeons to perform
ties and associated collateral costs are needed to operations that were not so long ago, impossible,
better evaluate the long-term cost/benefit ratio. tedious, visually and physically challenging, replete
Ultimately, it is felt that competition and marketing with complications, and not amenable to minimal
of various robotic systems such as the Amadeus access techniques. The future of robotics is yet to be
from Titan Medical, Inc. (Canada), the ARAKNES fully written but is already holding great promise.
robot from SSSA BioRobotics Institute and Surgical
Robotics S.p.a.’s Surgenius (both from Italy), the
DLR system (Germany), and Mazor Robotics Ltd’s Future of Robotics
SpineAssist (Israel) may drive costs down.
Another major limitation is that performance The future of robotics is poised to include earth,
of robotic procedures requires specialized training. under the sea, and space—the great frontier. In
A chief complaint is the steep learning curve to 2005, studies were already underway by the
become proficient in the needed technical skills. National Aeronautics and Space Administration
3 Overview of General Advantages, Limitations, and Strategies 21

(NASA) for robotic application in emergency sur- 7. Marescaux J, Leroy J, Gagner M, et al. Transatlantic
gery on astronauts in a submarine to simulate con- robot-assisted telesurgery. Nature. 2001;413:379–80.
Abstract.
ditions in space [28]. The project is called NEEMO 8. Marescaux J, Rubino F. Robot-assisted remote sur-
7. Additionally, testing telerobotic capabilities, the gery: technological advances, potential complica-
Pentagon also invested $12 million in a project tions, and solutions. Surg Technol Int. 2004;12:23–6.
using a “trauma pod” surgical robot. The system Abstract.
9. Marescaux J, Leroy J, Rubino F, et al. Transcontinental
tests the ability to evacuate wounded soldiers robot-assisted remote telesurgery: feasibility and
under enemy fire and then operate on them [11, potential applications. Ann Surg. 2002;235:487–92.
29]. To address the size limitations of instruments Abstract.
and versatility, the University of Nebraska Medical 10. Anvari M, McKinley C, Stein H. Establishment of the
world’s first telerobotic remote surgical service: for
Center has led a multicampus effort to provide col- provision of advanced laparoscopic surgery in a rural
laborative research on mini-robotics among sur- community. Surg Laparosc Endosc Percutan Tech.
geons, engineers, and computer scientists [30]. 2002;12:17–25. Abstract.
11. Morris B. Robotic surgery: applications, limitations,
Although surgical robotics is growing, the
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13. Bove P, Stoianovici D, Micali S, et al. Is telesurgery a
ever, as more industry investments are made and new reality? Our experience with laparoscopic and
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14. Marescaux J, Rubino F. Telesurgery, telementoring,
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 Part II
Surgical Techniques: Esophagus
 Robotic Assisted Minimally
Invasive Esophagectomy 4
Abbas E. Abbas and Mark R. Dylewski

cotomy for completion of the esophageal

Introduction resection and creation of an intrathoracic
esophagogastric anastomosis.
The esophagus is an organ that traverses three 2. THE: this also includes a laparotomy as
body cavities, hence the difficulty and possible described for TTE in addition to a cervicotomy.
morbidity associated with esophagectomy. Mobilization of the intrathoracic esophagus is
Resecting the esophagus always requires access- done through the hiatus and the neck, mostly
ing the peritoneal space, in addition to either a in a blunt fashion. The anastomosis is made at
direct approach to the intrathoracic esophagus as the neck.
in trans-thoracic esophagectomy (TTE) or an 3. McKeown esophagectomy (MKE) or the
indirect dissection of this portion of the esopha- “3-hole esophagectomy”: attempts to provide
gus as in transhiatal esophagectomy (THE). a more radical approach to the procedure. A
Multiple approaches have arisen for this opera- right thoracotomy is made for dissection of
tion but no one technique has been universally the entire thoracic esophagus and mediastinal
accepted as the standard. In fact, with the advent lymph nodes. This is followed by a laparot-
of minimally invasive techniques in the latter part omy as described above and a cervicotomy.
of the twentieth century, there have been even The gastric conduit is delivered to the neck as
more techniques described for esophagectomy. in THE where a cervical esophagogastros-
The most-commonly performed procedures for tomy is performed. This approach allows the
esophagectomy include: potential for a three-field lymphadenectomy
1. Ivor Lewis TTE procedure: which incorpo- of the entire lymph node basin of the esopha-
rates a laparotomy for gastric mobilization gus, in the neck, thorax, and abdomen. It also
and tubularization followed by a right thora- allows removal of most of the esophagus,
leaving only a short proximal segment to com-
plete the anastomosis.
4. Left thoracotomy or left thoracoabdominal
A.E. Abbas, M.D.
Department of Surgery, Ochsner Clinic approach: this is less commonly used than the
Foundation, 1514 Jefferson Highway, above-mentioned procedures. It allows resec-
New Orleans, LA 70121, USA tion of only the distal esophagus. The stomach
e-mail: [email protected]
is mobilized either through an incision in the
M.R. Dylewski, M.D. (*) left diaphragm or through an extension of the
Department of Cardiac Vascular and Thoracic
thoracotomy across the costal margin. After
Surgery, Baptist Health of South Florida, 6200 SW
72nd Street, Suite 604, Miami, FL 33143, USA the specimen is resected, the esophagogas-
e-mail: [email protected] trostomy is performed in the left chest.

K.C. Kim (ed.), Robotics in General Surgery, DOI 10.1007/978-1-4614-8739-5_4, 25

© Springer Science+Business Media New York 2014
26 A.E. Abbas and M.R. Dylewski

Table 4.1 Published reports on robotic esophagectomy

Horgan et al. [1] 2003 1 Hybrid RATS + laparoscopy THE
Dapri et al. [2] 2006 2 Hybrid RATS + Laparoscopy MKE
Gutt et al. [3] 2006 1 Hybrid Robotic laparoscopy THE
Kernstine et al. [4] 2007 14 Mix of hybrid RATS + laparotomy, MKE
(6) and totally laparoscopy, RALS
robotic (8)
Kim et al. [5] 2010 21 Hybrid RATS + Laparoscopy MKE
Sutherland et al. [6] 2011 36 Hybrid Robotic laparoscopy THE
Puntambekar et al. [7] 2011 32 Hybrid RATS + Laparoscopy MKE
Weksler et al. [8] 2011 17 Hybrid RATS + laparoscopy ILE
RATS robotic assisted thoracoscopic surgery, RALS robotic assisted laparoscopic surgery, THE transhiatal esophagec-
tomy, MKE McKeown esophagectomy, ILE Ivor Lewis esophagectomy

Each of the above procedures except perhaps Debating the merits of each approach is
for the left thoracotomy approach has been beyond the scope of this chapter, which focuses
described in a “minimally invasive” fashion. on the applicability of robotics to esophagectomy.
Thoracoscopy and laparoscopy may replace tho- The preferred approach by both authors is that of
racotomy and laparotomy, and in the hands of the totally endoscopic robotic-assisted three-field
surgeons experienced in these techniques, may approach, or a robotic MKE procedure. The tech-
offer results that are equivalent to those achieved nique described is that employed in the vast
by their traditional open counterparts while still majority of our patients with esophageal cancer or
providing all the established benefits of mini- end-stage benign esophageal disease.
mally invasive surgery.
More recently, robotic technology has entered
the arena of minimally invasive surgery. The ben- Technique
efits of dexterous dissection and manipulation in
a confined space make it ideal for esophageal dis- 1. Anesthesia (Fig. 4.1):
section in the mediastinum. In the abdomen, the All patients are done under general anesthesia
ability of the surgeon to handle and manipulate with endotracheal intubation. A 8 mm single
the stomach with excellent visualization allows lumen endotracheal tube is utilized through
the safe creation of the conduit. Robotic surgery which a right-sided bronchial blocker is placed.
has allowed fine dissection of lymph nodes with This blocker is used for the thoracic portion of
better precision than traditional endoscopic the procedure, after which it is simply removed
techniques. and the remainder of the case is done with double
The first published report of a robotic-assisted lung ventilation. Esophagogastroscopy is per-
esophagectomy is that by Horgan et al. [1] who formed by the surgeon to confirm location of the
described a transhiatal approach. Table 4.1 sum- tumor and clear the esophagus and stomach of
marizes several published reports for robotic any retained contents. It is important to avoid
esophagectomy. Most reported series have excessive insufflation of the stomach, which
described hybrid techniques with robotic-assisted would hinder the abdominal exposure and may
thoracoscopy in addition to laparotomy or lapa- affect mucosal integrity. A nasogastric tube is
roscopy [2, 4, 5]. Others have described a robotic- then passed and connected to low intermittent
assisted THE with cervical esophago-gastrostomy wall suction to keep the stomach decompressed.
[3, 6]. Few reports have described totally robotic There is no need for placement of an epidural
laparoscopic and thoracoscopic approach [4]. catheter as most patients can be easily managed
4 Robotic Assisted Minimally Invasive Esophagectomy 27

The first is a 12 mm port at the seventh

intercostal space (ICS), just anterior to the ante-
rior axillary line. A 5 or 10 mm thoracoscope is
placed and after ensuring intrathoracic placement
of the port, carbon dioxide insufflation of the
pleural space is administered to a maximum
pressure of 10 mmHg. The standard thoraco-
scope is then utilized to assist in proper place-
ment of the other three ports. A 8.5 mm port is
placed for the robotic camera at the sixth ICS,
mid-axillary line. It is important to avoid placing
this port too far posteriorly. Ideally this port will
be at the mid-point of the thoracic esophagus,
Fig. 4.1 Patient intubated with right bronchial blocker
and nasogastric tube about 2 in. below the azygous vein arch.
Following this an 8 mm port is placed in the third
ICS, mid-axillary line for the right arm and am
8 mm port is placed in the ninth intercostal space
at the mid-axillary line also (this one can be
slightly more posterior). Before placing the latter
three ports, it is helpful to pass a needle percuta-
neously at the proposed sites and using the thora-
coscope to confirm adequacy of location. The
standard guideline of ensuring at least a hand’s
breadth between ports is important to avoid
arm-collision.
For the thoracic dissection, the right arm (#1)
will alternate using the robotic harmonic scalpel
and the bipolar Maryland dissector while the left
arm (#2) will use mainly the Caudier forceps for
retraction. The assistant at the bedside will assist
in providing suction and in passing the stapler.
The lung is retracted anteriorly and the inferior
pulmonary ligament is divided. The mediastinal
pleura are then divided longitudinally both ante-
rior and posterior to the esophagus up to the
level of the azygous vein arch. The vein is then
dissected free and divided using the endo-GIA
stapler with a vascular load. Above the divided
Fig. 4.2 Right thoacoscopic ports vein, it is important not to divide the pleura and
to let it remain as a “tent” to overlie the eventual
conduit. This may help wall off any cervical
with routine parenteral non-opioids. Early extu- anastomotic leakage from the chest. The esopha-
bation is strongly recommended. gus is then dissected circumferentially to include
2. Right Robotic Assisted Thoracoscopic all the lymphatics and fatty tissue in-between the
Surgery (RRATS): azygous vein, aorta and pericardium. The har-
The patient is then placed in the left lateral monic scalpel is helpful in dividing the aortic
position with slight flexion and slight anterior esophageal branches. This dissection must
tilting. A total of four ports are placed (Fig. 4.2). include a complete mediastinal nodal dissection.
28 A.E. Abbas and M.R. Dylewski

Fig. 4.3 Left cervicotomy and delivery of penrose drain Fig. 4.4 Laparoscopic ports

port just above the umbilicus and again use a

Stations 7, 8 and 9 are left on the esophagus, laparoscope to aid in correct placement of the
while stations 2 and 4 are removed separately. robotic ports using a percutaneous needle before
After completing the dissection of the thoracic committing to the location of the port. Four
esophagus in its entirety, a penrose drain is other ports are placed. An 8.5 mm port for the
placed to encircle it at both the thoracic inlet and camera at the left paramedian line, about 1 in.
outlet of the esophagus. These drains help in above the level of the umbilicus and below the
identifying the esophagus in the next stages of lowest point of the greater curve of the stomach.
the operation. A flexible 19 F drain is then placed Two 8 mm ports are placed in the left flank (#3)
along the posterior esophageal gutter. This drain and the left midclavicular line (#2), at about the
may be secured to the pleura with an absorbable same horizontal level. A 13 mm port (#1) is
suture to avoid its dislodgement with ventilation. placed at the right midclavicular line, about
The instruments are then removed and the robot 7 cm below the costal margin. The preferred
is undocked. approach for liver retraction is used. The author
3. Left Cervicotomy: places a flexible retractor through a 5 mm port in
The patient is then positioned supine and a the right flank, which is secured to the table with
foam roll is placed under the left shoulder as well a self-retainer.
as under the left flank. A 4 cm incision is made Figure 4.4 shows the location of the abdomi-
along the inferior anterior border of the left ster- nal ports. Before docking the robot, the patient is
nocleidomastoid muscle. A careful circumferen- placed in a reverse Trendelenburg position to
tial dissection of the cervical esophagus is then help keep the omentum and bowel away from the
made with care to avoid injuring the left recurrent operating field.
laryngeal nerve. This dissection is carried down The #3 arm is used mainly for retraction using
to the level of the Penrose drain, which was pre- atraumatic double fenestrated robotic clamp. The
viously placed at the thoracic inlet. This drain is #2 arm or right hand will alternate the Harmonic
then partially delivered through the wound scalpel and any other instruments such as the
(Fig. 4.3). Bipolar Maryland dissector or a needle holder as
4. Robotic Assisted Laparoscopic Surgery the need arises. The #1 arm will mainly use the
(RALS): Caudier forceps to assist in dissection. Dissection
Following this, standard laparoscopic tech- is begun by dividing the gastrohepatic ligament
nique is used to establish a pneumoperitoneum. and the peritoneum along the edges of the dia-
The authors prefer a Verres needle through the phragmatic hiatus. It is helpful to delay complete
umbilicus. We then proceed to place a 12 mm division of the phrenoesophageal ligament until
4 Robotic Assisted Minimally Invasive Esophagectomy 29

the end of the gastric mobilization to avoid loss of

pneumoperitoneal pressure and also avoid creat-
ing a pneumothorax. The short gastric vessels are
then divided using the Harmonic scalpel. After
visualizing and confirming the location of the
right gastroepiploic arcade, the greater omentum
is divided just lateral to the right gastroepiploic
vessels along the entire length of the arcade. This
requires division of several omental branches and
it is important to always confirm that the main
vessels are not injured during this procedure espe-
cially in cases with excessive omental fat. The
attachments of the hepatic flexure are divided to
Fig. 4.5 Delivery of the specimen from the neck
allow exposure of the duodenum. Gentle “kocher-
ization” of the duodenum is then done. This pro-
motes a tension-free gastric outlet. The pylorus at
this stage is identified and can be approached
according to the surgeon’s preference regarding
gastric drainage. These preferences range from no
gastric drainage procedure to pyloroplasty and
certainly all the techniques are possible at this
time. One of the authors (MD) prefers to inject
Botox while the other author (AEA) performs a
pyloromyotomy using bipolar cautery. At this
time, the stomach is retracted anteriorly to expose
retro-gastric adhesions, which are divided until
the left gastric pedicle is identified. A complete
dissection is done of the lymphatic and nodal tis-
sue down to the trifurcation of the celiac artery. Fig. 4.6 Resected specimen
The artery is divided using the stapler at its most
proximal point. A separate dissection of nodal tis-
sue around the celiac trunk and hepatic artery is
then undertaken. for division of the stomach may be easier from
At this point the stomach has been completely the right subcostal 13 mm port. After completing
mobilized and the phrenoesophageal ligament is the conduit, the distal end of the specimen and
divided to deliver the penrose drain into the abdo- the proximal end of the conduit are connected
men. The stomach is then ready for tailoring of with a silk stitch.
the conduit. It is important at this point to pull The assistant is then asked to deliver the
back the nasogastric tube until its tip is in the tho- esophagogastric specimen from the neck along
racic esophagus. The assistant using the endo- with the attached conduit (Figs. 4.5 and 4.6).
GIA stapler divides the stomach. The conduit is During this procedure the surgeon remains at
fashioned as a long 5 cm tube extending from the the console to ensure that the conduit does not
incisura to the fundus. It is important to avoid twist and is free of tension. It is also important to
the common mistake of stapling too close to the close the diaphragmatic hiatus posterior to the
esophagogastric junction (EGJ) as this precludes conduit to avoid visceral herniation. This is done
an adequate lateral margin at the EGJ and may with interrupted silk sutures. The robot is then
predispose to local recurrence. The initial angle undocked and the surgeon returns to the table to
30 A.E. Abbas and M.R. Dylewski

extent of the dehiscence and rule out gastric tip

necrosis. The leak is treated according to the
extent of the anastomotic dehiscence. In cases of
disruption less than 50 % of the circumference of
the anastomosis, conservative management with
simple drainage, stent placement or passage of a
percutaneous sump catheter through the defect
into the gastric conduit. The cervical skin inci-
sion is always opened to allow drainage of any
infection. Cases with complete disruption of the
anastomosis are treated the same as those with
gastric necrosis.
Fig. 4.7 Incisions upon completion
Gastric Tip Necrosis
This is a rare but lethal complication related to
divide the proximal esophagus and complete the ischemia of the gastric conduit. This usually
cervical anastomosis and perform a laparoscopic requires taking down of the anastomosis, resect-
feeding jejunostomy. Figure 4.7 shows the ing the ischemic portion and diversion of the
abdominal incisions after closure. esophagus with a cervical esophagostomy. The
remaining healthy portion of the stomach is
returned to the abdomen. The patient usually also
Postoperative Management requires decortications. It is necessary to identify
these cases early to avoid the onset of sepsis.
Patients typically remain in the hospital until their
thoracic and nasogastric drains are removed. This Chylothorax
is usually achieved by postoperative day 4. They When identified, this complication should be
are discharged on jejunal tube feedings. A gastro- treated surgically. After esophagecotmy it is
grafin swallow study is done as an outpatient pro- almost always caused by complete division of the
cedure at postoperative day 10–14. When leakage main thoracic duct and can seldom be treated
is ruled out, the patient is allowed small amounts conservatively with fasting and TPN. Delayed
of food and drink. These rations are progressively repair may predispose to malnutrition, infection
increased over a period of 2 months while simul- and dehydration. Ligation of the thoracic duct
taneously decreasing the tube feeding. can usually be performed by means of a reopera-
tive right robotic-assisted approach. Injecting
100 cm3 of cream or olive oil in the jejunostomy
Complications tube helps in identifying the source of chyle leak.

The most common postoperative complications Vocal Cord Paralysis

are the same as those encountered after open Although this complication is usually temporary
esophagectomy. They may be classified accord- and secondary to retraction, it may impact on the
ing to onset into early and late complications. patient’s ability to clear pulmonary secretions.
If necessary patients are referred for medializa-
tion of the cords.
Early Complications
Delayed Gastric Emptying
Anastomotic Leaks Precautions to avoid this devastating complica-
These usually present after the fifth postoperative tion include performing a gastric drainage proce-
day. They range from mild to severe. Once identi- dure such as pyloroplasty or pyloromyotomy,
fied, endoscopy is performed to evaluate the creating a narrow straight conduit to avoid
4 Robotic Assisted Minimally Invasive Esophagectomy 31

pooling of contents, and avoiding a twist or kink Weksler et al. reported on 11 cases of robot
of the conduit at the time of pulling up of the con- assisted Ivor Lewis procedures [8]. In compari-
duit through the hiatus. Medical management son with their series of traditional MIE, robotic
includes prokinetic agents such as metoclo- thoracoscopic MIE did not offer clear
pramide or erythromycin. If the condition does advantages.
not improve, endoscopic pyloric balloon dilation Dunn et al. reported on 40 patients underwent
or pyloric Botox injection can be attempted. transhiatal RE [9]. Five patients were converted
from robotic to open. Complications included
anastomotic stricture (n = 27), recurrent laryngeal
Late Complications nerve paresis (n = 14), anastomotic leak (n = 10),
pneumonia (n = 8), pleural effusion (n = 18) and
Anastomotic Stricture death (n = 1).
Typically patients present with late onset dyspha- The authors present their own series of totally
gia. This may occur up to a year after surgery. endoscopic robotic McKeown procedures.
Usually this can be managed endoscopically by Author AEA’s series includes 33 patients (3
endoscopic dilation. Refractory strictures may be females, 10 %) with median age of 62 who under-
amelriorated with temporary self-expanding cov- went totally endoscopic robotic assisted
ered stents, placed for 4–6 weeks. In severe cases, McKeown esophagogastrectomy in an 18 month
surgical strictureplasty is performed. period from January 2011 to July 2012. Indication
for surgery was esophageal adenocarcinoma
Hiatal Hernia (n = 26, 79 %), squamous cell carcinoma (n = 3,
When the hiatus is not closed at the time of sur- 9 %), end-stage achalasia (n = 2, 6 %), giant
gery, there is a risk of visceral herniation. Surgical esophageal diverticulum (n = 1, 3 %), and com-
repair may be approached by means of a thora- plicated eosinophilic esophagitis (n = 1, 3 %).
cotomy on the side of the herniation or laparot- For the 29 cases of esophageal cancer, neoad-
omy. Minimally invasive repair is usually not juvant or definitive chemoradiation was adminis-
possible. tered in 15 cases (n = 51.7 %) and pathologic
stage was Stage 0 (n = 3, 10.3 %), IA (n = 8,
27.6 %), IB (n = 3, 10.3 %), IIB (n = 4, 13.8 %),
Outcomes After Ramie IIIA (n = 9, 31 %), IIIB (n = 2, 6.9 %). Stage 0
related to complete pathologic response after
Totally robotic esophagectomy has not been neoadjuvant therapy, which occurred in 3 of 15
reported frequently. Kernstine et al. [4] reported patients (20 %).
on 14 patients with a median age of 64 years who Mean duration of surgery was 310 min (range,
underwent robotic esophagectomy, 8 of who 270–340 min) with no cases of conversion to
were completely robotic MKE while 6 were open procedure. The mean number of lymph
hybrid procedures. Total operating room time nodes with the specimen in all cases was 16
was 11.1 ± 0.8 h (range, 11.3–13.2 h). (7–44). The median length of hospital stay was 7
Complications included death (n = 1), thoracic days (range, 4–31 days).
duct leak (n = 1), severe pneumonia (n = 1), anas- Complications are summarized in Table 4.2.
tomotic leak (n = 2) and bilateral vocal cord pare- Short-term complications after surgery occurred
sis (n = 1). Mean total operating time was 11.1 h. in 13 patients (39 %). Complications included
Kim et al. reported on 21 patients who under- mild anastomotic leak (n = 2, 6 %), vocal cord
went hybrid RATS/laparoscopic MKE in the paresis (n = 2, 6 %) and chylothorax requiring
prone position [5]. One patient had a positive reoperation (n = 2, 6 %). One patient died of mes-
margin; major complications included anasto- enteric ischemia on day 12 after surgery. Patients
motic leakage (n = 4), vocal cord palsy (n = 6), in the series were followed for a mean of 160.7
and intra-abdominal bleeding (n = 1). days (range, 12–492 days). Two patients have
32 A.E. Abbas and M.R. Dylewski

Table 4.2 Complications after RAMIE. Author AEA body cavities. It is also advantageous due to the
series of 33 MKE procedures
ability to perform a superior oncologic procedure in
Short-term terms of meticulous mediastinal and periceliac
Atrial arrhythmia 15 % nodal dissection; areas that are not easily exposed
UTI 9% by traditional endoscopic or even open surgery.
Pneumonia 9%
However, it is not the goal of the authors to
Wound infection 6%
convey that a robotic esophagectomy is a minor
Anastomotic leak 6%
Vocal cord paresis 6%
procedure. It requires advanced skills, usually
Delerium tremens 6% greater than those needed for other thoracic
Chylothorax 6% operations. It remains a major operation with a
ARDS 3% mortality rate of up to 10 %, in addition to the
Pulm embolism 3% risk for all complications that are seen with
Renal failure 3% esophagectomy by other means. It will be impor-
Mesenteric ischemia 3% tant to provide long-term follow-up for this
Death 3% procedure in order to truly assess its value in
Long-term managing esophageal cancer.
Anastomotic stricture 15 %
Delayed gastric emptying 3%
References
1. Horgan S, et al. Robotic-assisted minimally invasive
developed metastatic disease (lung, peritoneum), transhiatal esophagectomy. Am Surg. 2003;69(7):
five developed anastomotic stricture (15 %) and 624–6.
one patient (3 %) developed delayed gastric emp- 2. Dapri G, Himpens J, Cadiere GB. Robot-assisted
tying (DGE). Strictures and DGE were managed thoracoscopic esophagectomy with the patient in the
prone position. J Laparoendosc Adv Surg Tech A.
successfully by endoscopic balloon dilation. All 2006;16(3):278–85.
patients on follow-up are tolerating oral diet. 3. Gutt CN, et al. Robotic-assisted transhiatal esopha-
Author MD performed the procedure on 20 gectomy. Langenbecks Arch Surg. 2006;391(4):
patients with mean age of 63 years, 17 males. 428–34.
4. Kernstine KH, et al. The first series of completely
Fourteen patients had Stage IIIA disease. Mean robotic esophagectomies with three-field lymphade-
operative time was 303 min and conversion to nectomy: initial experience. Surg Endosc. 2007;
open surgery was necessary in one patient due to 21(12):2285–92.
adhesions. Average hospital stay was 9 days. 5. Kim DJ, et al. Thoracoscopic esophagectomy for
esophageal cancer: feasibility and safety of robotic
Ninety-day mortality was 10 %. Leak rate was assistance in the prone position. J Thorac Cardiovasc
15 % and vocal cord paresis was 5 %. Surg. 2010;139(1):53–9.e1.
6. Sutherland J, et al. Postoperative incidence of incar-
cerated hiatal hernia and its prevention after robotic
transhiatal esophagectomy. Surg Endosc. 2011;25(5):
Summary 1526–30.
7. Puntambekar SP, et al. Robotic transthoracic esopha-
As we have seen with most other traditional gectomy in the prone position: experience with 32
operations, esophagectomy has also been shown to patients with esophageal cancer. J Thorac Cardiovasc
Surg. 2011;142(5):1283–4.
be feasible in a minimally invasive fashion. Robotic 8. Weksler B, et al. Robot-assisted minimally invasive
assistance offers the same benefits normally esophagectomy is equivalent to thoracoscopic mini-
expected when applied in other procedures. In the mally invasive esophagectomy. Dis Esophagus.
case of esophagectomy, these benefits may be mag- 2012;25(5):403–9.
9. Dunn DH, et al. Robot-assisted transhiatal esophagec-
nified in terms of minimizing the usual severe insult tomy: a 3-year single-center experience. Dis Esophagus.
to the patient from an operation that invades three 2013;26(2):159–66.
 Robotic Assisted Operations
for Gastroesophageal Reflux 5
Daniel H. Dunn, Eric M. Johnson, Kourtney Kemp,
Robert Ganz, Sam Leon, and Nilanjana Banerji

remain limited. Medical management with proton

Introduction pump inhibitors is the mainstay as well as the first
line of treatment. All patients with a diagnosis of
Despite the fact that the management of patients GERD are initially tried on medical management.
with gastroesophageal reflux disease (GERD) has In general, only those who fail treatment are
become complex with more precise diagnostic offered surgical options for definitive treatment.
evaluations, surgical treatment options still Those patients with large sliding hiatus hernias,
paraesophageal hernias, severe regurgitation,
atypical laryngopharyngeal symptoms or pulmo-
D.H. Dunn, M.D. (*)
nary complications from reflux are exceptions to
Esophageal and Gastric Care Program, Virginia Piper
Cancer Institute, Abbott Northwestern Hospital, 2545 this fairly simple treatment algorithm.
Chicago Avenue, Minneapolis, MN 55404, USA For over a half-century, hiatus hernia repair
e-mail: [email protected] and fundoplication have been implemented as the
E.M. Johnson, M.D. only surgical procedures for GERD. However,
Department of Surgery, Abbott Northwestern the results of such operative approaches continue
Hospital, 2545 Chicago Avenue, Minneapolis,
to be unsatisfactory in the estimation of many
MN 55407, USA
e-mail: [email protected] gastroenterologists. Patients are told to avoid
operation at all costs. Recurrence rates of 25 % in
K. Kemp, M.D.
Specialists in General Surgery, Maple Grove 5 years are common. Reoperation for recurrent
Hospital, 9825 Hospital Drive, Suite 105, symptoms or complications of the hiatus hernia
Maple Grove, MN 55369, USA repair and Nissen fundoplication is similarly fre-
e-mail: [email protected]
quent. However, no other surgical procedures
R. Ganz, M.D., F.A.S.G.E. have been developed to replace fundoplication
Department of Gastroenterology, Abbott
for the surgical management of GERD [1].
Northwestern Hospital, 5705 West Old Shakopee
Road, Bloomington, MN 55437, USA As with many other surgical procedures, over
e-mail: [email protected] time, the operative management for GERD has
S. Leon, M.D. evolved into a minimally invasive approach.
Minnesota Gastroenterology, 5705 West Laparoscopic approach (as compared to the open
Old Shakopee Road, #150, Bloomington, procedures) has resulted in fewer post-operative
MN 55437, USA
complications such as wound infections and
N. Banerji, Ph.D. pneumonia. Hospital length of stay (LOS) has
Neuroscience and Spine Clinical
been reduced to an average of 1–1.5 days.
Service Line, Abbott Northwestern Hospital,
Minneapolis, MN, USA Symptom relief and re-operation rates have
e-mail: [email protected] improved. Additionally, patients have benefited

K.C. Kim (ed.), Robotics in General Surgery, DOI 10.1007/978-1-4614-8739-5_5, 33

© Springer Science+Business Media New York 2014
34 D.H. Dunn et al.

from less post-operative pain and have been able initial management of GERD. It is usually only
to return to work in 1–2 weeks. Short and long- those patients who are resistant to standard medi-
term results have improved, as our understanding cal treatments or escalate to manifestation of
of gastroesophageal reflux has improved [2, 3]. uncontrolled and/or additional symptoms of
Robotic technology has been available for regurgitations, nighttime reflux, cough, or hoarse-
many years but it was not until use of the robot ness are referred to the gastroenterologist. The
for prostatectomy was reported in 1988 that the gastroenterologist usually initiates the diagnostic
robot really had a place in the surgical manage- evaluation protocol for patients who develop
ment of diseases. However, the predominant use severe GERD-related complications or have
of robotic procedure is for urologic operations. uncontrolled or atypical symptoms.
The adoption of this technology by other surgical
specialties has been considerably restricted
because of the relatively narrow operative field Esophagogastroduodenoscopy
required by robotic instrumentation. As a conse-
quence, pelvic anatomy and operative interven- Esophagogastroduodenoscopy (EGD) is usually
tions for pelvic malignancies are ideally suited the first diagnostic procedure performed in the
for robotic technology. Similar limited field of diagnostic work-up for complicated GERD. The
operations are also encountered in esophageal endoscopy gives valuable information regarding
operations and are consequently ideal for the use the anatomy of the esophagus and gastroesopha-
of robotic procedures. Thus, robotic procedures geal junction. The presence and size of hiatus
for hiatus hernia repair, Nissen fundoplication, hernia and presence and degree of esophagitis
Heller myotomy and trans-hiatal esophagectomy can be classified by the Hill and LA grading sys-
with an abdominal approach without thoracos- tems. Barrett’s esophagus can be documented
copy or thoracotomy have been performed safely and strategy for treating or surveillance can be
with reasonable success [4, 5]. established. Long-term risk assessment can be
The robotic surgical procedures described in discussed with the patient. Strictures, eosino-
this chapter were performed with the da Vinci philic esophagitis, Cameron erosions and esoph-
robotic instrument (Intuitive Surgical, Palo Alto, ageal cancer can be diagnosed before beginning a
CA) for management of paraesophageal hiatus long-term approach to treatment.
hernias, giant hernias, and recurrent hiatus her-
nias as well as the more standard anatomy seen
with most patients with gasroesophageal reflux. pH Monitoring
The operations described here are hiatus hernia
repair with and without mesh, Nissen fundoplica- The 48-h pH-monitoring test (Bravo) is used to
tion, partial posterior fundoplication or the 270° obtain objective data regarding the degree of acid
wrap (Toupet) procedure, and the anterior fundo- reflux. Either 24- or 48-h tests can be used; how-
plication of Dor, and Collis gastroplasty. ever, the 48-h test is generally considered more
reliable. The percentage of time of esophageal
acid exposure to pH < 4.0 is recorded as a
Pre-operative Diagnostic DeMeester score (normal <14.72). Patients with
Evaluations high DeMeester scores are considered positive
for significant reflux.
Most patients with GERD undergo a period of pH-monitoring is not used in every patient. In
self-medication with over the counter treatments general, patients with very large hernias or large
for management of typical symptoms of heart- paraesophageal hernias may be considered oper-
burn or regurgitation for many years, before they ative candidates whether or not they had signifi-
present themselves to their primary physician. cant GERD or abnormal Bravo tests. Likewise
Primary care physicians are well versed in the pH-monitoring is not used in patients with known
5 Robotic Assisted Operations for Gastroesophageal Reflux 35

Fig. 5.1 High-resolution manometry of a typical patient with GERD showing normal esophageal motility and
decreased lower esophageal sphincter pressure

Barrett’s esophagus. pH-monitoring is particu- abnormal findings on endoscopy such as a dilated

larly helpful in making a diagnosis of gastro- esophagus, stricture or esophageal diverticulum,
esophageal reflux in patients with atypical manometry is critical. A typical picture of a low
symptoms or patients who do not respond to resting mean pressure of the lower esophageal
medical management. sphincter and normal esophageal motility is usu-
pH-monitoring using multichannel intralumi- ally observed in most of patients with typical
nal impedence-ph (MII-pH) monitoring has GERD symptoms (Fig. 5.1).
gained acceptance in several GI laboratories [6]. Preferably, a team of gastroenterologists with
The MII-pH monitoring can distinguish non-acid a special interest in GERD should evaluate the
as well as acid reflux thereby facilitating correla- outcomes of these studies.
tion of the reflux episodes with symptoms. Most In our clinical experience, a group of patients
GI laboratories choose one method and use that thought to have a clear diagnosis of GERD was
method exclusively. At our Institution the pre- confirmed to have achalasia on manometry, with
ferred diagnostic procedure of gastroenterolo- high-resolution manometry (HRM) showing typ-
gists is the Bravo pH monitoring test. ical pictures of failed swallows, low peristaltic
pressures, or no peristalsis (Fig. 5.2).
One particular patient had been treated for
Manometry GERD for many years, had done reasonably well
on PPI’s, and had a very large paraesophageal
Esophageal manometry is used to determine hiatus hernia with 70 % of her stomach in the
esophageal motor function as well as lower esoph- chest. She had regurgitation as a predominant
ageal sphincter pressure and relaxation with symptom along with heartburn. A diagnostic
swallowing. Manometry is used in most patients EGD procedure indicated esophagitis. However,
with typical symptoms of heartburn. In patients with review of the HRM was indicative of a combina-
dysphagia, regurgitation, atypical symptoms or tion of type II and III achalasia. Based on the
36 D.H. Dunn et al.

Fig. 5.2 High-resolution manometry of typical patient with Classic Achalasia showing poor to no peristalsis, the com-
mon cavity affects and high resting lower esophageal sphincter pressure without relaxation

manometry results, this patient was treated for performed laparoscopically. In addition, the room
achalasia with a Heller myotomy and Dor time (defined as “time in to time out”) is signifi-
fundoplication. cantly longer with the robotic procedure. In our
If patients have significant esophageal dys- experience, there exists a learning curve for sur-
motility on HRM and symptoms of dysphagia geons, and the room time as well as operative time
without anatomic obstruction, in our practice we decreases as the operative team gains experience.
selectively use this information to perform a par- The pre-operative time, i.e. time from a patient
tial 270° fundoplication (Toupet procedure) entering the room to incision time, makes up most
(Fig. 5.3). A loose wrap may function just as well of the extra time for the robotic procedure.
for these patients since a partial wrap has been The operating table needs to be turned away from
shown to be as durable as a loose full wrap in the anesthesiologist and the logistics of tube and
several studies [7–9]. monitoring placement is time consuming. It is best
to have an anesthesia team during the initial period
of implementation of these procedures, as the set
Operative Procedure up for esophageal surgery is different from robotic
pelvic operations. The docking time from first
There is an obvious difference in the operative incision to the surgeon beginning on the console
time required for patients undergoing robotic- decreases with experience. In our experience, fol-
assisted procedures vs. laparoscopic procedures lowing the first 10–15 cases the docking time sta-
for management of gastroesophageal reflux with bilizes in the range of 10–15 min.
robotic surgery requiring a longer time for For experienced laparoscopic surgeons who
completion in comparison to the same procedures perform anti-reflux operations frequently the
5 Robotic Assisted Operations for Gastroesophageal Reflux 37

Fig. 5.3 High-resolution manometry of patient with GERD showing poor esophageal motility with hiatus hernia and
low lower esophageal sphincter pressure

adjustment to using robotic technology is not port placement is different from the laparoscopic
challenging. Surgeons should be well versed in procedure. Placement of the camera port is crit-
laparoscopic fundoplication procedures before ical. The typical position of 12 cm caudad and
performing robotic assisted fundoplications. 2 cm to the patient’s left of the xiiphoid for
A robotic general surgeon experienced with anti- women or small men and 15 cm caudad and 2
reflux operations should proctor the first robotic cm to the left for large women or men does not
case. Each robotic program must determine the always function efficiently. The body habitus is
credentialing criteria for privileging surgeons for important and with experience the distance
these procedures. If possible, the first several cases from the xiphoid to the camera port becomes
should be performed with an experienced laparo- shorter. This distance is especially important
scopic surgeon as an assistant. After the surgeon for patients with large hiatus hernias because
and operating room team have gained experience, of the mediastinal dissection needed to reduce
the procedure can be performed assisted by surgi- the contents of the hernia sac. The position of
cal technologists, residents, or physician assis- the robotic arms is determined by the position
tants. As mentioned previously, operative time of the camera port. This distance is constant,
decreases with experience. The learning curve for again demonstrating the importance of the first
using the robotic technology is in the first 10–15 trocar placement for the camera. The 8 mm tro-
cases for experienced laparoscopic surgeons. cars for the arms of the robot are placed 4 cm
The operation begins with the laparoscopic cephalad to the 12 mm camera port and 8 cm to
placement of the ports. The configuration of the either side of the camera port.
38 D.H. Dunn et al.

Fig. 5.4 Dissection of the

hiatus in-patient with GERD
and moderate hiatus hernia

The liver retractor port is placed at a conve- arteries are taken down to mobilize the greater
nient position beneath the right costal margin. We curvature of the stomach for a Nissen fundoplica-
use a standard liver retractor from this position; tion. The number of short gastrics taken depends
however, a Nathanson retractor can be used in a on the amount of fundus needed for the wrap or if
sub-xiphoid position. The last port is placed in a a Collis gastroplasty is indicated. The harmonic
convenient left lateral subcostal position. This scalpel is used for all of the dissection including
port is used by the assistant for retraction and the mediastinum, mobilization of the esophagus
passing needles as well as for the stapler for and takedown of short gastric arteries.
patients who are having a Collis gastroplasty. The next step is taking the gastroesophageal
Once all the ports and the liver retractor are fat pad and separation of the anterior vagus nerve
placed, the robot is brought into the field. The from the esophagus and GE junction (Fig. 5.5).
patient is placed into a reverse Trendelenburg Removing the fat pad clears the distal esoph-
position and the camera port and two robotic agus and cardia of excess tissue, which might
arms are attached to the appropriate trocars. In interfere with an exact placement of the wrap,
our surgical practice, we do not routinely use the but more importantly with this procedure the
third arm of the robot. The operating surgeon GE junction can be better visualized. As the
then goes to the console and initiates the robotic anterior vagus is preserved after it is mobilized
part of the operation. from the esophagus with the GEJ fat pad the
Dissection of the hiatus with the robot is simi- wrap can be brought underneath the vagus and
lar to a laparoscopic approach. The advantage of this sling can serve to hold the wrap in place so
robotic technology is that the camera can be posi- that it does not slip (Fig. 5.6). The hiatus is then
tioned and secured in place by the operator. If nec- repaired with primary closure of figure of eight
essary, the camera can literally be placed through stitches with pledgets for reinforcement, if nec-
the hiatus to gain better visualization for large essary (Fig. 5.7).
paraesophageal hernias. This placement is impor- Bridging grafts, whether biologic or synthetic
tant for maximum mobilization of the esophagus have a high failure rate and multiple complica-
in the mediastinum, so that an adequate length of tions associated with their use. Most of the time,
esophagus, usually 3 cm below the diaphragm, a primary closure is possible. We use an onlay
can be obtained for the wrap (Fig. 5.4). graft only if the closure needs reinforcement with
Once the hiatus is dissected and the esophagus GoreTex suture and U clips (Fig. 5.8a, b).
circumferentially mobilized preserving the ante- Following repair of the hiatus, the esophagus
rior and posterior vagus nerves, the short gastric is examined to determine if a standard Nissen
5 Robotic Assisted Operations for Gastroesophageal Reflux 39

Fig. 5.5 Dissection of the

Anterior Vagus Nerve
showing the development
of a sling, which will hold
the fundoplication in place

Fig. 5.6 Takedown of the

gastroesophageal fat pad to
clearly identify the
junction of the longitudinal
esophageal muscle and the
serosa of the stomach

Fig. 5.7 Primary closure

of the hiatus with figure of
8 suturing, without use of
onlay or pledgets as
reinforcement
40 D.H. Dunn et al.

Fig. 5.8 (a and b) Hiatus

Hernia repair with primary
closure and reinforcement
with an onlay Gore-Tex
graft

fundoplication can be performed. If the esopha- different from the full wrap until the actual sutur-
gus can be brought down to at least 3 cm below ing of the wrap. The reduction and repair of her-
the diaphragmatic hiatus without tension, a 3 nia as well as mobilization of the esophagus and
stitch Nissen fundoplication over a 50–56 fr. dila- greater curvature of the stomach are all similar to
tor is performed. We often will tack the wrap to the standard Nissen fundoplication. In the Toupet
the diaphragm at the end of the procedure procedure, the fundus is brought around behind
(Figs. 5.9, 5.10, and 5.11). The robot is then the esophagus and sutured with three stitches to
undocked and the liver retractor removed, fol- the esophagus at 10 o’clock position. Left side of
lowed by evacuation of the pneumoperitoneum the fundic wrap is sutured to 2 o’clock position
and incision closure. on the esophagus. This leaves the anterior esoph-
agus open and approximately 270° of the poste-
rior esophagus wrapped (Figs. 5.12 and 5.13).
Partial Fundoplication
(The Toupet Procedure)
Dor (Anterior) Fundoplication
The principal indications for our patients under-
going a 270° fundoplication (or the Toupet pro- We have had minimal experience in using the
cedure) were dysphagia or esophageal dysmotility anterior fundoplication i.e. the Dor fundoplica-
diagnosed on HRM. Partial fundoplication is no tion for patients having GERD as their indication
5 Robotic Assisted Operations for Gastroesophageal Reflux 41

Fig. 5.9 Mobilizing the

fundus and bringing it
around the back of the
esophagus under vagus
nerve sling and mobilized
gastroesophageal fat pad

Fig. 5.10 Preparing the

fundoplication for suturing
to the esophagus

Fig. 5.11 Completed 360°

Nissen fundoplication
42 D.H. Dunn et al.

Fig. 5.12 270° fundopli-

cation for patients with
esophageal dysmotility or
patients who refuse a 360°
fundoplication because of
unwanted side effects

Fig. 5.13 Toupet, the

270° fundoplication

for operation. We have used the anterior fundo- Collis Gastroplasty

plication almost exclusively for patients with
achalasia. The Dor fundolplication has been an Our surgical practice has used the Collis gastro-
effective procedure for the reduction of symp- plasty procedure for the past 3 years almost
tomatic GERD following esophageal myotomy. exclusively for the management of patients with
The Dor fundoplication has been suggested as an large paraesophageal hiatus hernia or giant slid-
alternative for a full Nissen fundoplication ing hernia with foreshortened esophagus. The
(Figs. 5.14 and 5.15). esophagus is mobilized as much as possible and
Several studies have shown similar results the hiatus is closed. The gastroesophageal junc-
comparing an anterior wrap to a 360° wrap, tion must be at least 3 cm below the diaphragm
with fewer side effects for the anterior fundo- without tension; otherwise a Collis gastroplasty
plication in comparison to the full fundoplica- is performed. This is especially important in
tion [10]. patients with a BMI > 35. To perform the Collis, a
5 Robotic Assisted Operations for Gastroesophageal Reflux 43

Fig. 5.14 Anterior 180°

fundoplication or Dor
fundoplication. For this
case the anterior fundopli-
cation was performed with
a Heller myotomy

Fig. 5.15 Completed 180°

anterior fundoplication

second surgeon, surgical resident, or physician date the stapler. The amount of cardia removed
assistant is required because the procedure depends on the anatomy. A relatively small
requires stapling of the cardia of the stomach. A wedge of cardia can be removed and accomplish
wedge resection of the cardia using one of the the lengthening procedure.
GIA stapling devices is used to lengthen the The first two staple lines are directed at the
esophagus (Fig. 5.16a). dilator that is positioned nest to the lesser curva-
A 46–50 fr. dilator is placed into the esopha- ture of the stomach (Fig. 5.17). The third staple
gus to prevent narrowing of the “neo-esophagus” line is parallel to the esophagus and held against
(Fig. 5.16b). the dilator (Fig. 5.18a, b). After the wedge resec-
We have used the Echelon stapler with a green tion is performed (Fig. 5.19), the remaining fun-
load of both 60 and 45 mm. In our experience, the dus is wrapped around the neo-esophagus
45 mm is much easier to manipulate in the upper (Figs. 5.20 and 5.21). A Nissen fundoplication is
abdomen. It is used through the assistant’s port in then performed which allows a tension free wrap
the lateral upper abdomen. The standard 8 mm with reduced chance for recurrence due to hernia-
trocar is changed to a 12 mm trocar to accommo- tion or a slipped Nissen (Fig. 5.22).
44 D.H. Dunn et al.

Fig. 5.16 Collis Gastroplasty—Photographs and corre- and prevent undue cephalad tension on the fundoplication.
sponding illustrations of resecting a wedge of the gastric car- (a and b) Illustration of the first cut across the gastric cardia
dia and creating a neo-esophagus to lengthen the esophagus in the beginning of the lengthening of the esophagus

Fig. 5.17 Collis Gastroplasty—Photographs and corre- tion. The “second cut” using an Echelon 45 mm green load
sponding illustrations of resecting a wedge of the gastric to create a neo-esophagus. Illustration showing the “second
cardia and creating a neo-esophagus to lengthen the esoph- cut” ending at the point where the stapler is at the edge of
agus and prevent undue cephalad tension on the fundoplica- the dilator to prevent narrowing of the Neo-esophagus

Re-operative Robotic Procedures for these re-operative procedures that need to be

Recurrent Gastroesophageal Reflux, emphasized.
Recurrent Hiatus Hernia, It is prudent to note that tactile sensation is not
Incarcerated Hiatus Hernia possible with the robot. Haptic memory allows
and Esophageal Dysmotility surgeons to successfully tie knots with the robot
without being able to feel the tension. Surgeons
Re-operative procedures for recurrent hiatus her- can experience what it feels like when the knot or
nia can be challenging. For a majority of cases, suture is tight, thereby allowing them to keep the
these procedures can be performed using robotic suture intact. This also allows them to gauge
technology. There are some important aspects of how much pressure or pull they can exert while
5 Robotic Assisted Operations for Gastroesophageal Reflux 45

Fig. 5.18 Collis Gastroplasty—Photographs and corre- Echelon 45 mm green load to finish the creation of the
sponding illustrations of resecting a wedge of the gastric neo-esophagus. Accompanying illustration showing the
cardia and creating a neo-esophagus to lengthen the completed segmental resection of a portion of the cardia
esophagus and prevent undue cephalad tension on the of the stomach leaving the remaining fundus for the
fundoplication. (a and b) The “third cut” using an fundoplication

Fig. 5.19 Collis

Gastroplasty—Photographs
and corresponding illustra-
tions of resecting a wedge of
the gastric cardia and creating
a neo-esophagus to lengthen
the esophagus and prevent
undue cephalad tension on
the fundoplication.
Completed wedge resection
for esophageal lengthening
with illustration

Fig. 5.20 Collis

Gastroplasty—Photographs
and corresponding illustra-
tions of resecting a wedge of
the gastric cardia and creating
a neo-esophagus to lengthen
the esophagus and prevent
undue cephalad tension on
the fundoplication. Bringing
the fundus around the
esophagus and under the
anterior vagus nerve after the
segmental gastric resection
46 D.H. Dunn et al.

Fig. 5.21 Collis

Gastroplasty—Photographs
and corresponding illustra-
tions of resecting a wedge of
the gastric cardia and creating
a neo-esophagus to lengthen
the esophagus and prevent
undue cephalad tension on
the fundoplication. Bringing
the right and left portions of
the fundus in apposition for
finishing the fundoplication

Fig. 5.22 Collis

Gastroplasty—Photographs
and corresponding illustra-
tions of resecting a wedge of
the gastric cardia and creating
a neo-esophagus to lengthen
the esophagus and prevent
undue cephalad tension on
the fundoplication. Final
stitch of Collis gastroplasty
and 3 stitch Nissen
fundoplication

dissecting tissue. The challenge with re-operative and a gastric bypass performed in the standard
robotic surgery is that during a repeat procedure fashion. Since short gastrics are usually taken
surgeons are not able to assess the tensile strength with a Nissen fundoplication, care must be taken
of the structures that they are dissecting. to preserve the left gastric branches to the fun-
Therefore, it is much more likely to tear tissue dus. If gastric bypass is not an option or the
during a re-operation. If the wrap has migrated recurrent symptoms are of an obstructive nature,
into the chest through the hiatus, dissection can then reoperations should include a Collis gastro-
be extremely difficult and the ability to have tac- plasty, even if it appears that there is minimal
tile sensation may be more important than bene- tension on the esophagus after hernia reduction
fits of the robot (Fig. 5.23). In these instances, a and repair.
laparoscopic approach might be preferred. Patients, who have unremitting dysphagia
Obese patients (BMI > 35) who have recur- following Nissen fundoplicaton and manifest
rence should be considered for gastric bypass. In preoperatively unrecognized esophageal dysmotil-
this situation the Nissen or Toupet is taken down ity, should have a takedown of the Nissen. For a redo
5 Robotic Assisted Operations for Gastroesophageal Reflux 47

Fig. 5.23 Re-do hiatus

hernia repair and takedown
of Nissen fundoplication
showing posterior vagus
nerve, aorta and right and
left crus

of this type, use of the robot is particularly management in the general surgery program of
advantageous because of the precise nature of Abbott Northwestern Hospital (ANW) using the
dissection of the wrap as well as importance da Vinci Computer-Enhanced Robotic Surgical
of adequate visualization (Figs. 5.24 and 5.25). System (Table 5.1). Patients presenting with
The same procedure should be performed for recurrent hiatus hernias, large sliding hiatus her-
a Nissen that is too tight. Attempting to loosen nias, paraesophageal hiatus hernias and patients
the Nissen in this situation has the risk of still with recurrent hiatus hernia or other complica-
being too taut after the second operation. tions of previous hiatus hernia repairs are
Therefore a partial fundoplication is a more rea- included in this cohort. Mean age of the patients
sonable approach in these instances (Fig. 5.26). was 51.61 ± 14.67 years (median 52; range
The ability to visualize anatomy with high 19–86) and average pre-operative BMI was
definition optics used with robotic technology 30.40 ± 5.16 (median 30; range 20–47).
and articulated instruments for dissection in the A majority of the patients were referred from
chest is a definite advantage over the standard Minnesota Gastroenterology (MNGI) group. Prior
laparoscopic technology (Fig. 5.27). to the first visit with the surgeons, patients were
These operations are often tedious and time evaluated in a gastroenterology clinic for esopha-
consuming compared to a standard Nissen. In our geal disorders. Ninety-five percent of patients was
opinion, the benefits of improved ergonomics of evaluated by a gastroenterologist. Diagnostic
the robotic console cannot be matched with lapa- work-up included EGD, Bravo (48 h pH probe),
roscopic techniques (Fig. 5.28). high-resolution manometry (HRM) and UGI
X-rays. Patient response to medical therapy was
noted. All patients with heartburn as their major
Outcomes of Robotic Assisted symptom had failed medical management.
Operations for Gerd at Abbott For further outcome evaluations, patients were
Northwestern Hospital separated into two groups, namely, (a) patients
with symptomatic GERD diagnosed with large
Over a 4 year period from June 2007 to December (paraesophageal or sliding) hernias (n = 70) and
2011 175 patients, with 59 (33.72 %) men and (b) patients with symptomatic GERD with small
116 (66.28 %) women, have undergone robotic- or no evident hernias (n = 105) (Table 5.1).
assisted operations for symptomatic GERD Eighty-one percent of patients who had small
48 D.H. Dunn et al.

Fig. 5.24 Dehisced

Nissen fundoplication

Fig. 5.25 Takedown of

dehisced Nissen
fundoplication

Fig. 5.26 Re-do Nissen

fundoplicaton unwrapped
5 Robotic Assisted Operations for Gastroesophageal Reflux 49

Fig. 5.27 Left and right

diaphragmatic crura, aorta
before re-do hiatus hernia
repair and re-do Nissen
fundoplication

Fig. 5.28 Re-do Hiatus

hernia repair

hernias or no hernias had typical symptoms of In our case series, 91.4 % of patients with
heartburn, regurgitation or aspiration. Patients large hernias or paraesophageal hernias had a
with paraesophageal or large sliding hernias were BMI > 30 and 57.1 % had BMI > 35. In compari-
more likely to have atypical symptoms with son, 52.4 % of patients with small hernias had a
44.3 % presenting with cough, recurrent aspira- BMI > 30 and 18.1 % had BMI > 35 (Table 5.1).
tion, sore throat, hoarseness, dysphagia or sub- Early in our experience we did not have a limit on
sternal chest pain. In this group, typical symptoms the BMI for patients undergoing an anti-reflux
were present in 32.8 % cases. Presenting symp- procedure. It is apparent from our data and other
tom information was not available for 22.9 % published reports that the operative time, rate of
GERD patients with large hernias and 3.8 % hiatus hernia recurrence, and reoperations is
GERD patients with small hernias (Table 5.1). increased in those patients with BMI > 35 [10].
50 D.H. Dunn et al.

Table 5.1 Characteristics and presenting symptoms for Table 5.2 Surgical outcomes in 175 patients
175 patients undergoing robotic-GERD management
Large hiatal Small hiatal
procedures
hernias (n = 70) hernias (n = 105)
Small hiatal Room time (mins)a 188 ± 70 190 ± 58
Large hiatal hernias
Operative time 135 ± 42 120 ± 54
hernias (n = 70) (n = 105)
(mins)b
Age (years) 56 ± 24 49 ± 26 Mesh repairs 16 (22.9 %) 29 (27.6 %)
Pre-operative BMI
Median EBL (range) 34 (10–150) 30 (10–100)
<30 6 (8.6 %) 50 (47.6 %) (ml)
30–35 24 (34.3 %) 36 (34.3 %) Collis gastroplasty 18 (25.7 %) 8 (7.6 %)
>35 40 (57.1 %) 19 (18.1 %) Conversion to open 1 (1.4 %) 2 (1.9 %)
Pre-operative PPI 32 (45.7 %) 92 (87.6 %) Transfusions 0 0
therapy
LOS (days) 2.4 ± 0.9 1.9 ± 0.5
Presenting symptoms
Reoperations 3 (4.3 %) 11 (10.5 %)
Typical symptomsa 23 (32.8 %) 85 (81.0 %)
30-day symptom 64 (91.4 %) 90 (81.7 %)
Atypical symptomsb 31 (44.3 %) 16 (15.2 %)
reduction
Undeterminedc 16 (22.9 %) 4 (3.8 %)
30-day symptom 59 (84.3 %) 82 (78.1 %)
a
Typical symptoms included are heartburn, regurgitation, relief
sore throat, nighttime regurgitation and aspiration
b EBL estimated blood loss, LOS length of stay
Atypical symptoms are cough, chest pain, esophageal a
Room time is defined as time from patient entering the
spasm, dysphagia and bronchospasm
c room until the time when the patient leaves the room
Presenting symptoms were not documented for 20 b
Operating time is from first incision to all incisions
patients
closed at the end of the procedure. It includes “docking
time, time on the DaVinci console, undocking, and clos-
ing incisions”

These patients are generally referred for gastric (unpaired t-test, p = 0.84) or operative times
bypass or asked to lose weight to attain a (unpaired t-test, p = 0.05) (Table 5.2).
BMI < 35. Patients with large hernias or parae- We found that there were other factors that
sophageal hernias are more likely to have lengthened the operative time. Patients with BMI
BMI > 35 than those patients whose primary > 35 had a longer mean operative time at 146 min
symptom is heartburn. compared to 120 min for patients with BMI < 30.
Operative time was defined as time from inci- Presence of large hiatus hernias and paraesopha-
sion to skin closure and room time was measured geal hernias, which included more involved hia-
from time when a patient entered the room to he/ tus hernia repairs often times with, mesh
she leaving the room. The room time included increased mean operative time by 37 min. All re-
anesthesia time, which is invariably longer than operations were associated with increased opera-
the anesthesia time for laparoscopic operations tive times. In this group, there was a wide
for GERD. The patient must be turned, which variation in the range of operative times depend-
puts anesthesiologists at the foot of the bed. The ing on the number of recurrences and type of pro-
ventilator tubing must be stretched and secured cedure done for the previous operation(s).
the length of the patient. An arterial line is fre- In the two groups of patients presenting with
quently used because of the difficulty in monitor- large and small hernias, mesh repairs were per-
ing the patient in this position. The operative time formed in 22.9 % (n = 16) and 27.6 % (n = 29),
also includes the docking time, which is the time respectively (Table 5.2). The repair of the dia-
needed for placing the robotic ports and docking phragmatic hiatus is controversial and without
the robot. In our experience, the room time and any strong evidence to recommend a standard
operative time between patient with large and approach. With any hiatus dissection, even with-
small hernias were comparable with no statisti- out a hiatus hernia, the takedown of the phreno-
cally significant difference between room times esophageal attachments will unavoidably disrupt
5 Robotic Assisted Operations for Gastroesophageal Reflux 51

the hiatal opening. This can be repaired with death in an elderly patient with a prolonged
primary closure without mesh or reinforcing operation for a large paraesophageal hiatus
synthetic pledgets. However, several surgery- hernia. On post-operative day 1, the patient had
based repair approaches have been recommended a cardiac event from which he did not recover.
when the hiatus hernia is large and the hiatus One patient had DVT, which required heparin-
dilated. While these recommendations are not ization but no pulmonary complications were
specific for patients operated on with robotic evident.
technology, the repair of the hiatus with place- In our patient population, robotic assisted
ment of sutures can be much more precise in our anti-reflux procedures did not decrease the hospi-
experience. We utilize figure of eight sutures with tal length of stay (LOS) compared to laparo-
reinforcing pledgets as our preferred method. scopic anti-reflux procedures. Patients undergoing
Additionally, if the closure is tenuous we recom- laparoscopic Nissen fundoplication and hiatus
mend the use onlay biologics or goretex. Grafts hernia repair had a mean LOS of 1.1 days [13].
that bridge the gap in the hiatus have not worked The longer stay with the robotic procedures was
well in our experience. due in part to the gradually increasing co-
Total estimated blood loss for the procedures morbidities of our more recent patients and the
was in an acceptable range for our cohort of 175 increase in the numbers of patient with large her-
patients (Table 5.2). nias and paraesophageal hernias. The mean LOS
Eighteen patients with large paraesophageal for individuals undergoing Nissen procedures
hiatal hernias at presentation were treated with without a paraesophageal hiatus hernia repair
Collis gastroplasty. A review of data indicated that was 1.9 days whereas Nissens with a paraesopha-
increased use of Collis gastroplasty resulted in an geal hiatus hernia repair had a mean LOS of 2.4
improvement of outcomes for our patients with days (Table 5.2). Interestingly, a statistically sig-
large paraesophageal hiatus hernia and foreshort- nificant difference was noted in the LOS between
ened esophagus. While there are several who GERD patients with large (paraesophageal or
espouse negligible need for performing such sliding) hernias as compared to patient with small
esophageal lengthening procedures, there is little or no hernias (unpaired t-test; p < 0.0001).
doubt that Collis gastroplasty in selected patients Fourteen (8.0 %) patients required reopera-
reduces the incidence of recurrent hiatus hernia tions and all reoperations were performed with
[11, 12]. Collis gastroplasty has significantly the robotic technology (Table 5.2). Three patients
reduced the re-operation rate and hiatus recur- who had paraesophageal hernias developed
rence rate for our patients undergoing anti-reflux recurrent hernias and became symptomatic. Of
procedures. We routinely use Collis gastroplasty the 11 remaining reoperations (for patients with
for re-do Nissen fundoplication with the assump- small hernias), two required reoperations within
tion that recurrent symptoms following anti-reflux the first week after their first procedure. One
operations is largely due to recurrent hernias patient, with a BMI > 35, had immediate incar-
resulting from undue tension at the diaphragmatic ceration and obstruction of the fundoplication
hiatus. Of the 26 combined fundoplication and through the hiatus within 5 days of operation.
Collis gastroplasty operations we have performed, A second patient was readmitted to the hospital
there has been only one recurrent hernia. for unrelenting chest pain and dysphagia 7 days
There were no major intra-operative compli- following operation and a takedown of the fundo-
cations related exclusively to the use of the robot plication was required. Another fundoplication
or to the changes in the position of the anesthe- was not performed and the hiatus hernia repair
siologist relative to the patient as well as any of was left intact.
the monitoring equipment. Three patients had to There were six patients who underwent reopera-
be converted to open procedures for difficult tion for symptomatic reflux and/or recurrent hernia
exposure or dissection (Table 5.2). There was within 2–10 months of their first operation. Of these
one post-operative death. This was a cardiac patients, two had significant esophageal dysmotility
52 D.H. Dunn et al.

that was either unrecognized preoperatively or day. The hospital stay may be extended to 2 days
the severity of the condition underestimated. Of the for elderly patients or patients with significant
recurrent hernias, one individual had mesh repair co-morbidities. Patients having more extensive
and Nissen fundoplication, four patients had operations such as large paraesophageal hernias
primary hiatus hernia repair and Nissen fundopli- or upside-down stomachs in the chest may require
cation, and one patient had a primary hiatus hernia additional days in the hospital.
repair with a Collis gastroplasty. Six of the ten Generally, laparoscopic equipments are rela-
patients who had recurrent hernia as an indication tively sturdy, inexpensive and re-usable. The
for reoperation had BMI > 35. instruments are adaptable to a multitude of differ-
Early symptomatic relief was achieved in ent laparoscopic procedures and the same cam-
80.6 % (141 of 175) of our patients. Long-term eras can be utilized in all laparoscopic operations.
relief and need for continued PPIs and other In other words, laparoscopy is a relatively eco-
reflux medications is currently being evaluated. nomical way to perform a variety of general sur-
The patients who had regurgitation or atypical gical procedures including fundoplication. This
symptoms such as cough, sore throat or hoarse- raises the question, why should we use robotic
ness had slightly better symptomatic relief than technology for operations performed effectively
those who had mostly heartburn as their main with laparoscopic techniques?
symptom. Patients who had large symptomatic Robotic technology was first put to use in
hernias either paraesophageal or sliding type her- operations for prostate cancer. For this oncologic
nias also had improvement in some of the less operation, robotic-procedures have proven
well defined symptoms of chest discomfort, chest advantages over open procedures with less opera-
pain, chest pressure and dysphagia. tive blood loss, easier post-operative recovery,
less post-operative pain, comparable oncological
parameters, and decreased LOS [16]. Within a
Discussion relatively short period of time robotic prostatec-
tomy has become the standard for surgical man-
Laparoscopic fundoplication is considered the agement of prostate cancer. Currently, ~75 % of
gold standard surgical management option for patients having operative procedures performed
GERD [14]. It is an operation, which in experi- for management of prostate cancer undergo
enced hands has a negligible mortality, very low robotic assisted prostatectomy. This has been a
operative morbidity, and excellent short-term major change in practice for urologists who have
results [15]. However, discouraging long-term traditionally performed most procedures with
(>5 year) outcomes have prevented gastroenter- open techniques. Accepting and adapting to
ologists from recommending fundoplications robotic procedures was daunting for most and the
solely for (a) patients with intolerable symptoms early results indicated that the adaptation to a
or paraesophageal hernias which may be causing minimally invasive approach resulted in a signifi-
obstructive symptoms, (b) patients bleeding from cant number of complications. The learning
Cameron erosions, or (c) those who might be curve for robotic prostatectomy was steep. The
having episodes of torsion of the herniated stom- early results suggested that surgeons should be
ach. Patients whose main symptoms are related proctored for at least ten cases and a high level of
to regurgitation are not helped by medical man- proficiency was reached only at completion of
agement and thus present to operative interven- ~50 procedures. Nevertheless, at present time,
tion more often because of lack of alternative most surgeons consider robotic assisted prosta-
medical management options. Fundoplication is tectomy as a major advance in patient care.
very effective for the management of patients The adoption of robotic technology by the
with regurgitation. gynecological specialty has been a considerably
The average length of stay in the hospital for simpler and safer process for patients and the
patients having laparoscopic fundoplication is 1 transition from laparoscopic to robotic techniques
5 Robotic Assisted Operations for Gastroesophageal Reflux 53

in gynecology has proven to be remarkably The ergonomics of performing these operations,

straightforward. The learning curve for gynecol- especially with difficult paraesophageal hiatus
ogists using robotic technology has not been as hernia repairs, is ideal. The arms are at rest at the
steep and the number of cases to gain proficiency surgeon’s side with minimal movement. The
has been fewer. Consequently, gynecologic oper- shoulders are in a natural position without any
ations for benign disease have now overtaken the strain. The head is positioned on a cushion with
lead in numbers of patients having robotic- comfortable viewing ports for the camera. Much
assisted operations. The operative blood loss, of the positioning of camera and instruments and
improved oncologic parameters, post-op pain, all of the energy usage is accomplished with the
LOS and overall easier recovery have caused surgeon’s feet. Essentially, at the end of the day,
many gynecologic oncologists to adopt robotic the mere ergonomic advantages of operating with
technology [2]. the robot can make it worthwhile even without
Other surgical specialties notably cardiovas- the other obvious benefits, such as better visual-
cular, pediatric urology and thoracic surgery have ization and more precise dissecting and suturing.
had increasing numbers of cases and surgeons Robotic surgery is not for the casual user.
performing their operations robotically. Again, It requires frequent usage, as do more compli-
for many of these specialties the transition from cated operations, no matter how they are per-
open procedures to robotic was accompanied by formed. Recent discussions of the detrimental
a steep learning curve due to the lack of prior musculoskeletal and visual effects that are a
exposure to the use of laparoscopic technology. result of poor ergonomic positioning and tech-
During the initial period of adoption of robotic niques for laparoscopic general surgical proce-
technology, with the steep learning curve came dures require a serious look at the present state of
increased morbidity for the patients. Robotic laparoscopic surgery [18]. Surgeons who are
assisted operations for general gastro-esophageal considering devoting a major portion of their
management procedures have not increased as operative time in performing laparoscopic proce-
one might expect for procedures such as fundo- dures should consider robotic technology for
plication, Heller myotomy, trans-hiatal esopha- these same operations.
gectomy and low-anterior resection or abdominal The cost of developing a robotic program is
perineal resection [2, 17]. The lack of interest in significant for any hospital system. There is no
performing robotic assisted operations could be doubt that robotic technology is necessary for a
due to many factors. The learning curve is thought well-developed prostate cancer program. It is
to be quite steep. In actuality, for an experienced also necessary for a cutting edge gynecologic
laparoscopic surgeon, robotic assisted operations oncology program and by patient demand it is
are not difficult to learn and are somewhat easier becoming quite necessary for benign gyneco-
to perform than the same laparoscopic operation. logic procedures. The new robotic assisted opera-
The surgeon is supported in the operative process tions for head and neck cancers, especially those
by high definition optics and the three- procedures performed for tonsillar cancers and
dimensional vision in the robotic technology, posterior pharynx and tongue cancers, has
which provides better visualization than laparo- allowed patients to avoid the more disfiguring
scopic technology. Suturing with complete dex- operations traditionally performed by head and
terity is very similar to that for an open operation neck surgeons. This leaves general surgeons with
that is impossible to duplicate with the commonly little of the burden of justifying the cost of a
used endo-stitch. During laparoscopic proce- robotic general surgical program. The short-term
dures, it is difficult for many surgeons to utilize results for the patients in our series are similar to
laparoscopic needle drivers. Very few surgeons our experience with the laparoscopic approach.
have completely mastered this technique. The long-term results are unknown at this time.
The other advantage of robotic surgical- Perhaps the benefits for the surgeon mentioned
procedures is from an ergonomic viewpoint. above will be bolstered by a lower hiatus hernia
54 D.H. Dunn et al.

recurrence rate, fewer patients on anti-reflux 6. Vela MF, Camacho-Lobato L, Srinivasan R, Tutuian
R, Katz PO, Castell DO. Simultaneous intraesopha-
medications and result in fewer ergonomically
geal impedance and pH measurement of acid and non-
caused injuries for the surgeon. acid gastroesophageal reflux: effect of omeprazole.
Gastroenterology. 2001;120(7):1599–606.
7. Hafez J, Wrba F, Lenglinger J, Miholic J.
Fundoplication for gastroesophageal reflux and fac-
Conclusion tors associated with the outcome 6 to 10 years after
the operation: multivariate analysis of prognostic fac-
Robotic technology has become essential for the tors using the propensity score. Surg Endosc.
performance of complicated minimally invasive 2008;22(8):1763–68.
8. Shaw JM, Bornman PC, Callanan MD, Beckingham
operations for many surgical specialties. The
IJ, Metz DC. Long-term outcome of laparoscopic
technology will find its place in the operative Nissen and laparoscopic Toupet fundoplication for
armamentarium of many more specialties and gastroesophageal reflux disease: a prospective, ran-
surgeons. The role of robotic technology for gen- domized trial. Surg Endosc. 2010;24(4):924–32.
9. Varin O, Velstra B, De Sutter S, Ceelen W. Total vs.
eral surgeons is yet to be defined but the advances
partial fundoplication in the treatment of gastroesoph-
that have been made and some of the newer pro- ageal reflux disease: a meta-analysis. Arch Surg.
cedures performed such as single port cholecys- 2009;144(3):273–78.
tectomy portend a bright future for the robotic 10. Raue W, Ordemann J, Jacobi CA, Menenakos C,
Buchholz A, Hartmann J. Nissen versus Dor fundopli-
technology.
cation for treatment of gastroesophageal reflux dis-
ease: a blinded randomized clinical trial. Dig Surg.
Acknowledgment The authors are grateful to Gary 2011;28(1):80–6.
Edelburg for procuring images incorporated in this 11. Whitson BA, Hoang CD, Boettcher AK, Dahlberg PS,
chapter. Andrade RS, Maddaus MA. Wedge gastroplasty and
reinforced crural repair: important components of
laparoscopic giant or recurrent hiatal hernia repair.
J Thorac Cardiovasc Surg. 2006;132(5):1196–202.
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Sheppard BC, Mitsumori L, Rohrmann C, Swanstrom
1. Broeders JA, Mauritz FA, Ahmed Ali U, Draaisma LL, Pellegrini CA. Laparoscopic paraesophageal her-
WA, Ruurda JP, Gooszen HG, Smout AJ, Broeders nia repair: defining long-term clinical and anatomic
IA, Hazebroek EJ. Systematic review and meta- outcomes. J Gastrointest Surg. 2012;16(3):453–59.
analysis of laparoscopic Nissen (posterior total) ver- 13. Graber J, Dunn D, Johnson E, Alden P, Bretzke M,
sus Toupet (posterior partial) fundoplication for Markman J. Laparoscopic gastric fundoplication for
gastro-oesophageal reflux disease. Br J Surg. treatment of gastroesophageal reflux disease (GERD).
2010;97(9):1318–30. Results from 150 consecutive cases. Minn Med.
2. Anderson JE, Chang DC, Parsons JK, Talamini MA. 2002;85(1):38–42.
The first national examination of outcomes and trends 14. Salminen P. The laparoscopic Nissen fundoplication–
in robotic surgery in the United States. J Am Coll a better operation? Surgeon. 2009;7(4):224–27.
Surg. 2012;215(1):107–14. 15. Peters MJ, Mukhtar A, Yunus RM, Khan S, Pappalardo
3. Niebisch S, Fleming FJ, Galey KM, Wilshire CL, J, Memon B, Memon MA. Meta-analysis of random-
Jones CE, Litle VR, Watson TJ, Peters JH. ized clinical trials comparing open and laparoscopic
Perioperative risk of laparoscopic fundoplication: anti-reflux surgery. Am J Gastroenterol.
safer than previously reported-analysis of the 2009;104(6):1548–61.
American college of surgeons national surgical qual- 16. Bivalacqua TJ, Pierorazio PM, Su LM. Open, laparo-
ity improvement program 2005 to 2009. J Am Coll scopic and robotic radical prostatectomy: optimizing
Surg. 2012;215(1):61–8. the surgical approach. Surg Oncol.
4. Dunn DH, Johnson EM, Morphew JA, Dilworth HP, 2009;18(3):233–41.
Krueger JL, Banerji N. Robot-assisted transhiatal 17. Zhang P, Tian JH, Yang KH, Li J, Jia WQ, Sun SL,
esophagectomy: a 3-year single-center experience. Ma B, Liu YL. Robot-assisted laparoscope fundopli-
Dis Esophagus. 2013;26(2):159–66. cation for gastroesophageal reflux disease: a system-
5. Mi J, Kang Y, Chen X, Wang B, Wang Z. Whether atic review of randomized controlled trials. Digestion.
robot-assisted laparoscopic fundoplication is better 2010;81(1):1–9.
for gastroesophageal reflux disease in adults: a sys- 18. Glickson J. Surgeons experience more ergonomic
tematic review and meta-analysis. Surg Endosc. stress in the OR. Bull Am Coll Surg.
2010;24(8):1803–14. 2012;97(4):20–6.
 Achalasia
6
Julia Samamé, Mark R. Dylewski,
Angela Echeverria, and Carlos A. Galvani

increase of the LES pressure [1]. The triggering

Introduction event that leads to ganglion degeneration is not
known, but because this process is associated
Idiopathic achalasia, although rare, is the most with an inflammatory response including lym-
common primary motility disorder of the esopha- phocytes infiltration it would seem to most likely
gus [1]. This chronic condition is characterized implicate an autoimmune, viral or chronic degen-
by an incomplete or absent relaxation of the erative destruction in genetically susceptible
lower esophageal sphincter (LES) and lack of individuals [3]. Rarely, a mutation in the chromo-
peristaltic contraction of the esophageal body some 12 is implicated in the development of
that results in difficulty swallowing ultimately achalasia as a familial form inherited on autoso-
with dilation of the esophagus [2]. The etiology mal recessive mode, known as Allgrove’s syn-
remains unclear, but studies suggest that the dys- drome or “4A syndrome” which combines
function results from degeneration of ganglion achalasia, alacrymia, autonomic disturbance, and
cells in the myoenteric plexus of Auerbach with corticotropin insensitivity [4, 5].
loss of postganglionic inhibitory neurons. These The disease appears to have a stable incidence
neurons, by the secretion of vasoactive intestinal but rising prevalence (1.63/100,000 and
peptide (VIP) and nitric oxide mediate LES 10.82/100,000 respectively) as was shown in a
relaxation. Therefore, there is an unopposed ace- recent population-based study [6]. There is no
tylcholine stimulation of the sphincter with gender predominance and can occur at any age,
but the highest observance is in the seventh decade
with a second smaller peak of incidence at 20–40
J. Samamé, M.D. • A. Echeverria, M.D. years of age. Although achalasia is uncommon
Department of Surgery, University of Arizona, among children, when it appears it affects mainly
1501 N. Campbell Avenue, Tucson, AZ 85724, USA
teenagers and it is usually sporadic [7].
e-mail: [email protected];
[email protected]
M.R. Dylewski, M.D.
Department of Cardiac Vascular and Thoracic Clinical Findings
Surgery, Baptist Health of South Florida, 6200 SW
72nd Street, Suite 604, Miami, FL 33143, USA Up to 90 % of patients with achalasia present
e-mail: [email protected]
with dysphagia, mostly for solids but it can also
C.A. Galvani, M.D. (*) be for liquids [4]. Regurgitation of undigested
Department of Surgery, University of Arizona,
food is the second most frequent manifestation,
1501 N. Campbell Avenue, P.O. Box 245066,
Tucson, AZ 85712, USA presenting in approximately 60 % of patients.
e-mail: [email protected] This symptom is more common during nighttime

K.C. Kim (ed.), Robotics in General Surgery, DOI 10.1007/978-1-4614-8739-5_6, 55

© Springer Science+Business Media New York 2014
56 J. Samamé et al.

while in supine position, exposing patients to an malignancy, which is known to be more prevalent
increased risk of aspiration. Consequently, bouts in achalasia patients [11]. The endoscope is
of aspiration pneumonia may be elicited. About advanced through the gastroesophageal junction
40 % of the patients will complain of heartburn, without increased resistance, a feature that distin-
typically produced by the bacterial fermentation guishes primary from secondary achalasia or
and thus, acidification of retention food. As a benign strictures. Although retained food and
result, reflux symptoms that are unresponsive to saliva are often observed, a normal endoscopy
reflux therapy may suggest achalasia. Chest pain should not rule out the diagnosis of achalasia
is present in 40–50 % of cases, commonly because up to 40 % of patients will have a nega-
among young patients who have been symptom- tive study [3, 4].
atic for a short period and who often have vigor-
ous achalasia [8, 9].
There are occasions when this disease is asso- Esophageal Manometry
ciated with weight loss but many patients have
normal or less commonly, excess weight owing This study is considered the gold standard
to changes in eating habits, including slow eat- diagnostic modality for achalasia. The classic
ing, stereotactic movements with eating, and findings are aperistalsis of the esophageal body
avoidance of social functions that include meals with low-amplitude simultaneous waves, a LES
[4]. Pseudoachalasia can be indistinguishable with an elevated resting pressure, and absent or
from primary achalasia on routine clinical evalu- partial relaxation of the sphincter after swallow-
ation. For that reason, in aging patients who pres- ing. However, 55 % of patients will have either
ent with shorter durations of symptoms and normal or low pressure. The manometry is also
greater weight loss, further workup is recom- useful for the post-treatment evaluation of
mended [10]. patients after balloon dilation or Heller myotomy
[12]. Recently, the introduction of esophageal
topography in conjunction with high-resolution
Preoperative Evaluation esophageal manometry has led to the develop-
ment of the Chicago Classification of esopha-
Barium Swallow geal motility disorders. The ability to outline the
exact location of contractions is the strength of
The first diagnostic test in all patients with dys- esophageal topography and may benefit in the
phagia should be a barium swallow, as up to 95 % diagnosis of vigorous achalasia, in which spastic
of them will have positive findings. The typical contractions are noted in the distal esophageal
features of achalasia are: the classic tapering at segment [13].
the level of the gastroesophageal junction (“bird
beak”) and a dilated esophagus body along with
undigested food particles. With the progression Ambulatory pH Monitoring
of the disease, a sigmoid-shaped esophagus could
be seen. Another finding of this contrasted study This test should be performed preoperatively in
is a delayed emptying of the esophagus [2]. patients who have undergone pneumatic balloon
dilation or surgical myotomy to determine if
abnormal reflux is already present. In patients
Upper Endoscopy with a positive score, it is essential to distinguish
between true reflux and false reflux due to stasis
After a barium swallow has been performed, an and fermentation of food. After procedure, this
upper endoscopy should be performed to rule out test should be repeated to assess development of
other causes of esophageal obstruction such as new abnormal reflux [12].
6 Achalasia 57

Indications for Surgery Surgical Technique

Those patients who meet the diagnostic criteria for Perioperative Considerations
achalasia (manometric, endoscopic, radiographic)
and who are good surgical candidates should Preoperatively, patients are advised to ingest
undergo a minimally invasive surgical treatment. only clear liquids 2–3 days before surgery.
The aim of the therapy is to relieve the resis- Premedication with prophylactic anti-reflux is
tance at the level of the LES and to improve strongly recommended. Pneumatic compres-
esophageal emptying. For many years, the ther- sion stockings are placed routinely. In order to
apy of choice to accomplish this was the pneu- minimize aspiration risk during induction of
matic balloon dilatation. In 1991, the introduction anesthesia, the airway can be secured either
of minimally invasive techniques for the treat- after a rapid sequence induction with cricoid
ment of achalasia with high successful rates has pressure or with fiberoptic bronchoscope assis-
brought about a shift in the actual practice, where tance while the patient is awake. If possible, an
laparoscopic Heller myotomy is consider the orogastric tube (OG-Tube) is placed to fully
standard treatment option. This remarkable decompress the esophagus and the stomach.
change in the treatment algorithm was followed The anesthesiologist is advised not to force the
by documentation that laparoscopic treatment OG-Tube if resistance is found. In older patients
outperforms endoscopic modalities, and should with several comorbidities, a Foley catheter is
be continued with the incorporation of robotic- set and usually removed after the surgery.
assisted approach in the spectrum of minimally Intraoperative monitoring will be guided by the
invasive achalasia treatment options (Fig. 6.1) American Society of Anesthesiologists (ASA)
[12, 14–16]. recommendations.

Fig. 6.1 Evolution of the treatment algorithm for Achalasia

58 J. Samamé et al.

Fig. 6.2 Operating room set-up

Patient Position Trocar Placement

Once under general endotracheal anesthesia, the The positioning of the trocar is the same used in
patient is placed in a modified lithotomy position every advanced esophageal procedure. The first
over a “bean bag.” Its use prevents the patient trocar is placed through a gasless optical tech-
from moving down the table when in steep nique in the periumbilical area, utilizing a blade-
reverse Trendelenburg is needed. The beanbag is less 12-mm trocar with an optical tip that
then inflated and a 4-in. tape is used to secure the eliminates blind entry to the abdominal cavity.
patient to the table. The legs and pressure points This 12-mm trocar is required for the 30° robotic
are cushioned appropriately. The skin of the camera system. Its positioning left to the midline
abdomen is prepped and draped from the nipple allows better visualization of the gastroesopha-
line to the pubis. The exposure of the chest is geal junction (GEJ). Pneumoperitoneum is
required in the eventuality of conversion to thora- induced. Two 8-mm trocar ports are then placed,
cotomy. The bedside component of the robot is one each at the left and right mid-clavicular line
positioned over the patient’s left shoulder. The subcostal margin. The size of these trocars is
operating room set up is shown in Fig. 6.2. specific for the robotic system. An additional
6 Achalasia 59

Fig. 6.3 Trocar placement for robot-assisted Heller myotomy. Four trocars technique. (a) Arm 1 (red), hook cautery,
harmonic scalpel. Arm 2 (yellow), Cadiere grasper. Arm 3 (green), Cadiere grasper. (b) Corresponding trocars placement
for four trocars technique

Fig. 6.4 Trocar placement for robotic-assisted Heller myotomy. Five trocars technique. (a) Arm 1 (red), hook cautery,
harmonic scalpel. Arm 2 (yellow), Cadiere grasper. Arm 3 (green), Cadiere grasper. (b) Corresponding trocars placement
for five trocars technique

10/12-mm trocar is placed at the left lateral robotic arm is used for retraction and the assistant
abdominal wall to assist with suction and passage can use the fifth trocar for suction, passing of
of sutures. A 5-mm incision is made in the subxi- sutures or cutting. This technique is ideal when a
phoid area, and the left lobe of the liver is well-trained assistant in robotic approach is not
retracted using the Nathanson liver retractor, available (Fig. 6.4a, b).
allowing exposure of the anterior part of the Once the trocars are in place, the nursing per-
stomach and the hiatus (Fig. 6.3a, b). sonnel approximate the robotic surgical cart into
With a 5-trocar technique, an additional position and the arms are attached to the three
12-mm trocar is inserted. In this case, the third specific trocars. A Cadiere Forceps is placed in
60 J. Samamé et al.

is used to dissect and separate the esophagus

from the left crus to minimize the risk of inadver-
tent injury or perforation of the esophagus. The
dissection is continued in the posterior mediasti-
num lateral and anterior to expose the lower third
of the esophagus.
Once access to the posterior mediastinum is
obtained, the short gastric vessels are then
carefully divided, starting at the level of the lower
pole of the spleen (Fig. 6.6).
Full mobilization of the fundus is carried out,
by dividing posterior adhesions to the anterior
capsule of the pancreas. During this maneuver,
the surgeon uses an atraumatic grasper to retract
the stomach medially and the harmonic scalpel,
which allows performing this part of the opera-
tion in a bloodless fashion. The left side of the
esophagus is identified, by dissecting the left
crus from the esophagus. Only the anterior part
of the esophagus is dissected, respecting the pos-
terior attachments of the esophagus. After that,
attention is centered on the exposure of the right
crus. At this time, the assistant provides traction
of the stomach, meanwhile the surgeon, using an
Fig. 6.5 Surgical arm cart in position to start the atraumatic grasper and harmonic scalpel divides
procedure the gastrohepatic ligament below the hepatic
branch of the vagus nerve and extends the dissec-
tion upwards. The peritoneum overlying the
the surgeon’s left hand and in the right hand; the anterior surface of the right crus of the diaphragm
articulated hook cautery or the harmonic scalpel and the phrenoesophageal membrane is tran-
is positioned (Fig. 6.5). sected. The right crus is identified and separated
The assistant surgeon is situated on the from the esophagus by blunt dissection.
patient’s left side. During the case, the assistant is
in charge of cutting, suction and retraction. Also,
if needed, the assistant switches the robotic Heller Myotomy
instruments for the operating surgeon. For that
reason, basic training in laparoscopic surgery and After passing a #44F bougie through the mouth
robotics is essential. by the anesthesia team, the removal of the fat pad
is accomplished to better expose the GEJ. The
placement of the bougie helps with the perfor-
Dissection of the Lower Third mance of the myotomy. The assistant retracts the
of the Esophagus and the Division GEJ caudally with the atraumatic grasper to
of the Short Gastric Vessels increase the length of the intra-abdominal esoph-
agus. It is important at this point of the dissection
The procedure starts by dividing the peritoneum to identify and preserve the anterior branch of the
overlying the left crus of the diaphragm utilizing vagus nerve (Fig. 6.7).
the harmonic scalpel. The phrenoesophageal After its identification, the vagus nerve is dis-
membrane is transected as well. A blunt technique sected upwards in an extension of approximately
6 Achalasia 61

Fig. 6.6 Mobilization of

fundus and division of short
gastric vessels

Fig. 6.7 Identification of the anterior branch of the vagus Fig. 6.8 Myotomy
nerve

10 cm, divorcing it clearly from the esophageal Cadiere grasper in order to divide them with the
wall and moving it to the right side. The myot- articulated hook safely. The myotomy on the gas-
omy is started out just above the GEJ on the 12 tric side, is carried down in a “Hockey stick” con-
o’clock position using the articulated hook elec- figuration to transect the sling fibers of the stomach
trocautery. Methodical marking of the area is per- wall. Failure to achieve adequate proximal dissec-
formed by scoring the esophagus with the back tion of the esophagus with a subsequent short
of the hook electrocautery for about 6–7 cm myotomy is the most common reason for failure.
above the GEJ. The submucosal plane is reached
in one point by dividing the longitudinal and cir-
cular muscle layer (Fig. 6.8). Creation of the Partial
This is followed by extending the myotomy a Fundoplication (Dor)
minimum of 6 cm proximally and for about 2 cm
distally into the stomach. During the proximal The preferred antireflux procedure is the Dor
extension of the myotomy it is important to pro- fundoplication, which is an anterior 180° fundo-
vide counter-traction of the circular fibers with the plication. This operation is chosen because other
62 J. Samamé et al.

Fig. 6.9 Dor fundoplication, first row of sutures. The Fig. 6.10 Dor fundoplication, second row of sutures.
first stitch comprises the crura, fundus and muscular layer The first stitch comprises the stomach, the right edge of
of the esophagus. The second and third stitches incorpo- the myotomy, and the right pillar. Repair completed with
rate the esophageal and the gastric wall only a second and a third stitches between the greater curvature
of the stomach and the right side of the esophageal
muscle
than being an effective antireflux repair, it covers
the exposed mucosa. The Dor technique involves
two rows of sutures, each composed of three the tension of the fundoplication and to prevent
stitches. The first row of sutures includes the gas- the lateral rotation of the wrap.
tric fundus, the crura and the left side of myot-
omy (Fig. 6.9).
After passing a 2-0 silk 15 cm stitch to the sur- Outcome Evaluation
geon, the assistant grabs the fundus and pulls up
toward the left crus. The first stitch is a triangular Table 6.1 shows the results of the three largest
one, positioned between the fundus, the left pillar series from centers where this technique is used
and the left side of the myotomy. Two additional [17–19].
stitches incorporate the gastric wall and the left Overall, excellent or good results are consis-
side of the myotomy. Subsequently, the assistant tently obtained in more than 90 % of patients,
folds the stomach over the exposed mucosa and with no intraoperative esophageal perforations in
the second row of sutures is created by placing any of the series. Operative times ranged between
stitches between the stomach and the right edge 119 and 140.55 min including the robotic set-up
of the myotomy (Fig. 6.10). time. In two of these series, a significant decrease
The first stitch is placed between the stomach, in the average time was noticed after 30 cases
the right edge of the myotomy, and the right pil- revealing the importance of the learning curve
lar. Finally, the second and the third stitches are and the experience of the operating room team in
placed between the greater curvature of the stom- order to reduce the robot set-up time. The mean
ach and the right side of the esophageal muscle. length of hospital stay is 1.5 days in all three
Avoiding inclusion of the right pillar in the sec- series with no significant differences from lapa-
ond and third stitches of the fundoplication is roscopic Heller procedures.
vital, since this could represent a reason for post- Two out of fifty-nine patients in the study pub-
operative dysphagia. Two supplementary stitches lished by Horgan et al., 3/73 patients in our series
are placed between the gastric fundus and the rim and 1/104 in the study of Melvin et al., required
of the hiatus completing the fundoplication. The postoperative endoscopic treatment with com-
purpose of these last stitches is to further decrease plete relief of symptoms after the procedure.
6 Achalasia 63

Table 6.1 Robotic-assisted Heller myotomy outcomes [17–19]

Patients Average OT Perforation Excellent/good Additional
Author (year) (n) (min) rate (%) results (%) tto (%)
Horgan (2005) 59 149 0 92 3.4
Melvin (2005) 104 140.55 0 100 1
Galvani (2011) 73 119 0 96 4
OT operative time, min minutes, tto treatment

systematic review and meta-analysis comparing

Comments the robotic surgical system versus laparoscopic
Heller myotomy [16].
Laparoscopic Heller myotomy using the standard Several factors may play a role in decreasing
technique has evolved into an extremely safe and the morbidity of the procedure. The robotic sys-
accepted procedure offering better long-lasting tem provides a three-dimensional vision support
results in terms of controlling symptoms in the allowing the isolation and division of each indi-
treatment of Achalasia. However, it is impossible vidual muscle fiber. The increase of dexterity
for even experienced laparoscopic surgeons to and the elimination of tremors also contribute to
overcome some well-known disadvantages a precise dissection and give a clear view of the
related to laparoscopic surgery that transform submucosal plane, subsequently reducing the
this procedure into a technically challenging one risk of perforation. The freedom of movements
with a considerable learning curve [20]. This of the wristed instruments enables the adjust-
method provides a two-dimensional image, ment of the angle of work according to the direc-
which eliminates perception of depth and the tion of the fibers from circular to oblique at the
projection of the image on a screen also inter- GEJ; the Achilles’ heel of the laparoscopic
rupts the natural eye-hand-target working axis. myotomy is that the surgeon must operate in a
The necessity of the use of long instruments narrow field around the thoracic esophagus. This
through fixed entry points in the abdominal wall not only lengthens the intra-abdominal portion
limits the degree of freedom of motion and pro- of the esophagus but also admits for proper
motes friction on the instruments. The depen- extension of the myotomy. Even though this
dence on the camera operator during the surgery, technique is not exempt from the learning curve
the poor ergonomic positioning of the surgeon as calculated in 30 cases, it is extremely shorter
and the need for specialized training, may explain compared with the more than 200 procedures
in part why, in most laparoscopic series, the rate required in order to achieve proficiency with
of intraoperative esophageal perforation ranged laparoscopic approach. Moreover, there is mount-
from 1 to 16 %. ing evidence that the learning curve is necessary
Robotic technology has emerged as a suitable when performing laparoscopic myotomy to
alternative in the field of minimally invasive sur- reduce hospital stay and complication rates,
gery to overcome some of these technical imped- while in the case of the robotic approach, the
iments. As it relates to the surgical treatment of learning curve only affects the time consumed
achalasia, several reports including our own for the robotic system set-up but has no impact
experience have documented that robotic-assisted on the occurrence of intraoperative complica-
Heller myotomy is safer, has 0 % rate of esopha- tions [4, 17–19].
geal perforation and is associated with higher The evidence provided thus far is sufficient to
quality of life indices when compared with lapa- consider robotic-assisted Heller myotomy an
roscopic approach [17, 18]. Published in 2010, excellent minimally invasive treatment option for
these same concepts were reinforced by the first Achalasia. Benefits include a shorter and easier
64 J. Samamé et al.

learning curve, reduced morbidity, and excellent

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• Although prior endoscopic treatment leads to lasia: a decade of change. J Am Coll Surg.
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the untreated patients are achieved. the treatment of esophageal achalasia: evolution of the
6 Achalasia 65

surgical procedure and the therapeutic algorithm. Surg 18. Melvin WS, Dundon JM, Talamini M, Horgan S.
Laparosc Endosc Percutan Tech. 2012;22(2):83–7. Computer-enhanced robotic telesurgery minimizes
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 Part III
Surgical Techniques: Thoracic
 Complete Port-Access Robotic-
Assisted Lobectomy Utilizing 7
Three-Arm Technique Without
a Transthoracic Utility Incision

Mark R. Dylewski, Richard Lazzaro,

and Abbas E. Abbas

hospital stay, decreased postoperative pain,

Introduction preservation of pulmonary function, and fewer
overall complications [7]. However, the routine
Anatomical lobectomy with systematic mediasti- adoption of VATS lobectomy has been slow par-
nal lymphadenectomy is the “gold standard” for ticularly for larger tumors and more advanced
the treatment of early-stage non-small cell lung surgically treatable disease. The reasons for the
carcinoma [1]. Traditionally, a lobectomy has lack of adoption of VATS lobectomy are multi-
been performed through a large posterolateral factorial and have been outlined by Mack [8]. He
thoracotomy. Since the initial introduction of cited oncological control, limitations in instru-
minimally invasive thoracoscopic surgery in the mentation, operative times, and experience as
early 1990s [2–4], the procedure has rapidly aspects influencing adoption of the VATS platform.
demonstrated its potential for the treatment of The features of the VATS platform such as counter-
benign and malignant disease of the chest cavity. intuitive orientation, two-dimensional imaging,
Video-assisted thoracoscopic surgery for major reduced depth perception, and limited instrument
lung resection has been proven to be an accept- maneuverability have made many surgeons feel
able approach to the treatment of early-stage lung awkward during VATS lobectomy elevating con-
cancer. The safety, feasibility, and oncological cerns about sound oncological principles. These
effectiveness have been demonstrated in single concerns, in conjunction with the fear of sudden
and multi-institutional series [5, 6]. When com- hemorrhage and the inability to rapidly control
pared to traditional open lobectomy, the VATS bleeding, have made many thoracic surgeons hesi-
lobectomy technique is associated with shorter tant to adopt minimally invasive major lung resec-
tion. Consequently, most published series advocate
selecting patients with early-stage I NSCLC for
M.R. Dylewski, M.D. (*)
VATS lobectomy and the use of a facilitating non-
Department of Cardiac Vascular and Thoracic
Surgery, Baptist Health of South Florida, 6200 SW rib-spreading utility thoracotomy [9, 10]. This strat-
72nd Street, Suite 604, Miami, FL 33143, USA egy was adopted as a result of the technical
e-mail: [email protected] limitations of the VATS platform. This approach
R. Lazzaro, M.D. provides access for conventional surgical instrumen-
North Shore LIJ Health System, Lenox Hill Hospital, tation in order to facilitate safe dissection of hilar
100 E 77th Street, New York, NY 10075, USA
structures and eventual extraction of lung tissue.
A.E. Abbas, M.D. In an effort to overcome limitations of
Department of Surgery, Ochsner Clinic Foundation,
conventional minimally invasive instruments,
1514 Jefferson Highway, New Orleans,
LA 70121, USA robotic systems have been designed. The advent
e-mail: [email protected] of advanced three-dimensional video optics,

K.C. Kim (ed.), Robotics in General Surgery, DOI 10.1007/978-1-4614-8739-5_7, 69

© Springer Science+Business Media New York 2014
70 M.R. Dylewski et al.

superior range of motion blended with comput- tion of VATS and mirror that of other robotic
erized, intuitive integration of the surgeon’s fun- surgical subspecialties.
damental skills, has created a new opportunity The technique outlined in the following
for surgeons to offer a powerful alternative for chapter is an established technique for complet-
their thoracic surgical patients. Since the demon- ing a total endoscopic three-arm robotic video-
stration of feasibility and safety of robotic- assisted anatomical lobectomy and systematic
assisted thoracic surgery by several authors lymph node dissection that is performed through
[11–13], the procedure is increasingly being uti- a port-only approach. Once the lobectomy speci-
lized in the field of thoracic surgery for its poten- men is detached from the hilar structures, it is
tial advantages. Early investigations of removed from the chest cavity from a subcostal
robotic-assisted lobectomy have shown that the para-diaphragmatic location without the use of a
operative morbidity and mortality is low and traditional utility thoracotomy. We will report our
many of the same advantages seen with utiliza- 5-year experience utilizing this technique and
tion of VATS lobectomy can be realized with discuss the indications for the procedure, contra-
robotic-assisted pulmonary resection [14]. While indications, technical aspects of robotic video-
robotics has great promise in the field of pulmo- assisted pulmonary surgery, and the perioperative
nary surgery, many authors have raised concerns outcomes.
about the inherent higher costs of the procedure,
the increased operating room times, and the
steep learning curve over conventional mini- Technique
mally invasive techniques [15, 16]. It is our
experience that these drawbacks to robotic sur- All robotic-assisted pulmonary resections are
gery can be mitigated by refinements to the performed under general anesthesia with an
robotic surgical technique, developing specialty- endotracheal tube capable of maintaining one-
specific team approaches, and standardization of lung ventilation. Fiberoptic bronchoscopy is uti-
operating room practices in an effort to optimize lized to confirm correct positioning. Monitoring
the utilization of the robotic system for maxi- consists of pulse oximetry, electrocardiography,
mum efficiency. In fact a retrospective analysis end-tidal CO2, and pneumatic blood pressure
presented at CRSA 2012 by the lead author of measurements. The patient is positioned in the
176 robotic-assisted lung lobectomies that com- lateral decubitus position. To ensure free move-
pared to 76 VATS lobectomies performed ment of instruments passed through the para-
between 2005 and 2011, lobectomies performed diaphragmatic assistant port, it is critical that the
using robotic assistance reduced direct cost by top of the patient’s ipsilateral hip and lower rib
$560 dollars per case. The majority of cost sav- cage are in a parallel plane. If this cannot be
ing occurred as a result of reduced length of hos- accomplished with flexion of the operating table
pital stay and lower overall nursing care cost. alone, the beanbag can be placed underneath
The da Vinci surgical system (Intuitive Surgical, the hip for additional flexion. After placing the
Sunnyvale, CA) represents the ideal tool for dis- patient in the lateral decubitus position, the sur-
section of the pulmonary vascular and for the geon should define the anatomy of the lower rib
performance of a systematic lymph node dissec- cage by marking the position of anterior aspect of
tion. An improvement in robotic minimally the 10th, 11th, and 12th ribs. The position of the
invasive surgery over the conventional plat- para-diaphragmatic assistant port is placed ante-
forms has made the adaptability of minimally rior and inferior to the 10th rib along the anterior
invasive lobectomy easier as well as provided a axillary line. After confirming the location of the
greater probability of achieving complete onco- assistant port, the anterior robotic operating port
logical resection [17]. For the reasons outlined should be positioned at least 10 cm superiorly to
above, we believe that the trend in robotic- the assistant port along the anterior axillary line
assisted thoracic surgery will surpass the adop- (Fig. 7.1a).
7 Complete Port-Access Robotic-Assisted Lobectomy… 71

Fig. 7.1 (a) Layout of the external anatomy of the lower lobectomy. (Asterisk) When optional posterior #3 arm port
chest wall. (b) Introduction of 12-mm assistant port at is utilized, the #1 arm is placed in the anterior port side.
confluence of anterior 10th intercostal muscle and dia- (d) Port placement in relationship to the major oblique fissure.
phragm. (c) Port placement for three-arm robotic assisted (e) Docking for a three-arm robotic-assisted lobectomy

The initial access to the chest cavity is with the 10th intercostal muscles. The 12-mm
achieved by placing a 5-mm port in the anterior assistant port is placed under direct visual
axillary location approximately at the level of assistance. The port enters the chest at the con-
the 5th intercostal space. A pneumothorax is fluence of the muscle fibers of the diaphragm
induced with CO2 (pressure/flow 8 mmHg and and the anterior 10th intercostal muscle
8 ml/s). Using a 5-mm 30° laparoscopic camera (Fig. 7.1b).
focus on the anterior aspect of the diaphragm Utilizing the 5-mm thoracoscope, placed
where the diaphragmatic muscles intertwine through the 12-mm assistant port, two additional
72 M.R. Dylewski et al.

Fig. 7.1 (continued)

trocars are positioned along the major pulmonary tioned one or two interspace below the superior
fissure between either the 6th or 7th interspace. aspect of the oblique fissure within the corre-
Successful complete port-access robotic-assisted sponding rib space. As a result of the paraspinous
pulmonary surgery is dependent on proper place- muscles, the posterior intercostal space is restric-
ment of the midaxillary camera and posterior tive. The superior and inferior movements of the
thoracic port. Port placement is based on the rela- robotic instruments can be significantly affected
tionship of the major pulmonary fissure to the by the inflexible paraspinous musculature and
internal chest wall rather than external landmarks narrow ribs space. Improper positioning of the
(Fig. 7.1c, d). posterior port will hinder instrument movement.
For this reason, initial placement of a low- Limiting the size of the posterior operating port
lying camera will provide the best vantage point to (8 mm or less), when possible, is recom-
in order to visualize the pulmonary fissure and mended to minimize postoperative pain. If
chest wall simultaneously, thus facilitating accu- elected, an additional 5-mm port can be placed in
rate port placement. the posterior location approximately the 8th
It is important to maintain 10 cm or a hand- interspace and used with a 5-mm retracting
breadth of space between each port. The camera grasper. Three or four robotic arms are then
trocar (8 mm) is positioned in the midaxillary docked to their respective trocars (Fig. 7.1e).
location one interspace below the major oblique A 0° 3D (8 mm) camera is placed in the
fissure. A good rule of thumb is to utilize the ante- midaxillary port. The 5-mm lung grasping for-
rior sternal-xiphoid junction as a landmark to ceps are placed in the right robotic arm, and a
confirm proper positioning for the midaxillary bipolar dissector forceps (Intuitive Surgical, Inc.,
camera port. The initial 5-mm port is replaced Sunnyvale, CA) is placed in the left robotic arm.
with a (8 mm) trocar in the anterior axillary loca- The bipolar cautery is utilized for precise dissec-
tion. A larger port (12 mm) can be placed in the tion and isolation of the pulmonary vascular
anterior axillary location if a secondary access is structures. Avoidance of an access thoracotomy
needed for stapling. When utilizing a 12-mm incision maintains positive pressure within the
anterior axillary port, the robotic 8-mm port chest cavity with CO2 insufflation. When the CO2
needs to be introduced through the 12-mm port. pressure is maintained below 10 mmHg, hemo-
The posterior (5 mm or 8 mm) trocar is posi- dynamic side effects are minimal and can be
7 Complete Port-Access Robotic-Assisted Lobectomy… 73

Fig. 7.1 (continued)

addressed with minor adjustments by the arm, which is uniquely different from the mirror
anesthesiologist. image arms #1 and #2. Instruments held with
We prefer the three-arm robotic technique robotic arm #3 have an increased range of
with docking of the #3 robotic arm to the ante- motion compared to the other two robotic arms.
rior port. As the #3 robotic arm is a five-joint The #3 arm can be utilized to hold the primary
74 M.R. Dylewski et al.

dissecting instrument. For right-sided proce- base of the pulmonary ligament to the apex of the
dures, the robotic arms #2 and #3 are utilized, chest. Complete visualization of the anterior,
with #3 positioned anteriorly as noted, and #2 is posterior, and superior aspects of the hilum is
placed posteriorly. For left-side procedures, attained, allowing for precise anatomic dissec-
robotic arms #2 and #3 are utilized; robotic arm tion. Exposure of the ligament is achieved by lift-
#3 is positioned anteriorly, and #2 is placed pos- ing the lower lobe superiorly with “passive”
teriorly. When utilizing the four-arm robotic retraction. “Passive” retraction is best achieved
technique, it is necessary to use the #3 robotic by utilizing the full length of the shaft of the
arm for retraction assistance, and arms #1 and #2 instruments to “push” the lung as needed around
are positioned anterior or posterior depending on the chest cavity rather than to grasp and “pull”
the laterality of the case. When utilizing a four- the lung where needed. Utilizing a 3 × 3 rolled
arm robotic technique, it is necessary to dock the gauze held by a robotic instrument can improve
#3 arm posteriorly for retraction assistance only. the surgeon’s ability to manipulate the lung for
The #1 and #2 arms become the primary dissect- exposure. The console surgeon should not
ing instruments. One of the main disadvantages attempt to “actively” grab the lung in an effort to
to the four-arm technique is the increased likeli- reduce iatrogenic parenchymal trauma. Instead
hood of external instrument conflict particularly “passive” retraction should be used to push the
in patients with small chest cavities. Utility lung upward until the ligament is visualized and
access can be achieved through the subcostal the bedside assistant can grab the base of the liga-
assistant trocar for retraction, suctioning, and ment to provide exposure of the ligament for
access for passage of staplers. With rare excep- bimanual robotic dissection. While the bedside
tions, all stapling can be provided through the assistant maintains gentle cephalad traction on
subcostal accessory port. By utilizing the acces- the lung, the inferior ligament is divided with
sory port in this manor, instrument exchange, as electrocautery. Level 8 and 9 lymph nodes are
well as the need to undock and re-dock the arms removed during this maneuver. As the dissection
to the ports, substantially reduces the overall progresses towards the superior aspect of the lig-
operating room time. As experience with this ament, the ligament divides into anterior and pos-
technique is gained, this arrangement requires terior veils which envelope the hilum. Dividing
only one bedside operative assistant and surgical these veils anteriorly and posteriorly to the supra-
technician. Following the initial trocar position- hilar area allows for a circumferential release of
ing and docking of the robot, the primary operat- the mediastinal pleura from the hilum. During the
ing surgeon remains unsterile at the surgical dissection of the posterior veil, the lung is rotated
console until it is time to extract the lung speci- anteriorly and held in position with an external
men from the chest cavity. atraumatic grasper by the bedside assistant via
the assistant port. Next, the console surgeon pro-
ceeds with a subcarinal lymphadenectomy.
Hilar and Mediastinal Lymph Node Before forfeiting the posterior hilar exposure,
Dissection additional maneuvers can be performed to facili-
tate division of an incomplete oblique fissure.
Once the indications for lung resection are met, On the right side, thorough dissection of the
the procedure begins with mediastinal and hilar junction between the right upper lobe bronchus
lymph node dissection based on the disease pro- and bronchus intermedius should be completed.
cess. The lymph node dissection begins with The landmark to identify is the posterior aspect
division of the inferior pulmonary ligament. A 0° of the descending pulmonary artery. On the left
scope is placed in direct upright position with side, exposure of the main pulmonary artery and
minimal rotation from the horizon. Proper camera the origin of the ascending posterior pulmonary
port placement allows for visualization from the artery and superior segmental artery should be
7 Complete Port-Access Robotic-Assisted Lobectomy… 75

thoroughly dissected free of adjacent tissue. descending branch of the pulmonary artery
If these steps are performed correctly, a plane within the mid-oblique fissure. Following the
beneath the posterior oblique fissure can be eas- identification of the ascending posterior segmen-
ily created once the descending artery is exposed tal artery to the upper lobe and the superior seg-
from within the mid-oblique fissure. During the mental artery to the lower lobe, dissection with a
dissection of the oblique fissure and isolation of blunt dissector is performed beneath the posterior
the individual arteries, N1 lymph nodes are parenchymal bridge. A tissue stapler is passed
removed and collected for examination. through the assistant trocar and utilized to divide
Throughout the process of the lymph node dis- the posterior parenchymal bridge. The order of
section, a frozen section examination is per- the hilar structures divided for the right upper
formed on any suspicious hilar (N1) and lobe is as follows: ascending posterior artery,
mediastinal (N2) lymph nodes to determine a right upper lobe bronchus, and common truncus
clinically appropriate anatomical resection. anterior artery. Dividing the right upper lobe
Following the hilar dissection and removal of bronchus facilitates isolation of the truncus ante-
the subcarinal lymph nodes, dissection should rior branch of the pulmonary artery. The venous
be carried cephalad to the hilum. On the right structures are typically divided last in order to
side, levels 2, 3, and 4 lymph nodes are resected. avoid engorgement of the corresponding lobe. In
On the left, level 5 and 6 para-aortic lymph situations where dissection through the fissure is
nodes are resected. difficult, a fissure-less technique can be utilized.
However, the authors recommend performing
isolation of all major vessels prior to dividing the
Dissection and Division pulmonary vein to the respective lobe. This will
of Hilar Structures facilitate rapid division of the major arterial sup-
ply and limit the risk of lobar engorgement. In the
The major oblique fissure is separated, and the case of a middle lobectomy, the segmental pul-
arteries to the designated lobe are isolated and monary arterial branches to the respective lobe
individually divided. The bipolar dissector for- are individually isolated and divided with a vas-
ceps are utilized to meticulously divide the pul- cular stapler. When performing a lower lobec-
monary parenchyma when necessary. With the tomy, isolation and division of the common
use of the high-definition, three-dimensional descending pulmonary artery is performed when
camera, the surgeon can visualize the thin vis- feasible.
ceral pleural layer between the fissures and avoid When performing a left upper lobectomy, sep-
violating the parenchyma of the uninvolved lobe. aration of the oblique fissure is initially per-
Careful attention to this maneuver is important to formed. The order of the hilar structures divided
avoid excessive bleeding that may interfere with for a left upper lobe is as follows: lingual arter-
identification of vascular structures. Blunt dissec- ies, ascending posterior artery, left superior pul-
tion through the lung parenchyma should be monary vein, apical and anterior arterial
avoided. Division of the pulmonary vein prior to branches, and left upper lobe bronchus. Division
division of the arteries to the corresponding lobe of the left superior pulmonary vein will facilitate
is not recommended because of the risk of exposure of the apical and anterior arterial
engorgement of the pulmonary parenchyma. branches during a left upper lobectomy. For
Such engorgement will lead to increased bleed- lower lobectomies, the common descending pul-
ing during dissection of the hilar structures and monary artery is divided before the inferior pul-
lung parenchyma. In circumstances where there monary vein. The vein and arteries are stapled
is an incomplete fissure, we recommend initially with a 45-mm vascular tissue stapler, and bron-
dividing the posterior parenchymal bridge. This chi are stapled and divided with a 45-mm medium
is accomplished by exposing the common thick tissue stapler.
76 M.R. Dylewski et al.

Extraction of the Specimen Three patients underwent an en bloc chest wall

or diaphragm resection concurrently with lobec-
Once the anatomical resection is completed, the tomy. Robotic video-assisted lung resection was
specimen is placed in a 5 × 8-cm Lapsac (Cook successfully completed in 197 (98.5 %) patients.
Group Inc., Bloomington, IN). The Lapsac string Three patients required conversions to a muscle-
is then pulled out through the subcostal trocar sparing mini-thoracotomy for either bleeding, central
(Fig. 7.2a, b). tumor invasion, or completion of a sleeve lobec-
A small 2–3-cm subcostal incision is created tomy. Every type of lobectomy was performed
at the tip of the 11th rib. Once the anterior aspect (Table 7.1).
of the 11th rib is identified, the edge of the dia- Segmental resections were limited to the pos-
phragm is separated from its attachments to the terior apical segments of the right upper lobe and
anterior 10th intercostal muscle fibers as they the lingual or superior segment of the lower
insert into the anteroinferior aspect of the tenth lobes. The median number of lymph node sta-
rib. The extraction of the specimen from the chest tions removed totaled 5.0 (range 4–8). The results
cavity is not performed through a traditional of our series are listed in Table 7.2.
transthoracic approach. It is removed through a Mean and median operative times were 100
para-diaphragmatic, subcostal approach. Repair and 90 min, respectively (range 30–279 min).
of the diaphragm is accomplished using 0-vicryl The total operative room times were measured
on CT1 needle (Fig. 7.2c). from patient entering to exiting the operating
The suture is passed initially through the room. Mean and median total operating room
upper posterior edge of the divided oblique mus- times were 180 and 175 min, respectively. The
cles. It is then run as a semi-purse-string alone majority of patients were admitted from the post-
the open edge of the diaphragm from superior to operative recovery room directly to a standard
inferior. The suture is then run through the floor bed with continuous cardiac and pulse
inferior posterior edge of the divided oblique oximetry monitoring. No patient required an epi-
muscles. Tying the suture will reapproximate the dural catheter or PCA for postoperative pain con-
diaphragm to the anterior tenth intercostal mus- trol. The median length of stay in the ICU was 0
culature. After a final inspection of the thorax, (range 0–15). Fifteen patients required a stay in
paravertebral blocks are performed using 0.5 % the ICU during their postoperative hospital stay.
bupivacaine with epinephrine for analgesia. Thirteen patients during the first half of the series
A single 24 F Blake drain is placed and has been required an ICU stay, and two patients required
found to be sufficient for closed chest drainage in an ICU stay in the last half of the series. In our
this patient population. series, the most common cause for the patient to
require transfer to ICU was respiratory failure
and pneumonia.
Result

A review of our complete experience from Learning Curve

December 2006 through September 2010 identi-
fied 200 consecutive patients who underwent a Although, there is no standard definition for a
robotic video-assisted lung resection [14]. The learning curve, the traditional method of measure
patient characteristics are listed in Table 7.1. Of is to plot the average time verses number of
the study cohort, 154 patients underwent an cases. As the surgeon gains experience, the curve
anatomical lobectomy, four patients required a should begin to plateau. The learning curve is
bilobectomy, one patient had a pneumonectomy, then set to that number of cases required for the
and 35 patients underwent a formal segmentec- surgeon to reach the plateau. Unfortunately,
tomy. Three patients underwent a sleeve lobectomy. operative time alone cannot be the single criteria
7 Complete Port-Access Robotic-Assisted Lobectomy… 77

Fig. 7.2 (a) Retrieval of specimen bag through assistant port. (b) Opening of the assistant port site for specimen
removal. (c) Exposure of specimen removal site for repair of diaphragm
78 M.R. Dylewski et al.

Fig. 7.2 (continued)

Table 7.1 Patient characteristics (n = 200) Table 7.2 Results

Male/female 90/110 Mean/median operative time (min) 100/90
Median age (years) 68.0 (20–92) (30–279)
Median tumor diameter (cm) 2.0 (0.5–8.5) Mean/median total operating room 180/175
Tumor location time (min) (82–370)
RUL 52 Median docking time (min) 12 (6–20)
RML 18 Median chest tube duration (days) 1.5 (1–35)
RLL 27 Median length of ICU stays (days) 0 (0–15)
RML and RLL 4 Median length of hospital stay (days) 3 (1–44)
LUL 36 Median chest tube drainage (cc) 300 (90–2,000)
LLL 21 Median lymph nodes stations removed 5 (4–8)
Histology Median operative blood loss (cc) 70 (25–500)
NSCLC 125
Small cell carcinoma 1
Carcinoid 18 by which we gauge the success of a newly
Benign 26
adopted operative procedure. Additional mea-
Metastatic 29
sures, including procedural blood loss and peri-
Lymphoma 1
operative complications are equally important
Pathological stage (NSCLC n = 26)
Stage IA/IB
and need to be evaluated as part of the metrics.
106
Stage IIA/IIB 22
Our analysis of the learning curve has shown that
Stage IIIA 16 certain components of the curve differ greatly
Stage IV (T3N0M1) 2 between groups of surgeons as defined by their
Type of anatomical resection training level. Not only does the surgeon’s level
Lobectomy 154 of training impact the implementation of robotic
Bilobectomy/pneumonectomy 4/1 surgery into a surgeon’s practice, but also careful
Segmentectomy 35 patient selection should minimize surgeon frus-
Enbloc/sleeve lobectomy 3/3 tration while learning how to operate a robotic
7 Complete Port-Access Robotic-Assisted Lobectomy… 79

Operative Time

OPERATIVE TIME
250
Median Time:92 min
n=81
200

150

100

50

0
1
4
7
10
13
16
19
22
25
28
31
34
37
40
43
46
49
52
55
58
61
64
67
70
73
76
79
Estimated learning curve: 37 cases

Fig. 7.3 Learning curve for robotic-assisted lobectomy

surgical instrument. Attention to matching surgeon However, a recent study has reported robust
experience, surgeon robotic preparation, and long-term follow-up data on survival or outcome
patient/case selection provides a successful path measure for robotic-assisted pulmonary resec-
to optimize the safety of the robotic procedure, tion. Park and colleagues reported on a multi-
minimizing perioperative risk and establishing institutional review of the long-term oncological
the development of a robotic skill set which will results following robotic lobectomy, utilizing
preserve equivalent oncological outcomes to CALGB consensus technique, on 325 patients.
VATS or open. Robotic technology allows The authors concluded that “long-term stage-
surgeons to replicate their preferred technique specific survival is acceptable and consistent
now using a minimally invasive approach. with prior results for VATS and thoracotomy”
Advancements achieved in medical simulation [18].
should shorten the learning curve and increase
the use of minimally invasive techniques. Taking
into account the morbidity, mortality, and short- Complications
term outcome measures for our series, the num-
ber of cases require to reach the learning-curve A systematic review of the conventional video-
plateau was approximately 34 cases (Fig. 7.3). assisted thoracoscopic surgery versus thoracot-
Abbas and colleagues in an unpublished series omy performed by Whitson and associates [19]
of 103 patients undergoing robotic lobectomy for reported the overall complications in numerous
NSCLC have also demonstrated a shortened series of VATS lobectomy from 1995 to 2006
learning curve with overall complication and ranged from 6 to 34.2 %. The two largest series
major morbidity of 21 % and 6 %, respectively, reported by McKenna and associates [20] and
and a mortality of 0 %. Oncological outcomes Onaitis and associates [21] reviewed the full
have also remained a concern with the introduc- spectrum of complications occurring in patients
tion of robotic-assisted lobectomy for NSCLC. undergoing conventional video-assisted lobectomy.
80 M.R. Dylewski et al.

Table 7.3 Perioperative complications (n = 52) tion of the para-diaphragmatic assistant port and
60-day mortality 3 (1.5 %) specimen retrieval from this location. Potential
Supraventricular arrhythmia 6 (3.0 %) injury to the ipsilateral diaphragm and abdominal
Myocardial infarction/CVA 2 (1.0 %) viscera exists. In our experience, entrance into
Pneumonia 8 (4.0 %) the abdomen through the diaphragm can occur on
Effusion requiring drainage 17 (8.5 %) rare occasions. The risk of trans-diaphragmatic
Prolonged air leak (greater than 6 days) 15 (7.5 %) placement of a port and secondary injury of
Mural thrombus 1 (0.5 %) abdominal organs may be increased in patients
Bleeding requiring transfusion 2 (1.0 %) with previous intra-abdominal or thoracic surgery,
Splenectomy 1 (0.5 %)
pleural adhesions, paralysis of the ipsilateral dia-
Conversion for difficulty 2 (1.0 %)
phragm, hepatosplenomegaly, or obesity. In
Conversion for bleeding 1 (0.5 %)
patients with any of these potential risk factors,
Return to OR for bleeding 1 (0.5 %)
Transfusion for bleeding 2 (1.0 %)
reverse Trendelenburg, the use of continuous
Postoperative pneumothorax 3 (1.5 %)
CO2 insufflation, placement of the assistant port
under direct visualization and within the anterior
9th intercostal space, facilitate post placement
and ensure entrance of the chest cavity well
In these series, the 30-day morbidity rates were above the diaphragm. With these basic maneu-
15.3 % and 23.8 %, respectively. The most com- vers, safe placement of the para-diaphragmatic
mon complications included air leak ≥7 days, port can be accomplished.
atrial fibrillation, pleural drainage ≥7 days, and As an added advantage, extraction of the spec-
pneumonia. The 60-day mortality and overall imen bag is accomplished at the site of the para-
complication rate for our study cohort was 1.5 % diaphragmatic port located at the confluence of
and 26 %, respectively (Table 7.3). the anterior 10th intercostal muscle and adjacent
In our series, the majority of complications diaphragm. In our series, few complications have
occurred in patients who underwent a lobectomy been realized as a result of this technique of spec-
(90 %). Four patients who underwent a segmen- imen retrieval. There are several inherent benefits
tal resection suffered a complication. Forty-seven to utilizing this para-diaphragmatic technique for
patients following a lobectomy suffered compli- extraction of the lung specimen. Due to the ante-
cations. The majority of complications were rior and posterior fixation of the upper rib cage
grades 2 or 3 [22]. The most common complica- and the limited elasticity of the rib cage and inter-
tions occurring following a complete port-access costal muscle, removal of large specimens or
robotic-assisted segmentectomy or lobectomy tumors greater than 3 cm requires creation of a
were similar to complications observed after con- utility thoracotomy ranging from 3 to 8 cm.
ventional VATS lobectomy and included pneu- Theoretically, chronic post-thoracotomy pain is
monia, symptomatic postoperative effusion, and secondary to injury to the intercostal nerve, local-
air leak for more than 6 days. A summary of the ized rib trauma, or disruption of the costoverte-
literature regarding the perioperative outcomes bral and costosternal joints. Various differences
of robotic lobectomy and systematic review and exist among the described VATS lobectomy tech-
meta-analysis on pulmonary resection by robotic niques, and a complete port-access video-assisted
video-assisted thoracic surgery confirms the lobectomy may be technically feasible. However,
safety of robotic pulmonary lobectomy, with there is an inherent need for specimen retrieval
reported results similar to that of VATS lobec- via a utility incision. Even without active rib
tomy [23, 24]. However, several procedural- retraction, the intercostal nerve can be inadver-
related complications are specific to complete tently injured, and the sternocostal and costover-
port-access robotic-assisted pulmonary resection. tebral joints can be disrupted by excessive
These include complications related to the inser- traction. By utilizing the para-diaphragmatic
7 Complete Port-Access Robotic-Assisted Lobectomy… 81

specimen retrieval, we believe there is no risk to resection occurs as a result of aggressive traction,
rib injury, costosternal or costovertebral separa- direct puncture, or electrocautery injury. In our
tion. The specimen is retrieved through the soft experience, the injury that is most likely to occur
tissues of the upper abdomen and diaphragm that during robotic-assisted dissection of the pulmo-
are inherently more forgiving than the rib cage. nary vessels is a small tear in a side branch of the
In addition, the main trunks of the intercostal pulmonary vein or lobar arteries. This type of
nerves do not traverse the confluence of the injury is different than injuries that occur most
abdominal and chest wall cavity in this location, frequently in conventional VATS lobectomy.
thus, limiting the risk of nerve injury. During a VATS lobectomy, maximal traction is
Excessive bleeding from a major vascular placed on the lobe in order to expose and dissect
injury from a pulmonary artery or vein during a around the respective vessel. This predisposes the
minimally invasive video-assisted pulmonary origin of the vessel to an avulsion injury. Once
resection can be troublesome and dangerous this type of injury occurs, it often requires con-
because of limited access. Historically, cata- version to a traditional thoracotomy to achieve
strophic bleeding event during VATS lobectomy exposure and vascular control. Our techniques
have been rare. The largest series of VATS model the traditional open lobectomy technique,
lobectomies by McKenna and coworker [20] where the major arterial inflow to the lobe is
reported only 6 (0.5 %) patients in their series divided by dissection through the major pulmo-
required conversion to thoracotomy for bleed- nary fissure. During dissection of the pulmonary
ing. In our series of 200 complete port-access arterial branches with robotic instrument, the
robotic-assisted pulmonary resections, there lung is lying in the natural position and requires
was one (0.5 %) patient (number 46) who sus- minimal to no retraction during these maneuvers.
tained an injury to the superior segmental branch Although opponents of total endoscopic anatom-
while undergoing an attempted right lower lobe ical resection have strongly emphasized safety as
superior segmentectomy. The injury resulted in a major obstacle to adoption of endoscopic tech-
the need to convert to a conventional VATS niques, an inadvertent traction or avulsion injury
approach with a utility incision in order to place is unlikely to occur. In an effort to avoid a major
a clip on the small vessel. Eventually the patient fatality during a vascular injury, we recommend
required a right lower lobectomy to achieve an that gauze fashioned into a tightly rolled “cigar”
R0 resection. be placed within the chest cavity at all times.
This gauze can be utilized for general hemostasis
as well as for applying pressure in the event of
Tips and Pitfalls major bleeding, thus allowing time for conver-
sion thoracotomy. The gauze can be grasped
Vascular Isolation with the anterior robotic instrument to hold
pressure on the site of bleeding. Meanwhile, the
In our experience, the robotic dissection of criti- posterior and midaxillary ports can be removed,
cal structures is precise, and the added three- and a standard thoracotomy can be performed
dimensional high-definition imaging makes the unhindered.
procedure inherently more accurate than with
conventional instruments performed through a
utility incision. Reduced tactile feedback has Camera Selection
been recognized as a weakness of the robotic
technique. However, the advanced imaging and Our technique utilizes a 0° camera for two rea-
accuracy of dissection achieved with the robotic sons. During the conduct of the operation, a 0°
technique offsets this minor limitation. camera will be operating at a 60–90° angle with
Theoretically, the etiology of major vascular respect to the chest wall. When using a 30° cam-
injury during a minimally invasive pulmonary era, the camera will operate at a 20–40° angle
82 M.R. Dylewski et al.

with respect to the chest wall. As a result of this “passive” retraction rather than “active” retraction
difference, the 30° camera impedes the ability of to manipulate the lung around the chest cavity as
the bedside assistant to access the assistant port. previously described. By avoiding excessive trac-
In addition, the 30° camera causes excessive tion on the lung parenchyma being left behind,
torque on the rib above and below the port site, limited iatrogenic injury will be created.
thus risking rib fracture or intercostal nerve
injury. Proper positioning of the camera port is
critical to achieving visualization of all intended Lymph Node Dissection
structures. In order to optimize visual exposure,
we recommend placing the camera port one Unnecessary bleeding during the lymph node dis-
interspace below the oblique fissure in the midax- section will obscure the surgical field requiring
illary line and make the initial port incision the bedside assistant to clear the field with suc-
directly over the middle of the rib. In the case of tion. During dissection of the mediastinal and
malpositioning, the port can be moved above or hilar lymph node stations, the use of two maneu-
below the respective rib without changing the vers will minimize bleeding and expedite the dis-
incision site. In the event that there is poor expo- section. The lymph node dissection should be
sure to the inferior most aspect of the inferior conducted along the perivascular Layer, stripping
pulmonary ligament, or adhesions prevent mobi- all this fatty lymph node tissue en bloc away from
lization of the lower lobe, the camera can be the mediastinal structures. The surgeon should
briefly docked to the para-diaphragm access port avoid “active” traction on the lymph nodes to
to divide these attachments. Additional maneuvers avoid capsule disruption that will lead to bleeding
include releasing CO2 from the thorax, which that is difficult to control. With the use of a bipo-
will allow the diaphragm to move cephalad, lar dissector, the collection of lymph nodes can be
bringing the ligament into view or temporarily precisely dissected away from the adjacent medi-
utilizing a 30° scope in the down-to position to astinal structures until the majority of the nodes
visualize the ligament for safe division. are free of attachments. Then the entire collection
of nodes can then be gently lifted out of its respec-
tive bed, and the remaining attached tissue can be
Haptics Feedback and Retraction transected. Exposure of the deep subcarinal and
paratracheal nodes is achieved by countertraction
One of the most recognized differences between on adjacent structures rather than grasping and
the robotic technique as compared to the VATS pulling on the nodal packet.
technique is that it requires the surgeon to operate
through a console some distance from the
patient’s bedside. As a result, the surgeon cannot Discussion
take advantage of tactile feedback as in tradi-
tional surgery. During the conduct of the opera- Anatomical lobectomy with systematic mediasti-
tion, manipulation and retraction of the lung nal lymphadenectomy performed through a pos-
parenchyma is necessary. With loss of tactile terolateral thoracotomy remains the “gold
feedback, the surgeon may have difficulty deter- standard” for treatment of early-stage non-small
mining the extent of traction placed on the vis- cell lung cancer [1]. Even with advancements in
ceral pleura or hilar structures. Several technical thoracoscopic minimally invasive instruments,
maneuvers can be utilized to avoid iatrogenic conventional lobectomy remains the preferred
injury that may lead to prolonged air leaks or method. Opponents have argued that VATS
excessive bleeding. During a robotic-assisted lobectomy has not been shown to be the superior
hilar lymph node dissection, exposure is neces- approach when compared to muscle-sparing tho-
sary to perform a systematic lymph node dissec- racotomy and potentially exposes the patient to
tion. In an effort to reduce iatrogenic injuries to the risk of major complications during pulmo-
the lung parenchyma, we recommend utilizing nary resection in a closed chest [25]. In order to
7 Complete Port-Access Robotic-Assisted Lobectomy… 83

offset the restrictions imposed by a complete accelerated the acceptance of this technology
endoscopic VATS platform, a “utility” thoracot- into the thoracic surgeons practice. The da Vinci
omy (ranging from 2 cm to 8 cm with varying surgical system represents the most advanced
degrees of rib spreading for extraction of the robotic tool in order to perform individual isola-
specimen and/or facilitating the anatomical dis- tion and ligation of the pulmonary vasculature,
section [9, 10]) has become an integral element bronchus, and complete systematic lymph node
of the VATS lobectomy technique. With access dissection. By incorporating the da Vinci surgical
through a utility thoracotomy, surgeons are able system into a minimally invasive platform for
to make use of conventional surgical instruments pulmonary resection, surgeons can accomplish a
to conduct vascular isolation and mediastinal safe and reliable video-assisted anatomical thora-
lymph node dissection. The use of conventional coscopic lung resection without the need for a
instruments in this manner provides sufficient utility thoracotomy. In our experience, complete
flexibility and increased degrees of freedom in port-access robotic-assisted lung resection can be
order to perform an effective anatomical lung performed with individual isolation of the pul-
resection. The utility thoracotomy has also pro- monary artery and division of its branches.
vided safe and reliable access to hilar structures During this phase of the operation, a thorough
in the event of major vascular injury. VATS removal of the hilar (N1) and mediastinal (N2)
lobectomy with a utility thoracotomy has made lymph nodes can be performed. One of the main
this procedure more acceptable to thoracic sur- benefits of robotic-assisted techniques is the
geons who would otherwise be uneasy with per- meticulous dissection that can be conducted in a
forming a technically challenging procedure nearly bloodless field. With the use of a robotic
through port access with conventional endo- platform, precise dissections, lymphadenectomy,
scopic instruments. Consequently, few authors and vascular isolation can be performed with
perform totally endoscopic major pulmonary safety and reliability.
resection [26, 27]. Robotic video-assisted thoracoscopic pulmo-
Despite the maturation of minimally invasive nary resection is contraindicated in most patients
surgery, VATS lobectomy is generally reserved with unresectable clinical stage IIIA or IIIB non-
for a small population of patients who present small cell lung cancer and in central lesions
with a peripheral early-stage I NSCLC. The involving proximal bronchus, carina, or pulmo-
technical limitations of the VATS platform, nary artery that may require sleeve pneumonec-
when faced with potential hilar (N1) lymph tomy or major vascular reconstruction, similar to
node involvement, central, or T3 lesions, man- contraindications to conventional VATS pulmo-
agement of these patients with VATS technique nary resection. However, large lesions greater
may make it difficult to achieve a complete than 5 cm and more advanced clinically operable
resection of mediastinal and hilar disease. Other NSCLC are not felt to be a contraindication to
techniques have included limitations on the robotic-assisted pulmonary resection. In our
extent of hilar dissection and the use of simulta- experience, patients with clinically resectable
neous ligation of the hilar structures [28]. NSCLC who undergo a complete port-access
Because of the non-anatomical dissection, these robotic video-assisted thoracoscopic lung resec-
techniques have largely been discouraged. tion experience low mortality and morbidity rates
When compared with lobectomy performed by that compare favorably to conventional open and
conventional thoracotomy, the various methods VATS lobectomy.
of VATS lobectomy have been shown to be In conclusion, the technique of complete port-
associated with numerous advantages, but the access robotic video-assisted thoracoscopic pul-
techniques remain elusive to the majority of monary resection continues to be an evolving
practicing thoracic surgeons [6, 7]. technique and will require further refinements.
The introduction of robotic technology The technique described was specifically
combined with improved three-dimensional designed to limit the need for unnecessary chest
video platforms and wristed instrumentation has wall trauma and to provide reliable endoscopic
84 M.R. Dylewski et al.

access to the chest cavity in order to perform approach. Semin Thorac Cardiovasc Surg.
2011;23(1):36–42.
complex intrathoracic surgical procedures, a
15. Gharagozloo F, Margolis M, Tempesta B, et al.
technique that would improve upon conventional Robotic-assisted lobectomy for early-stage lung can-
VATS pulmonary resection while having the cer: report of 100 consecutive cases. Ann Thorac
potential for reducing mortality and morbidity. Surg. 2009;88:330–84.
16. Park BJ, Flores RM. Cost comparison of robotic,
video-assisted thoracic surgery and thoracotomy
approaches to pulmonary lobectomy. Thorac Surg
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 Robotic Pulmonary Resection
Using a Completely Portal 8
Four-Arm Technique

Robert James Cerfolio and Ayesha S. Bryant

The principle investigator of this study (Robert Cerfolio) has lectured for Intuitive
(Sunnyvale, CA).

Introduction Definitions and Nomenclature

of Robotic Thoracic Surgery
Over the past several years, minimally invasive
surgery (MIS) such as robotic surgery has become Robotic pulmonary resection is performed using
the standard of care in urology and gynecology; it several different techniques. A standardized
has also steadily gained a place as standard of care nomenclature system has been proposed by an
in thoracic surgery. One of the factors that have international robotic committee (publication
prompted the shift towards robotic surgery is the pending). A completely portal technique (no
limitation of video-assisted thoracoscopic surgery access incisions are used) has been championed
(VATS). VATS is limited by a two-dimensional by Dylewski and by us at the University of
view, ergonomic discomfort, and counterintuitive Alabama at Birmingham (UAB). We favor using
movement and non-wristed instruments. The four arms and thus have coined the term “com-
robot, on the other hand, provides a magnified pletely portal robotic lobectomy (CPRL)” tech-
three-dimensional view, small 5 and 8 mm wristed nique that uses either three or four arms.
instruments, and the ability for the surgeon to drive A “completely portal operation” is defined as an
his own camera and provide his own retraction. operation where only ports are used (e.g., inci-
However, robotic surgery requires a longer setup sions that are only as large as the size of the tro-
time, higher initial capital costs, in-depth training cars placed in them), the air in the pleural space
of the entire team, a lack of haptic feedback, and or chest cavity does not communicate with the
the need for more specialized and costly equip- ambient air in the operating room, carbon dioxide
ment compared to VATS. Despite these issues that is insufflated in the chest, and the portal
slow robotic adoption, most thoracic surgeons incision(s) is/are not enlarged at any time during
who have used both the robot and VATS for medi- the operation to be larger than the trocars placed
astinal and esophageal operations believe the through them except for the removal of a speci-
robotic approach affords distinct advantages. men that is contained in a bag [1]. The number of
However, the role of the robot for pulmonary robotic arms implemented during the operation is
resection remains controversial. also included in the nomenclature and will be
separated by a hyphen after the type of operation
is specified. Thus we prefer a CPRL-4 and
R.J. Cerfolio, M.D., F.A.C.S., F.C.C.P. (*) Dylewski has used a CPLR-3 approach for sev-
A.S. Bryant, M.D., M.S.P.H. eral years with outstanding results.
Division of Cardiothoracic Surgery, University
Robotic operations that make a utility incision
of Alabama at Birmingham, 703 19th Street S,
ZRB 739, Birmingham, AL 35294, USA are being defined as robotic-assisted procedures
e-mail: [email protected] (RA). A utility incision is defined as an incision

K.C. Kim (ed.), Robotics in General Surgery, DOI 10.1007/978-1-4614-8739-5_8, 85

© Springer Science+Business Media New York 2014
86 R.J. Cerfolio and A.S. Bryant

in the chest that may or may not have trocars or Robotic Positioning and Docking
robotic arms placed through it; the incision
allows communication between the ambient air Because we use a four-arm technique, the robot
in the operating room and the pleural space, is must be driven in over the patient head on a
less than 5 cm in size, does not spread the ribs, 15–30° angle as shown in Fig. 8.2. This allows
and CO2 insufflation is utilized selectively. Each the third arm and the robotic arm next to it (for
has its advantages and disadvantages. right-sided operation it is arm 2, for left-sided
operation it is arm 1) ample room to prevent col-
lisions between the robotic arms.
Procedure Overview

Patient Positioning Operative Technique and Trocar

Placement of CPRL-4
The patient is placed in a standard lateral decubi-
tus positioning. We have devised a technique, as We prefer the CPRL-4 method [2]. As shown in
shown in the following Fig. 8.1, that avoids arm Fig. 8.1, the pleural space is entered over the top
boards and bean bags and places the patients’ of the eighth rib using a 5 mm port in the pro-
arms on the operating room table with blankets in posed camera port first. We have continued to
between them. evolve our technique to improve it, and recently
We do not routinely use arterial lines, central we have started to place the camera port first
lines, Foley catheters, or epidurals. The avoid- instead of the most anterior port first. This avoids
ance of the commonly used devices above quick- accidental entry into the abdomen. In order to do
ens the operative setup and reduces unnecessary this, one must first carefully plan the most poste-
delays prior to surgery. rior port for robotic arm 3. Measurements using a

Fig. 8.1 Patient positioning

8 Robotic Pulmonary Resection Using a Completely Portal Four-Arm Technique 87

Fig. 8.2 Robot being driven in over the patient

ruler should be marked on the patient’s skin prior that will be docked with robotic arm 2. A 12 mm
to any incisions. Once the marks are made, the plastic disposable port is used for the 12 mm
camera incision is made first. A 5 mm VATS cam- camera and if the 8 mm camera is used, an 8 mm
era is used to ensure entry into the pleural space metal reusable trocar is placed. Prior to making
and warmed CO2 is insufflated to drive the dia- these two incisions, a small 21 gauge needle is
phragm inferiorly. The incisions are all carefully used to identify the most anteriorly inferior
marked out with a pen and measured to ensure aspect of the chest that is just above the diaphrag-
that there is at least 9 cm between it and the more matic fibers. This incision will have a 15 mm port
posterior robotic arm and then 10 cm between it and serve as the access port. A plastic disposable
and robotic arm 3, which always serves as the trocar is used. No robotic arms are attached to the
most posterior robotic arm as shown in Fig. 8.3. trocar that is placed in this incision. This incision
Robotic arm 3 is a 5 mm port, which is placed is carefully planned. It is made just above the dia-
a few cm anterior to the spinous processes of the phragm as anterior and inferior as possible and,
vertebral bodies. A paravertebral block is per- importantly, in order to be in between the ports
formed posteriorly using a local anesthetic and a used for robotic arm 1 and the camera. The access
21 gauge needle from ribs 3 to 11. The needle is port can be alternatively placed more posterior if
used to help select the ideal location for the sec- anatomy dictates between the camera and robotic
ond incision, the most posterior incision. The arm 2. It should be two or three ribs lower than
location chosen is two ribs below the major fis- these two ports. This affords room for the bedside
sure and as far posterior in the chest as possible, assistant to work. Once these incisions are care-
just anterior to the spinal processes of the verte- fully planned and their location is confirmed,
bral body. A small 5 mm incision is made and a they are made and the appropriate trocars are
5 mm reusable metal da Vinci trocar is placed. placed. Finally, the initial 5 mm anterior port that
This will be the position for robotic arm 3. The was made first and used to introduce the VATS
next few incisions are carefully planned and once camera to identify the internal landmarks is then
again marked or remarked or changed on the skin dilated to a 12 mm double cannulated port for
prior to making them. Ten centimeters anteriorly robotic arm 1. The robot is driven over the
to the most posterior incision and along the same patient’s shoulder on a 15° angle and attached to
rib (most commonly rib 8), a third incision is the four ports. In general, only four robotic instru-
planned. It is an incision for an 8 mm port and its ments were used for all of these operations—the
trocar is an 8 mm metal reusable da Vinci trocar Cadiere grasper, a 5 mm bowel grasper (used
88 R.J. Cerfolio and A.S. Bryant

Fig. 8.3 CPRL-4 technique features entering the pleural the camera and robotic arm 2 is space is not adequate more
space using a 5 mm port anteriorly in the midaxillary line anteriorly). Note that robotic arm 3 is a 5 mm port, robotic
(MAL) over the top of the seventh rib and then using a 5 mm arm two is an 8 mm port, the camera can be an 8 or 12 mm
VATS camera to make all other incisions based on internal port depending on the camera used, and robotic arm 1 is a
anatomy. The circled numbers in the figure represent the 12 mm port. The area with the dashed lines is the area where
robotic arms used. (C) is for the camera port, (A) is for no incisions are made and is the most posterior third of the
the 15 mm access port (which can also be placed between area between the mid-spine and the post edge of the scapula

exclusively through the most posterior port that is the trachea and remove #10R and separate the
attached to robotic arm 3 which serves as a retrac- azygos vein off of the trachea. Removal of the
tor of the lung), the Maryland forceps, and a cau- lymph nodes first opens up the anatomy and
tery spatula. affords visual inspection of the N2 nodes.LN# 9
Once the arms are in the chest under direct The dissection is carried down between the
vision, we use a zero-degree camera to reduce hilar structures and the phrenic nerve. The phrenic
pain and rubbing on the intercostal nerve and use nerve is gently swept down to remove the #10R
it the entire operation usually. lymph node avoiding the small phrenic vein that
goes to the large #10R lymph node that is rou-
tinely found in this area. Develop the bifurcation
Step-by-Step Operative Technique between middle and upper lobe veins by bluntly
of a Robotic Right Upper Lobectomy dissecting it off of the underlying pulmonary
artery. It can be encircled with the Cadiere forceps
First the pleural space is inspected and explored or curved bipolar dissector and a vessel loop. The
to ensure there are no metastatic lesions on the #10R lymph node between the anterior–apical
diaphragm or the parietal or visceral pleura. pulmonary artery branch and the superior pulmo-
Dissection is started at the N2 mediastinal lymph nary vein should be removed or swept up towards
nodes. If the lung deflates well, the nodes #9, #8, the lung. This exposes the anterior apical pulmo-
and #7 can be can be completely removed. If the nary artery branch. The dissection is continuing
lung does not deflate sufficiently, it is best to start of the hilar tissue to cleanly expose the main pul-
at the #7 station and then move cephalad towards monary artery. Encircle the superior pulmonary
8 Robotic Pulmonary Resection Using a Completely Portal Four-Arm Technique 89

vein with an 8 cm vessel loop and retract it off the done anterior to posterior; however, if the space
pulmonary artery behind it. Using the vessel loop between the middle lobe pulmonary artery and
as a guide, the linear stapling device is passed the right middle lobe vein is already developed, it
across the right superior pulmonary vein and can be done in the reverse direction, from poste-
fired. Next the anterior apical trunk pulmonary rior to anterior; this allows the stapler to be
artery branch is encircled with a vessel loop and directed away from the PA. If the stapler is
transected with a linear stapler in the same fashion brought in anteriorly, then as the fissure is com-
as the vein. In both cases the stapler is brought in pleted, the main pulmonary artery should be seen
from the assistant non-robotic port. Exposure and the stapler should be placed just above it and
might be improved by using the left-hand again ensuring that all small PA branches to the
EndoWrist instrument to deflect the trachea down- RUL have been taken. The right middle lobe PA
ward and enable the tip of the stapler device to go branch can be easily seen and should be pre-
above the trachea. The operation is now changed served. The RUL must be lifted up to ensure the
to a posterior approach in contrast to continue this specimen bronchus is included in the resected
anteriorly as done commonly via VATS lobec- specimen. The lobe, now free of any attachments,
tomy. The RUL bronchus’ anatomy is exposed. Its is placed remotely anteriorly and the remaining
upper aspect is seen coming off the trachea. The LN dissection of station 2R and 4R should be
dissection is continued inferiorly to expose the performed. The specimen is then bagged and
inferior edge of the RUL bronchus and free it removed. With completion of the lymph node
from the bronchus intermedius. Once the anatomy dissection and the lobe completely resected, an
is identified, a Cadiere forceps can be placed “Anchor” bag is inserted into the chest from the
under the RUL bronchus to confirm complete dis- assistant port. The lobe is held freely up in the
section of it. Further lymph node dissection (10R dome of the chest by the thoracic grasper. This is
and 11R, hilar and interlobar) is continued along to utilize gravity to facilitate bagging of the lobe.
the right main bronchus and the bifurcation The Anchor bag is placed below the freely
between the bronchus intermedius with the upper hanging lobe. The lobe is then dropped and
lobe bronchus identified. Encircle the right upper pushed into the bag. Visualize that the complete
lobe bronchus with a vessel loop and transect with specimen is contained in the bag while the assis-
a linear stapler (gold, green, or purple load). Care tant slowly closes the “Anchor” bag. The strings
must be taken to apply only minimal retraction on of the bag are brought out through the 15 mm
the specimen to avoid tearing of any small remain- access port. A small 20 Fr chest tube is placed
ing anterior PA branches. apically and posteriorly via the most anterior port
Next, the posterior segment of the pulmonary and guided into position by the EndoWrist instru-
artery is exposed. The surrounding N1 nodes can ment in the arm. Once completed, CO2 is turned
be removed and the posterior artery can be encir- off and the right thorax vented. The incisions are
cled with a vessel loop and taken with a vascular carefully inspected from inside via the camera to
stapler. A vessel-sealing device or titanium clips make sure there is no venous bleeding that was
applied by the EndoWrist Small Clip Applier tamponaded by the CO2.
could be used if the vessel is less than 6 mm in
size. The only step left is the completion of the
fissure between the upper and middle lobes, Robotic-Assisted Compared
which can be difficult. The anterior aspect of the to Completely Portal
pulmonary artery is carefully inspected to ensure
there are no PA branches remaining. If so these Other series which used a robotic-assisted
are usually quite small and can be easily torn and lobectomy (RAL) technique have come from
must be carefully ligated. The fissure between the Melfi (Italy) and Parks (United States). Recently
right upper lobe and the right middle lobe is now the two have combined their series and reported
taken with a gold or purple stapler. Usually this is long-term follow-up in 2012. In this report,
90 R.J. Cerfolio and A.S. Bryant

Park et al. [4] evaluated 325 patients who

underwent robotic lobectomy for early stage Discussion
NSCLC who also showed minimal morbidity and
mortality. Veronesi and Melfi in 2010 recently Minimally invasive techniques are the future of
reported the safety of a four-arm robotic-assisted thoracic surgery and most all-surgical special-
(RAL-4) lobectomy (using a 3–4 cm access ties. The robot currently represents the ultimate
incision as employed by VATS surgeons) in 54 MIS tool. One of the reasons to perform MIS
patients. However, Melfi now uses a completely includes immunologic benefits that may lead to
portal technique. Dylewski and Ninan in 2010 improved survival for patients with non-small
reported the effectiveness of a completely portal cell lung cancer [5–8]. The adoption of the
robotic lobectomy using three arms (CPRL-3) in robot for pulmonary resection will depend on
74 patients [3, 4]. Survival rates were similar to several factors: the availability of the robotic
those for similar-staged patients who underwent platform to the thoracic surgeon, the true cost
lobectomy by VATS or thoracotomy. of the operation, the measured and perceived
benefit to the patient, hospital, and surgeon, and
the time it takes to perform the operation. Most
Outcomes Review importantly is the surgeon’s current enthusiasm
for the VATS lobectomy that he or she per-
The largest series of a completely portal robotic forms. If a team is already adroit with VATS
lobectomy using four arms was our series pub- lobectomy and they believe that the lymph node
lished in 2011. It had 168 patients that underwent dissection is adequate, the desire to adopt
robotic pulmonary resection of which 104 had a robotic pulmonary resection into their practice
lobectomy. In that paper on patients with NSCLC, will be low. However, if their lymph node dis-
we matched (3–1) to patients who had a pulmonary section during VATS lobectomy was, as in our
resection via nerve- and rib-sparing thoracotomy. experience, suboptimal and difficult to teach,
In that study 16 patient had a CPRS-4 (segmentec- then it will probably be high.
tomy) as well. The results of our study are sum- In conclusion, the current literature shows that
marized in Table 8.1. The technical changes made robotic surgery is safe and efficient and has simi-
were the following: adding the fourth robotic arm lar survival rates compared to the open and VATS
posterior and using a 5 mm port so the surgeon can approaches for patients with NSCLC. The sur-
retract the lung for himself; placing a vessel loop geon can provide an R0 resection in patients with
around the artery, vein, bronchus, and fissures to cancer, even those with large tumors (up to
help guide the stapler; the removal of the tumor 10 cm). In addition, an outstanding mediastinal
above the diaphragm; and using CO2 insufflation. and hilar lymph node resection is achievable.
Results of CPRL-4 after technical modifications Technical modifications have led to decreased
show a trend in reduction of median operative operative times and may improve teachability, as
times and reduction in conversion rates. well as decrease patient morbidity and surgeon

Table 8.1 Summary of results from the CPRL-4 paper

Robotic group Matched group (thoracotomy) P-value
Blood loss (ml) 35 90 0.03
Chest tube duration (days) 1.5 3.0 <0.001
Morbidity 27 % 38 % 0.05
Pain score at 3 weeks postoperatively 2.5/10 4.4/10 0.04
Mortality 0% 3.1 % 0.11
Median hospital length of stay (days) 2.0 4.0 0.02
From Cerfolio RJ, Bryant AS, Skylizard L, Minnich DJ. Initial consecutive experience of completely portal robotic
pulmonary resection with 4 arms. J Thorac Cardiovasc Surg. 2011; 142(4): 740–6 with permission
8 Robotic Pulmonary Resection Using a Completely Portal Four-Arm Technique 91

frustration during the learning curve. Even though robotic pulmonary resection with 4 arms. J Thorac
Cardiovasc Surg. 2011;142(4):740–6.
hospitals are acquiring more robots for other spe-
3. Ninan M, Dylewski MR. Total port-access robot
cialties besides thoracic surgery, the capital cost, assisted pulmonary lobectomy without utility thora-
service contract costs, and equipment costs have cotomy. Eur J Cardiothorac Surg. 2010;38:231–2.
to be carefully considered and studied. Patient 4. Park BJ, Melfi F, Mussi A, Maisonneuve P,
Spaggiari L, Da Silva RK, Veronesi G. Robotic
selection is critical, especially during the learning
lobectomy for non-small cell lung cancer
curve. Surgeon’s teams that are earlier in their (NSCLC): long-term oncologic results. J Thorac
learning should start their robotic experience Cardiovasc Surg. 2012;143:383–9.
with wedge resections and/or mediastinal tumor 5. Mahtabifard A, DeArmond DT, Fuller CB, McKenna
Jr RJ. Video-assisted thoracoscopic surgery for stage
resections. When the team is ready for a lobec-
1 non-small cell lung cancer. Thorac Surg Clin.
tomy, small T1 or T2 lesions should be chosen in 2007;17:223–31.
patients without enlarged or calcified mediastinal 6. Whitson BA, Groth SS, Duval SS, Swanson SJ,
or hilar lymph nodes. The preoperative CT scan Maddaus MA. Surgery for Early Stage Non-small
cell lung cancer: a systematic review of the video-
should be carefully examined and complete fis-
assisted thoracoscopic surgery versus thoracotomy
sures improve attractiveness of early case selec- approach to lobectomy. Ann Thorac Surg. 2008;86:
tion. Finally we believe that lower lobes are a 2008–18.
better place to start than upper lobes. 7. Yan TD, Black D, Bannon PG, McCaughan M.
Systematic review and meta-analysis of randomized
and non-randomized trials on safety and efficacy of
video-assisted thoracic surgery lobectomy for early
References stage non-small cell lung cancer. J Clin Oncol.
2009;27:2553–62.
1. Cerfolio RJ, Dylewski M, Parks Bernard, Veronesi G, 8. Flores RM, Ihekweasu UN, Rizk N, Dycoco BA,
Kernstine K, Melfi F. International consensus paper Bains MS, Downey RJ. Patterns of recurrence and
for definitions and nomenclature for robotic thoracic incidence of second primary tumors after lobectomy
and pulmonary resection. Ann Thorac Surg; 2012. by means of video-assisted thoracoscopic surgery
2. Cerfolio RJ, Bryant AS, Skylizard L, Minnich DJ. (VATS) versus thoracotomy for lung cancer. J Thorac
Initial consecutive experience of completely portal Cardiovasc Surg. 2011;141:59–64.
 Part IV
Surgical Techniques: Stomach
 Gastric Cancer: Partial, Subtotal,
and Total Gastrectomies/Lymph 9
Node Dissection for Gastric
Malignancies

Woo Jin Hyung and Yanghee Woo

Introduction Indications

The management of gastric cancer patients Robotic surgery can be applied to those gastric
requires a multidisciplinary approach with sur- cancer operations where conventional laparo-
gery, the mainstay of curative treatment. Radical scopic approach is indicated [5–10]. Currently,
gastric resection and appropriate lymphadenec- minimally invasive surgery is most commonly
tomy is the standard of care. Operative proce- performed for early gastric cancer patients
dures for gastric cancer can be technically without perigastric lymph node (LN) involve-
challenging especially as minimally invasive ment, and these patients are good candidates
approaches. Many gastric cancer surgeons have for robotic gastrectomy with limited lymphad-
adopted robotic technology to assist them in the enectomy. This is based on the recommenda-
technically challenging procedure of gastrectomy tions of the Japanese gastric cancer treatment
with - lymphadenectomy [1–4]. With additional guidelines and classification [11, 12]. However,
robotic surgery training, experienced laparo- robotic technology may be most ideal for
scopic gastric cancer surgeons can safely provide patients with locally advanced gastric cancer
the advantages of minimally invasive surgery to without evidence of distant metastases that
their patients. Adherence to the oncologic prin- require gastrectomy and D2 lymphadenectomy
ciples of gastric cancer treatment can assure the since robotic surgery provides the advantages
patients that the long-term survival benefits of of increase dexterity of movement for more
surgery will not be compromised. precise dissection along the vessels during
retrieval of perivascular soft tissues containing
N2 lymph nodes [5].
W.J. Hyung, M.D., Ph.D. (*)
Department of Surgery, Yonsei University College Indications for robotic gastrectomy with lim-
of Medicine, 50 Yonsei-ro Seodaemun-gu, Seoul ited lymphadenectomy:
120-752, Republic of Korea • Stage IA (cT1N0M0) by 7th AJCC TNM
e-mail: [email protected]
classification
Y. Woo, M.D. • Mucosal and submucosal tumors not eligible
Division of GI/Endocrine Surgery, Center for
for endoscopic resection
Excellence in Gastric Cancer Care, Columbia
University Medical Center, New York, NY, USA • Failed endoscopic mucosal resection or endo-
scopic submucosal dissection
Department of Surgery, Columbia University College
of Physicians and Surgeons, New York, NY, USA Indications for robotic gastrectomy requiring
D2 lymphadenectomy:
Department of Surgery, New York Presbyterian
Hospital, New York, NY, USA • Stage IB (cT1N1M0; cT2N0M0)
e-mail: [email protected] • Stage IIA (cT2N1M0)

K.C. Kim (ed.), Robotics in General Surgery, DOI 10.1007/978-1-4614-8739-5_9, 95

© Springer Science+Business Media New York 2014
96 W.J. Hyung and Y. Woo

At this time, no evidence is available to sup- Operating Room Configuration

port robotic surgery for serosa-positive tumors
(T4a) or tumors which have invaded adjacent The configuration of the operating room should
organs (T4b) nor for palliative procedures. provide a safe and convenient environment for
the patient and the entire team of surgeons, anes-
thesiologists, scrub technologists, and circulating
Preoperative Work-Up nurses. The optimal configuration of the robot,
the surgeon console, the surgical cart, the anes-
A comprehensive and thorough preoperative thesia cart, the bedside assistant position, and the
work-up of patients undergoing robotic sur- monitors during a robotic gastrectomy is
gery for gastric cancer is essential to guide described relative to the patient on the operating
each step of surgeon’s operation. Preoperative table as the center of the room. Specific charac-
planning for robotic gastric cancer surgery teristics of robotic surgical system and operating
begins with pathologic confirmation of the room configuration have been previously
diagnosis, which should be done by endoscopic described in detail [4, 8–10, 13–17]:
biopsy. The operative planning requires com- • The robot system is placed directly cephalad
plete evaluation of the patient’s clinical status, to the patient with the center of the robotic cart
the identification of the location of the tumor, aligned with the patient’s head.
and the local extent of disease. Therefore, we • The anesthesia cart and the anesthesiologist
recommend that all patients scheduled for are positioned to the left side of the patient’s
robotic gastric cancer operations have at least head for easy access to the patient’s airway.
the following preoperative work-up: • The patient-side assistant stands to the lower
• Upper endoscopy with biopsy (to confirm left side of the patient with the scrub nurse,
diagnosis and identify the location of the scrub table, and the main assistant monitor on
tumor) the opposite side.
• Endoscopic ultrasound (to evaluate for inva- • The vision cart can be placed at the foot of the
sion depth and nodal status) operating table or if space does not allow for
• CT Scan of the abdomen and pelvis (to evalu- this configuration, the vision cart can be
ate for invasion depth, nodal status, and dis- placed to the patient’s upper right.
tant metastasis) • The surgeon console is positioned in the left
lower edge of the operating room to provide
the surgeon with a view of the patient and the
Operative Strategy overall access to the operating room.

Pertinent Anatomy
Patient Positioning, Port Placement,
Robotic gastrectomy and lymphadenectomy Robot Docking, and Preparation
requires an intimate knowledge of the gastric of the Operative Field
anatomy, especially the gastric vessels and the
accompanying nodal stations as defined by the Under general anesthesia the patient is positioned
Japanese Gastric Cancer Association [11, 12]. in supine with arms tucked at both sides. Sequential
The robotic procedural steps are described in compression stockings and urinary catheter are
relation to the dissection of the lymph node sta- placed. The entire abdomen from the nipple line to
tions required for D2 lymphadenectomy and the suprapubic region is prepared and draped in
should not deviate from the standard of care the standard sterile fashion. Five ports, two non-
operations, which are performed both by open or robotic 12 mm trocars and three 8 mm robotic tro-
laparoscopic approaches. cars, are used for robotic gastrectomy (Fig. 9.1).
9 Gastric Cancer: Partial, Subtotal, and Total Gastrectomies/Lymph Node Dissection… 97

tered view of the upper abdomen. This can be done

with either the insertion of an orogastric/nasogas-
tric tube or with a percutaneously placed needle
(e.g., long 18–20 gauge spinal needle) [18].

Liver Retraction
To maximize the full use of the three robotic arms
during robotic gastrectomy, a self-sustaining
retraction of the left lobe of the liver is required.
Proper liver retraction is necessary for adequate
exposure of the hepatoduodenal and hepatogas-
tric ligaments for complete dissection of the
suprapancreatic lymph nodes and clearance of
the soft tissues along the lesser curve of the stom-
ach. Before beginning the dissection for the gas-
trectomy, any of the several described techniques
may be used to retract the liver including the
suture-gauze liver suspension method [19–21].

Fig. 9.1 Ports used for robotic gastrectomy Intraoperative Determination

of the Resection Extent
To determine the extent of resection, intraopera-
The proper placement of the ports are essen- tive tumor localization is required. Most lesions
tial to ease of the robotic arm use during opera- cannot be readily visualized due to the lack of
tion, and therefore, care should be taken to ensure serosal involvement or palpated during a robotic
that the port placement is accurate and adjusted operation. Several methods of intraoperative
for patient’s abdominal wall girth as well as the tumor localization have been employed. These
intra-abdominal anatomy. Once the ports have include preoperative endoscopic tattooing of the
been correctly inserted, the patient is placed in tumor, intraoperative endoscopy [8], or laparo-
15° reverse Trendelenburg position and the surgi- scopic ultrasound [9, 22]. The authors prefer
cal cart is aligned and brought straight in to the using preoperatively placed endoclips and an
head of the patient. The robot arms are ready to intraoperative abdominal x-ray, which has been
be docked as described below. Instruments should found to be very successful [23].
be inserted into the abdominal cavity under direct
visualization as in any laparoscopic operation:
• The camera arm: the infraumbilical port (C) Procedure of Robotic Distal Subtotal
• The 1st arm: curved bipolar Maryland forceps [1] Gastrectomy and D2 LN Dissection
• The 2nd and the 3rd arms: the ultrasonic
shears or a monopolar device and the Cadiere Five Major Steps and Associated
forceps, interchangeably Vascular Landmarks
Three key maneuvers to optimize exposure 1. Left side dissection: left gastroepiploic
and facilitate accurate resection during the main vessels
operation are recommended before proceeding 2. Right side dissection and duodenal transec-
with the main operative procedure. tion: anterior superior pancreaticoduodenal
vein and the right gastroepiploic vessels
Gastric Decompression 3. Hepatoduodenal ligament and suprapancre-
Gastric decompression should be performed to atic dissection: right gastric artery, proper
manipulate the stomach and to make the unclut- hepatic artery, portal vein, and celiac axis
98 W.J. Hyung and Y. Woo

Fig. 9.2 (a) Greater curve

of the stomach is retracted
cephalad and toward the
anterior abdominal wall
creating a fanning effect to
facilitate the greater curve
dissection of the #4 lymph
node station. (b) Division
of the gastrocolic ligament
proximally allows for the
identification of the root of
the LGEA and LGEV and
retrieval of the 4sb

4. Approach to the left gastric vessels and the enter the lesser sac and divide the greater
splenic vessels omentum toward the lower pole of the spleen.
5. Lesser curvature dissection and proximal gas- • Near the lower pole of the spleen, identify,
tric resection ligate, and divide the left gastroepiploic ves-
sels at their roots (Fig. 9.2b).
Left Side Dissection • Identify the first short gastric vessel and clear
The left side dissection begins with a partial the greater curvature of the stomach toward
omentectomy from mid-abdomen toward the left the proximal resection margin.
gastroepiploic vessels along the greater curvature
of the body the stomach. The necessary exposure Right Side Dissection and Duodenal
of the omentum is achieved by grasping the soft Transection
tissues on the edge of the greater curvature of the The second major step moves the focus of the
stomach using the robot arm #3 (Cadiere) and operation to the patient’s right side. Right
pulling superiorly and anteriorly to create a drap- side dissection begins with mobilization of
ing of the greater omentum. This allows for safe the distal stomach from the head of the pan-
division and efficient retrieval of LN stations 4sb creas and dissection of the soft tissues contain-
and 4d (Fig. 9.2a): ing LN station #6. The borders of LN station
• Begin 4–5 cm from the greater curvature of #6 is defined by right gastroepiploic vein
the stomach near the mid-transverse colon and (RGEV), anterior superior pancreaticoduodenal
9 Gastric Cancer: Partial, Subtotal, and Total Gastrectomies/Lymph Node Dissection… 99

Fig. 9.3 The soft tissue

containing lymph node
station #6 has been cleared
above the ASPDV to
identify the root of RGEV
on the head of the pancreas
before ligation and division

vein (ASPDV), and the middle colic vein pancreatic region is one of the most chal-
(MCV) (Fig. 9.3): lenging steps of the D2 lymphadenectomy.
• Release the posterior stomach attachments to After identification and ligation of the
the anterior surface of the pancreas and the right gastric artery, a meticulous and pre-
first portion of the duodenum from the colon. cise dissection along the proper hepatic
• Dissect the soft tissues on the head of the pancreas artery (PHA), the portal vein (PV), and the
until the RGEV and ASPDV are identified. CHA is essential to success. Identify and
• Isolate, ligate, and divide the RGEV as it joins dissect along the PHA to the origin of the
the ASPDV. RGA. Ligate and divide the RGA and
• Retrieve the soft tissues anterior to and supe- retrieve the associated soft tissue of LN
rior to the ASPDV and superior to the MCV station #5 (Fig. 9.4).
on both sides of the RGEV. • Carefully lift and dissect to free the soft tis-
• Identify the right gastroepiploic artery which sues containing LN station #12a, which is
is usually located behind the RGEV ligate and anterior and medial to the PHA and medial to
divide it as it branches from the gastroduode- the PV (Fig. 9.5a).
nal artery (GDA). • Additional exposure with the third arm by
• Release the attachments anterior to the GDA upper lifting of the liver and gentle down-
until the common hepatic artery (CHA). Free ward retraction of the CHA by the assis-
the immediate supraduodenal area using tant maybe necessary during this portion
caution to avoid injury to the GDA and PHA of the procedure.
(4″ × 4″ gauze placed anterior to the GDA may • Continue dissection inferiorly along the PHA
provide a visual mark to identify the area of to clear the soft tissues superior to the CHA,
dissection). The duodenum approximately which contain LN station #8a.
2 cm distal to the pylorus has been cleared, • Identify and ligate left gastric vein, which will
transect using an Endo-linear stapler. become visible during the clearance of the soft
tissues in the suprapancreatic area as it drains
Hepatoduodenal Ligament into the portal vein (Caution: In some cases,
and Suprapancreatic Dissection the left gastric vein drains into the splenic
• Proper en bloc retrieval of soft tissues in vein and can be found running anterior to the
the hepatoduodenal ligament and the supra- splenic artery).
100 W.J. Hyung and Y. Woo

Fig. 9.4 Isolation of the

right gastric artery is being
performing using the
Maryland dissector in arm
#1 (right) with the
harmonic in arm #2 (left)

Fig. 9.5 (a) The portal

vein is exposed in the
hepatoduodenal ligament
after on block lymphad-
enectomy has been
performed to retrieve
lymph node stations 12a
and 8. (b) Dissection is
being carried out along the
celiac axis after division of
the left gastric artery to
retrieve the #9 lymph
nodes
9 Gastric Cancer: Partial, Subtotal, and Total Gastrectomies/Lymph Node Dissection… 101

Fig. 9.6 The soft tissues

along the left gastric artery
(LGA) and splenic vessels
are retrieved as LN station
#7 and #11p, respectively

• Skeletonize the CHA toward the celiac axis to to improve exposure of the remaining attach-
retrieve the soft tissues around the celiac ments of the lesser curvature of the stomach to
artery, which contain LN station #9 (Fig. 9.5b). the retroperitoneum and the diaphragmatic
crus. The soft tissues along the intra-abdominal
Approach to the Left Gastric Artery esophagus, the right cardia, and the lesser cur-
and the Splenic Vessels vature of the stomach containing LN stations
The soft tissues along the left gastric artery #1 and #3 are cleared until the proximal resec-
(LGA) and splenic vessels are retrieved as LN tion margin. Perform the truncal vagotomy at
station #7 and #11p, respectively (Fig. 9.6): this time by dividing the anterior and posterior
• To improve access to the origin of the LGA as branches of the vagus nerve.
it branches from the celiac axis, divide the ret- • Be sure to fully mobilize the stomach from
roperitoneal attachments along the lesser cur- its posterior attachments to prepare for
vature of the stomach. proximal gastric resection. Confirm the
• Using the Cadiere grasper (the robot arm #3), proximal resection line from the greater cur-
grasp the soft tissues containing the distal por- vature to the lesser curvature with sufficient
tion of the LGA by the stomach and lift the ped- margin and divide the stomach using a
icle superiorly and anteriorly to tent up the LGA. 60 mm blue load Endo-linear stapler ensur-
• Clear the soft tissues surrounding the root of ing sufficient proximal margin (Reloads are
the LGA for more complete exposure and usually required).
identification then securely ligate and divide This completes the procedure of robotic D2
the LGA at its root. lymphadenectomy for distal subtotal gastrectomy.
After placing the stomach in the left upper
quadrant, dissect the soft tissues off of the ante-
rior surface of the splenic artery and continue to Procedure of D2 Lymphadenectomy
skeletonize the artery until the splenic vein is During Total Gastrectomy
exposed. Retrieve lymph node station #11p along
the splenic vessels until halfway point is reached. The recommended procedure for advanced gas-
tric adenocarcinoma located in the upper body of
Lesser Curvature Dissection the stomach is a total gastrectomy with D2 lymph-
and Proximal Resection adenectomy. D2 lymphadenectomy for a proxi-
• At this point in the operation, the proximal mal gastric adenocarcinoma requires the retrieval
stomach is freely retracted to the patient’s left of LN #11d (along the distal splenic vessels)
102 W.J. Hyung and Y. Woo

Fig. 9.7 Spleen-preserving total gastrectomy

and LN #10 (in the splenic hilum). The procedure distal pancreas and carefully skeletonizing the
can be performed using two different methods: vessels toward the spleen.
spleen-preserving total gastrectomy or total gas- • To ensure retrieval of the LN #10, completely
trectomy with splenectomy. removal the soft tissues encasing the splenic
Complete dissection of the splenic hilum to hilum must be achieved.
preserve the spleen during LN #10 retrieval is • Then, return to the proximal splenic vessels to
challenging and complex procedure which may retrieve the remaining soft tissues along the
lead to unexpected bleeding and prolonged oper- distal splenic artery and vein for the LN #11p
ative time. While splenectomy-related postopera- and 11d dissection.
tive complications, such as subphrenic abscesses
and post-splenectomy syndrome, are well known
[7], spleen preservation might be recommended Reconstruction
for experienced surgeons.
After robotic gastric resection and complete
Spleen-Preserving Total Gastrectomy lymph node dissection, several methods for cre-
(Fig. 9.7) ation of an intracorporeal or extracorporeal gas-
Robotic spleen-preserving total gastrectomy trointestinal anastomosis have been described.
requires three of the following additional steps: The advantages and disadvantages to each
• After the division of the left gastroepiploic approach exist. The surgical extent and surgeon’s
vessels, the dissection continues along the preference dictate the selection of the gastroin-
greater curvature of the stomach to ligate and testinal reconstruction after robotic gastric cancer
divide the short gastric vessels. The esophago- surgery. In general, stapled anastomoses are pre-
phrenic ligament is released to completely ferred as it is less time consuming, but sutured
free the left side of the stomach. This portion anastomosis using robot assistance is another
of the procedure is facilitated by retracting the option [8]. Reconstruction using the stapling
stomach to the right side of the patient to device requires the patient-side assistant and can
expose the left diaphragmatic crus. be an opportunity for a hybrid operation.
• Approach to the splenic hilum by first identi- Therefore, many methods used during laparo-
fying the distal splenic vessels dorsal to the scopic gastroduodenostomy, gastrojejunostomy,
9 Gastric Cancer: Partial, Subtotal, and Total Gastrectomies/Lymph Node Dissection… 103

and esophagojejunostomy can be applied after nectomy than for D1 lymphadenectomy. Improved
robotic gastric resections [3, 4, 9–11]: surgical outcomes have been reported with spleen-
• Gastroduodenostomy, gastrojejunostomy, or preserving total gastrectomies when compared to
Roux-en-Y gastrojejunostomy total gastrectomy with splenectomy. No differences
• Intracorporeal or extracorporeal in complication rates have been found between lap-
• Linear or circular staplers including transoral aroscopic and robotic gastric cancer surgeries.
anvil placement Other possible complications are:
• Intra-abdominal fluid collections/abscesses
• Intraluminal and intra-abdominal bleeding
Postoperative Management • Pancreatitis/pancreatic leak/pancreatic fistula
• Anastomotic leak/stricture
Postoperative management of patients who have • Gastroparesis or ileus
undergone robotic gastrectomy is identical to • Obstruction
those patients who have undergone a laparoscopic
gastrectomy for gastric cancer. The patients are
monitored for ability for oral intake while given Benefits for the Patient
appropriate fluid maintenance, pain control, deep
vein thrombosis prophylaxis, and blood tests: • Less pain
• Gastrointestinal function is expected to return • Shorter length of hospital stay
approximately in 3 days after operation in • Decreased blood loss
patients without complications. • Faster gastrointestinal recovery
• Oral intake is resumed on postoperative day • Faster physical recovery
(POD) 2 and advanced as tolerated usually to • Better quality of life after surgery
liquid diet (POD3), soft diet (POD4), and reg- • Better cosmesis
ular diet (POD5).
• Median length of hospital stay is usually 5
days without complications. Benefits for the Surgeon

The robotic surgery system facilitates the process

Complications of performing laparoscopic surgery and provides
the surgeon with ergonomics, 3D view, control of
The reported complication rates for robotic gas- 4 arms, and accuracy of dissection, shorter learn-
trectomy vary. The largest series evaluating the ing curve that is provided by the inherent functions
short-term outcomes of robotic and laparoscopic of the robotic system. This computer-enhanced
gastric cancer surgery report wound-related surgical system thus allows surgeons to overcome
issues, intraluminal bleeding, and anastomotic various difficulties of laparoscopic surgery [4, 8].
leakage to be the most common complications The benefits specific to robotic gastric cancer
encountered after robotic gastrectomies [1]. operation is realized during the most difficult por-
These complications are not directly related to tions of the procedure including the dissection of
robot assistance since the ports placements and the splenic vessels, isolation of the esophageal
anastomoses are not performed using the robot. crux, and the suprapancreatic lymphadenectomy.
In general the morbidity and mortality associ-
ated with radical gastrectomies depend on the extent
of resection, LN dissection, experience of the sur- Dissection of Splenic Vessels
geon, and the experience of the institution where the
surgery is being performed [12–14]. Many of the The small branches of the splenic vessels are eas-
complications are related to the extent of LN dissec- ily identified and preserved allowing a pancreas–
tion and expectedly are higher with D2 lymphade- spleen-preserving D2 lymph node dissection,
104 W.J. Hyung and Y. Woo

thanks to image magnification, tremor filtering, controversial. Dissection of LN #14v had been a
and fine circumferential robotic arm movements. part of D2 gastrectomy defined by the 2nd edition
This approach allows surgeons to drive the vas- of the Japanese classification, but it has been
cular dissection around and to completely clear excluded from the latest edition [11]. However,
the lymphatic tissue without any vascular injury D2 (+ No. 14v) may be beneficial in tumors with
with minimal intraoperative bleeding [13, 14]. apparent metastasis to the LN # 6.

Disadvantages
Isolation of Diaphragmatic Crura • Longer operative time
• Initial cost of robot for hospital
It is a fundamental step to an en bloc dissection of • Financial burden to patient
cardia lymph nodes and is greatly facilitated by • Limited training opportunities
wristed instruments that allow complete encir-
cling of the distal esophagus [13, 15]. Moreover,
the four-arm robotic surgery system will facilitate Results
the insertion of the anvil head into the esophageal
stump that could be not so easy to do in conven- Robotic surgery for gastric cancer treatment is a
tional laparoscopy [15], and esophagojejunos- relative novel, but experience in the field is grow-
tomy, which is usually performed in the deep and ing. While many studies have studied laparoscopic
narrow space of the abdominal cavity, is feasible versus open gastric cancer surgery and demon-
to execute by the robot-sewing technique [24]. strated many benefits of minimally invasive sur-
gery without the loss of oncologic standards, the
evaluation of the robotic approach to treatment of
Lymphadenectomy Include LN #14v, gastric cancer patients is in its infant stages. Phase
#8a, #9, #11p, #11d, and #12a III clinical trials support the safety and effective-
ness of LG with lymph node dissection for the
Relatively difficult areas to access during laparo- treatment of patients with EGC [6]. Laparoscopic
scopic lymphadenectomy include LN #14v, #8a, gastric cancer surgery has been shown to produce
#9, and #11. Moreover, the infrapyloric area and better early postoperative outcome than conven-
the superior mesenteric vein, including LN sta- tional open surgery with comparative long-term
tions #6 and #14v, are the most frequent sources survival. Robotic system is a new technology that
of intraoperative bleeding, while the suprapan- holds significant promises for facilitating laparo-
creatic area including stations #7, #8a, and #9 is scopic treatment of gastric cancer, although scien-
the second most frequent source [13, 25]. If the tific evidence is still lacking.
dissection along these vessels is easily conducted,
the risk of bleeding can be reduced and lymphad-
enectomy can be better performed. The Outcomes Review
EndoWrist, tremor filtration, stable operative
platform, and three-dimensional vision offered The currently available studies are summarized.
by the robotic surgical system aid the surgeon to Ten case series evaluating robotic gastric cancer
perform a more accurate lymph nodes and ves- surgery with a total of 299 patients have been pub-
sels dissection [25]. lished between 2007 and 2012 (Table 9.1) [9, 13,
Some authors have recently reported a new 15–17, 26–30]. The two largest studies were by
integrated robotic approach for suprapancreatic Song et al. [9] in 2009 in which they summarized
D2 nodal dissection that appears to be safe and their initial 100 cases of robot-assisted gastrec-
feasible, even though the number of patients in tomy with lymph node dissection followed by
the study was small [26]. Actually, the role of LN another one [17] in 2011 with 61 patients. In gen-
#14v lymphadenectomy in distal gastric cancer is eral, these case series supported the safety and
 9

Table 9.1 Casa series of RG for gastric cancer

Author/year No. of patients Type of surgery (STG/TG) D2 LN dissection Mean OT (min) Mean EBL (ml) No. of resected LN LOS (days) Morbidity %
Anderson et al. 7 7/0 – 420 300 24 (17–30) 4 (3–9) 14.3
[16]
Patriti et al. [15] 13 9/4 13 286.0 103.0 28.1 ± 8.3 11.2 ± 4.3 46.2
Song et al. [9] 100 67/33 42 231.3 128.2 36.7 ± 13.3 (11–83) 7.8 (5–175) 14
Hur et al. [24] 7 5/2 0 205 – 36 9 14
Liu et al. [27] 9 2/5 (1WG + 1PG) – 150–440 10–100 19–24 (D1) 28–38 – 11
(D2)
Isogaki et al. [17] 61 46/14 (1PG) 39 388 (STG) 61.8 (STG) 43 ± 14 (TG) 13.3 (8–43) 4
520 (TG) 150 (TG) 42 ± 18 (STG)
D’Annibale et al. 24 13/11 24 267.5 30 28 (23–34) 6 (5–8) 8
[13]
Lee et al. [28] 12 12/0 0 253 135 46 (21–115) 6.6 ± 1.6 8
Yu et al. [29] 41 29/12 – 225 (STG) 150 ± 127 (STG) 34.2 ± 18.5 – 5
285 (TG) 180 ± 157 (TG)
Uyama et al. [26] 25 25/0 18 361 51.8 ± 38.2 (4–123) 44.3 ± 18.4 (26–95) 12.1 ± 3.2 11.2
TG total gastrectomy, STG subtotal gastrectomy, WG wedge resection, PG proximal gastrectomy, OT operative time, LOS length of hospital stay, EBL estimated blood loss
Gastric Cancer: Partial, Subtotal, and Total Gastrectomies/Lymph Node Dissection…
105
106 W.J. Hyung and Y. Woo

Table 9.2 NRCT robotic versus open gastrectomy for gastric cancer
Author/year Pernazza et al. [33] Caruso et al. [31]
Approach (R/O) R O R O
No. of patients 45 45 29 120
Resection type (STG/TG) 21/24 – 17/12 83/37
D2 LND 45 – 29 120
No. LN examined 34 – 28 32
EBL (ml) – – 198 ± 202 386 ± 96
LOS (days) – – 9.6 ± 2.8 13.4 ± 8.5
Morbidity (%) 24.5 13.3 41.4 42.5
Mortality (30 days, %) 4.4 8.9 0 3.3
Median follow-up (months) 26 26 25 44
R robotic, O open, TG total gastrectomy, STG subtotal gastrectomy, OT operative time

feasibility of robotic gastric cancer operations. Investigations comparing robotic gastrectomy

Robotic gastrectomy with D2-lymphadenectomy versus laparoscopic gastrectomy (Table 9.3) and
demonstrated adequate lymph node harvest and robotic gastrectomy versus laparoscopic
optimal R0-resection rates with low postoperative gastrectomy versus open gastrectomy (Table 9.4)
morbidity and short hospital stays [13, 16, 28]. have resulted in several publications most of
Several retrospective studies from Europe and which were conducted in early gastric cancer
Asia have compared the use of robotic gastrec- with the exception of one study which included
tomy with laparoscopic or open approaches. advanced gastric cancer patients.
Again, these studies concluded that D2 lymph All reports included patient characteristics,
node dissection is technically feasible [31] and intraoperative factors, postoperative complications,
had the benefit of less operative blood loss and and oncologic parameters. Kim et al. [25] was the
shorter postoperative hospital stay than laparo- first to compare robotic technique with both the
scopic and open gastrectomy groups [32]. Most open and laparoscopic ones in a small group of
common robotic disadvantages were found to be patients. According to the authors, robotic gastrec-
longer operative time, higher costs, loss of tactile tomy offers better short-term surgical outcomes
sensation, and the lack of oncologic results and than the open and laparoscopic methods in terms of
long-term outcomes. blood loss and hospital stay. The largest of the stud-
Subsequently, two studies compared robotic ies involving 236 robotic gastrectomies and 591
gastrectomy and open gastrectomy for gastric can- laparoscopic gastrectomies, while not randomized,
cer (Table 9.2). For the first time, Pernazza et al. supported outcomes of several of the smaller stud-
compared survival between the two groups with a ies, which found less blood loss and shorter hospi-
mean follow-up of 26 months and found no differ- tal stay in the robotic gastrectomy group. Moreover,
ence [33]. The second study conducted using a a study by Woo et al. demonstrated that robotic
strictly matched-case-controlled method demon- approach permits the experienced surgeon to fol-
strated no significant difference between the num- low oncologic parameters [36]. All resection mar-
ber of lymph nodes obtained during the gins in the robotic gastrectomy group were negative
laparoscopic and open procedures [31]. In addi- for cancer involvement and the number of lymph
tion, all resected margins in this study were free of nodes retrieved per extent of robotic dissection was
tumor in the robotic group, whereas tumor involve- sufficient and did not differ from the laparoscopic
ment was present in the margin of two specimens gastrectomy group. While these studies show
in the open group. The conclusion of this trial is promising results for robotic gastric cancer opera-
that robot-assisted gastric with D2 lymph node tions, the studies reveal a much longer operative
dissection is safe, technically feasible, and onco- time using the robotic approach and still long-term
logically effective compared to open surgery. oncologic outcomes results.
 9

Table 9.3 NRCT Robotic versus laparoscopic gastrectomy for gastric cancer [34]
Type of No of Type of surgery
Author/year approach patients (STG/TG/) D2 LN dissection (/) No. of resected LN OT (min) Blood loss (ml) Hospital stay (days) Morbidity %
Pugliese et al. R 18 18 18 25 ± 4.5 (18–40) 344 ± 62 90 ± 48 (50–200) 10 ± 3 (10–13) 6
[34] (240–460)
L 52 0/52 52 31 ± 8 (20–45) 235 ± 23 148 ± 53 10 ± 2.6 (7–24) 12.5
(145–360) (45–250)
Eom et al. R 30 0/30 20 30.2 (13–60) 229.1 (165–307) 152.8 (10–500) 7.9 (7–20) 13
[35]
L 62 0/62 34 33.4 (10–67) 189.4 (125–272) 88.3 (10–400) 7.8 (5–17) 6
Woo et al. R 236 62/172 105 39.0 219.5 91.6 7.7 11
[36]
L 591 108/481 279 37.4 170.7 147.9 7.0 13.7
Yoon et al. R 36 36/0 – 42.8 ± 12.7 305.8 ± 115.8 – 8.8 ± 3.3 16.7
[30]
L 65 65/0 – 39.4 ± 13.4 210.2 ± 57.7 – 10.3 ± 10.8 15.4
R robotic, L laparoscopic, TG total gastrectomy, STG subtotal gastrectomy, OT operative time
Gastric Cancer: Partial, Subtotal, and Total Gastrectomies/Lymph Node Dissection…
107
108 W.J. Hyung and Y. Woo

Table 9.4 NRCT robotic versus laparoscopic versus open gastrectomy for gastric cancer
Author/year Kim et al. [25] Huang et al. [35]
Approach (R/O) R L O R L O
No. of patients 16 11 12 39 64 586
Resection type (STG/TG) 16/0 11/0 12/0 32/7 34/5 407/179
Extent of LND (D1 + α or β/D2) 2/14 3/8 0/12 5/34 120
OT (min) 259 204 127 430 350 320
No. LN examined 41.1 ± 10.9 37.4 ± 10.0 43.3 ± 10.4 32.0 + 13.7 26.0 + 12.4 34.0 + 14.8
EBL (ml) 30 45 45 50 100 400
LOS (days) 5 7 7 7 11 12
Morbidity (%) 0 9 16 15 16 15
R robotic, L laparoscopic, O open, TG total gastrectomy, STG subtotal gastrectomy, OT operative time

laparoscopic surgery for gastric cancer will be

Future Aspects necessary. As robotic surgical systems are
advancements in technology, an improved tool to
Operative Time and Costs perform more precise and accurate laparoscopic
surgery, surgeons and patients may not wait for
A major concern regarding robotic gastric cancer the results of such potential studies.
surgery as with other operations is the signifi- Moreover, it is expected that the rapid devel-
cantly longer operating time and higher costs opment of surgical technology will provide more
associated with robotic surgery when compared useful diagnostic and therapeutic tools to benefit
to the open and laparoscopic approaches. As both the patients as well as the surgeons in the
studies have demonstrated, it is expected that near future. In the meantime, the surgeons are
once the surgeon and the robotic surgical team pushing the frontier of robotic surgical systems
overcome the initial learning curve the operation application and in the treatment of gastric cancer
time will be improved. it will be in its role in the treatment of advanced
The cost remains a major issue. A detailed anal- gastric cancers. In the near future, new approaches
ysis of the actual overall cost of undergoing a to gastric cancer management will provide novel
robotic gastrectomy is still lacking and maybe dif- opportunities of treatment, including improved
ficult to determine, especially since healthcare chemotherapeutic agents, more effective combi-
prices vary to widely among the many countries nations, immunochemotherapy, and molecular-
where robotic gastric cancer operations are cur- targeted therapies. In this context, minimally
rently being performed. Currently, prospective mul- invasive surgery could play a key role in improv-
ticenter studies comparing the cost-effectiveness of ing postoperative course and accelerating times
open versus laparoscopic gastrectomy [3] and to adjuvant treatments [15], and especially
robotic versus laparoscopic gastrectomy for gastric robotic surgery might be a correct alternative to
cancer are planned as secondary outcomes of more laparoscopic approach or the first choice for
comprehensive study designs (ClinicalTrials.gov. selected cases.
Identifier NCT01309256).

Conclusions
Oncologic Outcomes
Robotic surgery for gastric cancer is a safe and
Multicenter, randomized, controlled trials are feasible operation. The short-term benefits of
undoubtedly needed to establish the oncologic robotic gastrectomy parallel that of laparoscopy.
adequacy of most new drugs. However, it is Surgical oncologists who treat gastric cancer
unlikely that such a trial comparing robotic versus patients can readily adhere to the oncologic
9 Gastric Cancer: Partial, Subtotal, and Total Gastrectomies/Lymph Node Dissection… 109

principles of gastric cancer treatment including tric cancer: surgical technique and preliminary results.
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 Part V
Surgical Techniques: Bariatric
 Robotic Roux-en-Y Gastric Bypass
10
Erik B. Wilson, Hossein Bagshahi,
and Vicky D. Woodruff

remaining stomach and first segment of the small

Overview intestine. In 1994 Drs. Wittgrove and Clark per-
formed the first laparoscopic Roux-en-Y which
The gastric bypass procedure was initially enabled precise manipulation of tissue and
developed in the 1960s by Drs. Mason and Ito [1] enhanced the visual field [2]. Unfortunately, it
and based on the weight loss observed after ulcer also introduced significant postural stresses on
treatment in which patients had part of the stom- the surgeon due to the body habitus of the patient.
ach removed. Over the ensuing decades the pro- The advent of robotic-assisted Roux-en-Y gastric
cedure has been modified into the current form bypass in 2001 eliminated the stresses on the sur-
using a Roux-en-Y limb of intestine to produce geon and introduced several additional enhance-
the Roux-en-Y gastric bypass (RYGBP), some- ments [3]. Minimally invasive surgeons who
times referred to as proximal gastric bypass. The adopted robotic digital platforms early on have
Roux-en-Y connects a limb of the intestine to a developed refinement of techniques and proto-
much smaller stomach pouch which prevents the cols that lead to safe and effective applications
bile from entering the upper part of the stomach for Roux-en-Y gastric bypass with very low
and esophagus, thereby effectively bypassing the reported morbidity and mortality [4].
This chapter provides a procedure overview
and explores our experience with (1) patient posi-
E.B. Wilson, M.D. (*)
Department of Surgery, University of Texas Health tioning, (2) trocar placement, (3) a step-by-step
Science Center/Memorial Hermann Hospital, account of the full robotic-assisted procedure,
6431 Fannin Street, MSB4.162, Houston, and (4) advantages and limitations of robotic-
TX 77030, USA
assisted RYGBP.
e-mail: [email protected]
H. Bagshahi, M.D.
Department of Surgery, Harris Methodist Hospital,
800 Fifth Avenue, Suite 404, Fort Worth, Procedure Overview
TX 76104, USA
Reshape Bariatric and General Surgery of Fort Worth, Roux-en-Y gastric bypass for morbid obesity is
800 Fifth Avenue, Suite 404, Fort Worth, ranked in the top three most challenging advanced
TX 76104, USA minimally invasive procedures in modern general
e-mail: [email protected]
surgery [4]. As such, technique variations have
V.D. Woodruff, Ph.D. developed and a robust discussion has revolved
Department of Surgery, University of Texas Health
around creating the gastric pouch, gastrojejunal
Science Center, 6431 Fannin Street, Suite 4.294,
Houston, TX 77030, USA anastomosis, and jejunojejunal anastomosis. This
e-mail: [email protected] chapter discusses a full robotic-assisted approach

K.C. Kim (ed.), Robotics in General Surgery, DOI 10.1007/978-1-4614-8739-5_10, 113

© Springer Science+Business Media New York 2014
114 E.B. Wilson et al.

Fig. 10.1 Parallel docking view showing foot of patient Fig. 10.2 Parallel docking view showing position of
anesthesiologist with head of patient accessible

to dissect and create the gastric pouch, to create a

two-layered hand-sewn gastrojejunal anastomo- Trocar Placement
sis, and to perform a jejunojejunal anastomosis
with a 60 mm linear stapler. Robotic assistance A total of five or six trocar ports are placed for
then hand-sews the common enterotomy defect robotic-assisted RYGBP. The order of placement
and closure of the mesenteric defects. The details is shown in Figs. 10.3 and 10.4 and is as follows
of the procedure are explored in this chapter. (1) a peritoneal entry with a zero degree scope on
a 5 mm optical viewing in the right upper quad-
rant just to the right of the midclavicular line, one
Patient Positioning finger width below the costal margin—this port is
subsequently changed to the robotic “number two
Early in our experience we adopted a modifica- arm” after all other ports have been placed, (2) a
tion to the traditional cart position (over the 12 mm umbilical port for the robotic camera, (3)
patient’s head with both arms extended outward). a 5 mm left upper quadrant port placed at the level
The “parallel-docking” (Figs. 10.1 and 10.2) posi- of the umbilicus at the anterior axillary line with
tion with the patient’s right arm extended allows the “number three robotic arm” docked, (4) the
better access for anesthesia while leaving the head area between the umbilical port and left anterior
access open for intraoperative endoscopy and a axillary line port is bisected and an 8 mm robotic
leak test, performed at the end of the procedure. port is placed with the “number one robotic arm”
Prior to docking the robotic arms, a footboard is docked, (5) a 12 mm right mid-abdominal assis-
positioned and 20° reverse Trendelenburg is used. tant port is placed halfway between the umbilical
Finally, a gastric lavage tube is placed preopera- port and the RUQ port, and (6) if the liver is small,
tively to facilitate pouch creation and to stent the we prefer to use a 3 mm retractor or an internal
gastrojejunal anastomosis while sewing. liver retractor fashioned out of a Penrose drain
10 Robotic Roux-en-Y Gastric Bypass 115

and sutures (Fig. 10.5), reducing the need for an docked. This trocar placement allows for the
epigastric incision. A sixth port is created if the Roux-en-Y gastric bypass procedure to be accom-
liver is large, in which case an epigastric incision plished without the reported challenge of moving
is made to facilitate a Nathanson liver retractor the robot from one quadrant to another. Both
(Fig. 10.5) in order to elevate the left lateral lobe. upper and lower quadrants are easily visible and
When completed, the patient cart is ready to be manageable for work without re-placing trocars
and extending surgical and anesthesia time.

Three-Step Procedure

Step 1: Creation of the Gastric Pouch

The angle of His is identified with the fundus

retracted laterally. The peritoneum, over the
angle of His, is dissected with ultrasonic shears
or scissors and carried posterior to identify the
path for a linear stapler and the left crus of the
diaphragm. Next, the pars flaccida is identified
and opened. At this point it is important to iden-
tify the left gastric artery and its branches onto
the lesser curve for preservation, as this will be
the main blood supply to the gastric pouch and
the gastrojejunal anastomosis. The mesentery to
the lesser curve of the stomach is divided by a
vascular load linear stapler. A retrogastric plane
in the lesser curve is then created and the dissec-
tion is carried up to the angle of His. Once
accomplished, two serial applications of a
60 mm linear stapler are used to create a 20 mL
Fig. 10.3 Diagram of port placement gastric pouch.

Fig. 10.4 Nathanson liver

retractor
116 E.B. Wilson et al.

Fig. 10.5 Internal liver

retractor

Step 2: Creation of the Gastrojejunal advanced under guidance of the operating surgeon
Anastomosis into the jejunum and facilitates sewing the
remainder of the gastrojejunostomy. Once the
The greater omentum is divided with an ultrasonic inner layer is completed, the anterior outer layer
scalpel, to the level of the transverse colon. The is constructed with the same running suture from
proximal jejunum is identified at the ligament of the posterior outer layer that was left in situ. It is
Treitz and extended into the upper abdomen. It is typical that the outer and inner layers are both
critical to ensure that an adequate length of jeju- done with a continuous running suture.
num is measured to avoid tension on the anasto-
mosis (approximately 50–70 cm is suggested). It
is equally important to properly orient the jeju- Step Three: Creation
num so that proximal and distal ends are not mis- of the Jejunojejunostomy
identified during the creation of the gastrojejunal
anastomosis. We prefer to create an approximate 150 cm Roux
Once the area to be anastomosed has been limb. The Roux limb is measured out and draped
identified, the number three robotic arm is used into the RUQ. The number three robotic arm is
to maintain and properly orient the jejunum in the utilized to place a stay suture at the estimated dis-
upper abdomen. The outer posterior layer of the tal staple line and line up the bowel with the
anastomosis is created first using a long 2-0 direction of the linear stapler. A harmonic scalpel
Vicryl suture. After the posterior outer layer is is then used to make the enterotomies, followed
completed, the suture and needle are left in situ by a 60 mm linear stapler to create the anastomo-
and attention is focused on constructing the inner sis. The common enterotomy that remains is
layer of the gastrojejunal anastomosis. Using the closed with a single running layer of 2-0 Vicryl.
number two robotic arm, the gastrotomy and After the creation of the jejunojejunostomy, a
enterotomy are performed with 8 mm robotic silk suture is used to close the mesenteric defect
scissors while monopolar cautery is activated. between the Roux limb and the biliary limb of the
The inner layer of the anastomosis is also per- small bowel. At this point, an intraoperative
formed with a running 2-0 Vicryl suture. Once endoscopy is performed to evaluate a gastrojeju-
the bowel has been opened, the posterior inner nostomy. This ensures passage of the gastroscope
row is created. After this step has been per- into the Roux limb and ensures passage is airtight.
formed, the gastric tube placed preoperatively is The robot is then undocked.
10 Robotic Roux-en-Y Gastric Bypass 117

was in patients with a BMI >43 kg/m2, for whom

Advantages to Robotic-Assisted the difference in procedure time was 29.6 min
Roux-en-Y Gastric Bypass (RARYGB) faster for RARYGB (p = 0.009) [12].
Snyder et al. reported a nonrandomized cohort
A comparison of complication rates against study of 356 LRYGB cases against 249 RARYGB
standard laparoscopic techniques shows lower which directly compared laparoscopic hand-
morbidity and mortality rates for robotic proce- sewn versus robotic hand-sewn gastrojejunosto-
dures [5]. A study by Yu et al. reviewed the first mies. Demographics showed no difference
100 robotic gastric bypasses during surgeons’ between the two patient populations, mortality
learning curves and found no anastomotic leaks was nonexistent in both groups, and major com-
and no mortality [6]. Standard laparoscopic gas- plication rates were similar between the two
trointestinal leak rates are commonly reported up groups. Conversely, the gastrointestinal leak rate
to 6.3 % and mortality up to 2 % [7, 8]. A series was 1.7 % for LRYGB and 0 % for RARYGB,
of studies between 2002 and 2008 presented data which was significantly lower in the robotic
on operative times and complications after robot- group (p = 0.04), emphasizing a clinical benefit
ically assisted Roux-en-Y gastric bypass [3, 6, from the precision of robotics [6].
8–11]. A total of 603 patients received either The advantages that directly benefit the sur-
totally robotic (129 patients) or a hybrid robotic geon include a relief from painful ergonomic
procedure (474 patients). An average operative positioning and postures that affect the neck,
time of 201 min was long; however, the leak rate shoulders, and back. The superior upper abdomi-
was significantly low at 0.3 % (2 fistulas or nal visualization allows for robotic preciseness
leaks). This was remarkable since the current-day and eliminates shying away from the challenges
literature reported fistula and leak rates at 6.7 % that come from patients with prior surgery in the
[8]. The safety of the robotic operation was abdominal area. In the morbidly obese patient,
supported with a 0 % 30 day mortality. At the the surgeon enjoys a notable advantage from
time, the hybrid procedure, consisting of robotic robotics regarding improved mechanical effi-
gastrojejunostomy and laparoscopy for the ciency against large thick abdominal walls and
remainder of the case, was more popular. large livers, due to fatty infiltration. In these
However, Wilson reported, “Since 2008, the totally cases, robotics allows for more precise recon-
robotic approach has become more common with struction of the anatomy and effectively working
improved instruments and techniques where the in small spaces where laparoscopy struggles.
robot is docked at the beginning of the case and
the console surgeon performs the entire proce-
dure with the help of a bedside assistant to deploy Limitations to Robotic Roux-en-Y
any staplers needed for creations of the gastric Gastric Bypass
pouch and intestinal reconstruction (described
earlier)” [4]. Additionally, the advent of the Literature repeats limitations associated with the
FDA’s approval of the robotic stapler has created steep learning curve for manipulating the robot
the potential for a completely robotic one-surgeon between 12 and 15 cases to normalize outcomes,
operation, reducing the need for skilled bedside extended time to dock the robot, difficulty mov-
assistance. ing between quadrants, and lack of tactile sense
Reduced operative times are another advan- [6, 11]. Certainly, learning new technology and
tage, once the learning curve is overcome. skills can take time; however, surveys of robotic
Sanchez et al. recounted a randomized trial of general surgeons show the learning curve is
RARYGB versus LRYGB with significantly related primarily to the setup and docking of the
shorter operative times for the robotic approach. system and this improves with training.
The RARYGB took 130.8 min versus 149.4 min Performing Roux-en-Y gastric bypass at a con-
for the LRYGB (p = 0.02). The largest difference sole requires the surgeon to follow the same
118 E.B. Wilson et al.

principles and knowledge based on open and time was 155 min. There were no conversions.
laparoscopic surgery. The mean body mass index was 39.8 kg/m2 at
It is the suggestion of our practice that sur- 3 months postoperatively (70 % follow-up).
geons new to robotics first pay close attention to Complications were few and included 1 case of
proper patient selection, initially screening out gastrojejunal anastomotic leak (0.09 %) and
patients with BMIs ≥40 until a proficient skill 4 strictures (0.36 %). The mortality rate was zero.
level is achieved. Additionally, we suggest a More recently, we reported outcomes of 1,695
hybrid approach to perform different steps of a cases of RARYGB from 3 high-volume centers
gastric bypass until adequate skills are developed in Texas, Maine, and Florida. Mortality for the
to perform the bypass totally robotically [13–15]. series was zero at 30 days with 2 leaks (0.12 %)
The hybrid approach docks the robot for a smaller and 3 abscesses (0.18 %) [13, 17]. If leaks and
portion of the case and as more experience is abscesses were combined (5 total), the 0.29 %
added, the robot is utilized for a greater portion of remains an exceptionally low infection rate after
the procedure until total robotic bypass is gastric bypass, which is favorable against any
achieved. A parallel approach suggests that early leak rates reported in the literature. Stricture
on, many surgeons are best suited to dock only 3 requiring dilation was also low at 0.29 %. These
arms of the system until the potential trocar and data support the RARYGB is translatable and
arm interference issues are understood and man- reproducible in other practices and hospitals with
aged. The forth arm may be added after the pro- continued outstanding results.
cedure has been tried and analyzed. In the end, Lastly, a common perception is that because
robotic surgeons need to evolve their procedures the surgeon cannot tactically feel the tissue
because a standard robotic approach does not directly, or indirectly as with laparoscopic instru-
usually exist [4]. ments, the robot is dangerous. Actually, there are
While it is generally accepted that RARYGB some crude haptics that occur if the instruments
has a reported learning curve phase, few studies bump or hit each other, transmitting a tactile sen-
have published length of operative times during sation back to the surgeon’s console. Otherwise,
this ramp-up period. To provide to address this the concern is valid to the point that the surgeon
oversight, we first reviewed our initial learning must maintain visual contact through the monitor
curve cases to find operative times ranged from to guide the instrumentation and ensure appro-
148 to 437 min, with a mean of 254 min [16]. priate and safe manipulation is preserved. Even
These times reflect a hybrid laparoscopic and so, it has been our experience that as time work-
robotic approach due to early learning and ing with the robot is logged, the visual cues
account for the extended times. There were no become so strong a faux tactile sensation can be
leaks or deaths. Four patients had one complica- realized. Until then, the trade-off is better control
tion each, comprised of reoperation, incisional over the surgical instruments and a better view of
hernia, pulmonary embolus, and recurrent umbil- the surgical site.
ical hernia. We contend these results demonstrate
the feasibility and safety during the learning
curve phase of RARYGB. With 800 additional Conclusion
cases performed, our mean operating time is
90 min and continuing to move downward. The future is fast approaching with the advent of
A common argument, however, is that cases single incision or natural orifice approaches as
are not reproducible to other surgeons and prac- well as new integrated fluorescence imaging
tices. Tieu et al. looked at outcomes from 1,100 capability that provides real-time, image-guided
consecutive RARYGB cases at 2 high-volume identification of key anatomical landmarks using
centers that routinely perform RARYGB located near-infrared technology. Interactive digital plat-
in the Houston Texas Medical Center and a pri- forms between the robot, digital medical records,
vate practice in Maine [17]. The mean operative and digital imaging are already being designed.
10 Robotic Roux-en-Y Gastric Bypass 119

This capability may allow access to preoperative 6. Yu SC, Clapp BL, Lee MJ, et al. Robotic assistance
provides excellent outcomes during the learning curve
CAT scans or MRIs at the push of a button that
for laparoscopic Roux-en-Y bypass: result from 100
will direct the surgeon away from potential dan- robotic assisted gastric bypasses. Am J Surg. 2006;
ger or navigate through visceral fat, safely behind 192(6):746–9.
organs and anatomic structures to the point of 7. Flum DR, Salem L, Elrod JA, et al. Early mortality
among medicare beneficiaries undergoing bariatric
interest. The bottom line is that robotic-assisted
surgical procedures. JAMA. 2005;294(15):1903–8.
surgery extends the capabilities of minimally 8. Blachar A, Federle MP, Pealer KM, et al.
invasive surgeons with the added benefit of stable Gastrointestinal complications of laparoscopic Roux-
3D visualization and increased dexterity. en-Y gastric bypass surgery. Radiology. 2002;223(3):
625–32.
RARYGB is safe and effective and reduces the
9. Mohr CJ, Nadzam GS, Alami RS, Sanchez BR, Curet
learning curve of gastric bypass. Although the MJ. Totally robotic laparoscopic Roux-en-Y Gastric
operative time might be increased initially, the bypass: results from 75 patients. Obes Surg. 2006;
complication rates, most notably of anastomotic 16(6):690–6.
10. Hagen ME, Inan I, Pugen F, Morel P. The da Vinci
leak, are extremely low.
surgical system in digestive surgery. Rev Med Suisse.
There remain concerns about costs, but as 2007;3(117):1622–6.
more industry investments continue and more 11. Buchs NC, Pugin F, Bucher P, Hagen ME, Chassot G,
competition develops in this area, robotics will Koutny-Gong P, Morel P. Learning curve for robot-
assisted Roux-en-Y gastric bypass. Surg Endosc.
become the primary mechanism for surgical inter-
2012;26(4):1116–21.
action with a patient, because a digital platform 12. Parini U, Fabozzi M, Contul RB, Millo P, Loffredo A,
will allow for infinite opportunities to make sur- Allieta R, Nardi Jr M, Lale-Murix E. Laparoscopic
gery safer, better, faster, and ultimately cheaper. gastric bypass performed with the Da Vinci intuitive
robotic system: preliminary experience. Surg Endosc.
2006;20(4):279–83.
13. Snyder BE, Wilson T, Scarborough T, et al. Lowering
References gastrointestinal leak rates: a comparative analysis of
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1. Mason EE, Ito C. Gastric bypass in obesity. Surg Clin 2008;2:159–63.
North Am. 1967;47:1345–51. 14. Sanchez BR, Mohr CJ, Morton JM, et al. Comparison
2. Wittgrove AC, Clark GW, Tremblay LJ. Laparoscopic of totally robotic laparoscopic Roux-en-Y bypass and
gastric bypass. Roux-en-Y: preliminary report of five traditional laparoscopic Roux-en-Y gastric bypass.
cases. Obes Surg. 1994;4:353–7. Surg Obes Relat Dis. 2005;1(6):549–54.
3. Hubens G, Balliu L, Ruppert M, Gypen B, Van Tu T, 15. Wilson E. Robotic gastric bypass. Presentation in
Vaneerdeweg W. Roux-en-Y gastric bypass procedure American Society of Metabolic and Bariatric Surgery
performed with the da Vinci robot system: is it worth Annual Conference, Atlanta, GA; 2012 June.
it? Surg Endosc. 2008;22(7):1690–6. 16. Snyder B, Wilson T, Woodruff V, Wilson E.
4. Wilson EB. The evolution of robotic general surgery. Robotically assisted revision of bariatric surgeries is
Scand J Surg. 2009;98(2):125–9. safe and effective to achieve further weight loss.
5. Wilson, EB, Snyder B, Yu S, et al. Robotic bariatric World J Surg; March 2013 [EPub Ahead of Print].
surgery outcomes with laparoscopic biliopancreatic 17. Tieu K, Allison N, Snyder B, Wilson T, Toder M,
diversion and gastric bypass. Presentation in American Wilson E. Robotic-assisted Roux-en-Y gastric bypass
Society of Metabolic and Bariatric Surgery; 2008 update from 2 high-volume centers. Surg Obes Relat
June; Washington, DC. Dis. 2012;9(2):284–8.
 Robotic Sleeve Gastrectomy
11
Jorge Rabaza and Anthony M. Gonzalez

comorbidities are attributed not only to the

General Overview restrictive nature of the procedure but also to
restriction by the pylorus, decreased ghrelin,
The ever-increasing global epidemic of obesity is increased satiety, increased gastric emptying, and
a cause for worldwide concern. It is estimated that faster small bowel transit times with a component
if the trend continues, nearly half of all Americans of malabsorption [3–6] (Table 11.1).
will be obese by 2030 [1]. Comorbidities such as Historically, the SG evolved over time from
type II diabetes, hypertension, increased triglyc- other procedures. In 1988, Doug Hess performed
erides and hypercholesterolemia, and sleep apnea the first sleeve gastrectomy as part the duodenal
contribute to obesity as one of the United States’ switch [7]. Anthone in 1997, while performing a
leading causes of death [2]. The field of bariatric duodenal switch in a young patient with common
surgery has proven to be most effective and safe in bile duct stones, limited the procedure to only a
the treatment of this disease. sleeve gastrectomy due to the complexity of the
The three most common procedures per- procedure. In this specific patient, he observed
formed for weight loss in the United States and excellent weight loss results with the sleeve alone.
universally are the laparoscopic Roux-en-Y gas- Subsequently, between 1997 and 2001, he com-
tric bypass (LRYGB), the laparoscopic adjust- pleted 21 sleeve gastrectomies with similar results
able gastric band procedure (LAGB), and the [8]. Gagner [9] is credited with performing the first
sleeve gastrectomy (SG). The sleeve gastrectomy laparoscopic sleeve gastrectomy (LSG) in very
(SG) is a restrictive bariatric surgical procedure high-BMI patients as a first stage with subsequent
best described as a partial left gastrectomy of the laparoscopic gastric bypass Roux-en-Y (LGBYP).
fundus and body of the stomach so as to create a Recently, the American Society for Metabolic
long tubular “sleeve” along the lesser curvature and Bariatric Surgery (ASMBS) updated their
(Fig. 11.1). The weight loss and resolution of position statement on sleeve gastrectomy as a bar-
iatric procedure [10]. Based on several prospec-
tive randomized controlled trials and matched
J. Rabaza, M.D. (*)
South Miami Hospital, Baptist Health Medical cohort studies, the ASMBS recognizes the SG as
Group, 7800 SW 87 Avenue, Suite B-210, an acceptable primary bariatric procedure and as
Miami, FL 33173, USA a first stage for a Roux-en-Y gastric bypass
e-mail: [email protected]
(RYGB) or a duodenal switch (DS). Furthermore,
A.M. Gonzalez, M.D. the SG has been found to have a risk/benefit pro-
Bariatric Surgery, Baptist Health Medical Group,
file somewhere between that of the laparoscopic
7800 SW 87 Avenue, Suite B-210, Miami,
FL 33173, USA adjustable band (LAGB) and the RYGB [11–13].
e-mail: [email protected] The sleeve gastrectomy has several advantages

K.C. Kim (ed.), Robotics in General Surgery, DOI 10.1007/978-1-4614-8739-5_11, 121

© Springer Science+Business Media New York 2014
122 J. Rabaza and A.M. Gonzalez

complex management problem. The average

reported leak rate is approximately 2.7 % [15].
For revisional surgery, it can be greater than 10 %
[16]. The most common area for leak occurrence
is at the gastroesophageal junction. Leaks are
caused by local tissue ischemia combined with
increased intraluminal pressure of the sleeve.
A tight sleeve is a risk factor for a leak, and it is
thought that the size of the bougie used is
inversely proportional to the rate of leakage [17].
Patients with a distal stricture or a functional
obstruction caused by a spiraling staple line are
also at a greater risk. Leaks can be repaired surgi-
cally, however, usually requiring a multidisci-
plinary approach, which includes percutaneous
Fig. 11.1 Sleeve gastrectomy diagram drainage, endoscopic stenting and clipping by the
gastroenterologist, and maximization of nutrition
Table 11.1 Mechanism of the sleeve gastrectomy to enhance healing.
Stricture or stenosis is most common at the
• Decreased gastric volume
• Restriction by the pylorus
incisura angularis. Proper creation of the sleeve
• Decreased ghrelin with lateral traction and appropriate bougie size
• Increased gastric emptying when stapling at incisura is key in preventing
• Decreased small bowel transit time with strictures. Treatment options for stricture can be
malabsorption endoscopic dilatation, seromyotomy, or conver-
• Increased glucagon-like peptide 1 and YY sion to a RYGB.
One of the most recent advances in the field of
Table 11.2 Considerations for the sleeve gastrectomy bariatric surgery has been the introduction of the
da Vinci robotic platform (Intuitive Surgical,
Advantages Limitations
Sunnyvale, CA). Although the role of the robot in
• Relatively simple and • No long-term results
quick procedure • Infrequent bariatric surgery has been found to be advanta-
• Short learning curve complications are geous in the RYGB [18, 19], its role in the SG is
• Access to stomach difficult to treat less clear. Ayloo et al. [20] presented their initial
maintained • Irreversible experience with robotic-assisted sleeve gastrec-
• Good early results • Early and late GERD
• Extremely low morbidity tomy (RASG), concluding the RASG can be per-
and mortality formed safely with excellent outcomes. Diamantis
• Can use for failed LAGB et al. [21] reported their limited series also with
• Can convert to RYGB for similar results.
severe reflux
• Can convert to duodenal Our group originally adopted the use of the da
switch (DS) or RYGB for Vinci system with the intent of reducing the high
insufficient weight loss complication rates for revisional bariatric surgery
in patients with previous RYGB or vertical
and few limitations (Table 11.2). Although long- banded gastroplasties (VBG). The Michigan
term results are not available as they are for the Bariatric Surgery Collaborative, in a large multi-
LAGB and the RYGB, Sarela et al. [14] published variate analysis, found that the LSG had less risk
very favorable results at 8–9 years with 69 % for serious complications when compared with
excess weight loss. RYGB (OR 2.46 versus 3.58, respectively).
Although complications are rare, they can be Although the rate of staple-line dehiscence is
very problematic to treat. Gastric leaks following low in laparoscopic sleeve gastrectomies, these
a sleeve gastrectomy can be a very difficult and complications are feared and extremely problem-
11 Robotic Sleeve Gastrectomy 123

atic. Having taken care of some of these trouble- from the nipple line to the suprapubic area. An
some complications, it was our thought that the orogastric tube is then placed to decompress the
current limitations of laparoscopic surgery (such stomach. Lastly, the patient is draped without
as limited range of motion, poor ergonomics, the traditional anesthetic barrier in order to
lack of depth perception, and surgeon fatigue) allow the robot to be docked over the head. It is
could be risk factors for these rare but serious important always to ensure that the anesthesiologist
complications. Thus, we also adopted the da has instant and unobstructed access to the head of
Vinci system for the sleeve gastrectomy. the patient. Prior to docking the robot, the patient is
placed in the reverse Trendelenburg position at
approximately 15–20°.
Patient Positioning

The patient is placed in the supine position with Trocar Placement

the arms extended. The robot is docked straight
over the head of the patient, and anesthesia is A three-arm technique plus an assistant trocar is
positioned on the patient’s right side (Fig. 11.2). utilized. The camera trocar, which is a 12 mm
The bedside assistant stands on the patient’s right long trocar, is positioned above the umbilicus via
side and the robotic monitor is placed across a transverse or vertical incision. The two robotic
from the assistant on the patient’s left. Because working arms, which can be 5 or 8 mm robotic
the anesthesia’s positioning to the right of the trocars, are positioned at the anterior axillary line
patient, a peripheral IV should ideally be placed on both sides and just above the level of the cam-
in the right upper extremity. After induction of era port (Figs. 11.3 and 11.4). A 12 mm nonro-
anesthesia, a Foley catheter is placed, a footboard botic port is then placed approximately halfway
is properly secured, and straps are placed at the between a line from the umbilical port to the
level of the upper thighs. An upper body-warming right robotic port and slightly inferior. The liver
blanket is placed. The abdomen is then prepped is retracted with a Nathanson Hook Liver

Fig. 11.2 Operating room layout

124 J. Rabaza and A.M. Gonzalez

Fig. 11.3 Robotic sleeve gastrectomy port placement

Fig. 11.5 Nathanson retractor position

the patient’s right shoulder (Fig. 11.5). Finally

the robot is docked directly above the patient’s
head (Fig. 11.6).

Step-by-Step Review of the Critical

Elements of the Robotic Sleeve
Gastrectomy

The first step of the robotic sleeve gastrectomy

(RSG) is identification of the pylorus (Fig. 11.7).
Approximately 4–6 cm proximal to the pylorus,
the vascular attachment of the gastrocolic liga-
ment is divided with the use of an energy source
such as the Harmonic scalpel or the EndoWrist
vessel sealer. This is typically started a little dis-
tal to the midpoint of the greater curvature where
it is easier to enter the lesser sac than it is closer
to the pylorus.
Once the target area to begin the dissection is
Fig. 11.4 Robotic sleeve gastrectomy port placement decided, the console surgeon grasps the stomach
with a double fenestrated bowel grasper and gen-
Retractor (Mediflex Surgical Products), which is tly elevates it while the assistant provides coun-
placed just below the xiphoid and held in place tertraction of the gastrocolic ligament. We
with a retractor that is mounted to the bed over typically use the harmonic scalpel as the energy
11 Robotic Sleeve Gastrectomy 125

source (Fig. 11.8). It is important to stay close to along the greater curvature. Another technique
the stomach wall in order to avoid injury to the involves tucking the left grasper under the stom-
underlying colon. Once the lesser sac is entered, ach and elevating it for further exposure.
the dexterity of the console surgeon’s left grasper The dissection continues cephalad toward the
allows easier orientation of the Harmonic scalpel angle of His and the short gastric vessels. Once
the short gastric vessels are located, care must be
taken to avoid troublesome bleeding. This is
aided by the superior high-definition, three-
dimensional view that the robot provides.
Alternatively, the short gastric vessels can be
divided after completing the gastric stapling por-
tion, which allows the specimen to be retracted
laterally and the vessels to be approached medi-
ally, which often provides a better and safer
exposure for dividing the gastrosplenic attach-
ments and the short gastric vessels. After the
short gastric vessels are divided at the upper pole
of the spleen (Fig. 11.9), the attachments between
the fundus and left crus must be divided
(Fig. 11.10) for two reasons: first, to avoid a large
fundus at the superior portion of the stomach
(neofundus) (Fig. 11.11) and, second, to clearly
identify the gastroesophageal junction and to
avoid stapling close to this area.
Once this is completed, it is imperative to
aggressively dissect in the area of the phreno-
esophageal ligament in search of an occult hiatal
hernia. If a hernia is identified, it should be
Fig. 11.6 Robot docked overhead repaired in order to avoid disabling GERD later

Fig. 11.7 Locating the pylorus

126 J. Rabaza and A.M. Gonzalez

Fig. 11.8 Begin division of gastrocolic ligament

Fig. 11.9 Takedown of short gastric vessels

on. We prefer to perform the repair after creation aspect of the stomach. This will obviate a larger
of the gastric sleeve. Next, the distal portion the than intended sleeve construction.
gastrocolic ligament can then be divided to Once the vessels are divided and the stomach
approximately 4–6 cm proximal to the pylorus. is well mobilized, the creation of the gastric
Once this is completed, the usually flimsy poste- sleeve is started. First the anesthesiologist is
rior adhesions of the stomach to the underlying instructed to remove the temperature probe and
pancreas are divided in order to fully mobilize the orogastric tube and a 32–36 Fr bougie is care-
the stomach (Fig. 11.12). It is our opinion that fully passed orally. The bougie is used to calibrate
mobilization is not complete until the lesser cur- the gastric pouch. The bedside assistant surgeon
vature vessels are identified from the posterior provides lateral traction of the stomach, while the
11 Robotic Sleeve Gastrectomy 127

Fig. 11.10 Division of attachments between the fundus and the left crus

(2.0 mm). The console surgeon again gently

retracts the tip of the bougie medially toward the
duodenum with the articulating left-hand grasper
and lateral retraction of the greater curvature with
the right hand. The assistant bedside surgeon
then introduces the stapler. The stapler is placed
across the antrum in a more horizontal than verti-
cal orientation, paying close attention to the inci-
sura at all times (Figs. 11.14 and 11.15). This
technique allows a “wide turn” at the area of the
incisura, obviating a stricture or spiraling.
The transection is then continued proximally
along the lateral edge of the bougie while main-
taining lateral symmetrical traction. This tech-
nique is greatly facilitated by the dexterity and
Fig. 11.11 Upper GI of neofundus maneuverability of the robotic wristed instru-
ments. This portion of the transection is per-
formed with nothing less than a blue cartridge.
console surgeon, with the aid of the articulating As the staple line progresses proximally, it is
bowel grasper, gently guides the bougie into the important not to allow the staple line to spiral
proximal duodenum (Fig. 11.13). either anteriorly or posteriorly because this can
Once the calibration tube/bougie is in place, lead to a functional obstruction (Fig. 11.16). The
the transection begins. This is a critical first step, final critical step of the RSG is the completion of
and careful attention should be paid to the angle the transection at the angle of His. Most bariatric
of the stapler and its proximity to the incisura surgeons generally stay away from the gastro-
angularis. Because of the thickness of the tissue esophageal junction during the last staple firing
in this area, the first firing is performed with a in order to avoid a leak. However, leaving too
green cartridge of the Echelon 60 mm stapler large a fundus can lead to insufficient weight loss
128 J. Rabaza and A.M. Gonzalez

Fig. 11.12 Posterior dissection and complete gastric mobilization

Fig. 11.13 Placement of bougie

or incapacitating gastroesophageal reflux. During the other reinforces the staple line by oversewing
the last firing, it is important that the console sur- (Fig. 11.18). If an imbricating suture is used to
geon visualize 1–2 cm of gastric serosa just reinforce the staple line, then it should be done
medial (left) to the stapler (Fig. 11.17). The early with the bougie in place. Once the procedure is
“aggressive” dissection of the hiatus at the begin- completed, the staple line is carefully examined
ning of the case, in search of a hiatal hernia, will for bleeding. The staple line is also examined for
also help in identifying the GE junction. spiraling. If spiraling is found, the previous
The consensus among most bariatric surgeons divided gastrocolic fat is sutured to the staple line
is that reinforcing the staple line will decrease to prevent kinking or further spiraling.
bleeding. One of the authors of this chapter uses After the procedure is completed, we prefer
buttress material to reinforce the staple line, while intraoperative endoscopy, not only to ensure an
11 Robotic Sleeve Gastrectomy 129

Fig. 11.14 Critical first firing of staple line

Fig. 11.15 Critical first firing of staple line

intact staple line with air leak test but also to ensure All patients undergo an upper gastrointestinal
a uniform unobstructed lumen. Generally, a drain is series the following day with water-soluble con-
not necessary with most cases, but should be con- trast. If the study shows no leak or stricture, the
sidered in difficult or revisional cases. Fibrin glue patient is started on a clear liquid diet and dis-
is occasionally applied over the staple line when charged home the next day. They are advanced to
indicated. The resected stomach is removed via the full liquid diet for 2 weeks and then a solid soft
assistant port site or the umbilical site. Closure of diet for 2 more weeks. Follow-up is at 1 week;
this fascial site is important to prevent an immedi- 6 weeks; 4, 8, and 12 months; and then every
ate postoperative incarcerated incisional hernia. 6 months thereafter.
130 J. Rabaza and A.M. Gonzalez

Fig. 11.16 Second firing beyond incisura

Fig. 11.17 Proximal portion of sleeve gastrectomy

the use of the robot for sleeve gastrectomies

Review of Literature (Table 11.3).
We presented our preliminary experience in
Robotic surgery has emerged in different surgi- patients who underwent an RSG as treatment for
cal specialties (as gynecology, urology) with morbid obesity and made a comparison with a
obvious benefits demonstrated in these areas. meta-analysis of the standard laparoscopic
The use of the robot in bariatric surgery has approach in order to have a better understanding
been restricted only to those surgeries that are of both platforms. A total of 3,148 LSG patients
considered complex, such as revisions or bypass from 22 studies were analyzed and compared
surgery; there are only a few papers that report with 134 RSG patients. This series represents one
11 Robotic Sleeve Gastrectomy 131

Fig. 11.18 Oversewing of staple line

Table 11.3 Review of literature

Diamantis Ayloo Abdalla Elli Vilallonga Gonzalez
et al. [21] et al. [20] et al. [22] et al. [23] et al. [24] et al. [25]
Year 2011 2011 2012 2012 2012 2012
Number of patients 19 30 5 1 32 134
Leaks 0 0 0 0 0 0
Strictures 0 1 (3.3 %) 0 0 0 0
Bleeding 0 0 1 (20 %) 0 0 1 (0.7 %)
Mortality 0 0 0 0 0 0
Conversions 0 0 NP 0 0 0
Surgical time 95.5 ± 11.5 135 ± 28 NP 158 77.5 (56–130) 106.6 ± 48.8
Hospital length of stay 4 NP NP 4 NP 2.2 ± 0.6

of the few published RSG experiences and the Conclusion

largest one to date. Comparison of three of the
most common major complications after an LSG As obesity rates continue to rise in the United
(leak, bleeding, and stricture) as well as the surgi- States, more bariatric procedures are needed
cal time and hospital length of stay was reviewed, to battle this growing problem. The sleeve
since these variables may have a direct relation gastrectomy has proven to be an excellent proce-
with surgical technique. dure for resolution of morbid obesity and its
Our conclusions were that both laparoscopic comorbid medical issues. The use of the robot in
and robotic techniques are safe and feasible, show- sleeve gastrectomy has been reported sparingly,
ing good results in every measured parameter. but our experience, the largest reported to date,
However, surgical time was faster during the lapa- demonstrates that the robotic approach has simi-
roscopic approach, and hospital length of stay was lar results to its laparoscopic counterpart.
shorter with the robotic approach. The leak rate Although the enhanced dexterity of the robot
was slightly lower in the robotic platform (1.97 % greatly facilitates reinforcing the staple line by
vs. 0 %, p = 0.101); however, there were no differ- suturing, until recently, the use of the robot in
ences in strictures, bleeding, and mortality. sleeve gastrectomies has been limited by the lack
132 J. Rabaza and A.M. Gonzalez

of a robotic stapler, which essentially assigns the bypass, and adjustable gastric banding on type 2 dia-
betes. Surg Endosc. 2010;24:1005–10.
stapling portion of the procedure, arguably the
12. Bohdjalian A, Langer FB, Shakeri-Leidenmühler S,
most critical portion of the procedure, to the bed- et al. Sleeve gastrectomy as sole and definitive bariat-
side surgeon. The recent FDA approval of the ric procedure: 5-year results for weight loss and ghre-
robotic stapler, however, will now allow the lin. Obes Surg. 2010;20:535–40.
13. Jacobs M, Biscand W, Greg E. Laparoscopic sleeve
entire procedure to be completed by the console
gastrectomy: a retrospective review of 1- and 2-year
surgeon. Further experience with larger numbers results. Surg Endosc. 2010;24:781–5.
and randomization is necessary to determine its 14. Sarela AI, Dexter SPL, O’Kane M, Menon A,
clear benefit in sleeve gastrectomies. McMahon MJ. Long-term follow-up after laparo-
scopic sleeve gastrectomy: 8–9-year results. Surg
Obes Relat Dis. 2012;8(6):679–84. doi:10.1016/j.
soard.2011.06.020. ISSN 1550–7289.
15. Brethauer SA, Hammel JP, Schauer PR. Systematic
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bariatric procedure. Surg Obes Relat Dis. 2009;5(4):
1. Wang Y, Beydoun MA, Liang L, Caballero B, 469–75.
Kumanyika S, Shiriki K. Will all Americans become 16. Ramalingam G, Anton CK. Our 1-year experience in
overweight or obese? Estimating the progression and laparoscopic sleeve gastrectomy. Obes Surg. 2011;
cost of the US obesity epidemic. Obesity. 2008;16: 21(12):1828–33.
2323–30. 17. Gagner M. Leaks after sleeve gastrectomy are associ-
2. Mokdad AH, Marks JS, Stroup DF, Gerberding JL. ated with smaller bougies: prevention and treatment
Actual causes of death in the United States, 2000. strategies. Surg Laparosc Endosc Percutan Tech.
JAMA. 2004;291:1238–45. 2010;20:166–9.
3. Braghetto I, Davazo C, Korn O, et al. Scintigraphic 18. Snyder BE, Wilson T, Leong BY, Klein C, Wilson EB.
evaluation of gastric emptying in obese patients sub- Robotic-assisted Roux-en-Y gastric bypass: minimiz-
mitted to sleeve gastrectomy compared to normal sub- ing morbidity and mortality. Obes Surg. 2010;20:
jects. Obes Surg. 2009;19:1515–21. 265–70.
4. Karamanakis SN, Vagenas K, Kalfarentzos F, 19. Deng JY, Lourié DJ. 100 Robotic-assisted laparo-
Alexandrides TK. Weight loss, appetite suppression, scopic gastric bypasses at a community hospital. Am
and changes in fasting and postprandial ghrelin and Surg. 2008;74:1022–5.
peptide-YY levels after Roux-en-Y gastric bypass and 20. Ayloo S, Buchs NC, Addeo P, Bianco FM, Giulianotti
sleeve gastrectomy: a prospective, double blind study. PC. Robot-assisted sleeve gastrectomy for super-
Ann Surg. 2008;247:408–10. morbidly obese patients. J Laparoendosc Adv Surg
5. Shah S, Shah P, Todkar J, Gagner M, Sonar S, Solav Tech A. 2011;21:295–9.
S. Prospective controlled study of effect of laparo- 21. Diamantis T, Alexandrou A, Nikiteas N, Giannopoulos
scopic sleeve gastrectomy on small bowel transit time A, Papalambros E. Initial experience with robotic
and gastric emptying half time in morbidly obese sleeve gastrectomy for morbid obesity. Obes Surg.
patients with type 2 diabetes mellitus. Surg Obes 2011;21:1172–9.
Relat Dis. 2010;6:152–7. 22. Abdalla RZ, Garcia RB, Luca CR, Costa RI, Cozer
6. Tymitz K, Engel A, McDonough S, Hendy MP, CO. Brazilian experience in obesity surgery robot-
Kerlakian G. Changes in ghrelin levels following bar- assisted. Arq Bras Cir Dig. 2012;25(1):33–5. English,
iatric surgery: review of the literature. Obes Surg. Portuguese: PMID: 22569976.
2011;21:125–30. 23. Elli EF, Masrur MA, Giulianotti PC. Robotic
7. Hess DS, Hess DW. Biliopancreatic diversion with a sleeve gastrectomy after liver transplantation.
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Surg. 2006;16:1445–9. A, Neff KJ, Armengol M. The initial learning curve
9. Regan JP, Inabnet WB, Gagner M. Early experience for robot-assisted sleeve gastrectomy: a surgeon's
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effects of laparoscopic sleeve gastrectomy, gastric Surg. 2013.
 Robotic Biliopancreatic Diversion:
Robot-Assisted (Hybrid) 12
Biliopancreatic Diversion
with Duodenal Switch

Ranjan Sudan and Sean Lee

Our group adopted the da Vinci platform with

General Overview of Current the hope of reducing both the technical chal-
Applications lenges faced in laparoscopic approaches to this
operation and the resulting high complication
The first robot-assisted biliopancreatic diversion rates. Initially we performed the operation totally
with duodenal switch operation (BPD/DS) was robotically, but the first-generation robot had lim-
performed in October 2000, only months after ited mobility, only two working arms, and shorter
the Food and Drug Administration approved the instrument lengths that significantly limited our
da Vinci surgical system for use in general sur- ability to access the three abdominal quadrants
gery in July 2000 [1]. Subsequently, Roux-en-Y involved in this procedure, the right lower quad-
gastric bypass, laparoscopic adjustable band rant for the ileoileostomy, the left upper quadrant
operations, and sleeve gastrectomy have all been for the sleeve, and the right upper quadrant for
performed using the da Vinci platform [2, 3]. the duodenoileostomy. Thus, the totally robotic
However, the focus of this chapter will be the approach initially required multiple docking
hybrid BPD/DS. The BPD/DS is a malabsorptive positions. We first performed the ileoileostomy
bariatric procedure that has been performed by with the patient cart docked toward the foot end
laparotomy for over 20 years. It was first with the patient in lithotomy position. After com-
described by Marceau et al. [4] and by Hess and pletion of this part of the operation, we discon-
Hess [5]. The laparoscopic BPD/DS was first nected the anesthetic lines, rotated the patient bed
described by Ren et al. in 2000 [6], but complica- 180˚, reconnected the anesthetic lines and tubes,
tion rates were high for patients with BMI docked the da Vinci from the head end, and per-
>60 kg/m2 [7]. The BPD/DS is a technically chal- formed the rest of the procedure in the right upper
lenging operation and the vast majorities were and left upper abdominal quadrants.
still being performed by laparotomy in 2010 [8]. Although we had no complications related to
these maneuvers, the process had potential for
errors and was also quite time consuming.
R. Sudan, M.D. (*) Therefore, in the interest of patient safety and
Department of Surgery, Duke University Medical time conservation, we adopted a hybrid tech-
Center, Trent Drive, Durham, NC 27710, USA nique in which conventional laparoscopy was
e-mail: [email protected]
used to perform the ileoileostomy and the sleeve
S. Lee, M.D. gastrectomy, while the robot was used for a
Division of Metabolic and Weight Loss Surgery,
sutured duodenoileostomy. The duodenoileos-
Duke University Medical Center, Box 2834, Durham,
NC 27710, USA tomy is considered the most crucial portion of the
e-mail: [email protected] BPD/DS, and laparoscopic techniques using a

K.C. Kim (ed.), Robotics in General Surgery, DOI 10.1007/978-1-4614-8739-5_12, 133

© Springer Science+Business Media New York 2014
134 R. Sudan and S. Lee

circular stapler, a linear cutting stapler, or hand and is kept low profile so that the robot can be
suturing have been described for this anastomo- positioned over the patient’s right shoulder with-
sis. Since the robot allows for precise suturing, out interference from the anesthetic cart. The
we have found that the robot-sutured anastomosis abdomen is prepped and draped to expose the
is reliable, widely patent, and not prone to stric- upper body from the umbilicus to the xiphoid and
tures. It also preserves the maximum possible from the right anterior axillary line to the left
length of the first part of the duodenum. In fact, in anterior axillary line. A large bore stomach-
the last 12 years of our experience, no patient has sizing tube (Allergan®) is used to decompress the
suffered from a stricture in this location. stomach. It is subsequently used for sizing the
The newest generation robot (Si) has three sleeve and instilling dye into the stomach for a
instrument arms and has an extended reach allow- duodenoileostomy leak test. The drapes are
ing for greater flexibility in working in different dropped over the head and cover the patient’s
quadrants. We have therefore started performing face. The traditional barrier between the surgical
the ileoileostomy and sleeve gastrectomy por- field and the anesthesiologist is deliberately
tions robotically with a single docking. However, avoided so that the surgeon may stand above the
the procedures in the strictest sense are still not patient’s shoulders and operate in the lower abdo-
totally robotic because robotic staplers are not men with laparoscopic instruments so that the
available for general use. Once these are avail- robot can dock without interference.
able we will be able to develop a totally robotic
BPD/DS procedure. Although we look forward
to continuing advancement in the field of surgical Trocar Placement
robotics, for the purposes of this chapter, we will
focus on our hybrid technique with which we The abdomen is entered with a Veress needle in
have 11 years of experience. This method is also the left upper quadrant. A 0°, 10 mm laparoscope
less challenging for those users who are early in is then placed through a 12 mm optical trocar,
their learning curve with the da Vinci system and and the abdominal cavity is entered under direct
thus recommend this technique as a starting visualization in the midline about 15 cm below
point. the xiphoid. After confirming the absence of
injury related to Veress needle and the trocar
insertions, additional ports are placed. An 8 mm
Patient Positioning robot trocar is placed in the right anterior axillary
line at the edge of the right lobe of the liver and a
The patient is positioned supine. After induction second robotic trocar is placed just lateral to the
of anesthesia, a Foley catheter is placed. Arterial left midclavicular line. Accessory 12 mm ports
or central venous catheters are not routinely are placed in the left anterior axillary line and the
placed. The patient is secured to the bed with right midclavicular line at about the horizontal
belts, a footboard is placed to facilitate extreme level as the camera port. These port positions are
bed positioning as required, and pressure points individualized to a certain extent based on the
are protected adequately to prevent against a neu- patient’s body habitus and the size of the liver
ropathy because of the long duration of these pro- (Fig. 12.1). All port sites are preinjected with a
cedures. The arms are placed on adjustable arm long-acting local anesthetic prior to incision.
boards and are secured with bandages so they do
not slip off when the patient is tilted in either the
Trendelenburg or reverse-Trendelenburg posi- Key Steps
tions. A lower-body warming blanket is used to
keep the upper body free of obstructions so that it The patient is positioned in the Trendelenburg
does not interfere with robot docking. Adequate position and tilted slightly to the left. A 30°,
slack in the anesthetic lines and tubes is ensured 10 mm conventional laparoscopic camera is used
12 Robotic Biliopancreatic Diversion: Robot-Assisted (Hybrid) Biliopancreatic… 135

in the umbilical port site. Previously, we began rate or duration of the procedure, we have stopped
the operation by performing an appendectomy performing a routine appendectomy because of
because most open surgeons routinely did so to our experience with laparoscopic gastric bypass
prevent confounding the anatomy if an appen- patients who rarely need an appendectomy after
dectomy was needed later. Although performing bariatric surgery. The diagnosis of appendicitis
an appendectomy did not add to our complication using computerized tomography is quite accu-
rate, and since robotic duodenal switch results in
minimal right lower quadrant adhesions in most
patients, subsequent appendectomy should be
straightforward.
We now begin by identifying the ileocecal
junction and marking the ileum at 100 cm and
250 cm proximal to it with sutures. The bowel is
then divided at the 250 cm mark using a linear
cutter stapler and the mesentery is divided toward
its root using the harmonic scalpel to mobilize
the bowel. The bowel proximal to the 250 cm
mark becomes the biliary limb and the bowel dis-
tal to it will become the alimentary limb. The
biliary limb is then anastomosed to the ileum at
the 100 cm mark using a 60 mm long conven-
tional laparoscopic linear stapler. The enteroto-
mies for the stapler are created using an ultrasonic
shear and are closed using a single-layer running
2-zero suture using conventional intracorporeal
laparoscopic suturing (Fig. 12.2).
The mesenteric defect between the biliary
Fig. 12.1 Port positions limb and the common channel is closed with run-
ning nonabsorbable sutures.

Fig. 12.2 Side-to-side ileoileostomy

136 R. Sudan and S. Lee

Fig. 12.3 Division of

duodenum

The patient is then placed in a reverse zation is carried to the first part of the duodenum
Trendelenburg position. A Nathanson liver retrac- until the gastroduodenal artery is identified and
tor is placed through a stab incision near the the pancreas is noted to become adherent to the
xiphoid and used to elevate the left lobe of the duodenum. The duodenum is then divided using
liver. If the falciform ligament obscures visualiza- a linear stapler giving the proximal duodenal
tion, it may need to be excised or we will some- stump a length of about 4 cm (Fig. 12.3).
times attach it to the anterior abdominal wall. The mobilization of the greater curvature of
Open surgeons have performed routine chole- the stomach is then carried proximally inside the
cystectomy in the past, and we continue to per- gastroepiploic arcade until the highest short gas-
form routine cholecystectomy for several reasons. tric vessels are divided and the angle of His is
The risk of gallstone formation is likely even exposed (Fig. 12.4). It is beneficial to detach any
higher than in gastric bypass patients due to the of the filmy adhesion between the posterior wall
wasting of bile salts. There is no remnant stomach of the stomach and the pancreas to allow the
after BPD/DS, and the alimentary and biliopan- stomach to be freely mobilized. Using the 34
creatic limbs are very long, making purely endo- French sizing tube as a guide, a sleeve gastrec-
scopic techniques to retrieve common bile duct tomy is performed to create a stomach tube with
stones and ERCP essentially impossible. In addi- a capacity of 150 ml s (Fig. 12.5).
tion, performing a cholecystectomy in the pres- The distal stomach is stapled with at least
ence of scarring after a duodenoileostomy that lies 4.8 mm leg length staplers (green loads), and as
immediately adjacent to the gallbladder is likely the stomach becomes less thick, the loads can be
to be more difficult than after a RYGB where the switched to a leg length of 3.5 mm. The use of
anastomosis is in the left upper quadrant. The cho- staple-line reinforcements is optional. Our pref-
lecystectomy is performed using standard laparo- erence is to use robotic suturing with absorbable
scopic techniques, although admittedly the suture to oversew the distal stomach where it is
procedure is made somewhat cumbersome by the thickest, and staples may not approximate the
port placement for the BPD/ DS. edges of the stomach. Particular care is taken to
The preparation for a sleeve gastrectomy not narrow the stomach near the incisura. The
begins by mobilizing the greater curvature of the central diaphragm is carefully inspected and any
stomach using an ultrasonic device. The mobili- hiatal hernia identified is repaired.
12 Robotic Biliopancreatic Diversion: Robot-Assisted (Hybrid) Biliopancreatic… 137

Fig. 12.4 Mobilization of greater curvature

Fig. 12.5 Sleeve gastrectomy

The alimentary limb is then taken retrocolic to right side are usually Cadiere graspers as this
the right of the middle colic vessels and delivered allows handling of the bowel and retraction on
close to the first part of the duodenum. The robot the suture. Arms 1 and 2 are used for suturing,
is then docked over the right shoulder (Fig. 12.6). whereas arm 3 is used for retraction of a stay
The camera is inserted through the umbilical suture that helps align the orientation of the
port and a needle driver inserted through the left enterotomies for suturing. The posterior sero-
midclavicular port (arm 1). The second robotic muscular running layer is first started using
arm is placed using a port-in-port technique running 2-zero nonabsorbable suture. An enter-
through the right midclavicular port (arm 2), and otomy is then made in the duodenum and in the
the accessory arm is used through the right ante- ileum using the robotic hook cautery. A full-
rior axillary port (arm 3). The instruments on the thickness running layer of 2-zero absorbable
138 R. Sudan and S. Lee

Fig. 12.6 Operating room layout

Fig. 12.7 Proximal alimentary limb anastomosis

suture is started posteriorly and completed teric defect between the mesentery of the alimen-
anteriorly. The anterior seromuscular layer of tary limb and the retroperitoneum (Petersen’s
nonabsorbable suture completes the two-layer defect) is closed using running nonabsorbable
hand-sewn anastomosis (Fig. 12.7). suture. After confirming the absence of leaks and
At this stage methylene blue is instilled in the ensuring hemostasis, an endoscopic leak check is
stomach using the orogastric tube. The mesen- optional. We tend to perform endoscopy to rule
12 Robotic Biliopancreatic Diversion: Robot-Assisted (Hybrid) Biliopancreatic… 139

out leaks, evaluate for luminal staple-line bleeding, translates into greater safety for the patient.
and to ensure patency of the lumen. Once endos- Based on these findings we recommend perform-
copy is completed, the robot is undocked, the ing a robotic BPD/DS on patients whose anatomy
ports are removed under direct visualization, and is likely to be difficult only after a surgeon has
the resected specimens (gallbladder and greater mastered the technique in simpler patients.
curvature of stomach) are removed. We place a Laparoscopic BPD/DS in patients with a
suture on one end of the stomach specimen and BMI >60 has been reported to have a high mor-
use it as a handle to remove the stomach through tality [7]. However, in the last 12 years, we have
the midline port site. Using this technique we not experienced any short- or long-term mortal-
rarely have to enlarge the fascial defect to extract ity in our patients, and other authors have also
the specimen. Skin is closed with absorbable sub- reported no increase in mortality for high-BMI
cuticular suture. patients [10]. Leak rates in our early experience
were similar to those seen in the learning curve
of the laparoscopic Roux-en-Y gastric bypass,
Discussion of Advantages, and these rates have improved considerably
Limitations, and Relative since our first 50 cases. Patients seeking BPD/
Contraindications DS tend to be heavier as certain insurance com-
panies will not approve the procedure for
The indications for a BPD/DS are the same as for patients with a BMI <50 kg/m2. This can increase
any bariatric operation: a BMI >35 kg/m2 with the degree of difficulty of a case, and novice sur-
significant medical comorbidities or a BMI geons are cautioned about taking on more diffi-
>40 kg/m2. In practical terms, the operation is cult cases such as those with high BMI early in
very good for patients with severe diabetes and their experience.
hypercholesterolemia, but not so good for One limitation of the da Vinci surgical system
patients with severe gastroesophageal reflux dis- is that it is not able to operate easily in multiple
ease. Patients should not have this operation if quadrants. In order to access widely separated
there is a specific reason why they should avoid areas of the abdomen, or when changing the posi-
malabsorption, such as in those with Crohn’s dis- tion of the bed to enhance the intraabdominal
ease or severe osteoporosis. view, redocking of the robot is required. This is
The learning curve of the robotic BPD/DS for time-consuming and could pose added risk to the
a novice in laparoscopic and robotic techniques is patient. We have overcome this limitation by
about 50 cases. Age and male gender have been using a hybrid laparoscopic/robotic technique.
considered risk factors for bariatric surgery, but Another limitation is the loss of haptic sensation,
our own analysis of patient outcomes has not which is especially problematic when grasping
borne this out. Patient-related factors such as bowel as this can lead to bowel injuries. This was
enlarged livers, excessive abdominal wall torque, responsible for a leak and conversion to open sur-
and significant intraabdominal adiposity did gery in a patient early in our experience. Since
increase the risk for complications. The need for then, double fenestrated instruments have been
adhesiolysis from prior abdominal operations developed that are more suitable for grasping
such as open cholecystectomy increased the bowel and are now in use. A third limitation is the
duration, but not the risk of complications from a lack of articulation in the robotic harmonic and
robotic BPD/DS. We found very enlarged livers its short length. This can limit the reach in
greatly increased the degree of difficulty of a case patients with long torsos. Although this can often
initially [9]. However, with increasing experience be overcome by inserting the trocars deeper, it
we have developed greater skill using the acces- may necessitate the repositioning of trocars to an
sory arm for retraction purposes and we are able extent that makes the operation awkward. A new
to perform operations on patients with difficult energy device (ERBE) is now available, but we
anatomy with greater ease. This likely also do not yet have experience with it. As robotic
140 R. Sudan and S. Lee

technology advances, so our technique continues Length of stay is also significantly longer for
to evolve. We have recently begun to utilize a the BPD/DS compared to gastric bypass. This
totally robotic technique that we hope to intro- ranges between 4 and 5 days for BPD/DS and
duce in the near future. between 2 and 4 days for Roux-en-Y gastric
bypass [13, 14]. Our experience aligns with these
data also and reflects a difference in the approach
Review of Outcomes to postoperative management between the BPD/
DS and gastric bypass patient groups. Whereas
In our series of over 180 BPD/DS, we have had we advance gastric bypass patients to a liquid
no mortality. Our leak rate for primary operations diet on the first postoperative day irrespective of
is the same as that for a laparoscopic Roux-en-Y bowel function, BPD/DS patients are kept NPO
gastric bypass, at around 2 %. However, this until first flatus. This usually takes 3–5 days and
number includes our entire experience including thus our length of stay averages around 4 days
the learning curve. Our conversion rate is also after BPD/DS.
very low. After three conversions within our first
17 cases, we have not had to convert anyone to
open surgery. We now use the robotic platform
exclusively to perform all our BPD/DS opera- Conclusions
tions including revisions (such as conversion of
adjustable gastric banding or vertical banded gas- We have described a technique to perform a BPD/
troplasty to BPD/DS). DS using a hybrid laparoscopic/robotic approach
Large retrospective reviews as well as smaller that is safe and time efficient and that yields effi-
comparative studies have shown that excess body cacy commensurate with reports of other BPD/
weight loss and resolution of comorbid condi- DS techniques.
tions (such as hypertension and type II diabetes
mellitus) are superior for BPD/DS compared to
gastric bypass [11–13]. Mortality and postopera- References
tive complication rates are slightly higher for the
BPD/DS in these studies, but there is significant 1. Sudan R, Puri V, Sudan D. Robotically assisted biliary
pancreatic diversion with a duodenal switch: a new
variability in these rates amongst reports in the
technique. Surg Endosc. 2007;21(5):729–33.
literature. Our data is in line with this literature, 2. Jacobsen G, Berger R, Horgan S. The role of robotic
and we have reported a leak rate of 5.8 % and a surgery in morbid obesity. J Laparoendosc Adv Surg
conversion to open surgery in 2.2 %, with Tech A. 2003;13(4):279–83.
3. Ayloo S, et al. Robot-assisted sleeve gastrectomy for
improvement in these rates over time in our first
super-morbidly obese patients. J Laparoendosc Adv
47 patients [1]. Surg Tech A. 2011;21(4):295–9.
Operative times and hospital length of stay is 4. Marceau P, et al. Biliopancreatic diversion with a new
generally longer for the BPD/DS than gastric type of gastrectomy. Obes Surg. 1993;3(1):29–35.
5. Hess DS, Hess DW. Biliopancreatic diversion with a
bypass as well. One prospective comparative
duodenal switch. Obes Surg. 1998;8(3):267–82.
study showed mean operative times of 206 min 6. Ren CJ, Patterson E, Gagner M. Early results of lapa-
for BDP/DS and 91 min for LRYGB [14], and roscopic biliopancreatic diversion with duodenal
another reported times of 239 and 135 min, switch: a case series of 40 consecutive patients. Obes
Surg. 2000;10(6):514–23. discussion 524.
respectively, for conversion of failed gastric
7. Kim WW, et al. Laparoscopic vs. open biliopancreatic
banding to BPD/DS or gastric bypass [15]. Our diversion with duodenal switch: a comparative study.
experience with the hybrid robotic procedure has J Gastrointest Surg. 2003;7(4):552–7.
been that it does require longer operative times 8. DeMaria EJ, et al. Baseline data from American soci-
ety for metabolic and bariatric surgery-designated
[1]. On an average, a robotic case including a
bariatric surgery centers of excellence using the bar-
cholecystectomy and training time for fellows is iatric outcomes longitudinal database. Surg Obes
approximately 5 h. Relat Dis. 2010;6(4):347–55.
12 Robotic Biliopancreatic Diversion: Robot-Assisted (Hybrid) Biliopancreatic… 141

9. Sudan R, et al. Multifactorial analysis of the learning 13. Prachand VN, Davee RT, Alverdy JC. Duodenal
curve for robot-assisted laparoscopic biliopancreatic switch provides superior weight loss in the super-
diversion with duodenal switch. Ann Surg. 2012; obese (BMI > or = 50 kg/m2) compared with gastric
255(5):940–5. bypass. Ann Surg. 2006;244(4):611–9.
10. Buchwald H, et al. Duodenal switch operative mortal- 14. Sovik TT, et al. Randomized clinical trial of laparoscopic
ity and morbidity are not impacted by body mass gastric bypass versus laparoscopic duodenal switch for
index. Ann Surg. 2008;248(4):541–8. superobesity. Br J Surg. 2010;97(2):160–6.
11. Buchwald H, et al. Bariatric surgery: a systematic 15. Topart P, Becouarn G, Ritz P. Biliopancreatic diver-
review and meta-analysis. JAMA. 2004;292(14): sion with duodenal switch or gastric bypass for failed
1724–37. gastric banding: retrospective study from two institu-
12. Buchwald H, Oien DM. Metabolic/bariatric surgery tions with preliminary results. Surg Obes Relat Dis.
Worldwide 2008. Obes Surg. 2009;19(12):1605–11. 2007;3(5):521–5.
 Part VI
Surgical Techniques: Hepatobiliary/
Pancreas
 Robotic
Pancreaticoduodenectomy 13
(Whipple Procedure)

Martin J. Dib, Tara Kent,

and A. James Moser

laparoscopic PDs have been published by

Introduction
Palanivelu et al. [6] and Kendrick and Cusatti [7],
although less than 200 reports of laparoscopic
The major technical aspects of pancreatoduode- PDs are found in the English literature since
nectomy (PD) to resect tumors of the periampullary Garner’s first description. The slow adoption of
region have not changed significantly since it was laparoscopic PDs is a result of the technical
first established in the early twentieth century. burdens and complexity of this procedure [8].
Allen O. Whipple published the first case series Robotic-assisted surgery, with magnified ste-
of a single-stage PD in 1945, and Traverso and reoscopic visualization and computer-enhanced
Longmire described the addition of pylorus pres- 540° movement of the surgical instruments, has
ervation in 1978 [1, 2]. The high postoperative the potential to overcome the technical impedi-
mortality rates prevented the widespread use of ments to recreating time-tested techniques for
PD for several decades, but advancements in crit- open pancreatic surgery in a minimal access tech-
ical care, anesthesia, and attention to surgical nique. Variations of robotic-assisted PD and its
detail led to significant outcome improvements preliminary outcomes have been published by
[3, 4]. The most recent refinements have focused groups led by Giulianotti, Melvin, and Moser and
on minimally invasive adaptations, taking the Zeh [9–15].
advantages of technological innovations in com-
plex resections and anastomotic reconstructions.
The first laparoscopic PD was published by Selection Criteria
Gagner and Pomp in 1994 [5]. Reports of totally
Selection criteria for attempting minimally inva-
sive resection for pancreatic cancer are of equal
importance to the technical aspects and must
address potential oncological hazards including
M.J. Dib, M.D. • T. Kent, M.D., F.A.C.S.
the likelihood of residual tumor at the surgical
Department of Surgery, Beth Israel Deaconess
Medical Center, 330 Brookline Avenue, Stoneman margin and adequacy of lymph node sampling.
9th Floor, Boston, MA 02215, USA We select patients for robotic-assisted PD (RAPD)
e-mail: [email protected]; dibmartin@gmail. using a validated predictive model to maximize
com; [email protected]
the likelihood of R0 surgical resection among
A.J. Moser, M.D., F.A.C.S. (*) patients with pancreatic cancer [16]. Three factors
Institute for Hepatobiliary and Pancreatic Cancer,
are evaluated: evidence for any vascular involve-
Beth Israel Deaconess Medical Center, 330 Brookline
Avenue, Boston, MA 02215, USA ment on preoperative CT scan, abnormal lymph
e-mail: [email protected] nodes on endoscopic ultrasound (EUS), and tumor

K.C. Kim (ed.), Robotics in General Surgery, DOI 10.1007/978-1-4614-8739-5_13, 145

© Springer Science+Business Media New York 2014
146 M.J. Dib et al.

diameter greater than 2.6 cm on EUS. RAPD is device, through which a 10-mm port is inserted
offered only to patients at low-predicted risk of a for the passage of needles, staplers, and extrac-
non-R0 outcome: (a) EUS stage 1A; (b) absence tion bags.
of vascular involvement on CT and EUS stage less
than or equal to 2A; and (c) absence of vascular
involvement on CT and EUS stage 2B, but largest Step 1: Mobilization of the Right
tumor diameter <2.6 cm. Colon and Pancreatic Head

Following laparoscopic staging, the right colon is

Position, Equipment, and Trocar mobilized and rotated medially to expose the root
Placement of the mesentery. A flexible liver retractor is used
to retract segment 4 cranially. An extended
The patient is positioned supine on a split-leg Kocher maneuver is performed to release the
table with the right arm tucked and the left arm proximal jejunum from the ligament of Treitz.
extended, and the robot is docked from straight The jejunum is transected with a 3.5-mm linear
over the patient’s head. Seven laparoscopic ports cutting stapler 10 cm distal to the former liga-
are required (Fig. 13.1a, b). A 5-mm optical sepa- ment of Treitz and marked with an Endo Stitch
rator is used to access the peritoneal cavity in the 50–60 cm downstream to mark the intended loca-
left subcostal region. The camera port is placed tion of the duodenojejunostomy.
2–3 cm superior and to the right of the umbilicus
to improve exposure of the portal vein. Two
5-mm ports are placed in the right upper quadrant Step 2: Division of the Gastrocolic
and later converted to 8-mm robotic trocars. A Omentum, Proximal Duodenum,
5-mm port for the laparoscopic liver retractor is and Jejunum
inserted in the anterior axillary line. Two assis-
tant ports are placed in the lower quadrants. Once The gastrocolic omentum is divided with
resectability is ensured, a 5-cm extraction inci- LigaSure. The groove between the gastroepiploic
sion is created and sealed with a GelPoint® access vascular pedicle and the duodenum is opened

Fig. 13.1 Position of the ports during a robotic-assisted subcostal margin as shown. Assistant ports (A1, A2) are
pancreatoduodenectomy in male (a) and female (b). placed at the midclavicular line slightly inferior to the
The camera port (C) is placed to the right of the umbili- umbilicus and the extraction incision as an extension of
cus. Robotic ports (R1, R2, R3) are placed along the A2 medially
13 Robotic Pancreaticoduodenectomy (Whipple Procedure) 147

into the hepatic hilum. The portal lymph nodes are

swept into the specimen, searching for an aberrant
right hepatic artery. The bile duct is divided with a
stapler whenever possible to minimize contamina-
tion of the peritoneum with bile. The distal bile
margin is resected and sent to pathology.

Step 5: Mobilization of the Portal

Vein and Division of the Pancreatic
Neck

The origin of the right gastroepiploic vein is

identified as it enters the SMV and divided. The
SMV is dissected free from the pancreatic neck,
Fig. 13.2 Room setup. The patient is positioned supine
on a split-leg table, and the robot is docked from straight
and an articulated laparoscopic grasper is used to
over the patient’s head. The robotic surgeon operates the pass an umbilical tape beneath the pancreas. 2-0
console while the laparoscopic surgeon sits between the silk sutures are placed to occlude the transverse
patient’s legs. A triangle of safety is created between pancreatic arteries at the inferior and superior
the robotic surgeon, the laparoscopic surgeon, and the
scrub nurse, ensuring direct visualization among them
borders of the pancreas. The gland is divided
with cautery scissors in an attempt to identify and
sharply transect the pancreatic duct.
with the LigaSure. The right gastric artery is
mobilized from the hepatic artery and divided to
free the proximal duodenum. The duodenum is Step 6: Division of the
divided with a linear cutting stapler, after which Retroperitoneal Margin
the gastroepiploic pedicle is divided with a vas-
cular stapler. The pancreas is elevated from the retroperito-
neum using the third robotic arm. Venous tribu-
taries on the lateral margin of the SMV-PV,
Step 3: Docking the Robot superior pancreaticoduodenal vein, and tributar-
ies from the first jejunal vein to the uncinate pro-
The robot is brought over the patient’s head with cess are ligated with 3-0 silk ties and divided
arms 2 and 3 on the patient’s right and the patient sharply. Arterial branches from the SMA are
positioned right side up in steep reverse either divided with the LigaSure or controlled
Trendelenburg (Fig. 13.2). The robotic surgeon proximally with a silk tie and clip and transected
operates the console while the laparoscopic sur- distally with the LigaSure. The specimen is
geon sits between the patient’s legs. retrieved in a specimen bag and examined by fro-
zen section. Gold fiducials are placed in cases of
suspected malignancy. Lastly, antegrade chole-
Step 4: Portal Dissection and Division cystectomy is performed.
of the Bile Duct

The common hepatic artery (CHA) lymph node is Step 7: Reconstruction

resected and retrieved. The CHA is followed into
the porta hepatis. The gastroduodenal artery (GDA) A duct-to-mucosa pancreaticojejunostomy is
is temporarily occluded to confirm continued flow performed using a modified Blumgart technique.
within the CHA and then ligated and divided with a Interrupted 5-0 Vicryl sutures are placed around
vascular stapler. The PV is exposed and dissected the pancreatic duct to facilitate visualization. 2-0
148 M.J. Dib et al.

Fig. 13.3 Pancreaticojejunostomy. Picture demon- interrupted 5-0 Vicryl sutures and 2-0 silk horizontal
strates the corner stitch of the duct-to-mucosa anastomo- mattress sutures to anchor the seromuscular layer of the
sis performed using a modified Blumgart technique with jejunum

Fig. 13.4 Hepaticojejunostomy. Picture demonstrates the back row of the single-layer end-to-side anastomosis created
with interrupted 5-0 Vicryl

silk horizontal mattress sutures are passed layer end-to-side hepaticojejunostomy is created
through the pancreas to anchor the seromuscular with interrupted 5-0 Vicryl (Fig. 13.4). A running
layer of the jejunum. A small enterotomy is made technique is used for ducts >5 mm in diameter
in the jejunum with robotic scissors, and an inter- when visualization is optimal. Finally, an
rupted duct-to-mucosa anastomosis is completed antecolic, two-layer duodenojejunostomy is per-
(Fig. 13.3). The anastomosis is completed with formed (Fig. 13.5). A posterior layer of inter-
an anterior layer of 2-0 silk sutures. A single- rupted seromuscular 2-0 silk sutures is placed,
13 Robotic Pancreaticoduodenectomy (Whipple Procedure) 149

Fig. 13.5 Duodenojejunostomy. Picture demonstrates posteriorly, followed by a full-thickness running 3-0
the anterior corner stitch of the antecolic, two-layer anas- Vicryl after the duodenum and jejunum are opened
tomosis, with interrupted seromuscular 2-0 silk sutures

followed by full-thickness running 3-0 Vicryl progress (n = 4), unsuspected abutment of the
after the duodenum and jejunum are opened. Two PV by tumor (n = 2), and unsuspected micro-
round 19 F surgical drains are placed: one ante- scopic tumor at the pancreatic neck margin
rior and one posterior to the biliary and pancre- (n = 2) by frozen section. At intention-to-treat
atic anastomoses. The robot is undocked, and the analysis, pancreatic fistula as defined by the
right lower quadrant incision and camera port are International Study Group of Pancreatic
closed. The skin is closed with a monofilament Surgery occurred in ten patients (20 %). The
subcuticular closure. margin-negative resection rate was 89 %, and
the median number of lymph nodes collected
was 18 [12, 14, 15].
Outcomes

Analysis of outcomes in our first 50 patients Conclusion

undergoing attempted RAPD demonstrated a
median age of 72 years (range 27–85). The pre- Robotic-assisted pancreatoduodenectomy (RAPD)
dominant indications for surgery were pancre- allows the recreation of time-tested techniques
atic ductal carcinoma (14, 28 %), neuroendocrine for open pancreatic surgery through a minimally
tumor (10, 20 %), ampullary adenocarcinoma invasive approach. The robotic platform is able to
(9, 18 %), and intraductal papillary mucinous overcome the current limitations of laparoscopic
neoplasm (9, 18 %). The median duration of surgery, including limited range of motion, poor
attempted RAPD was 568 min (IQR 536–629) surgeon ergonomics, and lack of 3D view. Early
including the time to undock and convert to an outcomes of robotic-assisted major pancreatic
open procedure in eight patients (16 %). Median resection are comparable to laparoscopic and
blood loss was 350 mL (IQR 150–625), and 11 open approaches. Technological innovations and
patients (22 %) required transfusion during increased surgeon familiarity with this approach
their index hospital stay. Conversion to open will lead to greater adoption and acceptance.
procedure was required in eight patients (16 %), Next-generation robots may expedite these
and the reasons for conversion were failure to efforts, hopefully at lower cost.
150 M.J. Dib et al.

9. Giulianotti PC, Sbrana F, Bianco FM, Elli EF, Shah G,

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1. Whipple AO. Pancreaticoduodenectomy for Islet car- experience. Surg Endosc. 2010;24(7):1646–57.
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847–52. laparoscopic pancreaticoduodenectomy: a hybrid
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Obstet. 1978;146(6):959–62. tomy. In: Fischer JE, Jones DB, Pomposelli FB,
3. Howard JM. Pancreatico-duodenectomy: forty-one Upchurch Jr GR, editors. Fischer’s mastery of sur-
consecutive Whipple resections without an operative gery, vol. 133A. 6th ed. Philadelphia, PA: Lippincott
mortality. Ann Surg. 1968;168(4):629–40. Williams & Wilkins; 2011. p. 92–9.
4. Crist DW, Sitzmann JV, Cameron JL. Improved hos- 12. Zureikat AH, Nguyen KT, Bartlett DL, Zeh HJ, Moser
pital morbidity, mortality, and survival after the AJ. Robotic-assisted major pancreatic resection and
Whipple procedure. Ann Surg. 1987;206(3):358–65. reconstruction. Arch Surg. 2011;146(3):256–61.
5. Gagner M, Pomp A. Laparoscopic pylorus-preserving 13. Nguyen KT, Zureikat AH, Chalikonda S, Bartlett DL,
pancreatoduodenectomy. Surg Endosc. 1994;8(5): Moser AJ, Zeh HJ. Technical aspects of robotic-
408–10. assisted pancreaticoduodenectomy (RAPD).
6. Palanivelu C, Rajan PS, Rangarajan M, Vaithiswaran J Gastrointest Surg. 2011;15(5):870–5.
V, Senthilnathan P, Parthasarathi R, Praveen RP. 14. Zeh III HJ, Bartlett DL, Moser AJ. Robotic-assisted
Evolution in techniques of laparoscopic pancreatico- major pancreatic resection. Adv Surg. 2011;45:323–40.
duodenectomy: a decade long experience from a 15. Zeh HJ, Zureikat AH, Secrest A, Dauoudi M, Bartlett
tertiary center. J Hepatobiliary Pancreat Surg. 2009; D, Moser AJ. Outcomes after robot-assisted pancre-
16(6):731–40. aticoduodenectomy for periampullary lesions. Ann
7. Kendrick ML, Cusati D. Total laparoscopic pancreati- Surg Oncol. 2012;19(3):864–70.
coduodenectomy: feasibility and outcome in an early 16. Bao P, Potter D, Eisenberg DP, Lenzner D, Zeh HJ,
experience. Arch Surg. 2010;145(1):19–23. Lee Iii KK, Hughes SJ, Sanders MK, Young JL,
8. Gagner M, Palermo M. Laparoscopic Whipple proce- Moser AJ. Validation of a prediction rule to maximize
dure: review of the literature. J Hepatobiliary Pancreat curative (R0) resection of early-stage pancreatic ade-
Surg. 2009;16(6):726–30. nocarcinoma. HPB (Oxford). 2009;11(7):606–11.
 Robotic Distal Pancreatectomy
14
Anusak Yiengpruksawan

surgeon with intuitive hand-eye coordination,

Introduction three-dimensional vision, and dexterity enhance-
ment. The endowrist technology enables the
Similar to cholecystectomy and adrenalectomy, surgeon to perform meticulous, delicate, and
the surgical approach to distal pancreatectomy is complex tasks such as knot tying, suturing, and
evolving from an open to a minimally invasive vascular or lymph node dissection. For robotic
procedure [1–3]. The safety and feasibility of distal pancreatectomy, these advantages are
minimally invasive distal pancreatectomy (DP) especially of significance when splenic vessels
has been shown to be equal, if not superior, to its are to be preserved or extended lymphadenec-
open counterpart [3–9]. Unlike laparoscopic cho- tomy is required in cancer cases. The main draw-
lecystectomy, which is technically straightfor- back of robotic surgery is the lack of tactile
ward and commonly performed by most general feedback, which forces the surgeon to rely on
surgeons, laparoscopic distal pancreatectomy is a visual guidance. With the advent of da Vinci
much more complex and a less common proce- robotic technology, surgeons with experience in
dure. In addition, certain technical disadvantages open pancreatic procedures, but with limited lap-
associated with laparoscopy and the steep learn- aroscopic skills, can achieve proficiency in mini-
ing curve required to master the technique have mally invasive pancreatectomy in an efficient and
limited the global adoption of the laparoscopic safe manner.
DP approach and remain limited to a few pancre- Application of the robotic platform to pancre-
atic surgeons and centers. atic resection has evolved in a similar fashion as
Compared to laparoscopic surgery, the robotic laparoscopic pancreatectomy, with the left-sided
approach has several advantages. The greatest (distal) pancreas as an initial procedure. A stan-
advantage is that robotic surgery brings the open- dard distal pancreatectomy requires only extirpa-
surgery “feeling” or “experience” to the mini- tion compared to that of the right-sided (proximal)
mally invasive environment by providing the pancreas (i.e., Whipple procedure), which man-
dates complex vascular dissection in addition to
gastrointestinal reconstruction. Technical details
of robotic distal pancreatectomy were initially
A. Yiengpruksawan, M.D., F.A.C.S. (*) described by Giulianotti and later by others
Department of Surgery, The Valley Minimally [10–14]. This chapter describes the technical
Invasive and Robotic Surgery Center, The Valley
approach to robotic DP, including technical tips,
Hospital, North van Dien Avenue,
Ridgewood, NJ 07450, USA culminating from the author’s 10-year experience
e-mail: [email protected] in robotic pancreatic surgery.

K.C. Kim (ed.), Robotics in General Surgery, DOI 10.1007/978-1-4614-8739-5_14, 151

© Springer Science+Business Media New York 2014
152 A. Yiengpruksawan

Pneumoperitoneum Technique
Procedure Overview (Fig. 14.1)
To achieve initial pneumoperitoneum, the left
The standard position for DP begins by placing subcostal approach using a Veress needle tech-
the patient in an oblique 30° right lateral position nique is preferred. The insufflation tubing is con-
(left side up) supported by a pillow or a roll of nected to the needle, and the insertion is done
linen sheet behind the left mid-back, with both under continuous CO2 flow. The entry into the
arms tucked along the body and protected by peritoneal cavity is confirmed by a drop in CO2
foam protectors. Next, “fine tuning” of the initial pressure to near zero. [TIP: The needle insertion
positioning prior to docking the robot should be under pressure-monitoring technique is espe-
performed and will depend on the tumor loca- cially helpful in an obese patient. The ideal punc-
tion. For more proximal pancreatic lesions (pan- ture site is just right below the costal margin
creatic neck), the patient is placed in a less-oblique between the midclavicular and anterior axillary
angle (almost supine) with the table placed in a lines. Lifting the abdomen up prior to needle
reverse Trendelenburg position to allow for ade- insertion can help separate the omentum from the
quate exposure of the portal-SMV junction if anterior abdominal wall. Gastric decompression
necessary. For true pancreatic tail lesions, addi- prior to the procedure is mandatory to prevent
tional obliquing of the patient to 45° allows the inadvertent puncture of the distended stomach.
stomach to fall to the right, which improves This technique is contraindicated in patients with
exposure as well as facilitates the splenectomy splenomegaly, portal hypertension, or bowel dis-
portion of the procedure. tention.] However, in a patient with previous left
upper abdominal surgery, an open (Hassan’s)
technique is used with the camera port. The cam-
era port (12 mm) is placed 3–4 cm to the left of
the umbilicus or at the umbilicus if the lesion is
near the pancreatic neck.

Trocar Placement

As in patient positioning, choosing locations for

trocar placement should be based on patient’s
body habitus, location of the lesion, and the
extent of dissection and/or resection. After place-
ment of the camera port as described above, three
robotic trocars (8 mm) and a 12 mm accessory
ports are placed. The 12 mm accessory port and
one robot port are placed on the patient’s left,
while two robotic ports and, occasionally, an
additional 5 mm accessory port may be needed
on the patient’s right, and all are placed under
direct vision. Robotic trocars are usually placed
first. [TIP: Choosing the placement sites for the
fourth arm and accessory ports after the docking
of the surgical cart to the camera, right and left
instrument ports, allows the surgeon to assess the
possibility of robotic arm collision and whether
Fig. 14.1 Patient and port positioning the accessory ports are accessible before making
14 Robotic Distal Pancreatectomy 153

incisions.] The left robotic port (R2) is placed

along the left anterior axillary line at the level of
the umbilicus. The right robotic port (R1) is then
placed on the right upper abdomen along the
pararectal (for distal lesion) or midclavicular (for
more midline lesion) line, 3–4 cm above the
umbilicus, while the fourth robotic port (R4) is
placed along the right midclavicular (for distal
lesion) or anterior axillary line (for more midline
lesion) at the same level as the right robotic port.
A 12 mm accessory port is then placed between
the camera port and the left robot port and 4–5 cm
inferiorly. The 5 mm accessory port, if needed, is
positioned on the right abdomen in a mirror
image to the 12 mm accessory port. Fig. 14.2 Firefly fluorescence imaging showing illumi-
Once the trocars are placed and patient posi- nating spleen
tioning confirmed, docking of the robot is then
performed. The surgical cart is brought in superi-
orly, approximately 20° to the left of the patient’s splenectomy is planned. However, they should be
longitudinal axis. It is important to place the left intact if a surgeon intends to preserve the
robot’s fourth arm on the patient’s right side (sur- spleen using Warshaw’s technique (en bloc resec-
geon’s left) prior to docking. Once docked, tion of splenic vessels). [TIP: Viability of spleen
robotic instruments are placed through the robotic can be assessed more definitively by injecting
trocars. The R1 port holds the bipolar forceps, the ICG dye and shining infrared light on the spleen
R2 port uses a monopolar cautery hook, and the (“firefly” fluorescence imaging). If there is blood
R4 holds the grasper forceps. flow into the spleen, it will illuminate fluores-
cence green (Fig. 14.2). If majority of the spleen
does not illuminate, splenectomy should then be
Technique performed.]
Once the greater curve of the stomach is ade-
Step 1: Exposure of the Pancreatic quately mobilized, complete mobilization of
Neck, Body, and Tail splenic flexure of the colon is generally accom-
plished prior to pancreatic mobilization. This can
Using the grasper forceps (R4), the anterior wall be performed by continuing the dissection from a
of the mid-gastric body is grasped close to the medial to lateral approach or a lateral to medial
greater curvature and lifted cranially to open the approach, depending on patient anatomy, tumor
lesser sac space. The gastrocolic attachments are size, and location.
divided below and along the gastroepiploic The pancreatogastric fold (ligament) is next
arcade from the prepyloric antrum to the fundus divided to fully expose the pancreatic body. Care
using the electrocautery hook and the bipolar is taken not to injure the left gastric vein unless
coagulator. With lesions located close to the pan- subtotal pancreatectomy is to be performed. The
creatic neck, the right-sided dissection of the mobilized stomach is retracted superiorly and
omentum should be carried out until the right held cranially either by the fourth arm or a retrac-
gastroepiploic vessels and the duodenum are tor via an accessory port. [TIP: Suturing the
fully exposed. This step will help in localizing stomach to the falciform ligament and diaphragm
and exposing the superior mesenteric vein as it frees up the fourth arm, which would otherwise
courses underneath the pancreatic neck. Short be used to hold up the stomach. In addition, hav-
gastric vessels may be divided at this stage if ing the stomach fixed in position helps to create a
154 A. Yiengpruksawan

Fig. 14.3 Tagging of stomach to the anterior abdominal wall

stable operative field (Fig. 14.3).] Intraoperative which are quite avascular. The fourth arm (R4)
ultrasound of the pancreas, using a laparoscopic retracts the spleen medially, providing exposure
8 MHz probe, can be performed if the lesion is of the splenorenal and splenophrenic attachments.
small and in the proximal pancreas. Ultrasound Retraction is facilitated by leaving a small “tag”
images can be displayed in the surgeon console of splenorenal peritoneum connected to the spleen
using the TilePro system. to be used as a handle for grasping and to prevent
splenic bleeding secondary to retraction injury.
As the dissection continues to the left, the
Step 2: Mobilization of the Pancreas pancreas is gently lifted and rotated upward and
and Spleen and Identification held by the fourth arm grasper forceps. As the
of the Proximal Splenic Vessels posterior border of the dissection proceeds, the
splenic vein is identified about halfway to two-
Once the greater curve of the stomach and splenic thirds superiorly from the lower border of the
flexure of the colon are mobilized, and the lesion pancreas (Fig. 14.4). In some patients, the tortu-
is identified, the transverse mesocolon is retracted ous part of the splenic artery may be found
inferiorly to define the inferior border of the pan- immediately after identifying the splenic vein,
creas. The peritoneum overlying the inferior bor- indicating that the dissection has reached the
der of the pancreatic body is incised using the superior edge of the pancreas. The lesser sac
cautery hook and the loose areolar tissue posterior bursa is then entered by continuing the dissection
to the pancreas. Dissection is carried out toward between the artery and lymphatic tissue until the
the patient’s left along this plane. For pancreatico- bursa cavity is visualized. Sometimes it is much
splenectomy, mobilization of the spleen together easier to come around the upper edge of the pan-
with the distal pancreas in continuity is preferred. creas near the upper pole of the spleen since there
This approach is more efficient and less time con- is less fatty lymphatic tissue and the peritoneum
suming and involves less bleeding, since dissec- is much better defined. A vessel loop or an
tion is along the same plane leading to the umbilical tape can then be passed behind the
splenorenal and splenophrenic ligaments, both of pancreas and looped around it to help in further
14 Robotic Distal Pancreatectomy 155

region can be controlled with bipolar energy or

with just pressure gauze. To avoid inadvertent
ligation of celiac trunk or common hepatic
artery, the splenic artery should be exposed well
into the pancreas or ligated distal to the left gas-
tric artery. The latter artery may form a common
trunk with the splenic artery or arises separately
from the celiac trunk.]

Step 3: Pancreatic and Vascular

Transection

Fig. 14.4 Splenic vein Transection of pancreas for en bloc splenectomy

can be performed together with splenic vessels or
separately, depending on ease of dissection. The
pancreas is mobilized proximally up to the porto-
splenic junction (Fig. 14.6), and the splenic artery
and vein are identified.
If the vessels can be isolated, it is preferable to
divide the splenic artery first and then the vein to
avoid splenic congestion, but it is not essential.
The vessel can be divided using a vascular stapler
or clips (Hem-o-loks®). If the lesion is found
adherent to splenic vein close to the portal vein
trunk, partial resection (Figs. 14.7 and 14.8) or
resection of the portal vein with reconstruction
may be necessary.
Once the vessels have been controlled, the
Fig. 14.5 Splenic artery pancreas is subsequently divided with an endo-
GIA stapler (Fig. 14.9). Bioabsorbable staple line
reinforcement strips placed on the stapler car-
pancreatic mobilization (“hanging” technique). tridge (Seamguard®) can be used to reinforce the
Control of splenic artery at this location is suffi- stump to prevent pancreatic leak. Closure of sta-
cient if the margin of the proximal pancreatic pler jaws should be slow and gradual to allow for
resection is distal to it. For subtotal pancreato- smooth tissue approximation.
splenectomy, it is essential to isolate and control If the vessels cannot be safely dissected from
the artery near its origin from the celiac trunk. the pancreatic parenchyma, or the pancreas is too
This dissection requires an anterior approach to thick for the stapler, the pancreas is divided in a
reach the superior aspect of the pancreas stepwise fashion using a combination of cutting,
(Fig. 14.5) [TIP: To locate the origin of the cauterization, and suture ligation (Fig. 14.10).
splenic artery, often it is easier to start from the Care must be taken during this approach that the
common hepatic artery (since it is readily recog- vessels, which are partially exposed, can be pro-
nized) and then trace back toward the celiac tected at all times. The proximal stump of the
trunk. Lymph node dissection can also be simul- pancreas is then closed using running 3-0 Prolene
taneously performed. The left gastric vein may suture, and fibrin glue may be applied to decrease
have to be divided for better exposure. Nuisance pancreatic leak. If the pancreatic duct is visible, it
bleeding from lymphatic tissue around the celiac is first transfixed with the same suture.
156 A. Yiengpruksawan

Fig. 14.6 Portomesenteric-splenic junction

Fig. 14.7 Partial resection of SMV

Step 4: Splenic-Preserving Distal dictated by location of the lesion. For far distal
Pancreatectomy tumors, a lateral to medial approach may be used.
For body lesions, it is often safer to approach
Splenic preservation may be attempted for cer- splenic preservation from a medial to lateral
tain histologies and anatomy. There are two approach. [TIP: Knowledge of the relationship
approaches for splenic preservation, which are between the pancreatic tail and spleen from
14 Robotic Distal Pancreatectomy 157

Fig. 14.8 Celiac trunk after wedge resection of SMV

junction (Fig. 14.6), and the splenic artery and

vein are identified. A plane is developed between
the pancreas and the splenic vein, and pancreas
parenchyma is transected proximal to the lesion.
After the pancreas is transected, the distal
stump is grasped and carefully retracted laterally
toward the left while it is dissected away from the
vessels (Figs. 14.11 and 14.12). There are 3–4
short perforating vessels into the pancreatic body
that require meticulous dissection to achieve ade-
quate length before they can be ligated with fine
sutures and divided. Stay sutures may be placed
on the stump to allow for easy manipulation of the
Fig. 14.9 Pancreatic transection with staplers pancreas. Using the fourth arm (R4) to hold and
stabilize the pancreas during the dissection makes
the process much more efficient and safer. During
preoperative imaging study facilitates the distal the dissection and mobilization, there are two
dissection. In some patients, a short pancreatic areas requiring particular attention. The first area
tail or lack of one creates a wide gap; in others is at the looping portion of the splenic artery. Here,
the tail may lie snugly near the splenic hilum. For it is important to dissect along the curvature of the
the latter, the splenic flexure may have to be com- artery while paying careful attention to the medi-
pletely detached from the spleen in order to safely ally located splenic vein (Fig. 14.11). In some
free the tail from the hilum.] instances, the splenic artery may form a smooth
curve and appear to run parallel to the vein
Medial to Lateral Approach (Fig. 14.12). It is, therefore, important to study
Similar to pancreaticosplenectomy, the pancreas preoperative images and know the topographic
is mobilized proximally up to the portosplenic anatomy, including the vascular pattern before the
158 A. Yiengpruksawan

Fig. 14.10 Manual transection of pancreas

Fig. 14.11 Tortuous splenic artery (SA)

surgery. The second area is around the tail of the pancreas and spleen should be noted. For this
pancreas where several vessels may be found clus- approach, complete mobilization of the splenic
tered together and can be easily injured. flexure of the colon should be done initially. Once
the tail of the pancreas and spleen are fully
Lateral to Medial Approach exposed, the tail of the pancreas is retracted medi-
Lateral to medial approach is often used when the ally and downward. Small perforating vessels are
lesion is in the distal tail. As described above, pre- controlled with the bipolar electrocautery or clips.
operative evaluation of the CT scan with particular The pancreas can be divided once a margin of at
attention to the relationship of the tail of the least 2 cm proximal to the lesion is achieved.
14 Robotic Distal Pancreatectomy 159

Fig. 14.12 Straight splenic artery

Step 5: Specimen Extraction resect most pancreatic lesions through a robotic

approach, it is recommended that early on in the
The resected specimen is placed in the endobag learning curve, the surgeon begin with a simple
placed through the 12 mm accessory port. The distal pancreatosplenectomy for benign lesions.
specimen is brought out either through the However, before attempting one’s first robotic
enlarged 12 mm accessory port incision (for a DP, the surgeon should familiarize himself/her-
small specimen) or a Pfannenstiel incision (for a self with robotic surgery in general and observe a
larger specimen). [TIP: When a Pfannenstiel inci- similar procedure performed by other experi-
sion is made, it is better to keep pneumoperitoneum enced robotic surgeons. In terms of institutional
for easy access into the peritoneal cavity. This is credentialing, most institutions require that for
especially helpful in an obese patient with thick the initial experience, robotic surgery should be
preperitoneal fat. Care should be taken to prevent done under the supervision of an expert surgeon.
splashing of blood when the peritoneum is open.] Ideally, this is performed using a dual console
After adequate hemostasis is confirmed, a closed- system, which allows the experienced surgeon to
suction drain may be placed in the pancreatic bed assist directly. It must be emphasized that a low
and brought out through the left instrument port threshold for conversion and the use of common
incision. sense should always be considered in the early
learning stage.

Discussion
Published Outcome Studies to Date
Indications to proceed with the robotic approach
to distal pancreatectomy should be determined Since 2003, there have been several published
by surgeon’s experience with pancreatic surgery articles on robotic DP. However, most were case
and robotic surgery. While it is quite possible to reports describing technical aspects of robotic
160 A. Yiengpruksawan

DP. The first report with outcome analysis was

References
from Giulianotti et al. [11] who studied their
series of 46 robotic DPs over 10 years span. 1. Fernandez-Cruz L, Marinez I, Gilabert R, Cesar-
Their robotic-to-open conversion rate was 6.5 % Borges G, Astudillo E, Navarro S. Laparoscopic distal
with a postoperative pancreatic fistula rate of pancreatectomy combined with preservation of the
20.9 %. These results compared favorably with spleen for cystic neoplasm of the pancreas. J
Gastrointest Surg. 2004;8:439–501.
those from laparoscopic studies. The other pub- 2. Pietrabissa A, Moretto C, Boggi U, Di Candio G,
lished series by Waters et al. [12] described 17 Mosca F. Laparoscopic distal pancreatectomy: are we
robotic DP and compared them to open DP and ready for a standardized technique? Semin Laparosc
laparoscopic DP. Their conversion rate was 6 % Surg. 2004;11:179–83.
3. Uranues S, Alimoglu O, Todoric B, Toprak N, Auer T,
but with a reduced amount of blood loss in Rondon L, Sauseng G, Pfeifer J. Laparoscopic resec-
robotic DP group. However, the operative time tion of the pancreatic tail with splenic preservation.
was higher in robotic DP group in comparison to Am J Surg. 2006;192:257–61.
open DP and laparoscopic. Both studies 4. Papanivelu C, Shetty R, Jani K, Sendhikumar K, Rajan
PS, Maheshkumar GS. Laparoscopic distal pancreatec-
observed a better trend toward successfully tomy: results of a prospective non-randomized study
preserving splenic vessels when compared to from a tertiary center. Surg Endosc. 2007;21:373–7.
laparoscopic and open groups. Our own (unpub- 5. Pryor A, Means JR, Pappas TN. Laparoscopic distal
lished) series of 84 robotic distal pancreatec- pancreatectomy with splenic preservation. Surg
Endosc. 2007;21:2326–30.
tomy patients performed between January 2002 6. Honore C, Honore P, Meurisse M. Laparoscopic
and December 2011 also showed outcomes sim- spleen-preserving distal pancreatectomy: description
ilar to above reports. During the first 5-year of an original posterior approach. J Laparoendosc
period, our robotic-to-open conversion rate was Adv Surg Tech A. 2007;17:686–9.
7. Bruzoni M, Sasson AR. Open and laparoscopic spleen
as high as 18.4 % but has decreased significantly preserving, splenic vessel-preserving distal pancre-
since. There was no conversion in the last atectomy: indications and outcomes. J Gastrointest
2 years. Our overall pancreatic fistula rate was Surg. 2008;12:1202–6.
20 %, out of which 5 % was of ISGPF grade B 8. Nau P, Melvin WS, Narula VK, Bloomston PM,
Ellison EC, Muscarella P. Laparoscopic distal pancre-
and/or C pancreatic fistulas. There was no peri- atectomy with splenic conservation: an operation
operative mortality, and the median length of without increased morbidity. Gastroenterol Res Pract.
stay was 5 days. 2009;2009:846340.
As for robotic DP for pancreatic ductal carci- 9. Xie K, Zhi YP, Xu XW, Chen K, Yan JF, Mou YP.
Laparoscopic distal pancreatectomy is as safe and fea-
noma, although perioperative outcomes such as sible as open procedure: a meta-analysis. World J
tumor margins and number of harvested lymph Gastroenterol. 2012;18:1959–67.
nodes were similar to [11–13] both laparoscopic 10. Melvin W, Needleman B, Krause K, Ellison E. Robotic
and open groups, long-term survival outcomes resection of a pancreatic neuroendocrine tumor. J
Laparoendosc Adv Surg Tech A. 2003;13:33–6.
have not yet been adequately analyzed. Therefore, 11. Giulianotti P, Sbrana F, Bianco F, Elli E, Shah G,
a randomized multi-institutional controlled study Addeo P, et al. Robot-assisted laparoscopic pancreatic
is needed to evaluate its efficacy and cost- surgery: single-surgeon experience. Surg Endosc.
effectiveness before it can be recommended for 2010;24:1646–57.
12. Waters J, Canal D, Wiebke E, Dumas R, Beane J,
routine use. Aguilar-Saavedra J, et al. Robotic distal pancreatec-
tomy: cost effective? Surgery. 2010;148:814–23.
Acknowledgments Lawrence Harrison, M.D., a new 13. Yiengpruksawan A. Technique for laparobotic distal
addition to the Valley Robotic Program, for his cri- pancreatectomy with preservation of spleen. J Robot
tiques, comments, and corrections of this chapter. Surg. 2011;5:11–5.
Nino Carnevale, M.D. for his consistent support and 14. Buchs NC, Volonte F, Pugin F, Bucher P, Jung M,
assistance during the development of the Valley Robotic Morel P. Robotic pancreatic resection: how far can we
Program. go? Minerva Chir. 2011;66:603–14.
 Robotic Hepatic Resections:
Segmentectomy, Lobectomy, 15
Parenchymal Sparing

M. Shirin Sabbaghian, David L. Bartlett,

and Allan Tsung

with the intent to take advantage of the benefit

Introduction and History they can bring, including less postoperative pain,
decreased time of ileus, decreased length of stay,
Since Langenbuch first described a planned fewer postoperative complications, and improved
hepatic resection in 1888 [1], the practice of liver cosmesis [21–23]. Most recently, robotic tech-
resection has evolved tremendously. Improved nology has been applied for use in liver surgery.
understanding of hepatic anatomy [2–5], monu- Since the introduction of robotic technology to
mental advances in surgical and anesthesia the operating room in 1985 [24], telepresence has
technique [6–11], greater use of intraoperative emerged with its development inspired mostly by
ultrasound [12, 13], improved preoperative imag- military intent [25]. Advances with this technol-
ing techniques, and eventually the incorporation ogy have taken such great strides that robotic
of vascular stapling devices [14] as well as techniques are able to surpass limitations of lapa-
energy-induced hemostasis [15–17] have all con- roscopic surgery. For example, robotic technol-
tributed to improved outcomes from liver surgery ogy enables instrument movement with seven
[18–20]. With these improved outcomes realized, degrees of freedom (comparable to the human
indications for hepatic resection have been wrist) instead of just four degrees with laparo-
broadened to include patients with benign dis- scopic equipment; robotic optics are three dimen-
ease as well as select patients with abnormal liver sional, not two; surgeon tremor is eliminated; the
function. robot does not tire during long and sometimes
As comfort with liver surgery has grown, repetitive procedures, and robotic surgery offers
minimally invasive techniques have been applied the surgeon an opportunity to operate in an opti-
mal and comfortable position. These advantages
enable an improved ability to finely dissect (par-
M.S. Sabbaghian, M.D. • D.L. Bartlett, M.D. ticularly along the hilum of the liver), reconstruct,
Division of Surgical Oncology, Department of
and maintain vascular control even in more chal-
Surgery, University of Pittsburgh Medical Center,
5150 Centre Avenue, Pittsburgh, PA 15232, USA lenging locations [26]. This theoretically makes
e-mail: [email protected] robotic-assisted liver resection a safer minimally
A. Tsung, M.D. (*) invasive approach, allowing for the completion of
Division of Hepatobiliary and Pancreatic Surgery, more complex procedures. The first reported
Department of Surgery, University of Pittsburgh robot-assisted liver resection took place in the
Medical Center, Liver Cancer Center, Montefiore
Czech Republic in 2006 [27]. Since then, multi-
Hospital, 3459 Fifth Avenue, 7 South, Pittsburgh,
PA 15213, USA ple centers have used robot-assistance for liver
e-mail: [email protected] resection, and success has been reported with

K.C. Kim (ed.), Robotics in General Surgery, DOI 10.1007/978-1-4614-8739-5_15, 161

© Springer Science+Business Media New York 2014
162 M.S. Sabbaghian et al.

outcomes comparable to the laparoscopic Patient Positioning, Room Setup

approach, including similar short-term oncologic
outcomes [28]. The patient is positioned supine with the arms
As success as well as investigation of the tucked and legs split. The robot sits undocked at
robotic-assisted liver resection continues, it is the patient’s head. While we oblige what the
anticipated that more groups will adopt this tech- room allows, anesthesia usually works at the
nique. This chapter describes our methods of patient’s left shoulder and the scrub nurse at
commonly performed liver resections—right the patient’s right side. One surgeon stands at the
hepatectomy, left hepatectomy, left lateral sectio- patient’s right, one between the legs, and an
nectomy, and nonanatomic resection—using additional surgeon or assistant on the patient’s
robotic assistance. left (Fig. 15.1).
The patient will be in 30° reverse
Trendelenburg position for the duration of the
Indications for Robotic-Assisted case after ports are placed.
Hepatectomy

As robotic assistance is a more recently applied Right Hepatectomy

technology, appropriate patient selection has not
been explicitly defined. Currently, we recom- Access is gained to the abdominal cavity via a
mend using the Louisville Statement [29] as a 5 mm port ideally in the left upper quadrant
guide. This summary of the consensus confer- (LUQ), and pneumoperitoneum of 12 mmHg is
ence for applications of laparoscopic liver sur- created. Additional ports are placed using a
gery recommends surgery with minimally 5 mm, 30° scope for visualization (Fig. 15.2).
invasive technique for patients with a single Additional port sites include the 12 mm camera
lesion of 5 cm or less located in segments 2–6. It port to the right of the umbilicus, a robotic port at
suggests that major liver resection can be per- the right mid-abdomen on the anterior axillary
formed with minimally invasive technique but line and another robotic port to the left of the
only by those experienced both with liver sur- umbilicus. A 12 mm assist port is place 8–10 cm
gery as well as minimally invasive liver resec- inferolaterally to the camera port (this port will
tion. Importantly, the consensus conference be used for larger instruments, such as the ultra-
suggests that the surgeon should be facile with sound and the stapler), and a 5 mm assist port is
minimally invasive technique, including the skill placed 8–10 cm inferolaterally to the left abdom-
of intracorporeal suturing should bleeding inal robotic port. The scope is changed to a
become an issue. 10 mm, 30° scope and placed in the camera port.
Lastly, the LUQ port is changed to a robotic port.

Technique of Robotic-Assisted Step 1

Hepatectomy The round and falciform ligaments are divided
using hook cautery (Fig. 15.3), exposing the
The technique of robotic-assisted hepatectomy is, anterior surface of the hepatic veins.
as intended, the same as for open surgery except
minimally invasive equipment is used. Smooth Step 2
teamwork between two experienced surgeons The ligamentous attachments of the right liver
(one at the console and one assisting) familiar are dissected. With the patient’s right side up,
with liver anatomy is imperative for these the gallbladder fundus is retracted superiorly
robotic-assisted procedures. This enables proper via a grasper in the LUQ port, and the right
exposure, identification, and control of major lobe of the liver is retracted anteriorly using a
structures as they are/should be encountered. closed grasper in the right mid-abdominal port.
15 Robotic Hepatic Resections: Segmentectomy, Lobectomy, Parenchymal Sparing 163

Fig. 15.1 Suggested room setup

Fig. 15.3 Laparoscopic dissection of the falciform liga-

ment (Used with kind permission from Randal S.
McKenzie/McKenzie Illustrations)

The hepatic flexure is dissected and the colon is

reflected inferiorly. Attachments to the duode-
num are also dissected from the liver as neces-
sary. Gerota’s fascia, once exposed, is pushed
Fig. 15.2 Port placement, right hepatectomy (Used with
kind permission from Randal S. McKenzie/McKenzie posteriorly using another closed grasper. A cau-
Illustrations) tery device is used to divide the right triangular
164 M.S. Sabbaghian et al.

assist port. The gallbladder should stay in situ

until the portal dissection is completed. It should
be noted that this is different from the open tech-
nique…in the open technique, the gallbladder is
separated from the gallbladder fossa, but the
cystic duct remains intact to allow for a cholan-
giogram to be performed after hepatic parenchy-
mal transection. While maintaining superior
retraction of the gallbladder, portal tissue is
retracted laterally via the bipolar grasper in
robotic Arm 2. The hepatoduodenal ligament is
dissected using hook cautery in robotic Arm 1.
The right hepatic artery (HA) is identified and
defined (Fig. 15.5). If space allows, this is sta-
pled using a vascular load, roticulating stapler
Fig. 15.4 Laparoscopic dissection of the right triangular
ligament. A grasper is used to retract the gallbladder supe- through the 12 mm assist port. Otherwise, this
riorly. A closed grasper is used to lift the right liver up can be tied robotically, clipped with the robotic
while another instrument pushes Gerota’s fascia posteri- clip applier via robotic Arm 1, and then tran-
orly, exposing the right triangular ligament (Used with
sected. Next, the right portal vein (PV) is identi-
kind permission from Randal S. McKenzie/McKenzie
Illustrations) fied and defined. A silk tie is placed around it
(this is not tied), and robotic Arm 2 retracts this
and coronary ligaments up to the right hepatic tie superolaterally to expose the full length of the
vein/inferior vena cava (IVC) (Fig. 15.4). vein (Fig. 15.6). A vascular load, roticulating sta-
pler is used through the 12 mm assist port to
Step 3 ligate and transect the right portal vein. The right
Laparoscopic ultrasound of the liver is performed hepatic duct (HD) is identified and defined.
via the 12 mm assist port to confirm anatomy and A dissecting forceps may be more beneficial than
ensure that the procedure will include the pathol- the hook if the duct is deep within adjacent tis-
ogy that is anticipated. sue. The right HD is tied distally and then tran-
sected proximally (Fig. 15.7). It is important to
Step 4 identify bile coming from the proximal duct.
The robot is docked. The camera arm should be Once bile is identified, the proximal duct can be
aligned with the patient’s head, and the camera is clipped to maintain a clean field. The free, distal
docked in the camera port (Fig. 15.2). Arm 1 end of the right HD is doubly clipped to prevent
docks in the robotic port to the left of the umbili- leak. Note that during this time, the two assist
cus, Arm 2 docks in the right robotic port, and ports are used to help expose as necessary. Once
Arm 3 docks in the LUQ port. the portal dissection is completed, the gallblad-
der is dissected from the gallbladder fossa,
Step 5 placed in a laparoscopic bag, and removed from
Cholecystectomy and portal dissection. With a the abdominal cavity.
grasper in the robotic Arm 3 retracting the fun-
dus of the gallbladder superiorly, a bipolar Step 6
grasper in robotic Arm 2 holds lateral retraction The IVC is dissected. For exposure, the gallblad-
on the infundibulum while a robotic hook in Arm der fossa is gently pushed superiorly using a surgi-
1 dissects around the cystic artery and duct. After cal sponge sponge within a grasper via robotic
identifying the critical view, the cystic artery and Arm 3 (Fig. 15.8). Suction is used in the 12 mm
duct are clipped and transected (as with a assist port to push the right kidney posteriorly. The
laparoscopic cholecystectomy) via the 12 mm IVC is exposed. The liver is mobilized from the
15 Robotic Hepatic Resections: Segmentectomy, Lobectomy, Parenchymal Sparing 165

Fig. 15.5 Right hepatic artery dissection and ligation. If grasper in robotic Arm 3 to grasp the gallbladder fundus
unable to use a stapling device, the artery is tied, clipped, and retract it superiorly (Used with kind permission from
and ligated. Note that exposure is achieved by using a Randal S. McKenzie/McKenzie Illustrations)

Fig. 15.6 Right portal vein ligation. A silk tie is used to retract the vein and expose its full length, allowing the roticu-
lating stapler to fit with ease (Used with kind permission from Randal S. McKenzie/McKenzie Illustrations)
166 M.S. Sabbaghian et al.

Fig. 15.7 Right hepatic duct division. It is important to identify bile coming from the proximal duct after transection.
Both ends are ligated with robotic clips (Used with kind permission from Randal S. McKenzie/McKenzie Illustrations)

inferior vena cava by identifying and ligating (Fig. 15.9). The parenchyma is coagulated, placing
short hepatic veins. Using a dissector in robotic clips when appropriate. Progress is made along the
Arm 2 and cautery in robotic Arm 1, the short line of transection until the right hepatic vein is
hepatic veins are ligated with clips and silk ties, as encountered. Using a vascular load, roticulating
appropriate. To clip, a robotic clip applier is passed stapler through the 12 mm assist port, the right
through robotic Arm 1. To tie, a needle driver in hepatic vein is stapled intraparenchymally. The
robotic Arm 1 is used with a robotic dissector in remaining parenchyma is divided as necessary.
Arm 2. This is done up to the right hepatic vein.
Step 8
Step 7 The specimen is collected using a laparoscopic
The parenchyma is transected. All retracting bag. Hemostasis on the resection bed of the liver
instruments are removed, allowing the liver to is ensured. The proximal falciform ligament is
drop. The line of transection is defined using hook tacked to the diaphragm with a single figure of
cautery, following the line of demarcation on the eight stitch. The robot is undocked, and the speci-
liver’s anterior surface. Ultrasonography is men is removed from the abdominal cavity. Fascia
repeated to ensure again that the pathology will be is incised at the extraction point as necessary.
included in the point of transection. Figure-of-
eight stitches using 0-size absorbable suture are Step 9
placed on either side of the line of transection, and The abdomen is closed. Laparoscopic equipment
these are retracted to either side using robotic ports is used to remove ports under direct visualization
15 Robotic Hepatic Resections: Segmentectomy, Lobectomy, Parenchymal Sparing 167

Fig. 15.8 IVC dissection. For exposure, the gallbladder fossa is gently pushed superiorly using a surgical sponge
within a grasper via robotic Arm 3 (Used with kind permission from Randal S. McKenzie/McKenzie Illustrations)

and close fascia. Fascia at the extraction site may

need to be closed from the outside in standard
manner. The skin is closed.

Left Hepatectomy

Access is gained to the abdominal cavity via a

5 mm port ideally in the LUQ, and pneumoperi-
toneum of 12 mmHg is created (Fig. 15.10).
A 5 mm, 30° scope is used to visualize addi-
tional port placement, including a supraumbili-
Fig. 15.9 Figure-of-eight stitches are placed on either
side of the line of transection, and these are retracted to cal, 12 mm port for the camera; a right, subcostal
either side using robotic instruments. The parenchyma is robotic port at the midclavicular line; a left,
coagulated, placing clips when appropriate. Progress is robotic port at the anterior axillary line; a 12 mm
made along the line of transection until the right hepatic assist port 8–10 cm inferolateral and to the right
vein is encountered, and this is stapled intrahepatically.
The remaining parenchyma is divided as necessary (Used of the camera port; and a 5 mm assist port 8–10 cm
with kind permission from Randal S. McKenzie/McKenzie inferolateral and to the left of the camera.
Illustrations)
168 M.S. Sabbaghian et al.

Step 3
Laparoscopic ultrasound of the liver is performed
through the 12 mm assist port to confirm anat-
omy and ensure that the procedure will include
the pathology that is anticipated.

Step 4
The robot is docked. The camera arm should be
aligned with the patient’s head, and the camera is
docked in the camera port. Arm 1 is docked in the
left subcostal port; Arm 2 is docked in the right
robotic port, and Arm 3 in the left port at the ante-
rior axillary line.

Step 5
Portal dissection. With a closed grasper in
robotic Arm 2, the left liver is retracted anteri-
orly. Hook cautery is used in robotic Arm 1 to
dissect the left portal structures while a suction
tip or grasper is used in the 12 mm assist port to
retract. The left HA is identified and dissected,
Fig. 15.10 Port placement for left hepatectomy and left then tied robotically, clipped with the robotic
lateral sectionectomy (Used with kind permission from clip applier via robotic Arm 1, and transected.
Randal S. McKenzie/McKenzie Illustrations) Next, the left PV is identified. A grasper in
robotic Arm 3 grasps the ligamentum teres to
The scope is changed to a 10 mm, 30° scope for retract the liver anteriorly, allowing a grasping
use in the camera port, and the LUQ port is instrument in Arm 2 to retract portal tissue. After
changed to a robotic port. the left PV is further defined, a silk tie is placed
around it (this is not tied), and robotic Arm 1
Step 1 retracts this tie superiorly and to the left to
The round and falciform ligaments are divided expose the full length of the vein. A vascular
using hook cautery, exposing the anterior surface load, roticulating stapler is used through the
of the hepatic veins. 12 mm assist port to ligate and transect the left
PV. The left HD is identified and defined, using a
Step 2 dissecting forceps in robotic Arm 1 and a grasper
With the patient’s left side slightly turned up, the in robotic Arm 2 for lateral retraction of adjacent
ligamentous attachments of the left liver are dis- portal tissue. The duct is tied distally and then
sected with a cautery device. This includes the transected proximally. Bile is identified from the
left triangular and coronary ligaments up to the proximal duct. This can be clipped to maintain a
left hepatic vein. The left liver is then pushed clean field. The free, distal end of the left HD is
anteriorly with a closed grasper in the right, sub- doubly clipped to prevent leak.
costal port, allowing for exposure of the under-
surface of the left liver. The gastrohepatic Step 7
ligament is divided close to the left lateral seg- The parenchyma is transected, and the left hepatic
ments and caudate lobe using cautery in one of vein is controlled intraparenchymally. All retract-
the left-sided ports while a grasper in the 12 mm ing instruments are removed, allowing the liver to
assist port retracts. A replaced left hepatic artery drop. The line of transection is defined using
is isolated and divided at this time, if present. hook cautery, following the line of demarcation
15 Robotic Hepatic Resections: Segmentectomy, Lobectomy, Parenchymal Sparing 169

on the liver’s anterior surface. Ultrasonography is be removed in its entirety by wedge resection.
repeated to ensure again that the pathology will The robot is docked. The circumference of
be included in the point of transection. Figure-of- resection is defined with hook cautery according
eight stitches using 0-size absorbable suture are to what is appropriate by surgical or oncologic
placed on either side of the line of transection, guidelines. Ultrasound is repeated. If possible,
and these are retracted to either side using robotic figure-of-eight stitches using 0-Polysorb™ are
ports. The parenchyma is coagulated and divided, placed on either side of the line of transection,
placing clips when appropriate. Progress is made and these are retracted to either side using robotic
up to the left hepatic vein, which is then ligated ports. The parenchyma is coagulated and divided,
and transected using a vascular load, roticulating placing clips when appropriate. Otherwise, the
stapler through the 12 mm assist port. parenchyma is coagulated along the resection
line using appropriate retraction, delivering the
Steps 8 and 9 lesion out of the liver bed. The specimen is placed
Same as for right hepatectomy, although the in a laparoscopic specimen bag, hemostasis is
falciform does not need to be stitched to the ensured, and the specimen is removed. The robot
diaphraghm. is undocked. Laparoscopic equipment is used to
close fascia and remove ports under direct
visualization. The skin is closed.
Left Lateral Sectionectomy

Port placement and steps 1–4 are similar to left Current Experience
hepatectomy.
Review of the world literature reveals 9 case
Step 5 reports/series containing unique groups of
Parenchymal transection. The line of transection patients undergoing robotic liver resection for a
is defined just lateral to the falciform ligament. total of 144 cases [26, 30–38]. A majority (70 %)
Ultrasound is repeated to ensure that the pathol- of these cases have been performed for malig-
ogy is included within the specimen. Figure-of- nancy—39 % hepatocellular carcinoma, 29 %
eight stitches using 0-size absorbable suture are colorectal cancer metastases, 11 % other primary
placed on either side of the line of transection, hepatobiliary malignancy, 11 % other metastases,
and these are retracted to either side using robotic and 10 % not documented. Benign lesions have
ports. The parenchyma is coagulated and divided, included hemangioma (34 %), focal nodular
placing clips when appropriate. A roticulating, hyperplasia (21 %), adenoma (17 %), pyogenic
vascular load stapler can be used via the 12 mm abscess (10 %), hepatolithiasis (3 %), and not
assist port as defined pedicles for segments II and documented (14 %). The most common proce-
III are encountered. The specimen is collected, dures reported have been left lateral sectionec-
and the abdomen is closed as with right and left tomy in 37 patients (26 %), segmentectomy in 34
hepatectomies. (24 %), and right hepatectomy in 28 (19 %).
Other procedures performed include left hepatec-
tomy in 16 (11 %), wedge resection in 15 (10 %),
Nonanatomic Resection bisegmentectomy in 10 (7 %), extended right
hepatectomy in 3 (2 %), and extended left hepa-
Note that guidelines from the Louisville tectomy in 1 (1 %).
Statement are important to consider for this type Operative outcomes of these patients have
of liver resection. Optimal port placement varies been evaluated. Morbidity experienced from
dependent on where the lesion is. Ligamentous robotic-assisted liver resection was 14.6 %, and
attachments are taken down as necessary. this seems comparable to the 10.5 % (between 0
Laparoscopic ultrasound is performed prior to and 50 %) reported in the laparoscopic literature
resecting the lesion to ensure that the specimen can [23]. Reported liver-related morbidity for the
170 M.S. Sabbaghian et al.

robotic group included bile leak in 6 (4 %), For example, the Raven device is now being
transient liver failure in 2 (1.4 %), and ascites in tested for use as a more compact, lighter, less
1 (0.7 %). Surgical-related morbidity consisted expensive surgical tool with open-source software
of pleural effusion in 3 (2 %), wound infection in [43]. Additional efforts are also being made to
1 (0.7 %), ileus in 1, and bladder injury in 1. develop systems that can respond to touch and
General postoperative morbidity included tran- communicate this with the operating surgeon as
sient ischemic attack in 2 (1.4 %) and deep vein well as systems that can function autonomously
thrombosis in 2. Perioperative mortality was zero to assist the surgeon. Altogether, robotic-assisted
for the robotic-assisted cases, and this is compa- surgery’s overall use, particularly in liver surgery,
rable to 0.3 % in laparoscopic cases [23]. For will likely expand in the future. Further investiga-
other outcomes, including operative time, esti- tion into its appropriate role is necessary.
mated blood loss (EBL), and length of stay
(LOS), conclusions are difficult to ascertain. It is Acknowledgments The authors would like to acknowl-
suspected that case complexity as well as the edge Randal McKenzie/McKenzie Illustrations for figures
2–10.
learning curve of the surgeon/robotic surgery
team are relevant to this, as demonstrated for
other types of surgical procedures and techniques
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 Part VII
Surgical Techniques: Colon and Rectum
 Robotic Right Colectomy:
Four-Arm Technique 16
Gyu Seog Choi

placement to specimen extraction including

Introduction intracorporeal anastomosis and natural orifice
specimen extraction (NOSE), and treatment out-
Colorectal cancer is the second leading cause of comes. Both medial-to-lateral and lateral-to-
cancer-related deaths in the USA. There were medial approaches can be used to perform
102,900 cases of colon cancer and 39,670 cases robot-assisted right colectomy for colon cancers.
of rectal cancer in 2010 [1]. The overall preva- The techniques described here are based on the
lence of colorectal cancer was 1,139,710 in lateral-to-medial approach.
2009 [2]. Minimally invasive techniques have
been used to perform colon cancer surgery for
more than 20 years, and the use of laparoscopic Indications and Contraindications
colectomy has proven beneficial to patients dur-
ing convalescence. Several randomized trials The same criteria for laparoscopic colectomy are
have shown that laparoscopic colectomy is asso- applied to robotic right colectomy. According to
ciated with similar oncological outcomes to the National Comprehensive Cancer Network
open surgery [3–6]. After the Food and Drug Guidelines (version 3, 2012), laparoscopic colec-
Administration approved the da Vinci® surgical tomy can be considered based upon the following
robot system (Intuitive Surgical, Sunnyvale, criteria [7].
CA, USA) for intra-abdominal surgery in 2000, • Surgeon with experience performing laparo-
robotic approaches have been used for mini- scopically assisted colorectal operations.
mally invasive colon cancer surgery. This intro- • No disease in rectum or prohibitive abdominal
duction of surgical robot systems in colon cancer adhesions.
treatment has been shown to be safe and effec- • No locally advanced disease.
tive, particularly when dealing with complex • Not indicated for acute bowel obstruction or
procedures. perforation from cancer.
This chapter will cover the indications for • Thorough abdominal exploration is required.
robotic right colectomy, techniques from port • Consider preoperative marking of small
lesions.
Patients with contraindications for creating a
G.S. Choi, M.D., Ph.D. (*) pneumoperitoneum, with a tumor greater than
Colorectal Cancer Center, Kyungpook National
8 cm in diameter, or with an advanced tumor with
University Medical Center, 807, Hogukro, Buk-gu,
Daegu, 702-210, South Korea adjacent organ invasion are also contraindicated
e-mail: [email protected] for robotic colectomy.

K.C. Kim (ed.), Robotics in General Surgery, DOI 10.1007/978-1-4614-8739-5_16, 175

© Springer Science+Business Media New York 2014
176 G.S. Choi

Preoperative Assessment
and Patient Preparation

For accurate preoperative staging of colon can-

cers, assessments consist of a physical examina-
tion, colonoscopy, biopsy, measurement of
carcinoembryonic antigen, and abdominopelvic
computed tomography (CT) scan. A positron
emission tomography (PET)-CT scan is not rou-
tinely indicated, but can be used to obtain addi-
tional information.
After the patient has been admitted for robot-
assisted right colectomy, preoperative mechani-
cal bowel preparation is dependent on the
surgeon’s preference and is identical to that of
open or laparoscopic surgery.
The intraoperative preparation includes shav-
ing the patient from the costal margin to the pubic
bone. The abdomen and pelvic area are prepared
and draped in the usual sterile fashion.
Thromboembolic stockings and sequential com-
pression devices are placed to prevent deep vein
Fig. 16.1 Port placement
thromboses. A Foley catheter is inserted.
Intravenous antibiotics are administered immedi-
ately before the skin incision. Placement of a da Vinci system can cover in a single docking.
nasogastric or orogastric tube is optional. Ideally, the surgical target should be placed
within this camera cone; the camera port should
be at the tip, and all other ports should be placed
Position, Port Placement, outside it. With this principle, we use five ports
and Docking including one robot camera port, three robot arm
ports, and one port for an assistant. At first,
Patient Position abdominal insufflation is established using a
The patient is placed supine or in the lithotomy Veress needle or with open trocar placement by
position (necessary to perform transvaginal speci- the Hasson technique at the level of the antici-
men extraction in female patients). Both arms are pated camera port. A 12-mm camera port is
alongside the body to prevent any possibility of placed 5 cm to the left of and 2.5 cm below the
shoulder injury and to gain space for the patient cart umbilicus. Three 8-mm ports for the robot arms
and surgical assistants. After the patient has been are placed along an imaginary curvilinear line
draped and the placement of ports has been com- across the left upper quadrant to the right lower
pleted, the table is placed in a 10–15° Trendelenburg quadrant and out of the camera cone, as shown in
position and rolled to the left 10–15°. This position- Fig. 16.1.
ing allows the small bowel to move aside under • The da Vinci camera port (12 mm) is placed
gravity and expose the right mesocolon. 5 cm to the left of and 2.5 cm below the umbi-
licus. The distance to the symphysis pubis
Port Placement should be ~16–18 cm.
For optimal port placement in robotic surgery, • The da Vinci arm port ① (8 mm) is placed
the unique concept of “camera cone” is impor- 7–8 cm below the left costal margin and on the
tant. This is an imaginary conical area that the left midclavicular line.
16 Robotic Right Colectomy: Four-Arm Technique 177

Fig. 16.2 Configuration of the operating room after docking the patient cart

• The da Vinci arm port ② (8 mm) is placed on the right colectomy after introducing the patient cart.
midline and 4 cm above the symphysis pubis. There should be a clear view of the patient from
• The da Vinci arm port ③ (8 mm) is placed the surgeon’s console, a tension-free cable con-
2–3 cm lateral to the midclavicular line and nection to the equipment, and clear pathways for
2–3 cm above the anterior superior iliac spine. the operating team to move freely.
• The assistant’s port (5 mm) is placed 8–10 cm • The patient-side assistant is on the patient’s
caudal and 1–2 cm lateral to the da Vinci arm left side.
port ①. This port is used for suction/irrigation, • The scrub nurse is at the patient’s feet but can
ligation, and additional retraction. stand at the right side of an assistant surgeon
• The distance between all ports should be at according to the arrangement of the operating
least 8 cm. room.
The location of the camera port should be con- • The main assistant monitor is located at the
sistent. The instrument arm ports need to be right of the patient toward the feet.
adjusted based on the tumor’s location (cecum to • An anesthesiologist is positioned at the head
transverse colon) and the patient’s height. of the patient. Alternatively, an anesthesiolo-
gist can be positioned at the patient’s feet by
Patient Cart Docking fixing the lines of the ventilator along the
The patient is placed in a Trendelenburg position operation table.
and tilted to the left before introduction of the
patient cart. This is positioned obliquely at the
right upper quadrant of the abdomen. It is angled Surgical Techniques
45° from the perpendicular relative to the patient.
The robot arms are docked to the trocars. A 0° endoscope, monopolar curved scissors (arm
Figure 16.2 shows an overhead view of the ①); bipolar Cadiere forceps (arm ②); and double-
recommended operating room setup for robotic fenestrated grasper (arm ③) are used. Robot arm
178 G.S. Choi

Fig. 16.3 Exposure of the peritoneal attachment by retracting the appendix and terminal ileum with the grasper in the
robotic arm

① is used for dissection, robot arm ② for major ureter should be identified and preserved
retraction or countertraction, and robot arm ③ for retroperitoneally.
minor retraction. 4. Lifting the mesentery of the terminal ileum
exposes the avascular plane over the duode-
num and the head of the pancreas (Fig. 16.4).
Mobilization of Ascending Colon
and Terminal Ileum
Vascular Control and
The small intestine is placed toward the left upper Lymphadenectomy
abdominal quadrant, and the inferior dissection
starts at the retrocecal recess. This work is con- When the colonic mobilization is completed, vas-
tinued over the duodenum to the head of the pan- cular control is initiated by placing the bowels in
creas. At the same time, the lateral attachments of the normal anatomical position. The extent of
the ascending colon are taken down starting at any necessary vascular control depends on the
the right paracolic gutter and moving cranially to tumor location, planned anastomosis location,
the hepatic flexure until the ascending colon is and the patient’s anatomy. All lymph nodes and
mobilized completely. adipose tissue at the right side of the superior
1. Lifting and retracting the appendix and termi- mesentery artery are removed sequentially from
nal ileum caudally and superiorly with the the ileocolic artery to the middle colic artery. The
grasper in arm ③ provides major retraction to right colonic branches of the superior mesentery
expose the peritoneal attachment along the artery and vein are ligated with a Hem-o-Lok
right iliac vessels (Fig. 16.3). clip™ or sealing device (e.g., EndoWrist One
2. Additional exposure can be gained by retrac- Vessel Sealer™ or LigaSure™ or EnSeal™). Our
tion of the grasper in arm ② and by the assis- recommendation for lymphadenectomy in this
tant using a laparoscopic port. area is to maintain tension in the right mesocolon
3. Dissection through the avascular plane by elevating the ileocolic vessels using a grasper
between the ileocecum and the retroperito- through arm ③ and in the middle colic vessels
neal layer is done with the monopolar scissors with a grasper through the assistant port while
in arm ①. The right gonadal vessels and the this procedure is being finished.
16 Robotic Right Colectomy: Four-Arm Technique 179

Fig. 16.4 Lifting the mesentery of the terminal ileum to expose the avascular plane over the duodenum and the head of
the pancreas

1. For ileocolic vessel division, arm ③ is used to mesocolon is divided from its root to the colon.
lift up the ileocolic pedicle (Fig. 16.5). The marginal artery and vein are controlled with
2. The ileocolic vessels are skeletonized up clips or a sealing device. Colon mobilization is
1–2 cm above the root and ligated at 1–1.5 cm completed with partial omentectomy along the
from the root (Fig. 16.6). colon up to the resection site.
3. Once the ileocolic vessels have been divided,
lymphadenectomy is continued along the
superior mesenteric artery to the root of right Ileocolic Anastomosis and Specimen
colic and middle colic arteries. Ligation of the Extraction
right colic and middle colic vessels depends
on the tumor location (Fig. 16.7). Two approaches can be used to create the anasto-
4. The assistant’s port can be used to introduce mosis: extracorporeal and intracorporeal anasto-
hemostatic instruments (e.g., clips, mosis. In an extracorporeal anastomosis, the
LigaSure™, or EnSeal™) for ligating vessels. mobilized right colon and terminal ileum are
The assistant can use a laparoscopic bowel extracted through a 5–7 cm minilaparotomy. The
grasper to push the middle colic pedicle supe- skin incision is covered using a wound protector.
riorly for additional exposure to the superior Side-to-side anastomosis is created using a stan-
mesenteric axis during lymphadenectomy. dard linear stapler. However, as generally used in
a laparoscopic approach, extension of the camera
port (normally a transumbilical incision) for
Final Mobilization extraction of specimens and creating an anasto-
mosis is not indicated in the robotic approach
After all vessels have been securely divided and because the camera port is far lateral to the umbi-
lymphadenectomy is completed, the transverse licus. This is why most surgeons prefer an intra-
mesocolon is opened just above the head of the corporeal anastomosis to the cosmetically
pancreas to enter the lesser sac. The transverse inferior extracorporeal one.
180 G.S. Choi

Fig. 16.5 Robot arm ③ is used to lift up the ileocolic pedicle and perform a lymphadenectomy around the ileocolic
vessels

Fig. 16.6 Division of the ileocolic vein

Intracorporeal Anastomosis The ileum is then skeletonized in preparation

for anastomosis in a well-vascularized area.
1. For this, the mesentery of the ileum and trans- 2. The monopolar curved scissors in arm ① are
verse colon is divided at the selected anasto- replaced with a needle driver. The transverse
mosis location. A sealing device is used for colon and ileum are approximated with
dividing the mesentery to control bleeding. double stay sutures placed near the planned
16 Robotic Right Colectomy: Four-Arm Technique 181

Fig. 16.7 Lymphadenectomy around the right branch of the middle colic artery

Fig. 16.8 Stay sutures for approximating the free taenia of the transverse colon to the antimesenteric border of the ileum

enterotomy site. Additional single stay sutures Monopolar curved scissors in arm ① are used
are placed about 7–8 cm distal to the initial to create enterotomies.
double stay sutures, approximating the free 3. A port for robotic arm ② is temporarily
taenia of the transverse colon to the antimes- undocked and replaced by 12-mm laparo-
enteric border of the ileum (Fig. 16.8). scopic port. A linear stapler is introduced
182 G.S. Choi

Fig. 16.9 Insertion of a linear stapler in the enterotomies

Fig. 16.10 Final closure of the anastomosis using a linear stapler

through the port and inserted in the enteroto- (Fig. 16.10). The enterotomies can also be
mies (Fig. 16.9). The grasper in arm ③ is used closed using robotically placed sutures.
to lift the stay sutures upward to prevent 4. A plastic bag and a wound protector are used
inadequate stapling. Placing another liner sta- to protect contamination during specimen
pler across the colon and ileum distal to the extraction. After placing the specimen into the
enterotomies completes the anastomosis bag, the ileal end of the specimen is separated
16 Robotic Right Colectomy: Four-Arm Technique 183

Fig. 16.11 Hand-sewn colocolic anastomosis

from the transverse colon to avoid the speci- 2. Patients with a large tumor (>5 cm in its smaller
men folding during extraction. diameter), severe pelvic adhesions, pelvic
5. The specimen is extracted through an exten- inflammatory diseases, or of childbearing age
sion of the trocar incision or via Pfannenstiel are contraindications for this procedure.
incision. 3. A 12-mm laparoscopic trocar is placed trans-
There are other options for performing intra- vaginally through the posterior fornix vagi-
corporeal ileocolic anastomosis. Iso- or antiperi- nally (Fig. 16.12). Linear stapling devices are
staltic side-to-side anastomoses using a linear introduced through the trocar to perform anas-
stapler with robotic hand-sewn closure of the tomosis as described above.
enterotomies are the most commonly practiced 4. The specimen is wrapped in a sterile bag and
manner. A fully hand-sewn anastomosis is some- removed though an extension of the transvagi-
what time-consuming but can be attempted for nal trocar incision.
selective cases, especially for colocolic anasto- 5. The colpotomy is closed intra-abdominally or
mosis after a transverse colectomy (Fig. 16.11). transvaginally using a running suture.
The advantages of intracorporeal anastomosis
are minimal colonic mobilization, little chance of Exploration and Wound Closure
rotation of the bowels, and reduced size of the Once the specimen is removed, the minilaparot-
incision needed for extracting specimens. In omy incision is covered with a glove or other
addition, the surgeon is able to choose the best means, and insufflations are reestablished.
site of incision according to the patient’s history Conventional laparoscopy is used to check the
of abdominal surgery, for example, previous operation field and trocar sites.
Caesarean section or appendectomy incisions. • Any bleeding should be checked.
• The orientation of the anastomosed bowel
should be checked.
NOSE Procedure • The small bowel and omentum should be
reoriented necessarily.
1. In female patients, the NOSE technique can be • The trocar sites should be checked for
applied selectively using a transvaginal incision. bleeding.
184 G.S. Choi

Fig. 16.12 A 12-mm transvaginal trocar

• All trocar sites greater than 8 mm in diameter

should be closed with 2-0 absorbable sutures Results
at the fascial level.
The surgical outcomes of robot-assisted right
colectomy of colon cancer are summarized in
Postoperative Treatment Table 16.1. According to these retrospective and
prospective studies, robot-assisted right colec-
The patient’s postoperative management is no tomy for patients with colon cancers is techni-
different from those of conventional open and cally safe and feasible [8–10]. Robotic right
laparoscopic colectomy approaches. The in- colectomy showed good convalescence outcomes
hospital course depends on the surgeon’s experi- similar but not superior to those of minimally inva-
ence and preference. If necessary, the patient can sive surgery. Patients had short mean hospital stays
be transferred to an intensive care unit until all of 4.3–7.9 days. The overall postoperative compli-
vital signs are stable. cation rate has been reported as up to 24 % and
• Stable patients can be transferred to the recov- includes ischemia, colitis, anastomosis leakage,
ery room and to the regular nursing floor. and ileus (Table 16.1). Two reports concluded that
• The patient is encouraged to be ambulatory effective lymphadenectomy along the superior
the day after surgery. mesenteric vessels and easier intracorporeal anas-
• The clinical recovery process can follow the tomosis could be the potential benefit of robotic
individual center’s policy including any early surgery [11, 15]. Experience with robotic right
recovery protocol. colectomy demonstrated considerably low conver-
• The patient can be discharged from the hospi- sion rates (~2.5 %) compared with laparoscopic
tal 3–5 days postoperatively if stable and if colon resection with reported conversion rates of
there is no sign of bleeding or adverse events. 11–29 % [3–6]. However, these impressions have
 16

Table 16.1 Results of robot-assisted right colectomies for patients with colon cancer
No. of cases Blood Intraoperative Postoperative No. of
Authors Year Design (cancer) OP time (min) loss (mL) Conversions (n) LOS (days) complications (n) complications (n) harvested LNs
Delaney et al. [8] 2003 NR 1 267 100 – 5 – 1 NR
Rawlings et al. [9]a 2006 Prosp 17 218 66 0 5.2 NA NA NR
Robotic Right Colectomy: Four-Arm Technique

Spinoglio et al. [10] 2008 NR 18 NA NA 0 NA NA NA NA

D’Annibale et al. [11] 2010 Prosp 50 224 20 0 7 0 2 18.7
deSouza et al. [12]a 2010 NR 40 158 50 1 5 0 8 16
Luca et al. [13] 2011 Prosp 33 191 6.1 0 5 0 24 26.6
Park et al. [14] 2012 Prosp 35 195 36 0 7.9 0 17 29.9
Trastulli et al. [15] 2012 Prosp 20 328 55 0 4.5 0 5 17.6
Deutsch et al. [16]a 2012 Retro 18 219 76 NA 4.3 2 NA 21.1
LNs lymph nodes, LOS length of hospital stay, NA not applicable, NR not reported, OP operation, Prosp prospective, Retro retrospective
a
Studies include both benign and malignant cases
185
186 G.S. Choi

not yet been translated into objective clinical out- 3. Lacy AM, et al. Laparoscopy-assisted colectomy
versus open colectomy for treatment of non-metastatic
comes. Recently, we conducted a randomized
colon cancer: a randomized trial. Lancet. 2002;359:
comparative study of robotic versus laparoscopic 2224–9.
right hemicolectomy and concluded that robotic 4. Veldkamp R, et al. Laparoscopic surgery versus open
approach for this particular procedure was feasi- surgery for colon cancer: short term outcomes of a
randomised trial. Lancet Oncol. 2005;6:477–84.
ble and effective but not recommended for rou-
5. Guillou PJ, et al. Short-term endpoints of conven-
tine use because of its high cost and long tional versus laparoscopic-assisted surgery in patients
operation time [14]. Other comparative studies with colorectal cancer (MRC CLASICC trial): multi-
including long-term oncological outcomes have centre, randomised controlled trial. Lancet.
2005;365:1718–26.
not been reported.
6. Fleshman J, et al. Laparoscopic colectomy for cancer
is not inferior to open surgery based on 5-year data
from the COST Study Group trial. Ann Surg.
Conclusions 2007;246:655–62. discussion 662–664.
7. NCCN clinical practice guidelines in oncology: colon
cancer (v.3.2013). The National Comprehensive
Robot-assisted right colectomy for patients with Cancer Network. http://www.nccn.org. Accessed 10
colon cancers is technically safe and feasible. The Dec 2012.
improved surgical technique arises from the inher- 8. Delaney CP, et al. Comparison of robotically per-
formed and traditional laparoscopic colorectal sur-
ent properties of the robotic system such as the
gery. Dis Colon Rectum. 2003;46:1633–9.
elimination of tumor, a three-dimensional view, and 9. Rawlings AL, et al. Telerobotic surgery for right and
ambidextrous capability. These potential advan- sigmoid colectomies: 30 consecutive cases. Surg
tages can lessen the technical difficulties of vascu- Endosc. 2006;20:1713–8.
10. Spinoglio G, et al. Robotic colorectal surgery: first
lar control and lymphadenectomy during right
50 cases experience. Dis Colon Rectum. 2008;51:
colon cancer surgery. However, objective evidence 1627–32.
of its efficacy is insufficient at present. Further 11. D’Annibale A, et al. Robotic right colon resection:
studies comparing short-term outcomes, long-term evaluation of first 50 consecutive cases for malignant
disease. Ann Surg Oncol. 2010;17:2856–62.
oncological outcomes, and cost-related benefits of
12. deSouza AL, et al. Robotic assistance in right hemico-
robotic, laparoscopic, and open techniques are lectomy: is there a role? Dis Colon Rectum. 2010;
needed to determine the utility and efficacy of this 53:1000–6.
technology in the field of colon cancer surgery. 13. Luca F, et al. Surgical and pathological outcomes after
right hemicolectomy: case-matched study comparing
robotic and open surgery. Int J Med Robot. 2011;
7:298–303.
References 14. Park JS, et al. Randomized clinical trial of robot-
assisted versus standard laparoscopic right colectomy.
1. Jemal A, et al. Cancer statistics. CA Cancer J Clin. Br J Surg. 2012;99:1219–26.
2010;60:277–300. 15. Trastulli S, et al. Robotic right colectomy for cancer
2. Howlader N et al. SEER cancer statistics review, with intracorporeal anastomosis: short-term outcomes
1975–2009 (Vintage 2009 Populations), National from a single institution. Int J Colorectal Dis.
Cancer Institute, Bethesda, MD. http://seer.cancer. 2013;28:807–14. Accessed 10 Dec 2012.
gov/csr/1975_2009_pops09/, based on November 16. Deutsch GB, et al. Robotic vs. laparoscopic colorectal
2011 SEER data submission, posted to the SEER web surgery: an institutional experience. Surg Endosc.
site, April 2012. Accessed 10 Dec 2012. 2012;26:956–63.
 Robotic Right Colectomy:
Three-Arm Technique 17
Henry J. Lujan and Gustavo Plasencia

Since 2000, robotic-assisted surgery has been Initially, laparoscopic colectomy took longer
increasing in popularity, especially for cardiac, and was more expensive than conventional open
gynecologic, and urologic procedures [1]. colectomy. However, with time, it proved to offer
Recently, increased interest in robotic techniques significant advantages to the patient, including
for colon resection has emerged. The first robotic quicker return of bowel function, less postopera-
colectomies were reported by Weber et al. in tive pain, shorter hospital stay, and lower postop-
2002 and included one right colectomy [2]. Since erative morbidity and mortality [9]. Robotic
then, the da Vinci® surgical robot (Intuitive surgery purportedly offers advantages to over-
Surgical, Sunnyvale, CA) has been shown to be come the limitations of laparoscopic surgery [6].
safe and effective for colorectal procedures by Some surgeons believe this could lead to wider
other authors [1, 3–6]. Nevertheless, the role of use of minimally invasive surgery for colorectal
robotic surgery has not yet been established for resections.
colorectal surgery. Robotics for colorectal surgery has been
Laparoscopic colectomy has been shown to shown to be safe and feasible, and perioperative
have significant advantages over open colectomy and pathologic outcomes appear to be equivalent
[7–9]. Laparoscopic colectomy is even consid- to laparoscopic surgery. However, most authors
ered the gold standard by some authors [10, 11]. believe that the robot will have the greatest
Robotic colorectal surgery today may be in the impact on rectal resection [1, 6, 16]. It seems ide-
same position that laparoscopic surgery was 20 ally suited for pelvic dissection, where the supe-
years ago [12, 13]. Despite first being described rior visualization and articulating instruments
by Jacobs et al. in 1991, laparoscopic colectomy facilitate exposure, retraction, and difficult dis-
has been slow to be adopted as the preferred section. It is hypothesized that these advantages
approach to colon and rectal diseases. Estimates will result in lower conversion rates and higher
for the percentage of laparoscopic colectomies rates of adoption. Furthermore, possible advan-
performed in the USA range from 20 to 40 % and tages of better mesorectal excision, better preser-
for laparoscopic rectal resection range from 10 to vation of nerves, and easier operation in the obese
15 % [14, 15]. are all areas of ongoing investigation. But, for
partial colectomy, the benefits are more difficult
to foresee. In the literature, modest advantages in
visualization and possibly decreased blood loss
H.J. Lujan, M.D., F.A.C.S., F.A.S.C.R.S. (*) seem to be offset by longer operative times and
G. Plasencia, M.D., F.A.C.S., F.A.S.C.R.S.
higher costs thus far [1, 6, 16–20].
Department of Surgery, Jackson South Community
Hospital, Miami, FL 33157, USA If nothing else, robotic right colectomy is an
e-mail: [email protected]; [email protected] ideal case for a surgeon’s initial experience with

K.C. Kim (ed.), Robotics in General Surgery, DOI 10.1007/978-1-4614-8739-5_17, 187

© Springer Science+Business Media New York 2014
188 H.J. Lujan and G. Plasencia

robotic techniques [19]. It is a familiar procedure and arms can be used, but this limits the instru-
to general and colorectal surgeons alike and is ment options and degrees of articulation with
technically easier than other colon procedures today’s available instrumentation, and, therefore,
with relatively short operative times. It is com- we prefer 8 mm ports at this time. In cases of pol-
monly used as learning and/or teaching tool. It is yps or tumors, the lesion is localized prior to
a procedure that is easily converted to either lapa- docking the robot using a 5 mm laparoscope,
roscopic or open colectomy with relatively little which is always available. The table is then posi-
clinical consequence. tioned in 10–20° of reverse Trendelenburg and
The indications and setting for right colec- 20–30° of right side up to allow the small intes-
tomy are well described and include benign and tine to fall away from the midline. The robot is
malignant conditions, elective, urgent, and emer- docked from the patient’s right side or over the
gent operations. Benign conditions include right shoulder. The robotic camera is inserted
inflammatory bowel disease, volvulus, diverticu- through the 8.5 mm periumbilical port. The assis-
lar disease, arteriovenous malformations, isch- tant surgeon uses a lateral 12 mm port to intro-
emic colitis, and polyps not amenable to duce laparoscopic instruments, energy devices,
endoscopic removal. Adenocarcinoma, carcinoid and endoscopic staplers and suction as needed.
tumor, and appendiceal tumors account for most Using the bipolar fenestrated grasper (R2) and
malignant diseases. Surgery for the right colon is the hot shears (R1), a medial-to-lateral dissection
usually elective. However, urgent indications is realized. First, the assistant surgeon grasps the
include nearly obstructing lesions, ischemic coli- ileocecal junction to place the ileocolic vascular
tis, and hemorrhage. There are only a few emer- pedicle on tension. It is critical to identify the
gent indications, with perforation, complete cecum and ileocecal junction; this step cannot be
obstruction, and refractory hemorrhage the most overemphasized. A small window is created pos-
common [21]. teriorly near the origin of the ileocolic vessels.
The dissection is continued for 2–3 cm to reveal
the duodenum. Typically, the duodenum identi-
Technique fies the origin of the ileocolic artery. A second
window is created to isolate the base of the vas-
Our three-arm technique for robotic right colec- cular pedicle. It is divided at the level of the duo-
tomy with intracorporeal anastomosis is denum with a vascular stapler, clips, or energy
described below. We modified this technique device, which are brought in through the left lat-
from the description by Rawlings et al. [17]. eral 12 mm assistant port.
The patient is under general anesthesia in the The medial-to-lateral dissection is continued.
supine position. Room setup is shown in The right mesocolon is mobilized off the retro-
Fig. 17.1a, b. Pneumoperitoneum can be achieved peritoneum. This dissection is mostly blunt and
with a Veress needle. accomplished by pushing the mesocolon anteri-
As an alternative, open laparoscopic entry orly and the retroperitoneum posteriorly. This
(Hasson technique) or visual entry systems can be advanced to the lateral attachments, to the
(Optiview/Visiport) can be used per surgeon’s liver and hepatic attachments, and to the duode-
preference. A total of four ports (three robotic nal sweep as needed. The ileal mesentery is
ports and one assistant port) are placed as shown divided with an energy source or cautery to a
in Figs. 17.2 and 17.3. point 8–10 cm from the ileocecal valve. Typically,
An extra long 12 or 8.5 mm periumbilical port two small vessels or branches will be encoun-
for the camera is placed. Usually 2 cm below and tered and can be divided with the energy device.
2 cm lateral to the umbilicus (depending on the The mesocolic mobilization is then carried up to
patient’s body habitus). A left upper quadrant and the duodenum and the transverse mesocolon. The
suprapubic 8 mm robotic trocars are placed for terminal ileum is transected with an endoscopic
arms 1 (R1) and 2 (R2). Five mm robotic trocars stapler. Next the right branch of the middle colic
17 Robotic Right Colectomy: Three-Arm Technique 189

is identified and transected with the energy device ure and along the right transverse colon.
or stapler. The ascending colon can be left Sometimes omentum is removed with the speci-
attached to the right paracolic gutter to keep it men. Usually, the omentum is partially detached
from falling medially or completely detached and from the colon by dividing the gastrocolic liga-
the specimen placed above the liver for later ment. The transverse colon is isolated by creating
retrieval (if the resection is for cancer, the speci- a mesenteric window and then divided with the
men is placed in a bag). Lateral mobilization endoscopic stapler.
begins at the ileocecal junction along the right Next, attention is turned to construction of an
paracolic gutter and advanced to the hepatic flex- isoperistaltic, side-to-side anastomosis. For this
purpose, the terminal ileum and the transverse
colon stump are brought together side by side as
shown in Fig. 17.4a, b.
A 20 cm nonabsorbable suture on a Keith
needle is used to put a stay suture approximating
the transverse colon and terminal ileum up to the
abdominal wall to provide tension and elevate the
site of the anastomosis (Fig. 17.5).
Prior to creating the enterotomies, an endo-
scopic intestinal clamp (bulldog) can be placed
on the terminal ileum to prevent spillage. Using
an energy device or hot shears, a colotomy and
ileotomy are created (Fig. 17.6) through which
the jaws of the endoscopic linear stapler are
introduced to construct the common channel
Fig. 17.1 Room setup (Fig. 17.7).

Fig. 17.2 Trocar placement for robotic right colectomy

190 H.J. Lujan and G. Plasencia

in most cases. The extraction site is closed in two

layers. Any 12 mm port site incisions are closed.
The skin is closed in subcuticular fashion
(Fig. 17.10).
A summary of the critical steps is shown in
Table 17.1.
(See Figs. 17.11, 17.12, 17.13a, b, 17.14,
17.15, and 17.16a, b.) The first robotic right
colectomies described were hybrid, in other
words, an extracorporeal anastomosis was uti-
lized. When we perform a robotic-assisted right
colectomy with an extracorporeal anastomosis,
the mobilization, devascularization, and transec-
tion are performed under robotic guidance. The
specimen is brought out through an extraction
site, and the anastomosis is realized through this
same wound. We found it useful to perform right
colectomies in hybrid fashion early in our
learning curve. Specifically, our first four right
colectomy cases were performed in this fashion
emulating our laparoscopic technique. However,
inspired by the robotic platform, we have since
performed 50 robotic colectomies with intracor-
Fig. 17.3 Trocar placement for robotic right colectomy
poreal anastomosis. Table 17.2 summarizes our
experience with robotic colectomy with intracor-
poreal anastomosis.
The remaining common enterotomy is then We would like to comment on patient posi-
closed with 2-0 Vicryl in two running layers tioning. The lithotomy position may be consid-
using robotic suturing techniques (Fig. 17.8a, b). ered in particular circumstances. For example, if
Once complete, the stay suture is cut, and then intraoperative colonoscopy is necessary in order
attention is directed again to the specimen. As an to check the anastomosis or confirm adequate
alternative, a complete robotic-sewn anastomosis removal of the pathology, access to the perineum
can be fashioned. If necessary, the remaining lat- is necessary. Another example is when transrec-
eral and hepatic attachments are freed. A grasper tal or transvaginal extraction of the specimen will
with teeth or endoloop is introduced through the be performed. Finally, when the possibility of
12 mm left lateral port to hold the specimen (usu- avoiding a resection exists, as in colotomy and
ally by the transected terminal ileum), and the polypectomy, laparoscopic-guided polypectomy,
robot is undocked. The 12 mm assistant port inci- or wedge resection of a benign lesion, the lithot-
sion is then enlarged. Usually a 3–5 cm incision omy position is used.
is necessary depending on the size of the With robotic colectomy, specimen extraction
pathology. A wound retractor is placed to protect is typically transabdominal. As mentioned, intra-
the skin, and the specimen is extracted. The corporeal anastomosis allows the surgeon to
extraction incision site can be placed in the supra- choose the extraction site as shown in
pubic region or at any site per surgeon’s choice as Fig. 17.9a, b.
shown in Fig. 17.9a, b. Morcellation of specimen is a technique that
Finally, laparoscopy can be performed to visu- has not been widely studied and may have a roll
alize the anastomosis and confirm hemostasis. in specimen management in the future, the goal
It is not necessary to close the mesentery defect being (as with intracorporeal anastomosis, tran-
17 Robotic Right Colectomy: Three-Arm Technique 191

Fig. 17.4 (a and b) The terminal ileum and the transverse colon stump are brought together side by side

srectal, and transvaginal removal) smaller extrac- [6]. The mean operative time for these cases was
tion site incisions. 167 min (range, 152–228). These series included
One final note: although this chapter describes right colectomies with both extracorporeal and
a three-arm technique, a fourth arm can be added intracorporeal anastomotic techniques. Conversion
intraoperatively if needed (Fig. 17.11). In select rate was very low, 1.1 % to laparoscopic and 1.1 %
cases, particularly in the obese patient, it may be to open. Intraoperative complications occurred in
advantageous to start with a four-arm technique one patient (0.7 %). Overall postoperative morbid-
to facilitate the procedure. ity was 12.7 %.
Table 17.3 summarizes the techniques, dissec-
tion, anastomosis, operative times, and conver-
Outcomes sion rate for the largest published series to date
[17, 19, 22–24]. In 2011, we published our series
In their systematic review of the literature, comparing 25 laparoscopic to 22 robotic right
Antoniou et al. identified 39 series, which colectomies [22]. Outcomes were similar and no
reported a total of 210 robotic right colectomies conversions to open were necessary. Operative
192 H.J. Lujan and G. Plasencia

Fig. 17.5 A 20 cm nonabsorbable suture on a Keith needle is used to put a stay suture approximating the transverse
colon and terminal ileum up to the abdominal wall to provide tension and elevate the site of the anastomosis

Fig. 17.6 Prior to creating the enterotomies, an endoscopic intestinal clamp (bulldog) can be placed on the terminal
ileum to prevent spillage. Using an energy device or hot shears, a colotomy and ileotomy are created

times were longer in the robotic group; however, By only utilizing three robotic arms, port
intracorporeal anastomosis was used in the placement is easier because there is less concern
robotic group, whereas an extracorporeal tech- with arm collisions. This is especially useful dur-
nique was used in the laparoscopic group. We ing the initial experience when the surgeon is
used a three-arm robotic colectomy technique challenged with multiple nuances of a new tech-
from the start of our learning curve initially to nique. As experience is gained, a fourth arm can
simplify the setup and decrease arm collisions be used selectively. We have found it advanta-
(Fig. 17.17). geous to use the fourth robotic arm in right
17 Robotic Right Colectomy: Three-Arm Technique 193

Fig. 17.7 The jaws of the endoscopic linear stapler are introduced to construct the common channel

Fig. 17.8 (a and b) The remaining common enterotomy is then closed with 2-0 Vicryl in two running layers using
robotic suturing techniques
194 H.J. Lujan and G. Plasencia

Fig. 17.9 (a) Extraction site placement for three-arm (b) Alternative extraction site placement for three-arm
robotic right colectomy with intracorporeal anastomosis. robotic right colectomy with intracorporeal anastomosis.
The 12 mm assistant trocar site is extended as shown. The 8 mm suprapubic R2 trocar site is extended as shown

Fig. 17.10 The skin is closed in subcuticular fashion

17 Robotic Right Colectomy: Three-Arm Technique 195

Table 17.1 Critical steps of robotic right colectomy with colectomies in the obese patient and when the
intracorporeal anastomosis
dissection is challenging.
Figures We believe the technique as we described
1. Identification of ileocecal 17.10 above can be used in most cases and decreases
junction (IJ)
time-consuming exchanges of instruments to the
2. Traction on IJ to expose the 17.10
ileocolic vessels at their origin
robotic arms. A 12 mm left lateral port allows the
3. Identify duodenum 17.10 assistant to quickly do the necessary exchanges
4. Transect ileocolic vessels 17.11 of graspers, suction, harmonic scalpel, suture
at their origin transfer, and laparoscopic staplers. The assistant
5. Medial-to-lateral dissection 17.12 is kept actively involved in the procedure, and
6. Transect terminal ileum 17.13a, b robotic arm exchanges are minimized. This is
7. Identify and divide right 17.14 useful when the assistant is teaching the proce-
colic and right branch dure to the console surgeon. It may also make the
of middle colic
17.15 operation more efficient.
8. Transect transverse colon
9. Intracorporeal side-to-side 17.4a, b, 17.5, 17.6, In general, a medial-to-lateral dissection tech-
isoperistaltic anastomosis 17.7, and 17.8a, b nique is the preferred approach [25]. However, in
10. Specimen extraction 17.16a, b some cases, because of anatomical variations, we
(wound protector) start with a lateral-to-medial dissection. At this

Fig. 17.11 If needed, an additional port (R3) can be added to the right lower quadrant
196 H.J. Lujan and G. Plasencia

Fig. 17.12 Medial-to-lateral dissection

Fig. 17.13 (a and b) Transect terminal ileum

17 Robotic Right Colectomy: Three-Arm Technique 197

Fig. 17.14 Identify and divide right colic and right branch of middle colic

Fig. 17.15 Transect transverse colon

point, we recommend starting with a medial-to- ies from 85 to 214 min [19]. In the systematic
lateral dissection; however, the surgeon’s ability review mentioned above, the mean operative
to apply either approach is useful and both seem time for robotic right colectomy was 167 min
to be effective. We found that lateral-to-medial (N = 210) [6]. If we limit the data to laparo-
dissection is often necessary, feasible, and does scopic right colectomy with intracorporeal
not require patient repositioning. For example, in anastomosis, the mean operative times as
the obese patient, it may first be necessary to get reported in the literature range from 136 to
adequate length of mesentery, in order to iden- 190 min [26, 27, 28, 29]. Our operative times
tify, isolate, and transect the ileocolic vessels at for a robotic right colectomy with intracorpo-
their origin. real anastomosis averaged 189 min (N = 50)
The mean operative time for a laparoscopic “skin-to-skin.” Thus, our robotic operative
right colectomy as reported in the literature var- times compare favorably with laparoscopic
198 H.J. Lujan and G. Plasencia

Fig. 17.16 (a and b) Specimen extraction (wound protector)

right colectomy times reported in the literature abdominal wall. There is probably less traction
despite being early in our experience [22]. and tension applied to the colon and the mesen-
Additionally, we found that the transition tery during an intracorporeal anastomosis, as
from an extracorporeal to intracorporeal anasto- well as less trauma to the incision, which may
mosis was facilitated by the robotic platform. translate into less postoperative ileus and fewer
The improved surgical dexterity makes the complications. Some studies have supported this
switch to an intracorporeal anastomosis easier, potential benefit of the intracorporeal anastomo-
and this may lead to a higher adoption rate for sis [26, 27]. Grams et al. reported earlier return
intracorporeal anastomosis, which is not very of bowel function, shorter length of hospital
commonly used in laparoscopic right colectomy stay, and fewer complications [26]. Hellan et al.
today. With an extracorporeal technique, the sur- found similar outcomes with intracorporeal and
geon is often extracting, transecting, and creat- extracorporeal anastomosis, but shorter incisions
ing an anastomosis through a small incision. with intracorporeal anastomosis [27]. We found
Trying to accomplish this is sometimes difficult this to be true in our experience as well, with the
especially in the obese patient with a thick mean extraction site excision measuring 4.6 cm
17 Robotic Right Colectomy: Three-Arm Technique 199

Table 17.2 Summary of our experience with robotic Table 17.2 (continued)
right colectomy with intracorporeal anastomosis
Robotic right
Robotic right Complication colectomy (n = 50)
Demographic colectomy (n = 50) Anastomotic leakb 1
Mean age (range) 71.1 (52–89) 30-Day mortality 0
Mean BMI (range) 29.3 (19.4–68.8)
Gender Female 23 Stage N = 28
Male 27 0 4
Indicationa I 5
Adenocarcinoma 28 II 10
Adenoma 20 III 8
Diverticulitis (right-sided) 1 IV 1
Crohn’s 1 a
Elective surgery
b
Only reoperation requiring diverting loop ileostomy
Robotic right
Variable studied colectomy (n = 50)
Mean operative time (range) 189.2 min (123–288) versus 5.3 cm for the intracorporeal versus extra-
Mean total operative time 256.6 min (182–376) corporeal anastomosis [22]. Other practical
(range) advantages of the intracorporeal anastomosis
Mean estimated blood loss 48.6 ml (10–300) include flexibility in choosing the extraction site
(range)
since it is not determined by the anastomosis and
Mean extraction site length 4.3 cm (3–6.4)
(range) the ability to prevent twisting of the mesentery
Conversions to open surgery 0 by direct visualization prior to completion of the
anastomosis.
Robotic right Finally, there are very few studies to date
Variable studied colectomy (n = 50) addressing the oncologic outcomes with robotic
Intracorporeal anastomosis 50 techniques. It is likely that for robotic right
Mean specimen length (range) 18.5 (10–37) colectomy and partial colectomy, results will be
Mean lymph node harvest (range) 18.3 (0–40) similar to laparoscopic colectomy. In their study
Length of stay (range) Mean 3.7 days of 50 consecutive right colectomies for cancer,
(1–21)
D’Annibale et al. reported similar pathologic
Median 3 days
parameters and similar lymph node harvest in
both groups [23]. They concluded robotic right
Robotic right
Complication colectomy (n = 50)
colectomy was safe and provided adequate onco-
Urinary retention 2
logic resection with acceptable short-term results.
Wound infection 1 Because the da Vinci robot is a tool to perform
Nausea/vomiting 2 laparoscopic surgery, studies will likely show no
Ileus 4 difference and no untoward effects as has been
Dehydration 1 demonstrated with laparoscopic right colectomy
Atelectasis 1 for cancer. Future studies will reveal recurrence
UTI 1 rates and long-term survival.
Pneumonia 1
Pleural effusion 1
Hypotension 1 Conclusion
Acute coronary syndrome 1
Postoperative rectal bleeding 1 In conclusion, as several authors and we have
Transfusion 2 demonstrated, robotic right colectomy is safe and
Intra-abdominal abscess 2
feasible [2, 17, 19, 22–25]. Operative times actu-
(continued) ally seem to be comparable to laparoscopic col-
200 H.J. Lujan and G. Plasencia

Table 17.3 Data of the largest published series of robotic right colectomy
# of ports Operative
Study (reference) Year N Technique (Robot arms) Anastomosis time (min)
Rawlings et al. [17] 2007 17 MtL 5 (4) IC Mean 219
Spinoglio et al. [24] 2008 18 MtL 5 (4) NR 267a
deSouza et al. [19] 2010 40 MtL > LtM 4 (3) EC Mean 159
D’Annibale et al. [23] 2010 50 MtL 5 (4) IC Median 224
Lujan et al. [22] 2011 22 MtL > LtM 4 (3) IC Mean 189
N = number of patients, # = number, MtL = medial-to-lateral, LtM = lateral-to-medial, IC = intracorporeal, EC = extracor-
poreal, NR = not reported
a
Only last case reported

Fig. 17.17 Robotic right colectomy operative times and total operating room times: our published experience with the
first 22 cases with intracorporeal anastomosis

colectomies for benign disease. Dis Colon Rectum.

ectomy. The true advantage of robotics may lie in 2002;45(12):1689–96.
its ability to simplify complex tasks, and robotics 3. D’Annibale A, Morpurgo E, Fiscon V, et al. Robotic
and laparoscopic surgery for colorectal diseases. Dis
may facilitate the adoption of minimally invasive Colon Rectum. 2004;47:2162–8.
techniques, intracorporeal anastomosis, and pro- 4. Mehran A, Daniel WB, Fahad B, Robert G, Trevor C.
mote associated advantages. Robotic-assisted laparoscopic colorectal surgery. Surg
Laparosc Endosc Percutan Tech. 2004;14(6):311–5.
5. Baik SH. Robotic colorectal surgery. Yonsei Med J.
2008;49(6):891.
References 6. Antoniou SA, Antoniou GA, Koch OO, Pointner R,
Granderath FA. Robotic assisted laparoscopic sur-
1. Maeso S, Reza M, Mayol JA, et al. Efficacy of the Da gery of the colon and rectum. Surg Endosc. 2012;
Vinci surgical system in abdominal surgery compared 26:1–11.
with that of laparoscopy: a systematic review and 7. Shabbir A, Rosiani A, Wong K-S, Tsang CB, Wong
meta-analysis. Ann Surg. 2010;252:254–62. H-B, Cheong W-K. Is laparoscopic colectomy as cost
2. Weber P, Merola S, Wasielewski A, Ballantyne GH. beneficial as open colectomy? ANZ J Surg.
Telerobotic-assisted laparoscopic right and sigmoid 2009;79:265–70.
17 Robotic Right Colectomy: Three-Arm Technique 201

8. Fleshman J, Sargent DJ, Green E, et al. Laparoscopic 20. Delaney CP, Lynch AC, Senagore AJ, Fazio VW.
colectomy for cancer is not inferior to open surgery Comparison of robotically performed and traditional
based on 5-year data from the COST study group trial. laparoscopic colorectal surgery. Dis Colon Rectum.
Ann Surg. 2007;246(4):655–64. 2003;46(12):1633–9.
9. Schwenk W, Haase O, Neudecker J, Muller JM. Short 21. Mutch M, Cellini C. Surgical management of colon
term benefits for laparoscopic colorectal resection. cancer In: Beck DE, Roberts PL, Saclarides TJ,
Cochrane Database Syst Rev. 2005;20(3):CD003145. Senagore AJ, Stamos MJ, Wexner SD, eds. The
10. Romano G, Gagliardi G, Bianco F, Parker MC. ASCRS textbook of colon and rectal surgery. Second
Laparoscopic colorectal surgery: why it is still not the Edition, New York, NY: Springer Science + Business
gold standard and why it should be. Tech Coloproctol. Media, LLC., 2011;711–20.
2008;12:185–8. 22. Lujan HJ, Maciel VH, Romero R, Plasencia G.
11. Bordeianou L, Rattner D. Is laparoscopic sigmoid Laparoscopic versus robotic right colectomy: a single
colectomy for diverticulitis the new gold standard? surgeon’s experience. J Robotic Surg. 2013;7:95.
Gastroenterology. 2010;138:2213–6. 23. D’Annibale A, Pernazza G, Morpurgo E, Monsellato
12. Lauter DM, Froines EJ. Initial experience with 150 I, Pende V, Lucandri G, et al. Robotic right colon
cases of laparoscopic assisted colectomy. Am J Surg. resection: evaluation of first 50 consecutive cases for
2001;181(5):398–403. malignant disease. Ann Surg Oncol.
13. Jacobs M, Verdeja MC, Goldstein HS. Minimally 2010;17:2856–62.
invasive colon resection (laparoscopic colectomy). 24. Spinoglio G, Summa M, Priora F, Quarati R, Testa S.
Surg Laparosc Endosc. 1991;1(3):144–50. Robotic colorectal surgery: first 50 cases experience.
14. Carmichael JC, Masoomi H, Mills S, Stamos MJ, Dis Colon Rectum. 2008;51:1627–32.
Nguyen NT. Utilization of laparocopy in colorectal 25. Ballantyne GH, Ewing D, Pigazzi A, Wasielewski A.
surgery for cancer at academic medical centers: does Telerobotic-assisted laparoscopic right hemicolec-
site of surgery affect rate of laparoscopy? Am Surg. tomy: lateral to medial or medial to lateral dissection?
2011;77(10):1300–4. Surg Laparosc Endosc Percutan Tech. 2006;16(6):
15. Kang CY, Halabi WJ, Luo R, Pigazzi A, Nguyen NT, 406–10.
Stamos MJ. Laparoscopic colorectal surgery: a better 26. Grams J, Tong W, Greenstein AJ, Salky B. Comparison
look into the latest trends arch surg. Surg. 2012; of intracorporeal versus extracorporeal anastomosis
147(8):724–31. for laparoscopic-assisted hemicolectomy. 2010;24:
16. Pigazzi A, Garcia-Aguilar J. Robotic colorectal sur- 1886–91.
gery: for whom and for what? Dis Colon Rectum. 27. Hellan M, Anderson C, Pigazzi A. Extracorporeal
2010;53:969–70. versus intracorporeal anastomosis for laparoscopic
17. Rawlings AL, Woodland JH, Vegunta RK, Crawford right hemicolectomy. JSLS. 2009;13:312–7.
DL. Robotic versus laparoscopic colectomy. Surg 28. Franklin ME, Gonzalez JJ, Miter DB, Mansur JH,
Endosc. 2007;21(10):1701–8. Trevino JM, Glass JL, et al. Laparoscopic right hemi-
18. Zimmern A, Prasad L, deSouza A, Marecik S, Park J, colectomy for cancer: 11-year experience. Rev
Abcarian H. Robotic colon and rectal surgery: a series Gastroenterol Mex. 2004;69 Suppl 1:65–72.
of 131 cases. World J Surg. 2010;34(8):1954–8. 29. Scatizzi M, Kroning KC, Borrelli A, Andan G, Lenzi
19. DeSouza AL, Prasad LM, Park JJ, Marecik SJ, E, Feroci F. Extracorporeal versus intracorporeal
Blumetti J, Abcarian H. Robotic assistance in right anastomosis after laparoscopic right colectomy
hemicolectomy: is there a role? Dis Colon Rectum. for cancer: a case–control study. World J Surg.
2010;53:1000–6. 2010;34:2902–8.
 Robotic Left Colectomy
18
Eduardo Parra-Davila and Carlos M. Ortiz-Ortiz

plete elimination of tremors produced by

Introduction surgeon’s hand. The ergonomic position of the
surgeon while working on the console reduces
Laparoscopic colorectal surgery has increased all the muscle strain on the surgeon in the difficult
over the world due to its known benefits such as and long procedures [1].
less pain, shorter stay, reduced recovery time, The da Vinci system has been used for differ-
early ambulation, and decreased associated ent types of general surgery procedures, and there
comorbidities. However, laparoscopic colecto- has been increased interest in the last few years in
mies have been a challenge due to steep learning colorectal surgery; however, there is still no stan-
curves, limited dexterity of laparoscopic instru- dardized technique. For left colon resection
ments, and suboptimal visualization. With the several procedures have been described:
use of a surgical robot, laparoscopic limitations 1. Hybrid technique: Mainly consists of laparo-
can be overcome offering the patient a good alter- scopic mobilization of splenic flexure fol-
native for a minimally invasive procedure. lowed by docking for pelvic dissection and
The robotic platform has several advantages completion of procedure.
over conventional laparoscopy. It provides a 2. Single-docking technique [1]: Incorporates
magnified full high definition 3D camera that is mobilizing the second and third robotic arm
always under the surgeon’s control with instru- for different parts of the procedure.
ments that have a free articulating endowrist and 3. Double-docking technique: Incorporates
arms that facilitate the dissection and retraction docking from left upper quadrant for dissec-
of the specimen in complex surgeries. The move- tion of the splenic flexure and then changing
ments of the robotic arms are precise with com- the docking to the left lower quadrant.
Recently the introduction of an articulating
vessel sealer has allowed mobilization of the
E. Parra-Davila, M.D., F.A.C.S., F.A.S.C.R.S. (*) splenic flexure with minimal changes in the
Director of Minimally Invasive and Colorectal
Surgery, Director of Hernia and Abdominal Wall
current port placement of a single-docking
Reconstruction, Celebration Health-Florida Hospital, technique.
410 Celebration Place, Suite 401,
Celebration, FL 34747, USA
e-mail: [email protected]
Patient Selection
C.M. Ortiz-Ortiz, M.D.
Department of General Surgery, Florida
Hospital—Celebration, 410 Celebration Place,
Robotic-assisted left colectomy is recommended
Suite 401, Celebration, FL 34747, USA for small T0 (unable to be removed by colonos-
e-mail: [email protected] copy), T1 tumors with invasion to submucosa,

K.C. Kim (ed.), Robotics in General Surgery, DOI 10.1007/978-1-4614-8739-5_18, 203

© Springer Science+Business Media New York 2014
204 E. Parra-Davila and C.M. Ortiz-Ortiz

and certain T2–T4 tumors that have an approach

feasible for minimally invasive surgery. Patient Positioning
Absolute and relative contraindications for
robotic-assisted left colectomy include bulky The patient is positioned in modified lithotomy
disease with invasion to adjacent organs, colonic position with legs abducted and slightly flexed.
obstruction that needs emergent decompression, The patient’s arms are tucked along the side of
or patient with contraindications for the body, and pads are placed in possible pressure
pneumoperitoneum. points. This position is fixed with a vacuum-
Ideal patients to start a robotic colorectal pro- assisted mattress device. Once the patient is
gram include the following: secure, the patient is placed with a 15°–20°
1. No previous medical conditions Trendelenburg position and with a tilt of 15° to
2. BMI < 30 the right side of the patient. After adequate
3. No previous intra-abdominal surgery patient positioning, we perform the robotic cart
4. No previous radiotherapy docking.
5. Low TNM status

Port Placement and Robotic

Patient Preparation Position

Bowel preparation is based on surgeon prefer- Currently we are performing the robotic left col-
ences. In our patients we prepare the bowel with ectomy with the following options depending on
milk of magnesia unless the exact location of the case selection and body habitus.
lesion is unknown, in which case full bowel 1. Trocar placement for single docking
cleansing is ordered. We follow the guidelines for (Fig. 18.2a, b)
perioperative intravenous antibiotics [2]. This trocar placement configuration is best
Intraoperative preparation includes [2]: when using the da Vinci vessel sealer, which is
1. Foley catheter wristed and provides the range of motion for
2. Orogastric tube for stomach decompression the splenic flexure to be reached from the first
3. DVT prophylaxis with bilateral sequential and the third arms.
compression devices and subcutaneous low 2. Trocar placement for hybrid technique
molecular weight heparin (Fig. 18.3a, b)
4. Warmer to avoid hypothermia This trocar placement is used when antici-
pating pelvic adhesions and/or rectal surgery.
The first portion of the procedure (splenic
OR Configuration flexure takedown) is done laparoscopically,
and then the second portion (pelvic dissec-
The operation room setup is shown in Fig. 18.1. tion) is done with the robot docked from the
The patient’s left side of the table is kept clear to left side.
permit adequate docking of the robotic cart. 3. Trocar placement for double docking totally
During the procedure, the robotic cart is robotic approach (Fig. 18.4a, b).
approached toward the left side of the table at the With this trocar configuration the robot is
left upper or lower quadrant depending on docked at the left upper quadrant to start the
whether splenic flexure mobilization is needed or mobilization of the splenic flexure. Once that
not. The surgical assistant is located on the is accomplished the robot is then docked at the
patient’s right side, and the scrub nurse is at the left lower quadrant for the pelvic portion of
lower right side. the procedure.
18 Robotic Left Colectomy 205

Fig. 18.1 Configuration of operating room for robot, console, and instrument table

vessels and the ureter are identified and preserved.

Instrument Allocation The IMA is divided near the root with Hem-o-lok®
to the Robotic Arms clips (Weck Closure System, Research Triangle
Park, NC, USA) or with the da Vinci vessel sealer.
• Instrument arm 1 with monopolar curved scis- The inferior mesenteric vein is identified by
sors or da Vinci vessel sealer: docked to the dissecting superiorly toward the ligament of
RLQ port as a surgeon’s right hand Treitz and is divided near the inferior border of
• Instrument arm 2 with Maryland bipolar for- the pancreas.
ceps: docked to the LUQ port as a surgeon’s The medial dissection continues laterally until
left hand the left colon is separated from the retroperito-
• Instrument arm 3 with bowel grasper: docked neum and superiorly over the pancreas until the
to the RUQ port as a surgeon’s second left lesser sac is entered. Lateral detachment is initi-
hand ated along the white line, while the sigmoid
Initially, the surgeon makes an assessment of colon is retracted medially by the robotic arm 2
what seems easier either the medial or lateral or the assistant. The lateral dissection continues
approach. If the medial approach is chosen, the cephalad to the mid portion of the descending
mesocolon over the inferior mesenteric artery colon. The splenic flexure is mobilized if neces-
(IMA) is retracted upwardly with the bowel sary to achieve a tension-free anastomosis.
grasper forceps. The peritoneum around the base The transverse mesocolon is opened just above
of the IMA is incised and dissected with monopo- the body of the pancreas to enter the lesser sac.
lar scissors. The periaortic hypogastric nerve Dissection of the transverse mesocolon contin-
plexus is carefully preserved. The left gonadal ues toward the distal transverse colon and the
206 E. Parra-Davila and C.M. Ortiz-Ortiz

Fig. 18.2 (a) Trocar placement for single-docking technique. (b) Configuration of operating room for robot, console,
and instrument table for single-docking technique
18 Robotic Left Colectomy 207

Fig. 18.3 (a) Trocar placement for hybrid technique. (b) Configuration of operating room for robot, console, and
instrument table for hybrid technique
208 E. Parra-Davila and C.M. Ortiz-Ortiz

base of the descending colon. The omentum If lateral dissection is chosen, the first step is
attached to the transverse colon is dissected in medial traction of the colon starting the dissec-
the avascular plane, beginning from the middle tion laterally as described above, and the medial
third of the transverse colon. The renocolic and dissection follows once the colon is up in the air.
splenocolic ligaments are divided, and the This sequence works for the double-docking
splenic flexure is fully mobilized. During the technique as well, and the only difference is that
splenic flexure mobilization, robotic arm 1 has the dissection is done in two steps: the splenic
the da Vinci vessel sealer, and we take advantage flexure and the descending colon dissection are
of its wristed range of motion to go behind the performed with a different location of the robotic
lateral attachments and also for the blunt medial cart for each phase. In the splenic flexure dissec-
dissection. The assistant can contribute signifi- tion, the robotic cart is placed over the left shoul-
cantly by inserting his/her instruments through der, and in the descending colon dissection, it is
the remaining port. The da Vinci vessel sealer placed at the left lower quadrant. In the hybrid
can also be used on robotic arm 3 to dissect the technique the splenic flexure is done laparoscopi-
omentum from the transverse colon. If complete cally, and the descending colon is done roboti-
splenic flexure mobilization is not feasible with cally as described for the double-docking
the robot docked, it can be performed laparo- technique (Figs. 18.5a, b, 18.6, 18.7, 18.8, 18.9,
scopically at the end of the robotic dissection. and 18.10).

Fig. 18.4 (a) Trocar placement for double-docking technique. (b) Configuration of operating room for robot, console,
and instrument table for double-docking technique
18 Robotic Left Colectomy 209

Fig. 18.4 (continued)

Fig. 18.5 (a) Vessel sealer-controlling vessels in mesentery. (b) Dividing IMA with robotic clip applier. (c) Vessel
sealer cleaning mesentery at proximal resection

Fig. 18.6 Vessel sealer during medial dissection toward splenic flexure

Fig. 18.7 Lateral mobilization of splenic flexure with vessel sealer

18 Robotic Left Colectomy 211

Fig. 18.8 Medial mobilization toward ligament of Treitz

Fig. 18.9 Vessel sealer preparing rectum for stapler Fig. 18.10 Dissection of distal margin (rectum) with
transaction stapler

Compared to laparoscopic surgery, the robotic

Limitations system is not able to transmit tactile sensation to
the surgeon in the console. Additionally, there are
Clinical outcomes of robotic left colectomies are limitations in the instruments that are available,
quite comparable with those of the laparoscopic particularly the stapler (recently FDA approved),
technique. The safety and feasibility of both that require the assistant at the bedside to perform
hybrid and totally robotic colon surgery have some components of the procedure. The nature of
already been established, and the only difference the instrument exchange required in robotic sur-
in approach appears to be longer operative times gery can also add to the operative time and to
with the totally robotic approach [3–6]. potential injury to the patient. Lastly, accessing all
212 E. Parra-Davila and C.M. Ortiz-Ortiz

the parts of the abdominal cavity necessary to

References
perform a left colectomy can be a challenge requir-
ing more than one docking, adding to the com- 1. Choi DJ, Kim SH, Lee PJ, et al. Single stage totally
plexity of the procedure and the operative time. robotic dissection for rectal cancer surgery: technique
and short term outcome in 50 consecutive patients.
Dis Colon Rectum. 2009;52(11):1824–30.
2. Parra-Davila, Eduardo MD, Diaz-Hernandez, Juan
Conclusions MD. J Robot Surg 2011;5(1):57–64.
3. Weber PA, Merola S, Wasielewski A, Ballantyne GH.
Robotic left colectomy has been proven to be feasi- Telerobot-assisted laparoscopic right and sigmoid
ble and can be expected to have additional advan- colectomies for benign disease. Dis Colon Rectum.
2002;45:1689–94.
tages from the enhanced visualization and 4. D’Annibale A, Morpurgo E, Fiscon V, Trevisan P,
maneuverability of instruments and precision in dis- Sovernigo G, Orsini C, Guidolin D. Robotic and lapa-
section over laparoscopic surgery especially in com- roscopic surgery for treatment of colorectal diseases.
plicated procedures. Comparative studies are needed Dis Colon Rectum. 2004;47:2162–8.
5. Anvari M, Birch DW, Bamehriz F, Gryfe R, Chapman
to determine whether these advantages will translate T. Robotic-assisted laparoscopic colorectal surgery.
into improved clinical outcomes. This technology Surg Laparosc Endosc Percutan Tech. 2004;14:
continues to evolve to add to the complement of 311–5.
tools that will increasingly make this platform a part 6. Rawlings AL, Woodland JH, Vegunta RK, Crawford
DL. Robotic versus laparoscopic colectomy. Surg
of the armamentarium of the colorectal surgeon in Endosc. 2007;21:1701–8.
order to provide better care for the patient.
 Totally Robotic Low Anterior
Resection 19
Jung Myun Kwak and Seon Hahn Kim

resections has therefore evolved and is currently

Introduction being widely adopted [6–10].
Since we started using the da Vinci® robotic
Since the first robot-assisted colectomy was system to perform surgery for rectal cancers in
reported by Weber et al. [1] in 2002, robotic July 2007, we have developed a single-stage
surgery has been performed in a variety of opera- totally robotic technique that does not require
tions and embraced a wide range of diseases, movement of the patient cart during the entire
including those benign and those malignant [2–4]. dissection of the LAR [5]. We have improved this
At present, given the particular advantage of uti- technique during the course of more than 200
lizing robotics in pelvic procedure, there is a operations to further facilitate easy and safe oper-
great interest in the application of a robotic surgi- ations. In this chapter, we describe the surgical
cal system for total mesorectal excision (TME). technique of totally robotic LAR currently used
The majority of recent studies have been focus- at our institute and review short-term clinical,
ing on robotic TME for rectal cancer [5–12]. pathological, and oncological outcomes based on
The surgical procedure for low anterior resec- the literature.
tion (LAR) involves more than one abdominal
quadrant. Even when omitting the splenic flexure
mobilization, the operator should mobilize a Procedure Overview
wide operative field from the left colon to the bot-
tom of the pelvic floor. This limits the application Patient Positioning for Totally
of the current robotic system, which has a limited Robotic LAR
range of arm movement secondary to a fixed
position of the patient cart. Due to this limitation, Proper positioning of the patient is an essential
the complete robotic rectal resection initially first step for total robotic LAR procedures.
required movement of the patient cart during the Without proper patient positioning and port
operation, which was troublesome and time con- placement, robotic-assisted procedures are
suming [2, 13]. A hybrid technique for rectal tedious to perform and patient outcomes can be
compromised. Attention should be placed not
only on patient safety issues but also on safe
docking of the robot and good exposure of the
J.M. Kwak, M.D., Ph.D. (*) • S.H. Kim, M.D. Ph.D. surgical field.
Department of Surgery, Korea University Anam
After the induction of general anesthesia, the
Hospital, Anam-dong 5-Ga, Seongbuk-Gu, Seoul
136-705, Republic of Korea patient is placed in a modified lithotomy posi-
e-mail: [email protected] tion with a beanbag mattress to prevent sliding.

K.C. Kim (ed.), Robotics in General Surgery, DOI 10.1007/978-1-4614-8739-5_19, 213

© Springer Science+Business Media New York 2014
214 J.M. Kwak and S.H. Kim

Fig. 19.1 Patient positioning for totally robot-assisted low anterior resection

A body warmer to prevent hypothermia and a camera. Since there is an ideal distance (about
sequential compression device to prevent deep 15 cm) between the scope and the target anatomy,
vein thrombosis on the legs can be applied. Legs the camera port should be shifted a few centime-
are placed in adjustable stirrups with the knees ters lateral to the umbilicus if the patient has a
flexed. The left leg is less abducted as compared small body size. The intra-abdominal pressure is
to the right one so as not to interfere with the maintained at 8–12 mmHg. The first da Vinci®
approach of the robotic system. After position- 8-mm port is placed on the right lower quadrant
ing as seen in Fig. 19.1, the angle of (RLQ), approximately at the McBurney point.
Trendelenburg position and the angle of right The second 8-mm robotic port is inserted in the
side down tilting can be adjusted during the ini- right upper quadrant (RUQ), mostly on the mid-
tial exposure step. clavicular line (MCL). The third 8-mm port is
placed in the left upper quadrant (LUQ), approxi-
mately 1–2 cm above the camera port at the
Trocar Placement crossing of the MCL. The fourth port is inserted
in the left lower quadrant (LLQ), approximately
Proper port placement is crucial since the current one to two centimeters lateral to the MCL. These
da Vinci® system is rather bulky and requires suf- four ports are used for the robotic instrument
ficient room between arms, not only to avoid arms and are separated from each other by at
external collision but to also maximize internal least 8 cm. To allow the assistant access, a 5-mm
movement. trocar is placed in the right flank area, near the
Six ports are used, namely, one 12-mm camera anterior axillary line at the umbilicus level. This
port, four 8-mm robotic working ports, and one is used for suction/irrigation, clipping of vessels,
5-mm port for the assistant. After pneumoperito- and retraction of tissues. The port placement is
neum is achieved by either an open technique or shown in Fig. 19.2. The port position can be
a Veress needle, a 12-mm trocar is placed through altered according to the patient’s physique.
an incision around the umbilicus for the robotic However, there are several principles when placing
19 Totally Robotic Low Anterior Resection 215

Fig. 19.2 (a) Trocar arrangement for totally robot- distance and a wider angle between the two right side
assisted low anterior resection. (b) Schematic figure trocars. ASIS anterior superior iliac spine; MCL midcla-
showing desirable trocar placement which has a longer vicular line

the trocars. Since the anterior iliac spine and the cult, is mainly caused by distended small bowel
12th rib are fixed in position, the RLQ port should with fatty mesentery. The right-sided omentum
always be placed first at McBurney point, and should be repositioned over the liver to create
then the RUQ port is positioned close to the right more space in the RUQ, then to maximally dis-
costal margin. The camera port is placed around place the small bowels to this space. This step is
the umbilicus in order to be positioned at the achieved with conventional laparoscopic
same distance from the RLQ and RUQ ports. If instruments.
possible, it is better to have a longer distance and
a wider angle between the two right trocars, as
shown in Fig. 19.2. Robot Positioning and Docking

Once initial exposure has been achieved, the

Initial Exposure patient cart is brought in for docking. The patient
cart is positioned obliquely at the LLQ of the
The first step of robotic LAR involves optimiz- abdomen along the imaginary line from the
ing exposure and exploring the abdominal cav- camera port to the left anterior superior iliac
ity laparoscopically. A zero-degree robotic spine. The robotic arms are then docked to the
camera or a conventional laparoscope is used. trocars. When using all three da Vinci® instru-
The whole abdominal cavity is inspected care- ment arms, setup joint of the camera arm should
fully for metastatic disease. The operating table be positioned towards the patient’s side to allow
is tilted to provide initial exposure of the oper- space for the instrument arms ② and ③. Before
ating field, by shifting the small bowel loops starting the console activity, the robotic arms
into the RUQ (Fig. 19.1). In general, inadequate should be adjusted to create maximal space in
exposure, which makes robotic surgery diffi- between, shown as a well-spread fan (Fig. 19.3).
216 J.M. Kwak and S.H. Kim

Fig. 19.3 The robot docked to the patient for totally robot-assisted low anterior resection. The patient cart is positioned
obliquely at the LLQ of the patient

Vascular Ligation and Sigmoid Colon neum and superiorly over the pancreas until the
to Splenic Flexure Mobilization lesser sac is entered. The left gonadal vessels and
the ureter are identified and preserved. Lateral
• Instrument arm ① with monopolar curved detachment is initiated along the white line while
scissors: Docked to the RLQ port as a sur- the sigmoid colon is retracted medially by the
geon’s right hand assistant. Lateral countertraction by the instru-
• Instrument arm ② with Cadiere forceps: ment arm ② facilitates safe dissection. The lateral
Docked to the LUQ port as a surgeon’s second dissection continues cephalad to the middle por-
left hand tion of the descending colon. Splenic flexure is
• Instrument arm ③ with Maryland bipolar for- mobilized if necessary to achieve a tension-free
ceps: Docked to the RUQ port as a surgeon’s anastomosis. The transverse mesocolon is opened
left hand just above the body of the pancreas to enter the
Initially, the mesocolon over the IMA is lesser sac. Dissection of the transverse mesoco-
retracted upwardly with the Cadiere forceps. The lon continues towards the distal transverse colon
peritoneum around the base of the IMA is incised and the base of the descending colon. Then
and dissected with monopolar scissors. The peri- omentum attached to the transverse colon is then
aortic hypogastric nerve plexus is carefully pre- dissected in the avascular plane, beginning from
served. The IMA is divided near the root with the middle third of the transverse colon. The
Hem-o-lok® clips (Weck Closure System, renocolic and splenocolic ligaments are divided
Research Triangle Park, NC, USA) (Fig. 19.4). and the splenic flexure is fully mobilized. During
The inferior mesenteric vein is identified by dis- splenic flexure mobilization, only robotic arms 1
secting superiorly toward the ligament of Treitz and 3 are aligned to minimize external collision;
and is divided near the inferior border of the however, the assistant can contribute significantly
pancreas. by inserting his/her instruments through the
The medial dissection continues laterally until remaining ports. If complete splenic flexure
the left colon is separated from the retroperito- mobilization is not feasible with whatever rea-
19 Totally Robotic Low Anterior Resection 217

Fig. 19.4 IMA is clipped and divided at its origin. The periaortic hypogastric nerve is identified and swept down

sons, it can be performed lastly, after completion tance by using both hands for TME. The assis-
of robotic pelvic dissection. tant applies cephalic traction using a cotton tie
around the sigmoid colon. The robotic Cadiere
grasper retracts the rectum anteriorly, thus
Pelvic TME exposing the plane between the mesorectal fas-
cia and the inferior hypogastric nerves. The
• Instrument arm ① with monopolar curved avascular space between the mesorectal fascia
scissors: Docked to the RLQ port as a sur- and the presacral fascia is sharply dissected with
geon’s right hand monopolar scissors. The inferior hypogastric
• Instrument arm ② with Cadiere forceps: nerves and, distally, the pelvic nerve plexus are
Docked to the LLQ port as a surgeon’s second identified and preserved. Further posterior dis-
left hand section down to the levator ani muscle is
• Instrument arm ③ with Maryland bipolar for- approached from the left lateral plane, while the
ceps: Docked to the LUQ port as a surgeon’s rectum is lifted up using the Cadiere forceps.
left hand The left lateral dissection is performed while the
The robotic instruments of the RUQ and LUQ rectum is drawn to the right side by the assistant.
ports are dedocked and redocked to the LUQ and Then, the right lateral dissection is completed in
LLQ ports, respectively. Before beginning the the reverse order used for rectal retraction.
console activity, the robotic arms should again Finally, anterior dissection is performed by
be adjusted to create maximal space in between, incising the peritoneal reflection. Sharp dissec-
shown as a well-spread fan. The assistant then tion is continued until the correct plane between
uses the RUQ port to retract the rectosigmoid the rectum and vagina/seminal vesicles/prostate
cephalad and the 5-mm assistant port for suction is achieved. The rectum is retracted downward
and/or retraction (Fig. 19.5). Therefore, five with the instrument attached to robotic arm 3
instruments are used in the operative field (three (Maryland grasper), and the vagina/prostate is
robotic and two handheld), maximizing assis- counter-retracted upward with the instrument
218 J.M. Kwak and S.H. Kim

Fig. 19.5 The assistant is using both his hands through the RUQ port and the assistant port in the pelvic phase

attached to robotic arm 2 (Cadiere forceps). endostapler. The remaining steps are performed
During the pelvic dissection stage, the assistant using conventional laparoscopic methods. After
uses the RUQ port as well, therefore maximizing extending the robotic 8-mm port on RLQ to a
assistance by use of both hands. 12-mm port, an articulating linear endostapler
An effective method to enhance the exposure loaded with a gold cartridge (4.2 mm) is used via
of the pelvic cavity in postmenopausal women is the RLQ port. A distal rectal washout is then per-
suspension of the uterus from the abdominal wall formed, and the rectum is divided using an endo-
using a suture (Fig. 19.6). A similar suspension stapler to achieve at least a 2-cm distal margin.
can be made with a suture around the thick, fatty The specimen is delivered through a small
peritoneum to retract the bladder in obese incision at the LLQ port, and the wound is cov-
patients. ered with an impermeable protector. Transection
of the proximal bowel is performed extracorpore-
ally. The anastomosis is performed intracorpore-
Rectal Division and Anastomosis ally using a standard double stapling technique.
A diverting ileostomy is selectively constructed
Robotic stapling devices are currently unavail- in cases with air leaks, incomplete doughnuts,
able. Therefore, after adequate TME down to the preoperative radiation, extreme difficulty in pel-
pelvic floor, undocking of the robotic arms, vic dissection, or coloanal anastomosis.
movement of the patient cart away from the oper- Recently, we modified our technique to maxi-
ating table, and a switch to a laparoscopic setting mize the advantages that we could gain from
are necessary for rectal transection using an using a robotic system. After TME, the instrument
19 Totally Robotic Low Anterior Resection 219

Fig. 19.6 The uterus is lifted up to the anterior abdominal wall using a suture to enhance the exposure of the pelvic
cavity in postmenopausal woman

arms ① and ③ are dedocked; however, the robotic dissection nor at the phase of splenic flexure
camera and the instrument arm ② are left in place mobilization. Robotic third arm controlled by the
to provide stable and constant upward traction surgeon can provide effective lifting up of IMA.
with Cadiere forceps and a stable camera view Because not only the pelvic nerves but also the
(Fig. 19.7), both of which make it easier to apply periaortic nerves are important for voiding/sex-
and fire the endostapler. ual functions [14, 15], we believe that robotic
dissection around the IMA pedicle is a critical
step. The three-dimensional magnified view and
Potential Advantages of Totally EndoWrist function could be helpful in identify-
Robotic LAR ing and preserving the periaortic hypogastric
nerve plexus. Also, these technical advantages
Once a surgeon’s preference is established, it is could enable easier mobilization of a difficult
hard to adapt a new surgical approach to his/her splenic flexure than conventional laparoscopic
practice. Because most experienced laparoscopic approach.
colorectal surgeons feel quite comfortable when Second, it may be inconvenient to perform an
they perform laparoscopic mobilization of the intraoperative colonoscopic examination because
left and sigmoid colon, they don’t contemplate the bulky patient cart is located between the
the introduction of a totally robotic procedure patient’s legs. Under the hybrid setting, it is impos-
into their practice. sible to apply our modified stapling technique.
However, a hybrid technique may have some Unfortunately, it may be very difficult to
limitations. First, it has no advantage from demonstrate the clinical benefits of these potential
robotic technology, neither at the phase of IMA advantages of totally robotic LAR. In the present
220 J.M. Kwak and S.H. Kim

Fig. 19.7 During rectal transection with an endostapler, the undocked robotic camera and robotic arm ② (Cadiere
forceps, arrow) provide more stable vision and better exposure

situation in which more stringent scientific If the patient has had previous abdominal sur-
evaluations in the setting of multicentre, random- gery, the initial creation of the pneumoperito-
ized clinical trials are required to verify the ben- neum should be carefully planned and executed.
efits of the robot-assisted rectal cancer surgery, it Once the peritoneal cavity is entered, it is more
is far too early to talk about the superiority convenient to resolve any adhesions laparoscopi-
between the totally robotic and hybrid approach. cally that can interrupt dissection or bowel repo-
Nonetheless, we should be concerned how we sitioning prior to docking of the robotic arms. If
can maximize this advanced technology in every the adhesions are too extensive or dense to per-
step of the procedure. form adhesiolysis using laparoscopic instru-
ments, a longer incision is made to lyse the
adhesions under direct visualization. Air leaks do
Limitations not matter once the fascia is closed properly.
The current robotic surgical system has limited
Very few limitations specific to fully robotic LAR instruments and bulky arms and lacks tactile feed-
exist. As shown in Table 19.1, the clinical out- back. However, improvements in robotic engineer-
comes of our fully robotic LAR technique are ing will undoubtedly contribute to the evolution of
quite comparable with those of our laparoscopic instruments, which will translate into expansion of
counterpart or other series performed using hybrid the applications of surgical robotic systems. Recently
technique. No intraoperative complication related developed new technologies such as a fluorescent
to robotic vascular ligation and sigmoid colon image or robotic stapler seem promising. We hope
mobilization was recorded. As the safety and fea- that incorporation of sensors into the tips of instru-
sibility of the various types of robotic colon sur- ments, which can provide a degree of “tactile” sen-
gery are already proven in previous studies, there sation, would be developed in the near future. These
is no issue arguing about fully robotic approach technological advancements are expected to over-
except longer operating time [1–4]. come the current pitfalls of the robotic system.
 19

Table 19.1 Comparison of clinical outcomes between the robotic and the laparoscopic surgery for rectal cancer
Operation time Conversion Hospital stay Total complication
Study Country (year) Study design Surgery Number (min) (%) (days) (%)
Kwak et al. [11]a Korea (2011) Case matched Robot, total 59 270 (241–325)* 0.0 NA 32.2
Totally Robotic Low Anterior Resection

Lap 59 228 (177–254) 3.4 NA 27.1

Park et al. [10] Korea (2011) Case matched Robot, hybrid 41 231.9 ± 61.4 * 0.0 9.9 ± 4.2 29.3
Lap 82 168.6 ± 49.3 0.0 9.4 ± 2.9 23.2
Baek et al. [9] USA (2011) Case matched Robot, hybrid 41 296 (150–520) 7.3 6.5 (2–33) 22.0
Lap 41 315 (174–584) 22.0 6.6 (3–20) 26.8
Bianchi et al. [8] Italy (2010) Comparative Robot, mixed 25 240 (170–420) 0.0 6.5 (4–15) 16.0
Lap 25 237 (170–545) 4.0 6.0 (4–20) 24.0
Patriti et al. [7] Italy (2010) Comparative Robot, hybrid 29 202 ± 12 0.0* 11.9 ± 7.5 30.6
Lap 37 208 ± 7 29.2 9.6 ± 6.9 18.9
Baik et al. [6] Korea (2009) Comparative Robot, hybrid 56 190.1 ± 45.0 0.0* 5.7 ± 1.1* 5.4*
Lap 57 191.1 ± 65.3 10.5 7.6 ± 3.0 19.3
NA not available
*P value <0.05
a
Values in parentheses are interquartile range
221
222 J.M. Kwak and S.H. Kim

viewed and compared with laparoscopic surgery

Preferable Indications and Relative
in Table 19.1.
Contraindications
In general, longer operating time is widely
considered to be one of the downsides of robotic
Our indications for robotic rectal cancer resec- surgery, along with higher cost and lack of tactile
tion are identical to those for laparoscopic sur- sense, as compared with conventional laparo-
gery. There are no contraindications applied scopic procedure. Notably, although it is just a
solely to robotic rectal cancer surgery. Proper numerical difference, some authors have reported
training, whether in vivo or in vitro, or even vir- even shorter operating time for robotic rectal can-
tual reality, is required prior to attempting robotic cer resections using a hybrid technique [6, 7, 9].
surgery to ensure that this novel technology is From these results, it can be inferred that the tech-
applied correctly. A well-trained team approach nical advantages of the robot can make difficult
is also an important factor to reduce the operating pelvic dissection easier and shorten the operating
time and ensure that the surgery goes smoothly. time. As we overcome the learning curve and
There is a steep learning curve before operating standardize every step of the procedure, the oper-
time, lower morbidity, and the surgeon’s comfort ating time can be expected to decrease further.
comparative to those obtained by conventional The excellent conversion rate has been
laparoscopic surgery can be achieved. reported consistently in several series of robot-
Some cases may prove to be more difficult to assisted rectal cancer surgery, and this is prom-
operate on using robot-assisted surgery before the ising and encouraging when considering
surgeon has gained experience with this technol- reported conversion rates in laparoscopic rectal
ogy. These include morbidly obese patients, male cancer surgery ranged from 12 to 20 % [16, 17].
patients, and low-lying rectal cancer cases. Since converted patients may have higher com-
Surgeons should be selective about which cases plication rates and worse oncological outcomes,
they perform robotically at the beginning of their this result can lead to better postoperative
learning curves. However, as experience is gained, course, as well as improved oncological and
the factors listed above could change preferable functional outcomes [18, 19].
indications for using robot-assisted surgery. In terms of postoperative recovery, similar
Contraindications are largely contingent on the outcomes were reported in most series.
experience of the surgeon. Intestinal obstruction, Postoperative complications after robot-assisted
severe adhesion with/without previous surgery, and rectal cancer resection seem to be equivalent to
marked obesity are relative contraindications. laparoscopic surgery. When comparing our data
Absolute contraindications include carcinoma with with other series performed by hybrid tech-
direct invasion into adjacent structures, perforation, nique, no significant differences are observed in
and mid- or lower rectal carcinoma greater than operating time, conversion rate, and morbidity.
5 cm in diameter. Systemic factors that contraindi- To the best of our knowledge, there was no
cate a laparoscopic approach, such as severely report of patient injury or mortality from device
impaired cardiovascular or respiratory functions malfunction.
and uncorrectable coagulopathy, apply equally to As most studies are based on data from highly
conventional and robot-assisted laparoscopy. experienced laparoscopic colorectal surgeons,
there is a definitive difference in the surgeon’s
expertise between the two operative techniques.
Outcomes This difference may attenuate the benefits of
robotic surgery, resulting in similar clinical out-
Short-Term Outcomes of Safety comes rather than superior results due to its tech-
and Feasibility nological advantages. In view of the results
achieved so far, skillful laparoscopic surgeons
Short-term clinical outcomes for robot-assisted can perform robot-assisted rectal cancer surgery
rectal surgery for rectal cancer have been re- safely and feasibly.
19 Totally Robotic Low Anterior Resection 223

Table 19.2 Pathologic outcomes between the two groups

LN harvested DRM CRM (%
Study Country (year) Study design Surgery Number (number) (cm) involved)
Kwak Korea (2011) Case matched Robot, total 59 20 (12–27) 2.2 (1.5–3.0) 1.7
et al. [11]a Lap 59 21 (14–28) 2.0 (1.2–3.5) 0.0
Park Korea (2011) Case matched Robot, hybrid 41 17.3 ± 7.7 2.1 ± 1.4 4.9
et al. [10] Lap 82 14.2 ± 8.9 2.3 ± 1.5 3.7
Baek USA (2011) Case matched Robot, hybrid 41 13.1 (3–33) 3.6 (0.4–10) 2.4
et al. [9] Lap 41 16.2 (5–39) 3.8 (0.4–11) 4.9
Bianchi Italy (2010) Comparative Robot, mixed 25 18 (7–34) 2 (1.5–4.5) 0.0
et al. [8] Lap 25 17 (8–37) 2 (1.8–3.5) 4.0
Patriti Italy (2010) Comparative Robot, hybrid 29 10.3 ± 4 2.1 ± 0.9 0.0
et al. [7] Lap 37 11.2 ± 5 4.5 ± 7.2 0.0
Baik Korea (2009) Comparative Robot, hybrid 56 18.4 ± 9.2 4.0 ± 1.6 7.1
et al. [6] Lap 57 18.7 ± 12 3.6 ± 1.7 8.8
LN lymph node, DRM distal resection margin, CRM circumferential resection margin
*P value <0.05
a
Values in parentheses are interquartile range

Oncological Outcomes In our study, we compared the short-term

surgical and oncological outcomes of robot-
There is increasing evidence that the number of assisted rectal cancer surgery with those of lapa-
harvested lymph nodes has an important impact roscopic surgery [11]. Both the short-term
on survival [20]. Table 19.2 showed no signifi- surgical and oncological outcomes were compa-
cant differences regarding this issue, and the rable between the groups. Although the mean
reported mean/median numbers are acceptable follow-up period (17 months in robotic group
considering a recommendation from the College versus 13 months in laparoscopic group) was not
of American Pathologist for a 12-node minimum long enough to allow a definitive assessment, the
[21]. Also, other parameters such as distal resec- pattern of cancer recurrence was not different
tion margin length or circumferential resection between the two groups. Expectation of improve-
margin involvement rate, which can be an index ment in local disease control by robotic dissec-
of surgical quality, were not different between the tion will be evaluated with follow-up research.
two groups in rectal cancer surgery. Only prospective clinical trials with long-term
Evidence of the oncological outcomes of follow-up can clearly answer whether the techno-
robot-assisted rectal cancer surgery is very lim- logical advantages of robotic surgical system can
ited, as shown in Table 19.3. In a multicenter translate into favorable surgical or oncological
study for robotic TME by Pigazzi et al., the outcomes. Currently, several multicenter, ran-
3-year overall survival rate was 97 % in 143 con- domized controlled trials of robot-assisted versus
secutive patients with rectal cancer undergoing conventional laparoscopic resection for rectal
robotic surgery, and isolated local recurrences cancer have been undertaken. Attention is now
were not found during the mean follow-up period focused on how these trials will develop and their
of 17.4 months [12]. In that study, the absence of overall results.
a control group, relatively short follow-up period,
and extensive use of neoadjuvant chemoradiation
could have been barriers to reaching definitive Functional Outcomes
conclusions. Nevertheless, their excellent results
suggest that a robotic surgical system is likely to A current issue of great interest in robot-assisted
improve local disease control. TME for rectal cancer is whether it can preserve
224 J.M. Kwak and S.H. Kim

Table 19.3 Short- and midterm oncological outcomes of robot-assisted proctectomy for rectal cancer
Mean F/up
Study Patient Surgery Number (month) Oncological outcome
Kwak et al. [11]a Korea (2011) Robot, total 55 17 (11–25) 1 locoregional recurrence/
2 distant metastasis
Lap 54 13 (9–22) 1 locoregional recurrence/
2 distant metastasis
Pigazzi et al. [12] USA (2010) Robot, hybrid 143 17.4 3-year DFS 77.6 %/3-year
OS 97 %/no isolated local
recurrence
Patriti et al. [7] Italy (2010) Robot, hybrid 29 29.2 ± 14.0 0 % of local recurrence/no
Lap 37 18.7 ± 13.8 difference in OS and DFS
5.4 % of local recurrence
DFS disease-free survival, OS overall survival
a
Values in parentheses are interquartile range

voiding and sexual function by avoiding injury to rectal cancer in laparoscopic and robotic surgery.
autonomic nerves following rectal resection. They assessed functional outcomes using stan-
Because the incidence of postoperative voiding dardized, internationally approved multiple ques-
and sexual dysfunction is high even with incor- tionnaires and invasive urodynamic tests to
poration of autonomic nerve-preserving tech- provide the most objective results. Although the
niques in TME and always results in poor quality number of patients enrolled was relatively small,
of life, better functional outcomes with robotic they demonstrated that robot-assisted TME was
approach can offset an indictment of its high cost. associated with early recovery of voiding and
In terms of laparoscopic TME with pelvic sexual function compared to laparoscopic TME.
autonomic nerve preservation, there are two con- Well-designed studies should be followed to ver-
trary hypotheses about the impact of laparoscopic ify the benefit of robotic approach to preserve
approach on postoperative voiding and sexual postoperative voiding and sexual function.
function; one is that the magnified view of the
pelvis afforded by the laparoscope may facilitate
identification of the autonomic nerves and thus Conclusions
prevent inadvertent injury, while the other is that
several technical pitfalls of laparoscopic surgery Single-stage totally robotic LAR is feasible and
may predispose to nerve injury. However, Jayne expected to have additional advantages from
et al. [14]. showed that laparoscopic rectal resec- maximal use of advanced robotic technology.
tion did not adversely affect voiding function, but Our data shows equivalent clinical and pathologi-
there was a trend towards worse male sexual cal outcomes when compared to its laparoscopic
function from the MRC CLASICC trial’s counterpart and other studies performed by
patients. They also found that TME and conver- hybrid technique. Longer operating time is a
sion to open surgery were independent predictors shortcoming of totally robotic procedure, but par-
of postoperative male sexual dysfunction [14]. tially caused by initial unfamiliarity.
Several studies have reported low conversion A great deal of progress has occurred in the
rates of robotic resection for rectal cancer [6–11], field of colorectal surgery over the last few years,
and we can expect this to result in better and this has generated a great deal of interest in
preservation of voiding and sexual function. using robotic systems to perform rectal cancer
Recently, Kim et al. [22]. reported a comparative surgery. Although the initial reports are promis-
study of functional outcomes after TME for ing, more stringent scientific evaluations in the
19 Totally Robotic Low Anterior Resection 225

setting of multicenter, randomized clinical trials 10. Park JS, Choi GS, Lim KH, Jang YS, Jun SH. Robot-
assisted versus laparoscopic surgery for Low rectal
are essential to verify the safety, efficacy, and
cancer: case-matched analysis of short-term out-
long-term functional and oncological benefits of comes. Ann Surg Oncol. 2010;17:3195–202.
this new technology. Developing of adequate 11. Kwak JM, Kim SH, Kim J, Son DN, Baek SJ, Cho JS.
training program and high cost are real issues that Robotic vs. laparoscopic resection of rectal cancer:
short-term outcomes of a case control study. Dis
must be solved. The future, however, looks very
Colon Rectum. 2011;54:151–6.
promising because of the great potential of 12. Pigazzi A, Luca F, Patriti A, Valvo M, Ceccarelli G,
robotic surgical systems to extend the capabilities Casciola L, Biffi R, Garcia-Aguilar J, Baek JH.
of surgical performance beyond human limita- Multicentric study on robotic tumor-specific mesorec-
tal excision for the treatment of rectal cancer. Ann
tions, and it will greatly improve the quality of
Surg Oncol. 2010;17:1614–20.
surgical care. 13. Spinoglio G, Summa M, Priora F, Quarati R, Testa S.
Robotic colorectal surgery: first 50 cases experience.
Dis Colon Rectum. 2008;51:1627–32.
14. Jayne DG, Brown JM, Thorpe H, Walker J, Quirke P,
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 Robotic Hybrid Low Anterior
Resection 20
Eric M. Haas and Rodrigo Pedraza

prolonged procedure with high conversion rate,

Background high morbidity rate, and jeopardized oncological
outcomes [3]. Therefore, the routine utilization
Laparoscopic surgery is considered by many to of the laparoscopic approach for the management
be the surgical approach of choice for disease of rectal cancer is cautioned. Accordingly, the
processes requiring colon resection. rationale for robotic-assisted laparoscopic sur-
Laparoscopic colectomy has been widely recog- gery for the treatment of rectal cancer is based on
nized as a safe alternative for curative resection achieving the advantages of a minimally invasive
for colon cancer [1] and has steadily gained platform without high conversion rates and with-
adoption. Currently it is estimated that in high- out compromising oncological and pathological
volume institutions, 50 % of all colectomies for outcomes.
cancer are performed with the laparoscopic The concept of a robotic hybrid procedure was
approach [2]. This enthusiasm, however, has not first popularized by Pigazzi et al. [4]. The hybrid
been reflected when approaching patients approach utilizes conventional laparoscopy to
requiring rectal resection with curative intent achieve parts of the procedure and the robotic
for rectal cancer. As such, it is currently esti- platform to achieve the portions related to pelvic
mated that approximately only 10 % of rectal dissection. In this approach, the abdominal por-
resections for rectal cancer are performed with tion of the procedure is performed laparoscopi-
the utilization of a minimally invasive surgical cally, whereas the pelvic portion is accomplished
approach. robotically. The rationale for the utilization of
Early experience of laparoscopic surgery for this approach is based on the premise that this
the treatment of rectal cancer resulted in a hybridization enhances the surgeon ability to
complete the procedure with the various mini-
mally invasive approaches to maximize the ben-
efits while minimizing the intrinsic limitations of
E.M. Haas, M.D. (*) • R. Pedraza, M.D. both techniques.
Division of Minimally Invasive Colon and Rectal During the non-pelvic portions of the proce-
Surgery, Department of Surgery, The University dures, the intrinsic advantages of the robotic
of Texas Medical School at Houston, Houston,
platform such as enhanced optics and dexterity
TX 77030, USA
are not as much as a beneficial factor as it when
Colorectal Surgical Associates, Ltd, LLP, 7900
operating in the confined anatomy of the rec-
Fannin, Suite 2700, Houston, TX 77054, USA
e-mail: [email protected]; tum. Furthermore, colon dissection and mobi-
[email protected] lization usually requires multiple quadrant

K.C. Kim (ed.), Robotics in General Surgery, DOI 10.1007/978-1-4614-8739-5_20, 227

© Springer Science+Business Media New York 2014
228 E.M. Haas and R. Pedraza

maneuvers thus resulting in potential re-docking

of the robot leading to procedure interruption Surgical Technique
and longer operative times. In addition, the uti-
lization of advanced platforms such as the Patient Positioning
robotic technique may be precluded, as the
limitations of conventional laparoscopic sur- The patient is placed on modified lithotomy posi-
gery are not exposed during abdominal proce- tion with moderate Trendelenburg and both arms
dures. As such, we perform the abdominal tucked. It is imperative to ensure correct patient
portion of the procedure with conventional positioning and proper techniques to secure the
laparoscopic technique and the pelvic portion patient to the operating table, as portions of the
with the robotic assistance. This hybridization procedure will require extreme tilt and angula-
avoids the robotic cart re-docking and opti- tion. There are several appropriate techniques to
mizes the attributes of each minimally invasive secure the patient depending on the size of the
surgical approach. While conventional laparo- patient, available equipment, and surgeon prefer-
scopic technique serves ideally for multi-quad- ence. We prefer to use a wrapped technique, in
rant procedures and for variable anatomy, the which a 3 in. tape is utilized to secure the patient
robotic approach performs optimally for a at the level of the chest, in such a fashion to pre-
fixed segment and confined spaces such as the vent movement, yet avoiding excessive tension as
pelvic cavity. to restrict airway flow (Fig. 20.1).

Fig. 20.1 Patient positioning. The patient is placed on modified lithotomy position with moderate Trendelenburg and
both arms tucked. The patient is secured to the operating table using a wrapped technique
20 Robotic Hybrid Low Anterior Resection 229

Port Placement

It is best to choose port placement based on ideal

location for the utilization for the robotic plat-
form. Although such placement may result in
suboptimal location during the laparoscopic por-
tions, it is most important to ensure proper place-
ment for the robotic arms to optimize the range of
motion of the robotic instruments and to avoid
collision during the pelvic portions of the proce-
dure. The exact port placement varies based on
patient body habitus; thus, the following should
be use as a general reference. The frame of refer-
ence in the vertical plane is adjusted based on the
distance between the umbilicus and the pubic
symphysis, whereas the frame reference in the
horizontal plane is based on the distance between
the midline and the anterior superior iliac spines.
The port placement consists of a 12-mm camera
port, which is located 2 cm above and 2 cm lat-
eral to the umbilicus. We prefer direct abdominal
entry utilizing the OptiView® (Ethicon Endo- Fig. 20.2 Layout of port placement for robotic hybrid
Surgery, Cincinnati, OH) bladeless trocar; how- rectal resection. One umbilical 12-mm camera port, one
12-mm assistant port in the right hypochondrium, and
ever, the use of the Veress needle or other entry three (1, 2, and 3) 5-mm ports for the robotic arms are
techniques is appropriate based on surgeon expe- placed as depicted
rience and preference. The additional ports are
not placed until pneumoperitoneum is established
and laparoscopic exploration is performed. This difficult port placement to master and the one
is important for three reasons: first, unexpected with highest variability: on one hand it has to be
findings such as metastatic disease can be evalu- placed laterally in order to provide 8 cm of hori-
ated; second, adhesions at proposed port sites can zontal clearance with respect to port 2; on the
be taken down before port placement; third, by other hand if placed far laterally, the iliac bone
establishing the pneumoperitoneum and enlarg- will impede instrument reach into the pelvis.
ing the surface area of the abdominal wall, the
port placement will be optimized. A total of three
8-mm ports for the robotic arms are then placed Laparoscopic-Assisted Abdominal
and the assistant 12-mm port as shown in Dissection
Fig. 20.2. Port 1 is placed along in the right lower
quadrant along a line between the anterior supe- In our institution, we perform the left colon
rior iliac spine and the camera port, at distance of mobilization utilizing a medial-to-lateral
8 cm of separation from the midline in the hori- approach. The lateral attachments of the colon
zontal plane (Fig. 20.2). Port 2 is placed at a vari- help with retraction and dissection in the retro-
able height above the level of the camera port peritoneal plane, which allows early identifica-
1–2 cm above the camera port at the level of 8 cm tion of the ureter and vascular structures. The
in the horizontal plane. Port 3 is ideally placed procedure commences with laparoscopic explo-
2 cm above the anterior superior iliac spine and ration and, if needed, lysis of adhesions. The
8 cm from port 2 in the horizontal plane small bowel is retracted to the right of the midline
(Fig. 20.2). However, the latter is the most and ligament of Treitz is identified. This is the
230 E.M. Haas and R. Pedraza

Fig. 20.3 Once the small bowel is retracted to right and the vein, and the retroperitoneal plane is established using
superior, the inferior mesenteric vein (IMV) is readily a triangulation lift technique (a, b, and c). The inferior
identified (a). The medial peritoneum is incised inferior to mesenteric vein is divided (d)

initial stem and can be cumbersome, especially in creas, laterally to the white line of Toldt, and
the obese; however, this exposure is essential and inferiorly to the level of the takeoff of the left
must be performed to successfully initiate the colic artery from the inferior mesenteric artery.
procedure. Exposure is facilitated with right tilt One will often be able to identify the ureter in this
(left side elevation) and slight Trendelenburg plane as well.
with traction of the small bowel superiorly out of Once the retroperitoneal plane is fully devel-
the pelvis as well. With this exposure, the inferior oped (Fig. 20.4a), attention is then drawn to the
mesenteric vein is readily identified running par- gastrocolic ligament, which is detached from the
allel to the ligament of Treitz before it enters colon at the level of the distal transverse colon
deep to the pancreatic body (Fig. 20.3a). At this (Fig. 20.4b). The lesser sac is entered and the
level, the medial peritoneum is incised just infe- splenic flexure takedown is performed
rior to the vein, and the retroperitoneal plane is (Fig. 20.4b, c, d). When maximum exposure and
established using a triangulation lift technique reach have been achieved, attention is drawn to
(Fig. 20.3a, b, c). The inferior mesenteric vein is the descending colon (Fig. 20.5a, b), which is
divided (Fig. 20.3d) and the retroperitoneal plane released from the peritoneal attachments (white
fully developed (Fig. 20.4a). Proper dissection in line of Toldt) in a caudal to cranial direction and
the retroperitoneal plane of dissection is carried the splenic flexure mobilization is then com-
superiorly along the inferior border of the pan- pleted in this direction.
Fig. 20.4 With the retroperitoneal plane is fully devel- of the distal transverse colon (b). The lesser sac is
oped (a), attention is then drawn to the gastrocolic entered and the splenic flexure takedown is performed
ligament, which is detached from the colon at the level (b, c, and d)

11. Deutsch GB, Sathyanarayana SA, Gunabushanam V,

et al. Robotic vs. laparoscopic colorectal surgery: an
institutional experience. Surg Endosc.
2012;26:956–63.

Fig. 20.5 Takedown of lateral attachments of the Retroperitoneal plane is fully developed and the left colon
descending colon in a caudal to cranial fashion with the fully mobilized (c and d)
splenic flexure mobilization in this direction (a and b).
232 E.M. Haas and R. Pedraza

Fig. 20.6 Operative room configuration. The robotic cart access to the perineum, which is required for a transanal
is ideally docked in left side of the patient, in an acute approach or specimen extraction
angle. Robotic docking between the patient’s legs hinders

Robotic Docking Robotic-Assisted Pelvic Dissection

Once the left colon is mobilized, the patient is The robotic pelvic segment of the procedure is
placed in steep Trendelenburg position with the left commenced with retraction of the small bowel
side elevated, the laparoscopic instruments are superiorly out of the pelvic cavity. The rectosig-
removed and the robotic instruments are placed and moid is retracted anteriorly with the utilization of
the robotic cart is then docked. It is important to the third robotic instrumentation arm, and the
recognize that once the robotic cart is docked, fur- peritoneum is incised medially at the level of the
ther patient position modifications are precluded. sacral promontory, and the retroperitoneal plane
The robotic cart is ideally docked in left side of is identified (Fig. 20.7). Careful and meticulous
the patient, in an acute angle (Fig. 20.6). dissection in this plane is paramount to remain in
Alternatively, some prefer robotic docking the proper plain and avoid injury to the hypogas-
between the patient’s legs; however, this patient- tric nerves and iliac vessels. Once the plane is
cart configuration hinders access to the perineum, developed, the left ureter is identified and the tis-
which is needed for a transanal approach or trans- sue planes are further developed. The superior
anal specimen extraction, unless the robot is rectal artery is readily visualized and is lifted to
undocked. Furthermore, we do not recommend facilitate ongoing dissection in the retroperito-
complete robotic undocking as we favor to neal plane (Fig. 20.7d). The extent of the plane is
perform the anastomosis under direct robotic carried out laterally to the peritoneal reflection,
visualization, since the dexterity and maneuver- inferiorly to the presacral plane, and superiorly to
ability provided by the robotic instrumentation the confluence of the superior rectal and inferior
would afford a more reliable suture repair in cases mesenteric artery (Fig. 20.8). At this level, conti-
in which an anastomotic defect is encountered. nuity is established with previously exposed
20 Robotic Hybrid Low Anterior Resection 233

Fig. 20.7 The rectosigmoid is retracted anteriorly with fied (a, b, and c). The superior rectal artery is readily visu-
the utilization of the third robotic instrumentation arm, alized and is lifted to facilitate ongoing dissection in the
and the peritoneum is incised medially at the level of the retroperitoneal plane (d)
sacral promontory, and the retroperitoneal plane is identi-

Fig. 20.8 The eagle sign. Continuity is established with rectal artery represents the inferior “wing,” and the inferior
previously exposed retroperitoneal plane during the laparo- mesenteric artery represents the “body” of the “eagle” (a).
scopic portion of the procedure, exposing the anatomy of The division of the inferior mesenteric artery is then carried
the vascular pedicle (a). The “eagle sign” is exposed: the out with an endoscopic stapling or energy device placed via
left colic artery represents the superior “wing,” the superior the assistant port or with robotic application of clips (b)
234 E.M. Haas and R. Pedraza

Fig. 20.9 Presacral plane dissection. The second robotic instrument arm serves to gently retract the mesorectum with-
out grasping (a), while the first arm dissects to the alveolar plane (b and c). Dissection in the presacral plane continues
through the retrorectal fascia and to the level of the levator ani muscles (c and d)

retroperitoneal plane during the laparoscopic effort to accomplish a proper mesorectal excision.
portion of the procedure, thus fully exposing the The second robotic instrument arm (typically the
anatomy of the pedicle. This exposure results in bipolar cautery) serves to gently elevate the
the “eagle sign” with the superior “wing” repre- mesorectum without grasping, while the first arm
senting the left colic artery, the inferior “wing” (typically the scissors with electrocautery) read-
representing the superior rectal artery, and the ily dissects to the alveolar plane (Fig. 20.9a).
“body” representing the inferior mesenteric This serves to avoid traumatic tearing of the fas-
artery (Fig. 20.8a). The inferior mesenteric artery cia propria and maintains an intact mesorectal
is then divided with the use of an endoscopic sta- envelop. The third arm facilitates this dissection
pler or energy device placed through the assist by initially retracting on the rectosigmoid in a
port or with robotic application of clips cephalad fashion. Once the upper and middle
(Fig. 20.8b). The third arm now elevates the portions of the presacral plane are developed
divided portion of the pedicle to expose any using cautery and sharp dissection typically with
remaining retroperitoneal attachments, which are the robotic shears, the third arm is repositioned
then readily divided. Attention is then drawn to deep to the upper third of the mesorectum and
the lateral attachment, which is then divided from then elevates this portion to further assist in
the level of the laparoscopic dissection to the exposure (Fig. 20.9b, c). Dissection in the presa-
upper portion of the rectum. cral plane then continues through the retrorectal
During the pelvic portion of the procedure, the fascia and to the level of the levator ani muscles
avascular presacral plane is entered, and the (Fig. 20.9c, d).
dissection is continued in this plane carefully Once the full extent of the posterior dissec-
preserving the fascia propria of the rectum in an tion has been achieved to the level of the levator
20 Robotic Hybrid Low Anterior Resection 235

Fig. 20.10 The right lateral rectal dissection, which is carried down through the lateral stalks (a, b, c, and d)

ani, attention is then drawn to lateral and ante- noted during the air insufflation test can be over-
rior dissection (Figs. 20.10, 20.11, and 20.12). sewn using the aid of the robotic platform.
The lateral dissection is carried down through In cases in which the rectal pathology is
the lateral stalks, which contain the middle rec- located in close proximity to the anal verge, an
tal vessels (Figs. 20.10 and 20.11). It is impor- “ultralow” anterior resection may be warranted.
tant to maintain the dissection close to the In such cases, we favor a combined approach
rectum so as to avoid inadvertent injury to the with distal transection performed through a peri-
nerve plexus. The final portion of the rectal dis- neal approach with the aid of a Lone Star retrac-
section involves entrance to the anterior cul-de- tor (CooperSurgical, Inc., Trumbull, CT)
sac with the establishment of the rectovaginal (Fig. 20.15). Through the perineal approach, the
plane in women and Denonvilliers’ fascia in distal margin is achieved, the rectum is divided,
men (Fig. 20.12). and the planes are met with the ones established
For the purposes of an oncological procedure, during the robotic dissection. The rectum is
the rectum has to be dissected, mobilized, and extracted transanally and the anastomosis is per-
resected with the entirety of the mesorectal formed with hand-sewn technique from the
envelope (Fig. 20.13a, b). For low anterior resec- perineum (Fig. 20.15).
tions we perform the rectal division with surgical
stapler (Fig. 20.13c, d) and then extracorporeal-
ize the bowel via a small Pfannenstiel incision Outcomes
(Fig. 20.14a, d). Bowel continuity is established
via an end-to-end anastomosis using a circular Robotic hybrid rectal resection is a safe and feasible
stapling device under robotic visualization surgical technique for the management of benign
(Fig. 20.14b, c). In this fashion, any small leaks and malignant rectal diseases. Current literature
Fig. 20.11 The left lateral rectal dissection. Carried down through the lateral stalks (a, b, c, and d)

Fig. 20.12 Anterior rectal dissection. The entrance to the cul-de-sac is accomplished and the rectovaginal plane in
women or Denonvilliers’ fascia planes in men are established
Fig. 20.13 Completion of robotic rectal dissection. For of the mesorectal envelope (a and b). The rectal division
the purposes of an oncological procedure, the rectum has is carried out with a surgical stapler (c and d)
to be dissected, mobilized, and resected with the entirety

Fig. 20.14 Specimen extracorporealization via a small Pfannenstiel incision (a and d). The bowel continuity is
established via an end-to-end anastomosis using a circular stapler, under robotic visualization (b and c)
238 E.M. Haas and R. Pedraza

Fig. 20.15 Perineal approach with transanal extraction for “ultralow” robotic rectal resection. A hand-sewn anastomosis
is performed in such cases

evaluates outcomes following the hybrid technique after two phases comprising 25 surgical cases [10].
in comparison to those following conventional For laparoscopic surgeons attempting to adopt
laparoscopic rectal resection. In general, these robotic surgery as part of their minimally inva-
available data demonstrate that the robotic hybrid sive surgical armamentarium, we believe that the
approach results in similar clinical and pathologi- hybrid approach may be the most practical way
cal outcomes as compared to conventional lapa- to obtain exposure during the learning curve
roscopy (Table 20.1) [5–9]. While totally robotic phases of one’s experience. This hybrid tech-
rectal surgery, also referred to as single-stage nique affords the completion of a significant por-
robotic rectal surgery, has demonstrated to be a tion of the procedure laparoscopically and the
viable approach for the management of rectal dis- remaining segment performed robotically. Thus,
eases, we tend to approach the majority of the the transition from conventional laparoscopy to
robotic rectal resections with a hybrid technique. robotic surgery is facilitated and accomplished
Our preference for the hybrid technique is based more readily.
on several factors; however, it is important to rec- The hybrid approach affords a safe abdominal
ognize that the approach may be altered based on cavity entry, but most importantly the entry is per-
individual case characteristics. formed through an approach that all laparoscopic
Learning curve represents a key concept when surgeons are accustomed to. The initial laparo-
adopting and implementing a new surgical scopic exploration allows a thorough four-
modality. It has been estimated that the learning quadrant abdominal exploration, which is
curve in robotic colorectal surgery is achieved imperative in oncological cases. Furthermore, it
20 Robotic Hybrid Low Anterior Resection 239

Table 20.1 Studies comparing outcomes following robotic hybrid and pure laparoscopic rectal resection for rectal
cancer
Postoperative
Operative Conversion complication Hospital CRM Lymph node
Author Technique N time (min) rate rate stay (days) involvement extraction
Baik Lap 57 191.1 ± 65.3 10.5 % 19.3 % 7.6 ± 3.0a 8.8 % 18.7 ± 12
et al. [6] Hybrid RALS 56 190.1 ± 45.0 0 10.7 % 5.7 ± 1.1a 7.1 % 18.4 ± 9.2
Bianchi Lap 25 237 4% 24 % 6 (4–20)b 4% 17 (8–37)b
et al. [7] (170–545)b
Hybrid RALS 25 240 0 16 % 6.5 (4.15)b 0 18 (7–34)b
(170–420)b
Park Lap 82 168.6 ± 49.3a 0 23.2 % 9.4 ± 2.9 3.7 % 14.2 ± 8.9
et al. [8] Hybrid RALS 41 231.9 ± 61.4a 0 29.3 % 9.9 ± 4.4 4.9 % 17.3 ± 7.7
Data are reported as mean ± standard deviation
CRM circumferential resection margin, Hybrid RALS hybrid robotic-assisted laparoscopic surgery, Lap laparoscopic
technique, N number of cases
a
Statistically significant difference
b
Data are reported as median (range)

additionally facilitates takedown of intra- surgery in patients with colorectal cancer (MRC
CLASICC trial): multicentre, randomised controlled
abdominal adhesions in an expeditious fashion.
trial. Lancet. 2005;365:1718–26.
Moreover, the hybrid technique allows expedi- 4. Pigazzi A, Ellenhorn JD, Ballantyne GH, Paz IB.
tious laparoscopic splenic flexure takedown and Robotic-assisted laparoscopic low anterior resection
left colon mobilization. In the hybrid approach, with total mesorectal excision for rectal cancer. Surg
Endosc. 2006;20:1521–5.
the robotic cart docking typically represents a
5. Baik SH, Ko YT, Kang CM, et al. Robotic tumor-
onetime event during the procedure, whereas specific mesorectal excision of rectal cancer: short-
re-docking may be required while performing a term outcome of a pilot randomized trial. Surg
totally robotic approach [11]. Ultimately, the Endosc. 2008;22:1601–8.
6. Baik SH, Kwon HY, Kim JS, et al. Robotic versus
overriding benefit of the hybrid technique is
laparoscopic low anterior resection of rectal cancer:
found in the ability to utilize both the laparo- short-term outcome of a prospective comparative
scopic and robotic platform at particular portions study. Ann Surg Oncol. 2009;16:1480–7.
of the procedure such that the merits of each 7. Bianchi PP, Ceriani C, Locatelli A, et al. Robotic ver-
sus laparoscopic total mesorectal excision for rectal
approach are optimized.
cancer: a comparative analysis of oncological safety
and short-term outcomes. Surg Endosc. 2010;24:
2888–94.
References 8. Park JS, Choi GS, Lim KH, Jang YS, Jun SH.
Robotic-assisted versus laparoscopic surgery for low
1. Clinical Outcomes of Surgical Therapy Study G. A rectal cancer: case-matched analysis of short-term
comparison of laparoscopically assisted and open col- outcomes. Ann Surg Oncol. 2010;17:3195–202.
ectomy for colon cancer. N Engl J Med. 2004;350: 9. Patriti A, Ceccarelli G, Bartoli A, Spaziani A,
2050–9. Biancafarina A, Casciola L. Short- and medium-term
2. Fox J, Gross CP, Longo W, Reddy V. Laparoscopic outcome of robot-assisted and traditional laparo-
colectomy for the treatment of cancer has been widely scopic rectal resection. JSLS. 2009;13:176–83.
adopted in the United States. Dis Colon Rectum. 10. Bokhari MB, Patel CB, Ramos-Valadez DI, Ragupathi
2012;55:501–8. M, Haas EM. Learning curve for robotic-assisted
3. Guillou PJ, Quirke P, Thorpe H, et al. Short-term end- laparoscopic colorectal surgery. Surg Endosc. 2011;
points of conventional versus laparoscopic-assisted 25:855–60.
 Robotic-Assisted Extralevator
Abdominoperineal Resection 21
Kang Hong Lee, Mehraneh D. Jafari,
and Alessio Pigazzi

duration of hospital stay, reduced cost, and

Current Applications of Robotic reduced intensive care unit admissions [6].
Abdominoperineal Resection However, laparoscopy has some limitations
secondary to the anatomical structure of pelvis,
The evolution of surgical technique, instrumenta- rigid visualization system, instrument length,
tion, and superior outcomes of minimally inva- and articulation. The da Vinci robot has the
sive surgery has made laparoscopy the standard potential to overcome some of the limitations of
of care for colon cancer treatment. The feasibility laparoscopy by providing improved three-
and the advantages of laparoscopic colectomy in dimensional vision, enhanced ergonomics,
terms of faster recovery, lower postoperative articulated instruments, and tremor elimination
pain, and shorter hospital stay have been demon- [7–9]. Early experiences with robotic rectal
strated by large prospective studies [1–5]. resection highlight the potential for decreased
Laparoscopic abdominoperineal resection conversion rates, lower blood loss, and superior
(APR) with total mesorectal excision (TME) mesorectal grade compared to conventional
for low rectal cancer has been shown to be safe laparoscopy [8–11].
and effective. It is associated with several Robotic APR can be performed utilizing a
advantages including lower morbidity, shorter fully robotic technique or a hybrid laparoscopic–
robotic technique whereby the robot is docked
after mobilizing the sigmoid colon and dividing
the vessels with conventional laparoscopic
K.H. Lee, M.D., Ph.D. techniques.
Department of Surgery, Hanyang University College
of Medicine, 17 Haengdang-dong, Seongdong-gu,
Seoul 133-792, South Korea
e-mail: [email protected]
Indications
M.D. Jafari, M.D.
Currently the most common indications for APR
Department of Surgery, University of California,
Irvine School of Medicine, 333 City Blvd., West in the era of minimally invasive surgery are:
Suite 850, Orange, CA 92868, USA • Rectal cancer invading the sphincter complex
e-mail: [email protected] • Rectal cancer in patients who are not candi-
A. Pigazzi, M.D., Ph.D. (*) date for sphincter preservation because of
Division of Colorectal Surgery, Department of poor functional status or comorbidities
Surgery, University of California, Irvine Medical
• Recurrent rectal cancer
Center, 333 City Blvd., West Suite 850, Orange, CA
92868, USA • Anal cancer, which recurs after or does not
e-mail: [email protected] respond to chemoradiotherapy

K.C. Kim (ed.), Robotics in General Surgery, DOI 10.1007/978-1-4614-8739-5_21, 241

© Springer Science+Business Media New York 2014
242 K.H. Lee et al.

and will be used for the insertion of the stapler, if

Robotic Positioning and Docking
necessary. A second 8 mm trocar (R2) is inserted
as a mirror image of R1. The third 8 mm robotic
Room setup is standard as for any robotic colorec- trocar (R3) is inserted 10–12 cm lateral to R2,
tal procedure keeping in mind the necessary usually directly above the left ASIS. The first
space requirements for the surgeon, the assistant, 5 mm laparoscopic port (L1) is inserted in the
and the operating room personnel. The patient is MCL about 12 cm superior to R1. The second
positioned in modified lithotomy in Trendelenburg 5 mm laparoscopic trocar (L2) is inserted half-
position with a degree of right-sided table tilt way between MCL and midline a handbreadth
enough to keep the small intestine out of the pel- superior to L1 (Fig. 21.2).
vic cavity. The robot cart is docked utilizing a left
hip approach, more or less aligning the main post
of the cart with the left anterior iliac spine and the Operative and Technical Steps
camera port (Fig. 21.1). (Hybrid Technique)

Laparoscopic Mobilization
Trocar Placement of Sigmoid Colon and Ligation
of Vessels
A total of six ports are inserted under direct visu-
alization. The camera port (C) is placed halfway Both surgeon and assistant stand on the patient’s
between the xiphoid process and symphysis right side. Medial to lateral dissection of the sig-
pubis. A 12 mm trocar (R1) is inserted in the moid colon is begun at the inferior mesenteric
midclavicular line (MCL) halfway in between C artery (IMA). The sigmoid mesocolon is retracted
and the right anterior superior iliac spine (ASIS). anteriorly and dissection is begun at the sacral
This port can be used for ileostomy placement promontory. The parietal peritoneum medial to

Fig. 21.1 The robot is docked from the left hip and the surgeon assistant stands on the right of the patient
21 Robotic-Assisted Extralevator Abdominoperineal Resection 243

avoiding injury to the hypogastric nerve plexus.

The retroperitoneal structures including the left
ureter are identified and swept posteriorly. The
IMA (either at the origin or distal to the takeoff of
the left colic artery) is skeletonized and divided
via vessel sealer device and/or vascular stapler
(Fig. 21.3). Atraumatic graspers are fundamental
as with any laparoscopic bowel resection case to
minimize injury.
In contrast with robotic low anterior resection,
splenic flexure mobilization is not necessary in
abdominoperineal resection. A shorter length of
the colon is needed for creation of a colostomy in
APR compared to the colorectal anastomosis in
LAR. In general, the colon is able to reach the
abdominal wall without the need of further
mobilization. However, in certain patients,
Fig. 21.2 Robotic laparoscopic port placement
including patients with high BMI, further mobili-
zation may be necessary. The lateral reflections
of the left colon are taken down with a combina-
the right common iliac artery at the sacral tion of blunt dissection and electrocautery. The
promontory is incised. A combination of sharp colon is then divided above the IMA stump via an
and blunt dissection is used to isolate the IMA Endo GIA stapler.

Fig. 21.3 The “T” configu-

ration is visualized at the
junction of the left colic
artery and the superior
hemorrhoidal artery
244 K.H. Lee et al.

Robotic Setup and Instrument Total Mesorectal Excision

Selection
A total mesorectal excision is begun at the
The four-arm da Vinci robot is docked using the sacral promontory using only monopolar and
left hip approach once the mobilization of the sig- bipolar cautery. The dissection begins posteri-
moid colon is completed (Fig. 21.1). A 0° robotic orly while the assistant surgeon retracts the rec-
camera is inserted in port C. Robotic arm 1 is tum cephalad and anteriorly (Fig. 21.4). The
docked to the R1 port; robotic arms 2 and 3 are avascular plane is between the presacral fascia
docked to R2 and R3 trocar, respectively, in and the mesorectum. The dissection is contin-
sequence. A monopolar scissors is inserted in R1. ued laterally around the rectum preserving both
Alternatively a hook with monopolar energy source hypogastric nerves, which are located anterolat-
can be useful for dissection. A fenestrated bipolar erally. Anteriorly, the rectovesical/rectovaginal
forceps with bipolar energy source is inserted in R2 fold of the peritoneum is incised to expose
for holding, traction, and coagulation of vessels. A Denonvilliers’ fascia or the rectovaginal sep-
fenestrated forceps or a robotic suction irrigator tum. Maintaining a plane posterior to
devices inserted in R3 for traction. Grasping of the Denonvilliers’ fascia prevents bleeding from
mesorectum should be avoided with the robotic the pampiniform plexus surrounding the semi-
graspers. The assistant uses the two laparoscopic nal vesicles in men. The third arm allows for the
ports. A laparoscopic grasper is used via the L2 retraction of the rectum during posterior
port for retraction and manipulation of the sigmoid dissection, the lateral sidewalls during lateral
colon and rectum, and an irrigation and suction sys- dissection, and the bladder/vagina during ante-
tem is used via the L1 port for countertraction. rior dissection.

Fig. 21.4 Posterior dissection

21 Robotic-Assisted Extralevator Abdominoperineal Resection 245

care must be taken to avoid urethral injury in

Extralevator Abdominoperineal
male patients. The dissection is continued dis-
Resection
tally into the ischiorectal fat as far as feasible just
before encountering the perineal skin.
The dissection is continued distally, and a wide Robotic-assisted transabdominal resection of
resection of the levators near their origin is car- the levator muscles allows for a controlled tran-
ried out using robotic scissors in order to mini- section of the pelvic floor and minimizes the risk
mize the possibility of a positive circumferential of accidental injury to vascular structures under
margin (Fig. 21.5a). Care is taken not to lift the direct vision. This approach also renders the
rectum off the levator muscle as in a conventional perineal resection very quick and simple, with-
low anterior resection. Instead, the muscle will be out the need to turn the patient prone and thus
taken widely at its origin along the bony struc- potentially improving the perineal wound heal-
tures of the deep pelvis, and the ischiorectal fat ing rate [12]. In addition, this technique may
will be dissected en bloc using robotic instru- offer the flexibility of varying the extent of leva-
ments (Fig. 21.5b). The posterior limit of the rec- tor muscle excision depending on the location of
tal dissection can be decided by palpating the the tumor [12].
position of the coccyx tip via digital rectal exami-
nation from below while manipulating a robotic
instrument on the coccyx from above. Perineal Procedure and Stoma
The levator transection is continued posteri- Creation
orly toward the midline and the anococcygeal
ligament is transected (Fig. 21.6). The lateral Once the rectum is freed and hemostasis is
limit of transection of the levator muscle is the achieved, the robot is undocked. The patient is
medial edge of the obturator fascia, where auto- placed in steep Trendelenburg, and a member
nomic nerve and vessels originating from the of the surgical team via a perineal approach
internal iliac artery and vein are found. Anteriorly, creates a circumferential incision around the
the levator transection is continued along the anus from the perineal body to the coccyx.
plane posterior to Denonvilliers’ fascia/posterior Because the levator muscles have been divided,
wall of the vagina toward the perineum. Extreme the prior dissection plane is quickly encountered

Fig. 21.5 (a) The division of the right levator muscles; (b) complete division of the levator muscles
246 K.H. Lee et al.

Fig. 21.6 Division of the

anococcygeal ligament

Fig. 21.7 Cylindrical APR

specimen

and the “cylindrical”-shaped specimen is easily Outcomes

delivered through the perineum (Fig. 21.7).
The perineal incision is closed in three layers.
A transabdominopelvic drain is placed. The Total mesorectal excision has been shown to
abdomen is re-insufflated and inspected; an end dramatically reduce rates of local recurrence and
colostomy is brought out at an appropriate is the accepted standard of care for rectal cancer
location. [13–15]. However, the benefits of TME in LAR
21 Robotic-Assisted Extralevator Abdominoperineal Resection 247

have not been reproduced in abdominoperineal open abdominoperineal resection. Am J Surg.

2011;202(6):666–70. discussion 670-2.
resection. This has been thought to reflect, in
7. Ballantyne GH. Robotic surgery, telerobotic surgery,
part, a higher rate of circumferential resection telepresence, and telementoring. Review of early clin-
margin (CRM) involvement leading to a higher ical results. Surg Endosc. 2002;16(10):1389–402.
rate of local recurrence, and lower survival rates 8. deSouza AL, et al. A comparison of open and robotic
total mesorectal excision for rectal adenocarcinoma.
after APR compared with LAR [13, 14, 16, 17].
Dis Colon Rectum. 2011;54(3):275–82.
A higher rate of positive CRMs can be attrib- 9. Pigazzi A, et al. Robotic-assisted laparoscopic low
uted, in part, to the hourglass-shaped resection anterior resection with total mesorectal excision for
of the rectum seen with traditional APR tech- rectal cancer. Surg Endosc. 2006;20(10):1521–5.
10. Baik SH, et al. Robotic versus laparoscopic low ante-
niques that exposes the tumor-bearing area
rior resection of rectal cancer: short-term outcome of
around the anorectal ring. Extralevator abdomi- a prospective comparative study. Ann Surg Oncol.
noperineal resection (EAPR) has been proposed 2009;16(6):1480–7.
in an effort to decrease the rate of CRM positiv- 11. deSouza AL, et al. Total mesorectal excision for rectal
cancer: the potential advantage of robotic assistance.
ity, lower rectal perforation incidence, and lower
Dis Colon Rectum. 2010;53(12):1611–7.
local recurrence rates [18–22]. These beneficial 12. Marecik SJ, et al. Robotic cylindrical abdominoperi-
results are achieved by wide resection of the neal resection with transabdominal levator transec-
levator muscles surrounding the tumor in the tion. Dis Colon Rectum. 2011;54(10):1320–5.
13. Eriksen MT, et al. Inadvertent perforation during rec-
deep pelvis producing a cylindrical surgical
tal cancer resection in Norway. Br J Surg. 2004;
specimen rather than an hourglass-shaped speci- 91(2):210–6.
men and decreasing the chance of a close, or 14. Heald RJ, et al. Abdominoperineal excision of the
involved, surgical margin [22]. EAPR allows for rectum–an endangered operation. Norman Nigro
Lectureship. Dis Colon Rectum. 1997;40(7):747–51.
en bloc resection of tissue and is associated with
15. Kapiteijn E, et al. Preoperative radiotherapy com-
lower CRM positivity and lower chances of rec- bined with total mesorectal excision for resectable
tal perforation, resulting in lower rates of local rectal cancer. N Engl J Med. 2001;345(9):638–46.
recurrences. We believe this technique is espe- 16. Nagtegaal ID, et al. Low rectal cancer: a call for a
change of approach in abdominoperineal resection.
cially suited for a robotic approach given the
J Clin Oncol. 2005;23(36):9257–64.
versatility of robotic surgical instruments in rec- 17. Wibe A, et al. Oncological outcomes after total meso-
tal cancer surgery [18–23]. rectal excision for cure for cancer of the lower rectum:
anterior vs. abdominoperineal resection. Dis Colon
Rectum. 2004;47(1):48–58.
18. Bebenek M. Abdominosacral amputation of the rec-
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1. Anderson C, Uman G, Pigazzi A. Oncologic out- 19. Bebenek M, et al. Therapeutic results in low-rectal
comes of laparoscopic surgery for rectal cancer: a sys- cancer patients treated with abdominosacral resection
tematic review and meta-analysis of the literature. Eur are similar to those obtained by means of anterior
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2. Aziz O, et al. Laparoscopic versus open surgery for Surg Oncol. 2007;33(3):320–3.
rectal cancer: a meta-analysis. Ann Surg Oncol. 20. Holm T, et al. Extended abdominoperineal resection
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3. Liang Y, et al. Laparoscopic versus open colorectal vic floor for rectal cancer. Br J Surg. 2007;94(2):
resection for cancer: a meta-analysis of results of ran- 232–8.
domized controlled trials on recurrence. Eur J Surg 21. West NP, et al. Multicentre experience with extraleva-
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adenocarcinoma. Eur J Surg Oncol. 2009;35(5): 22. Kang CY, et al. Robotic-assisted extralevator abdomi-
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 Robotic Single-Port Colorectal
Surgery 22
Byung Soh Min, Sami Alasari,
and Avanish Saklani

procedure. Then, in 1992 the laparoscopic single

Introduction and History port emerged by Pelosi and Pelosi again in the
field of gynecology. They reported a successful
Single-port surgery is an emerging technique in single-port subtotal hysterectomy [2]. With the
minimal access surgery, and its real benefit in its increasing popularity of laparoscopic techniques,
current form is debatable. This is because, while more and more surgeons have become interested
single-port surgery is not ergonomically efficient in minimally invasive surgery (MIS). The increase
and requires high level of technical proficiency, in uptake of MIS led to an explosive increase in
its benefits seem limited to cosmesis and subjec- novel MIS techniques. Natural orifice translumi-
tive patient satisfaction. This dilemma becomes nal endoscopic surgery (NOTES) was a revolu-
more acute when it comes to oncologic surgery: tionary concept and succeeded in getting a lot of
can surgeons maintain the same quality of sur- hype: however, its clinical application as an alter-
gery with this new technique or is there trade-off/ native to laparoscopic approach, at this moment,
compromise between access ports and quality of seems remote. One of the major obstacles in
surgery? In this chapter we will seek answers for NOTES is technology, i.e., lack of instruments or
these questions. We believe that the robotic surgi- system to enable surgeons to overcome technical
cal system for single-port colon surgery will and ergonomic challenges [3]. In contrast, laparo-
enable more surgeons to perform single-port sur- scopic single-port approach seems to have some
gery without compromising oncologic integrity. benefits over NOTES in the sense that surgeons
The first published report of single-port surgery, are able to perform this with available technology
although it may be different from modern tech- and conventional (multiport) laparoscopic instru-
nique, came in 1971 [1]. The authors reported a ments. A stepwise approach (i.e., from conven-
successful series of tubal sterilizations using a spe- tional multiport to reduced port and then to single
cial instrument specifically made for a single-port port) seems to be rational and may help overcome
the learning curve with reduced efforts. Moreover,
some laparoscopic experts consider single-port
B.S. Min, M.D., Ph.D. (*) • S. Alasari, M.D.
Department of Surgery, Yonsei University College surgery as a bridge between conventional
of Medicine, 50 Yonsei-ro Seodaemun gu, (multiport) laparoscopic surgery and NOTES [4].
120-752 Seoul, South Korea Starting from relatively simple procedures such as
e-mail: [email protected]; [email protected]
appendectomy and cholecystectomy, the applica-
A. Saklani, M.S., F.R.C.S. tion of single-port technique has been expanding
Colorectal Division, Tata Memorial Centre, Surgical
to include procedures like hysterectomy, nephrec-
Oncology, 402 Valencia B, Hiranandani Gardens,
Powai, Mumbai 400076, Maharashtra, India tomy, and more complex general surgical
e-mail: [email protected] procedures [5, 6]. In late 2008, Bucher et al.

K.C. Kim (ed.), Robotics in General Surgery, DOI 10.1007/978-1-4614-8739-5_22, 249

© Springer Science+Business Media New York 2014
250 B.S. Min et al.

were the first to publish about the laparoscopic Although the terminologies may be differ-
single port surgery right hemicolectomy [7]. Since ent, they all indicate a type of MIS that primar-
then the number of articles published about ily introduces multiple (more than two)
laparoscopic singel-port colorectal surgery has laparoendoscopic (or robotic) instruments
increased exponentially, and each report describes through a single access port (usually through
different techniques and tips, which may raise an trans-umbilical incision) or skin incision. To
issue of standardization of the technique. avoid possible confusion, in this chapter we
With the robotic era, the first robotic single- will use the terms “single-port surgery,” “lapa-
port surgery was reported in 2008 by Kaouk et al. roscopic single-port surgery,” and “robotic sin-
[8]. He succeeded in performing a radical prosta- gle-port surgery,” unless otherwise defined by
tectomy, pyeloplasty, and radical nephrectomy cited studies.
using the current da Vinci S(tm) surgical robotic
system with conventional arms. Ostrowitz et al.
published the first case report of robotic single- Access Ports for Single-Port Surgery
port right hemicolectomy at the end of 2009.
They also used da Vinci S system with conven- Different kinds of access ports are commercially
tional two robotic arms and scope [9]. Since then, available and include SILS port (Covidien;
multiple robotic single-port surgeries have been Mansfield, MA), R-Port (ASC, Wicklow,
published for cholecystectomy and hernia repair Ireland), homemade port using a surgical glove
as well as colorectal surgery [10–13] using the da and Alexis wound retractor (Applied Medical,
Vinci S or Si system either with conventional Santa Margarita, CA, USA), GelPort or
arms or the single-site platform. GelPOINT (Applied Medical, Santa Margarita,
CA, USA), OCTO Port (Dalim, Korea), TriPort
and QuadPort (Olympus, Japan), and da Vinci
Definitions and Terminologies SS platform (Intuitive, USA). Apart from da
Vinci single-site platform, which is exclusively
Several terminologies have been used in litera- for robotic single-port surgery and is attached to
ture to describe single-port surgery. We reviewed da Vinci Si system, almost all of the access ports
the literature and summarize abbreviations that were originally for laparoscopic single-port sur-
are currently used (see Table 22.1). gery. A few of these access ports have been eval-
uated in literature. Thus far, among commercially
available access ports, only SILS port [9] and
Table 22.1 Summary of the terminology definitions GelPort [14] have been used in published litera-
Terminology Abbreviation
ture on robotic single-incision surgery. Based on
Single-incision surgery SIS
these reports, the SILS port seems to have limi-
Single-port surgery SPS tations in the size of the whole access port.
Single-access surgery SAS It tends to be too small for robotic instruments,
Laparoscopic Single-port surgery SPLS which are bulkier than laparoscopic instruments,
Robotic single-port surgery SPRS and spaces between the instruments are inade-
Single-incision laparoscopic surgery SILSa quate, which results in frequent arm collision
Single-incision robotic surgery SIRS and limitation of range of motion. Another lim-
Single access port SPA iting factor is that there is limited room for a
One-port umbilical surgery OPUS third robotic arm or for an assistant. GelPort
Laparoendoscopic single-site surgery LESS may be a better alternative because it allows the
Single-site laparoscopy SSL surgeon to design individual port configurations
Robotic single-site surgery RSS within the access port and may help overcome
Natural orifice trans-umbilical surgery NOTUS the limitations in space, crowding of robotic
a
SILS is trademark of Covidien arms and external clashing.
22 Robotic Single-Port Colorectal Surgery 251

Our preference is a homemade port using a HALC. The readmission rate reported in two
surgical glove and Alexis wound retractor. The studies were 6.3 and 13.8 %, and when compared
glove port offers multiple advantages over com- to multiport surgery found not to be significantly
mercially available products. Its construction is different. The reported complications from lapa-
simple and additional cost is negligible since the roscopic single-port surgery in literature were
Alexis wound retractor would have been used in ileus, wound infection/hematoma, and anasto-
standard laparoscopic or multiport robotic colorec- motic bleeding/leakage, which also were
tal surgery for specimen extraction. Other major observed in multiport surgery as well as conven-
benefits of this port include accommodation of tional open. Makino in his review concluded that
variable abdominal wall thickness and the virtual despite the technical difficulty, in early series of
absence of air leaks, which frequently hinder pro- highly selected patients laparoscopic single-port
cedures involving standard MIS ports [12]. colorectal surgery was found to be safe and fea-
sible in the hands of highly skilled surgeons.
However standardization of the technique, learn-
Laparoscopic Single-Port Colorectal ing curve and long-term evaluation are still in its
Surgery Overview infancy and need to be evaluated in large random-
ized controlled trails.
Laparoscopic single-port surgery has been widely
described for appendectomy and cholecystec-
tomy. Although most reports have small numbers Why Robotic Single-Port Surgery?
related to a single surgeon’s experiences, infor-
mation pooled from these series regarding access Robotic colorectal surgery was reported in 2002
port evaluation and technical tips make a firm by Weber et al. [16]. Since then this has been
base for performing more complex and multi- adopted by colorectal surgeons in high-volume
quadrant procedures like colorectal surgery. specialized centers. Recently meta-analysis and
Another factor that has facilitated single-port several large systematic reviews have confirmed
surgery has been the evolution in surgical tools the safety and feasibility of robotic colorectal
such as advanced articulating or flexible instru- surgery without inferiority in oncological out-
ments including even energy devices, staplers, come. Furthermore, randomized controlled trials
and endoscopes. are ongoing to provide a better level of evidence
In a large systematic review, Makino et al. in for this procedure. The advantages of the robotic
2012 examined the safety and feasibility of lapa- approach articulated in published robotic papers
roscopic Single-port colorectal surgery for both largely focus on better high-definition three-
benign and malignant conditions [15]. He dimensional vision, filtration of physiologic
reviewed 23 studies including 378 patients. The tremor, human wrist-like motion of robotic
conversion rate was 1.6 % (6 cases) to open, instruments, stable camera control, better ergo-
1.6 % (6 cases) to hand-assisted laparoscopy col- nomics, and reduction of the fatigue associated
ectomy (HALC), and 4 % (14 cases) to conven- with conventional laparoscopy.
tional multiport laparoscopy. Additional These advantages of the robotic interface help
laparoscopic ports were required in 12 patients overcome many of the limitations of single-port
out of 247 (4.9 %). The overall mortality and surgery such as internal and external collisions,
morbidity rates were 0.5 % (2 cases) and 12.9 % difficulty in achieving traction for triangulation,
(45 cases), respectively. The causes of death were loss of ergonomics, body fatigue, instability of the
pulmonary embolism and metastasis for a pallia- camera, poor positioning with the assistant, and
tive case. Of the four case-matched studies two lack of stereotactic sense due to a two-dimensional
studies showed shorter hospital stay for the view. Although efforts have been made to mini-
single-incision laparoscopy than HALC and mul- mize the above limitations with use of articulated
tiport laparoscopy. One study reported lower instruments and special cameras, the results have
postoperative pain in SPLS over multiport and been less than perfect with limited adoption by
252 B.S. Min et al.

laparoscopic surgeons. This is more so in colorec- He reported a three robotic single-port right
tal surgery where multiquadrant access is hemicolectomy using da Vinci S system and 3
required. By adopting the robotic system to sin- ports including a camera inserted through one
gle-port approach, theoretically surgeons can incision. The incision was through or around the
have stable and three-dimensional operative view umbilicus with a 4-cm length incision. There
and human wrist-like functioning robotic instru- were no reported complications. The average
ments that allow adequate traction and counter- operative time was 152 min. The first case was
traction. Additionally, the surgeon can restore converted to non-robotic single-incision right
intuitive control of the instruments in the opera- hemicolectomy during mobilization of the
tive field despite the instruments being crossed by ascending colon, due to uncontrollable air leak-
reassigning the hands at the console so that the age around the ports. The second and third cases
instrument in the operative field corresponds to were successfully completed without air loss by
the appropriate hand on the console. purse-stringing sutures around each individual
There are, however, some potential drawbacks port and the use of the SILS port, respectively.
of using the robotic system to perform single-port Singh et al. in 2010 reported the first case of
surgery. Because the robotic arms are bigger than robotic single-port right hemicolectomy [14].
laparoscopic instruments, a larger size skin incision He performed the procedure using a GelPort as an
may be necessary. Additionally, this may also limit access port through a 4-cm abdominal incision.
the ability to introduce additional laparoscopic Their operative time was 179 min and estimated
instruments through the access port, as is com- blood loss was minimal. There were no reported
monly done in laparoscopic single-port surgery. intra-/postoperative complications. In 2012 Lim
et al. published a multimedia article about robotic
single-port anterior resection for sigmoid colon
Robotic Single-Port Colorectal cancer [12]. They reported short-term results of 20
Surgery Overview patients who underwent this procedure. The mean
estimated blood loss was 24.5 ml (range 5–230).
The first robotic single-port surgery for radical The mean operative time was 167.5 min (range
prostatectomy was published by Kaouk et al. 112–251), and there were no conversions.
This was followed by pyeloplasty and nephrec- The median skin incision length was 4.7 cm (range
tomy; since then, several animal as well as human 4.2–8). The mean proximal and distal resection
trials have been published for numerous benign margins were 12.9 (range 7.5–25.1) and 12.3 cm
and malignant procedures. In the colorectal field, (range 4.5–19.2), respectively. The mean har-
robotic single-port surgery is still a novel tech- vested lymph node was 16.8 (range 0–42). The
nique and only a few surgeons have reported their immediate postoperative pain score was 2.8 (range
results in literature (Tables 22.2 and 22.3). 1–5) and 1.4 [1–3] on the first postoperative day.
Ostrowitz et al. was the first to publish about The mean length of hospital stay was 6 days (range
robotic single-port colectomy in 2009 [9]. 5–9). Obias et al. reported their comparative study

Table 22.2 Single-port colorectal operative outcome

Patient no./ Incision OR timea
Author Study type procedure Port type lengtha (cm) (min) EBLa (ml) Con.
Ostrowitz Case report 3 RHC 3 ports + SILS 4 152 75 1 to lap
due to
air leak
Singh Case report 1 RHC GelPort 4 179 Minimal 0
Lim Retrospective 20 AR Glove + Alexis 4.7 167.5 24.5 0
OR operative time, EBL estimated blood loss, Con conversion, Lap laparoscopic
a
All results in mean
22 Robotic Single-Port Colorectal Surgery 253

Table 22.3 Short-term outcome instructed to drive the left instrument with the
LOS right hand effector and the right instrument with
Author (days)a COMP LNa Margins Mortality the left. Both procedures were satisfactorily com-
Ostrowitz 3.6 0 22 Negative 0 pleted with no external collision of the robotic
Singh 4 0 14 Negative 0 arms in acceptable times and with no technical
Lim 6 0 16.8 Negative 0 complications. He concluded that the chopstick
LOS length of stay, COMP complication, LN lymph node surgery significantly enhances the functionality
a
All results in mean
of the surgical robot when working through a
small single incision.
In our experience, arm collision seems to be
between robotic and laparoscopic single-port more complex than that can be resolved with a
colectomy [17]. They compared 11 patients hav- single solution. Theoretically to make an opti-
ing robotic single-port colectomy to 10 patients mal chopstick arrangement, the crossing point
receiving laparoscopic single-port colectomy. should be the remote center of robotic arms and
In the robotic group all of the patients had single- should be located at the level of skin incision.
port right hemicolectomy with three conversions However, in procedures that deal with a wide
to conventional laparoscopy. There were three range of motion in the peritoneal cavity, it is
cases of postoperative complications (ileus, often difficult to keep the crossing point fixed at
anastomotic bleeding, and wound infection). the ideal location. Inadequate location of the
The laparoscopic group consisted of hemicolecto- crossing point, subsequently, may result in arm
mies and ileocecectomies. One case was converted collision. Choosing an adequate access port
to open due to adhesions, and one case had postop- seems to be another key to success. Ostrowitz
erative bleeding requiring drainage. There was no et al. reported that the very first case of robotic
statistically significant difference in measured single-port surgery had to be converted due to
clinical parameters between the two groups. air leak. He associated this with dilatation of the
port site caused by external clashing of the large
robotic arms when he was trying to use them
Technical Consideration parallel to each other without crossing [9].
According to the authors, they succeeded in
Laparoscopic single-port surgery is reported to subsequent cases using SILS port (Covidien)
be limited by the coaxial arrangement of the without an air leak. Singh et al. reported a suc-
instruments. Although it may not be as frequent cessful case of robotic single-port right colec-
as in laparoscopy, arm collision is still a signifi- tomy using GelPort as an access port [14]. They
cant problem in robotic single-port surgery. made a 4-cm-sized skin incision and put a
Joseph et al. in 2010 reported a chopstick surgery GelPort into it. Because they didn’t need to
technique to use the robotic arms through a single puncture abdominal fascia to insert individual
incision without collision [18]. He conducted an ports, they could avoid excessive stretch of the
experimental study using the da Vinci S robot in wound and therefore could prevent air leak dur-
a porcine model to perform cholecystectomy and ing the surgery and could reduce postoperative
nephrectomy with three laparoscopic ports intro- wound pain. Lim et al. demonstrated a glove-
duced through a single incision. The chopstick port technique and suggested similar advan-
arrangement crosses the instruments at the tages as GelPort [12]. An additional advantage
abdominal wall so that the right instrument is on of their technique is the availability of a third
the left side of the target and the left instrument robotic arm and an assistant port through the
on the right. This arrangement prevents collision five fingers of a glove port. The very low com-
of the external part of robotic arms. To correct for parative cost of a glove is also an obvious
the change in handedness, the robotic console is advantage of this technique.
254 B.S. Min et al.

is in the left robotic arm and, reciprocally, the left

Robotic Single-Site Platform
hand to control the screen left instrument even
though the instrument is in the right robotic arm.
The robotic single-port platform developed by The second part of the platform is a set of semi-
Intuitive Surgical incorporates the principle of rigid, nonwristed instruments with standard da
crossing the instrument arms internally with the Vinci instrument tips. The potential disadvantages
ability of reassigning hands at the console of this set may be that it is limited to two arms
(Fig. 22.1). while we need three arms in colorectal surgery.
The set includes a multichannel access port They do not have a wrist at the distal end of the
with four cannulas and an insufflation valve. Two instrument and that the traction and grasping
curved cannulas are for robotically controlled power of the instruments are weaker than conven-
instruments, and the other two cannulas are tional ones. This platform reported to be helpful in
straight; one cannula is 8.5 mm and accommodates relatively simple procedures like cholecystectomy
the robotic endoscope, and the other cannula is a and some minor urological procedures.
5-mm bedside-assistant port. The curved cannulas
are integral to the system, since their configuration
allows the instruments to be positioned to achieve Surgical Technique
triangulation of the target anatomy. This triangula-
tion is achieved by crossing the curved cannulas Patient Selection
through the access port. Same-sided hand–eye
control of the instruments is maintained through Benign diseases including diverticular disease
assignment of software of the Si system that and inflammatory bowel disease-related condi-
enables the surgeon’s right hand to control the tions might be good indications for this tech-
screen right instrument even though the instrument nique. At this point, the efficacy of single-port
surgery for malignant disease is controversial,
and surgeons should consider its limitations and
potential benefits that have been shown by cur-
rent evidences seriously before they apply this
technique to the patients. Early stages of colon
cancer that confined to colon wall (T1–3) without
lymph node metastasis (N0) may be candidates
of this technique when the patients fully under-
stand and when the informed consents are prop-
erly signed.
Technical limitation of the technique should
be taken into consideration at the time of patient
selection. Sigmoid colon diseases seem to be the
best fit for the resection. Proximal descending
colon may not be adequate because splenic flex-
ure mobilization is sometimes limited especially
when the patient is obese or/and tall. Rectum dis-
tal to peritoneal reflection may also be inadequate
because of the limited reach of the instruments.
Especially currently available laparoscopic sta-
plers have limited angulation that proper resec-
tion of distal rectum can seldom be made. Robotic
stapler, which is currently not available, may
Fig. 22.1 Robotic single-port platform by intuitive make difference in near future.
22 Robotic Single-Port Colorectal Surgery 255

Fig. 22.2 Operating room setup

Patient Position and Operating

Theater Setting

The patient is adequately padded and safely

secured to the operating table in the Lloyd-Davis
position with 15° Trendelenburg and 30° right side
tilt. The patient-side robotic cart is positioned and
locked in a 70° angle with the foot of the bed on the
patient’s left side at the level of the umbilicus and
a 15° tilt toward the patient’s head (Fig. 22.2).

Surgical Technique Fig. 22.3 Homemade glove port

The access device is a port constructed from a affixed to the outer ring and folded onto it to take
small size Alexis wound retractor manufactured up the slack of the plastic sleeve of the Alexis
by Applied Medical and a size 7 right-handed wound retractor. This ensures that the inner and
surgical glove. Initially, a 3.5-cm vertical trans- outer rings fit snuggly against the abdominal wall
umbilical incision is made. Once the Alexis preventing an air leak (Fig. 22.3).
wound retractor is placed into the peritoneal cav- Two 12-mm trocars are then inserted into the
ity in the standard manner, the surgical glove is third and the fifth finger of the glove. Three 8-mm
256 B.S. Min et al.

Fig. 22.4 Port setup after all robotic arms docked

robotic metal trocars are inserted into the remaining colon mesentery is retracted supero-anteriorly
three fingers in the configuration depicted in using the double fenestrated grasper on arm #3.
Fig. 22.1. The trocars are secured to the glove Peritoneum of the left mesocolon is incised supe-
with silk ties. The 30° up laparoscope is docked riorly from the sacral promontory, identifying the
via the third finger 12-mm trocar. The other inferior mesenteric artery (IMA) along the way.
12-mm trocar is for the assistant’s use. The assis- After skeletonization, the IMA is ligated and
tant stays directly at the patient’s right side. The divided at the root level with robotic Hem-o-lock
robotic arms are numbered 1–3 and are coupled clips, preserving the hypogastric nerve plexus.
with the three 8-mm robotic trocars. Arms #1–3 The peritoneal incision is then extended up to
handle the monopolar scissors, the bipolar the duodenojejunal junction, exposing the infe-
grasper, and the double fenestrated grasper, rior mesenteric vein (IMV). The IMV is tempo-
respectively. The da Vinci console-operating sur- rarily spared, so as to utilize its “tenting effect,”
geon, using the right and left hands, respectively, which is caused by the traction of the small
controls instruments on arm #1 and arm #2. The bowel during the medial-to-lateral mobilization
double fenestrated grasper will be anchored to of colonic mesentery. Medial-to-lateral dissec-
the robotic arm #3, which will be mainly used for tion is then performed until the lower border of
static retraction and will be operated by surgeon’s pancreas superiorly and Toldt’s line laterally,
right hand when necessary (Fig. 22.4). identifying and protecting vital structures such as
After pneumoperitoneum is established the left ureter and gonadal vessels. The left colon
through the assistant’s 12-mm port, the sigmoid is then freed laterally up to the splenic flexure.
22 Robotic Single-Port Colorectal Surgery 257

The posterior side of upper rectum is mobilized the endo-stapler properly from the umbilical
to facilitate later application of circular stapler port. The entire dissection except the distal rec-
for anastomosis. tal division had been completed using the sin-
Following complete mobilization of the left gle-port technique. Because currently available
colon, the mesentery and mesorectum are then endo-staplers have limited flexion angles, we
divided using an energy-based device roboti- could not divide the distal rectum properly from
cally or if preferred, by the patient-side assis- the umbilical port and had to make an additional
tant. The assistant then divides the distal port in the suprapubic area from which we were
resection margin using an articulating endo- able to apply the endo-stapler.
stapler. One of the robotic instruments is usu- We have found that splenic flexure mobiliza-
ally disengaged, and the robotic arm uncoupled tion in tall obese patients and the pelvic dissec-
to make space for comfortable movement by tion (total mesorectal excision) were the most
the assistant. The robot is then undocked and challenging parts of our technique, and our
the colon is exteriorized through the Alexis patient selection is based on these technical limi-
wound retractor. The IMV is ligated and the tations. However we look forward to technologi-
proximal margin is transected between a purse- cal advance in the near future including new
string clamp and a bowel clamp. The anvil of staplers that will allow greater articulation, which
the circular stapler is inserted into the proximal will enable us to overcome current limitations
colonic segment and secured with a purse (Table 22.4).
string. Finally, the port is reconstructed and the
anastomosis is completed laparoscopically
using a circular stapler.
Table 22.4 Summary of our experience of robotic
single-port colectomy
Outcomes Parameter Value
Gender
Since single port is still in its early stages, there Male 36
are no long-term results for this procedure pub- Female 37
lished so far. We have been performing robotic Types of surgery
single-port colectomies since 2009 and have Right hemicolectomy 33
thus far completed 73 cases. These have Anterior resection 37
included the following procedures: right hemi- Low anterior resection 2
colectomy (33 cases), anterior resection for sig- Age (mean, years) 54.3
moid colon cancer (37 cases), and low anterior Body mass index (mean, kg/m2) 23.2
resection (2 cases). In our experience, we have AJCC stage
been able to complete 96 % of the cases using I 34
the single-port technique. Conversions included II 21
III 17
one right hemicolectomy, one anterior resec-
Lymph node harvest (mean) 19.8
tion, and one low anterior resection, and all
Resection margin involvement 0
these were conversions to multiport robotic col-
Conversion (to multiport) 3 (4.1 %)
ectomies. Two of the conversions, a right hemi- Operation time (mean, min) 167.2
colectomy and an anterior resection, occurred Estimated blood loss (mean, ml) 40.2
during our initial experience and were due to Mortality (within postoperative 30 days) 0
external arm collision and reach limitation. Overall morbidity (within postoperative 13 (17.8 %)
A recent conversion of a single-port low ante- 30 days)
rior resection was due to not being able to apply Length of stay (mean, days) 6.2
258 B.S. Min et al.

The group of Oleynikov from the USA is also

Learning Curve
developing a multi-dexterous miniature in vivo
robotic platform that is completely inserted into
Because the procedure is not well standardized the peritoneal cavity through a single incision
and is relatively new, no single study has been [22]. The platform consists of a multifunctional
published about the learning curve. Currently robot and a remote surgeon interface. The robot
available reports are all from robotic/laparo- has two arms and specialized end effectors that
scopic experts who already have passed their can be interchanged to provide monopolar cau-
learning curves in either robotic or laparoscopic tery, tissue manipulation, and intracorporeal
multiport surgery. Possible issues regarding the suturing capabilities. Its use has been demon-
learning curve of robotic single-port surgery are strated in multiple non-survival porcine studies.
as follows: whether training in multiport robotic Moreover, another new surgical robot is being
surgery is mandatory, whether training in single- developed and tested by investigators from Japan
or multiport laparoscopic surgery is mandatory, [23]. The robot consists of a manipulator for
and how do we shorten the learning curve. vision control, and dual tool tissue manipulators
can be attached at the tip of a sheath manipulator.
The group of Simaan described a novel insertable
Future Innovation for Robotic robotic effectors platform with integrated ste-
Single-Port Surgery reovision and surgical intervention tools for
SPRS. This design provides can be inserted
The ideal robotic platform for single-port surgery through a single 15-mm access port. Dexterous
should have a low external profile, the possibility surgical intervention and stereovision are
of being deployed through a single access site, achieved by the use of two snakelike continuum
and the possibility of restoring intra-abdominal robots and two controllable charge-coupled
triangulation while maintaining the maximum device cameras [24].
degree of freedom for precise maneuvers and
strength for reliable traction.
Several robotic prototypes for single-port sur- Conclusion
gery are being tested.
The Single-Port lapaRoscopy blmaNual roboT Rrobotic single-port colorectal surgery is still in
(SPRINT) is part of a major Array of Robots its infancy. While robotic single-port colorectal
Augmenting the KiNematics of Endoluminal surgery is feasible in selected cases, further evo-
Surgery (ARAKNES) program coordinated by lution of technique and technology will be
Dario and Cuschieri and funded by the EU required for complex procedures (rectal cancer)
Framework 7 program [19]. This robot has a three- for universal adoption. Research and develop-
dimensional high-definition television imaging ment is ongoing to develop appropriate platforms
system and is operated through a console in the for robotic single-port surgery. It is possible that
sterile field so that the surgeon is not remote from the platforms for robotic single-port surgery may
the patient. This robot comprises of two arms with evolve to be organ specific, i.e., the robotic plat-
6 degrees of freedom that can be individually form for gall bladder may be different from the
inserted and removed in a 30–35-mm diameter one for colorectal surgery.
umbilical access port. The system is designed to
leave a central lumen free during operations, thus
allowing the insertion of other laparoscopic tools
[20]. Preliminary in vitro testing by Sanchez et al.
References
[21] from Italy suggested that in the near future, 1. Thompson B, Wheeless RC. Outpatient sterilization
the robot could become a reliable system in the by laparoscopy. A report of 666 patients. Obstet
field of robotic single-port surgery. Gynecol. 1971;38(6):912–5.
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2. Pelosi MA, Pelosi III MA. Laparoscopic supracervi- 14. Singh J, Podolsky ER, Castellanos AE, Stein DE.
cal hysterectomy using a single-umbilical puncture Optimizing single port surgery: a case report and
(mini-laparoscopy). J Reprod Med. 1992;37(9):777– review of technique in colon resection. Int J Med
84. PubMed PMID: 1453397. Robot. 2011;7(2):127–30. PubMed PMID: 21394870.
3. Rattner D, Kalloo A, Group ASW. ASGE/SAGES 15. Makino T, Milsom JW, Lee SW. Feasibility and safety
Working Group on Natural Orifice Translumenal of single-incision laparoscopic colectomy: a system-
Endoscopic Surgery. October 2005. Surg Endosc. atic review. Ann Surg. 2012;255(4):667–76. PubMed
2006;20(2):329–33. PMID: 22258065.
4. Abe N, Takeuchi H, Ueki H, Yanagida O, Masaki T, 16. Weber PA, Merola S, Wasielewski A, Ballantyne GH.
Mori T, et al. Single-port endoscopic cholecystec- Telerobotic-assisted laparoscopic right and sigmoid
tomy: a bridge between laparoscopic and translume- colectomies for benign disease. Dis Colon Rectum.
nal endoscopic surgery. J Hepatobiliary Pancreat 2002;45(12):1689–94. PubMed PMID: 12473897;
Surg. 2009;16(5):633–8. PubMed PMID: 19373428. discussion 95–6.
5. Jung YW, Kim YT, Lee DW, Hwang YI, Nam EJ, 17. Obias V, editor. Robotic versus laparoscopic single
Kim JH, et al. The feasibility of scarless single-port port right hemicolectomy. Chesapeake Colorectal
transumbilical total laparoscopic hysterectomy: initial Society meeting. Apr 2011.
clinical experience. Surg Endosc. 2010;24(7):1686– 18. Joseph RA, Salas NA, Johnson C, Goh A, Cuevas SP,
92. PubMed PMID: 20035346. Donovan MA, et al. Video. Chopstick surgery: a novel
6. Ponsky LE, Cherullo EE, Sawyer M, Hartke D. Single technique enables use of the Da Vinci Robot to per-
access site laparoscopic radical nephrectomy: initial form single-incision laparoscopic surgery. Surg
clinical experience. J Endourol. 2008;22(4):663–6. Endosc. 2010;24(12):3224.
PubMed PMID: 18324901. 19. Tang B, Hou S, Cuschieri SA. Ergonomics of and
7. Bucher P, Pugin F, Morel P. Single port access laparo- technologies for single-port laparoscopic surgery.
scopic right hemicolectomy. Int J Colorectal Dis. Minim Invasive Ther Allied Technol. 2012;21(1):46–
2008;23(10):1013–6. PubMed PMID: 18607608. 54. PubMed PMID: 22066862.
8. Kaouk JH, Goel RK, Haber GP, Crouzet S, Desai 20. Piccigallo M, Scarfogliero U, Quaglia C, Petroni G,
MM, Gill IS. Single-port laparoscopic radical prosta- Valdastri P, Menciassi A, et al. Design of a novel
tectomy. Urology. 2008;72(6):1190–3. PubMed bimanual robotic system for single-port laparos-
PMID: 19041022. copy. IEEE-ASME Trans Mechatron. 2010;15(6):
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PubMed PMID: 23161281. 2010.
 Robotic Transanal Surgery
23
Sam Atallah and Matthew Albert

Synnyvale, CA) could be used to perform

Introduction transanal surgery. Initial experiments were con-
ducted in a dry lab and using a cadaveric model
Over recent years, new techniques for local [5]. This approach was also shown to be feasible
excision of benign- and early-stage, well-selected using a specialized glove port [6]. Subsequent to
neoplasms of the rectum have been developed. this, robotic transanal surgery (RTS) was suc-
Transanal minimally invasive surgery (TAMIS) cessfully performed for local excision of a rectal
was pioneered in 2009 as a method for local exci- neoplasm in a live patient [7].
sion of rectal neoplasia, and preliminary experi-
ence shows that TAMIS provides high-quality
local excision, comparable to transanal endo- Patient Selection
scopic microsurgery (TEM) [1–4].
TAMIS uses ordinary laparoscopic instru- The indications for RTS are the same as for
ments to perform intraluminal full-thickness TAMIS and TEM. They include resection of
local excision in combination with FDA-approved benign rectal neoplasms and, for curative-intent
single ports, such as the SILS Port (Covidien, surgery, well-selected T1 carcinomas, with histo-
Mansfield, MA) or the GelPOINT path transanal logically favorable features, where the risk of
access platform (Applied Medical, Inc.). The nodal metastasis is low [8]. The indication for
success with this approach was met with such RTS may also be broadened to include local exci-
enthusiasm that soon after its development, sion of cT0 lesions in patients with locally
investigation began into the use of robotics with advanced rectal cancer after neoadjuvant therapy
the TAMIS platform. for the purpose of confirming mural cPR (ypT0).
In 2010, it was learned that the da Vinci This can be considered a valid option since the
Robotic Surgical System (Intuitive Surgical, Inc., risk of occult node positivity for ypT0 lesions is
low, at 3–6 % [9–14]. While most segments of
the rectum can be reached with RTS, this
S. Atallah, M.D., F.A.C.S., F.A.S.C.R.S. (*)
Center for Colon and Rectal Surgery, Florida approach is most suited for mid-rectal lesions
Hospital, 242 Loch Lomond Drive, Winter Park, (5–10 cm from the anal verge).
FL 32792, USA RTS should not be considered as an alternative
e-mail: [email protected]
to standard oncologic resection for locally advanced
M. Albert, M.D., F.A.C.S., F.A.S.C.R.S. tumors. The lesion should not occupy more than
Center for Colon and Rectal Surgery, Florida
40 % of the luminal diameter. RTS may have
Hospital, 661 E. Altamonte Drive, Suite 309,
Altamonte, FL 32701, USA special applications beyond local excision, such as
e-mail: [email protected] for transanal repair of complex fistulae, such as for

K.C. Kim (ed.), Robotics in General Surgery, DOI 10.1007/978-1-4614-8739-5_23, 261

© Springer Science+Business Media New York 2014
262 S. Atallah and M. Albert

repair of a rectourethral fistula. This, in fact, has

been attempted with limited success.

Preoperative Workup

All patients who have been selected to undergo

RTS resection must have also undergone colo-
noscopy to assess for synchronous lesions and to
obtain a biopsy of the rectal lesion. For malig-
nant, early-stage tumors of the rectum, endorec-
tal ultrasound is performed to determine
preoperative T and N stage. Pelvic 3-Tesla (3 T)
MRI is a valid alternative. Currently, only patients
with histologically favorable, early-stage malig-
nancy (uTis or uT1uN0M0 cancer) are consid-
ered candidates for TAMIS. More advanced
lesions require standard resection (APR vs. LAR)
except in patients who are not medically fit to
undergo major surgery. CEA level and CT body
imaging is also performed to assess for tumor
metastasis. Patients with stage IV disease or
Fig. 23.1 The robotic trocar is introduced into the
locally advanced lesions are not candidates for GelPOINT Path TAMIS port via three cannulas. The can-
RTS unless the objective is palliation. nulas are placed into the TAMIS port gelatinous lid which
is then placed and secured onto its sheath (not shown)

Operating Room usual fashion. The abdomen should also be prepped,

in the event that the lesion cannot be excised locally,
The patient is brought into the operating theater and or should abdominal access become necessary.
positioned modified lithotomy in Allen stirrups. For RTS, the GelPOINT path transanal access
This position is recommended based on initial, platform is used (Applied Medical, Rancho Santa
cadaveric studies, which have demonstrated this Margarita, CA). The device consists of a rigid
position to be optimal for robotic access [5]. This is cylindrical sleeve, which helps protect against
preferred, regardless of the position of the lesion in injury to the sphincter mechanism. The sleeve is
the rectal wall. A downward-angled lens is pre- lubricated with petroleum jelly and introduced
ferred for posterior lesions, and an upward-angled into the anal canal using an obturator provided by
lens is preferred for anterior lesions. the manufacturer. Once seated above the anorec-
The operating room should be fitted with stan- tal ring, the sleeve is sutured to the skin with 2-0
dard laparoscopic equipment, including light silk stay sutures.
source, video monitor, and CO2 insufflator, as For both TAMIS and RTS, patients are phar-
well as the da Vinci Robotic System. We strongly macologically paralyzed to prevent rectal lumen
recommend general anesthesia with muscle paral- collapse, and humidified CO2 is used with the
ysis to avoid collapse of the rectal wall, which pressure set to 15 mmHg. With the GelPOINT
often occurs with diaphragmatic excursion. path port seated in place and pneumorectum
Parenteral antibiotics are administered 30 min established, a laparoscope is introduced to per-
prior to incision (our preference is single-dose form cursory visualization of the target lesion
ertapenem 1 g intravenously). The patient must and to assess the rectum for luminal expansion.
undergo mechanical bowel prep preoperatively as Next, three GelPOINT path cannulas are intro-
well. The patient is then prepped and draped in the duced at an equilateral distance (Fig. 23.1). The
23 Robotic Transanal Surgery 263

Fig. 23.2 The setup for RTS. The robotic cart is docked operates a suction irrigator device to assist with smoke
over the left (or right) shoulder with the patient positioned evacuation. The robotic arms are configured using either
modified lithotomy in Allen stirrups. A bedside assistant an 8-mm or 15-mm lens with 8-mm working arms

da Vinci robotic 8-mm trocars are then placed local excision. Resection using RTS is typically
into these cannulas. The GelPOINT path lid is performed by demarcating the perimeter of the
next placed onto the sleeve, which had already lesion, providing an appropriate margin. This is
been seated in position, and the robotic cart is done using thermal energy. For evacuation of
then docked over the patient’s right shoulder smoke, a bedside assistant uses a 5-mm laparo-
(Fig. 23.2a, b). Next, a robotic hook cautery and scopic suction-irregator device; this is passed
Maryland grasper are secured (Fig. 23.3). The directly into the GelPOINT path lid, without the
console surgeon then performs a full-thickness need for a trocar (Fig. 23.4). We find that a simple
264 S. Atallah and M. Albert

short burst of suction maintains image clarity

without collapsing the rectal lumen. The speci-
men may be tented gently using a robotic
Maryland grasper while hook cautery allows for
full-thickness excision (Fig. 23.5). Importantly,
the CO2 insufflation provides a natural “pneumo-
dissection” thereby augmenting the ease and clar-
ity of local excision using RTS.
To retrieve the resected specimen, the robot
must be dismounted from the GelPOINT path
interface. The lesion can be retrieved with a
5-mm grasper, the lid to the port simply removed
Fig. 23.3 A T1 well-differentiated adenocarcinoma aris- allowing for specimen extraction.
ing from a tubulovillous adenoma measure 3 cm is shown The next step is closure of the full-thickness
being removed during RTS for local excision rectal wall defect, which is always recommended.

Fig. 23.4 The robot is now

docked transanally. The
console surgeon performs the
excision, assisted only by the
need for periodic smoke
evacuation. A 5-mm
laparoscopic smoke evacuator
can be operated by a bedside
assistant
23 Robotic Transanal Surgery 265

Fig. 23.5 The tumor is now

visible and a hook cautery
and Maryland grasper are all
that are needed to complete
the RTS local excision of
rectal neoplasm

Fig. 23.6 Once local

excision has been completed,
the full-thickness defect is
closed using needle drivers
and a V-Loc suture, obviating
the need for knot tying

To do this, the hook cautery and Maryland

grasper are exchanged with two robotic needle Discussion
drivers. Robotic intraluminal suturing is then car-
ried out using a V-Loc 180 Absorbable Wound RTS illustrates a novel approach to the resection
Closure Device (Covidien, Mansfield, MA). This of well-selected and appropriately staged rectal
allowed for suturing without the need for intralu- neoplasia. A key advantage of RTS over TAMIS
minal knot tying, since the unidirectional barbs or TEM is that the console surgeon is able to per-
on the suture self-lock as they pass through the form intricate surgery more easily within the nar-
rectal wall. The defect can be closed with a single row, cylindrical lumen. The EndoWrist movement
running V-Loc stitch, thereby completing the allows for greater intraluminal dexterity. This,
operation (Fig. 23.6). together with magnified 3D optics, enhances the
266 S. Atallah and M. Albert

surgeon’s ability to perform transanal local exci- a cadaveric model. Tech Coloproctol. 2011;15(4):
461–4.
sion with improved precision. This also improves
6. Hompes R, Rauh SM, Hagen ME, Mortensen NJ.
the ability to successfully complete complex Preclinical cadaveric study of transanal endoscopic da
tasks, such as intraluminal suturing. RTS is a new Vinci® surgery. Br J Surg. 2012;99(8):1144–8.
approach to transanal access, and its ability to doi:10.1002/bjs.8794.
7. Atallah S, Parra-Davilla E, deBeche-Adams T, Albert
accomplish intricate tasks with ease makes this
M, Larach S. Excision of a rectal neoplasm using
method suitable for complex cases, where local robotic transanal surgery (RTS): a description of the
excision or other advanced transanal procedures technique. Tech Coloproctol. 2012;16(5):389–92.
(such as transanal repair of rectourethral fistulae) 8. Nascimbeni R, Burgart LJ, Nivatvongs S, Larson DR.
Risk of lymph node metastasis in T1 carcinoma of the
may prove difficult with TAMIS or TEM.
colon and rectum. Dis Colon Rectum. 2002;45(2):200–6.
Although greatly advantageous, RTS increases 9. Garcia-Aguilar J, Shi Q, Thomas Jr CR, Chan E,
operative cost substantially, and therefore this Cataldo P, Marcet J, Medich D, Pigazzi A, Oommen
approach should be reserved for more complex S, Posner MC. A phase II trial of neoadjuvant chemo-
radiation and local excision for T2N0 rectal cancer:
cases, where standard TAMIS and TEM are not
preliminary results of the ACOSOG Z6041 trial. Ann
possible. RTS is a technique still in its infancy, Surg Oncol. 2012;19(2):384–91.
and its application for rectal surgery has not yet 10. Kundel Y, Brenner R, Purim O, Peled N, Idelevich E,
been fully defined. RTS is currently undergoing Fenig E, et al. Is local excision after complete patho-
logical response to neoadjuvant chemoradiation for
further investigation, and more data are necessary
rectal cancer an acceptable treatment option? Dis
to establish its efficacy and practicality. A com- Colon Rectum. 2010;53(12):1624–31.
parative analysis of the available platforms for 11. Kim CJ, Yeatman TJ, Coppola D, Trotti A, Williams
advanced transanal surgery would be useful. B, Barthel JS, Dinwoodie W, et al. Local excision of
T2 and T3 rectal cancers after downstaging chemora-
diation. Ann Surg. 2001;234(3):352–8. discussion
358–9.
References 12. Bedrosian I, Rodriguez-Bigas MA, Feig B, Hunt KK,
Ellis L, Curley SA, et al. Predicting the node-negative
1. Atallah S, Larach S, Albert M. Transanal minimally mesorectum after preoperative chemoradiation for
invasive surgery: a giant leap forward. Surg Endosc. locally advanced rectal carcinoma. J Gastrointest
2010;24(9):2200–5. Surg. 2004;8(1):56–62.
2. Lim SB, Seo SI, Lee JL, Kwak JY, Jang TY. Feasibility 13. Bujko K, Nowacki MP, Nasierowska-Guttmejer A,
of transanal minimally invasive surgery for mid-rectal Kepka L, Winkler-Spytkowska B, Suwaski R, et al.
lesions. Surg Endosc. 2012;26(11):3127–32. Prediction of mesorectal nodal metastases after
3. Barendse RM, Doornebosch PG, Bemelman WA, chemoradiation for rectal cancer: results of a ran-
Fockens P, Dekker E, de Graaf EJ. Transanal employ- domised trial: implication for subsequent local exci-
ment of single access ports is feasible for rectal sur- sion. Radiother Oncol. 2005;76(3):234–40.
gery. Ann Surg. 2012;256(6):1030–3. 14. Yeo SG, Kim DY, Kim TH, Chang HJ, Oh JH, Park
4. Lorenz C, Nimmesgern T, Back M, Langwieler TE. W, Choi DH, Nam H, et al. Pathologic complete
Transanal single port microsurgery (TSPM) as a mod- response of primary tumor following preoperative
ified technique of transanal microsurgery (TEM). chemoradiotherapy for locally advanced rectal can-
Surg Innov. 2010;17:160–3. cer: long-term outcomes and prognostic significance
5. Atallah SB, Albert MR, deBeche-Adams TH, Larach of pathologic nodal status (KROG 09–01). Ann Surg.
SW. Robotic transanal minimally invasive surgery in 2010;252(6):998–1004.
 Part VIII
Surgical Techniques: Endocrine
 Robotic Thyroidectomy
and Radical Neck Dissection Using 24
a Gasless Transaxillary Approach

Jandee Lee and WoongYoun Chung

minimally invasive operative techniques have

General Overview of Robotic been introduced, including mini-incision, video-
Thyroidectomy assisted, endoscopic, and laparoendoscopic
single-site surgery (LESS). Endoscopic thyroid
History and Development of Robotic surgery was first described in 1997 [2]; this was a
Thyroidectomy totally endoscopic approach requiring carbon
dioxide insufflation of the neck. Since then, com-
The open method of thyroid surgery, first plete endoscopic approaches to the thyroid have
described in the nineteenth century, originally been further divided into cervical approaches,
required an 8–10 cm transverse skin incision. with port placements in the neck and extra cervi-
Since then, the length of the incision has been cal approaches, with the latter introduced to hide
greatly reduced, and an incision between 4 and neck scars. These include port placements in the
6 cm in length has become standard [1]. Although axilla and incisions through the breast, chest
the open method is quick, provides adequate wall, and even the postauricular region [3–5].
access, and leaves a scar that is often well hidden The results of recent cadaveric experiments have
in the skin crease, the possibilities of scar hyper- suggested a completely scarless technique,
trophy and neck discomfort due to sensory known as natural orifice transluminal endoscopic
changes after surgery have resulted in the devel- surgery (NOTES™), in which the thyroid is
opment of minimally invasive techniques as well approached from the oral cavity [5].
as endoscopic methods. With recent advances, cancer surgery is mov-
The potential benefits of minimally invasive ing toward the goals of adequate resection with
surgery include reduced trauma to adjacent tis- minimum collateral damage. In neck surgery,
sues, decreased postoperative discomfort, and however, where vital structures are in close
better cosmetic outcomes. Various types of proximity to each other and the operative field is
a deep and narrow space, these minimally inva-
sive approaches can be especially challenging
J. Lee, M.D., Ph.D.
Department of Surgery, Eulji University College of [5, 6]. The advent of the da Vinci robot system
Medicine, Hagye 1-dong, Nowon-gu, Seoul, (Intuitive Inc., Sunnyvale, California, USA) has
South Korea further revolutionized the surgical management
e-mail: [email protected]
of thyroid disease within the endoscopic envi-
W. Chung, M.D., Ph.D. (*) ronment. These technical advances have
Department of Surgery, Yonsei University College of
increased understanding of the essential neck
Medicine, 134 Shinchon-dong, Seodaemun-ku,
Seoul, South Korea anatomy and have improved surgical techniques.
e-mail: [email protected] Robotic surgery addresses some of these issues,

K.C. Kim (ed.), Robotics in General Surgery, DOI 10.1007/978-1-4614-8739-5_24, 269

© Springer Science+Business Media New York 2014
270 J. Lee and W. Chung

with better visualization and a range of manipu- this goal closer. Robotic methods can aid surgery
lators that can fit within deep and narrow spaces in traditionally hard-to-reach places in the neck
during neck operations. The optical channels of area via an axillary approach. Several studies
the robotic system can replace two-dimensional comparing the efficacy of complete thyroid resec-
with three-dimensional imaging, thus enhancing tion and the extent of cervical lymph node (LN)
the precision of anatomic dissection. dissection by robotic and conventional open tech-
Furthermore, the computer provides motion niques found that short-term oncologic effective-
scaling and tremor elimination, facilitating more ness, as determined by postoperative [131I] iodine
difficult surgical procedures. One of the most (131RI) scanning, serum thyroglobulin (Tg) con-
significant advantages of this robotic system is centration, and the number of harvested cervical
its three-dimensional view, which improves LNs, was similar. By comparison, robotic thy-
visualization of the surgical field and allows roidectomy has shown excellent oncologic results
greater precision and accuracy. Another advan- and low complication rates when performed by
tage is the wrist-like motion of the robotic arm, experienced surgeons [4, 17–22]. Moreover,
which provides finer and more dexterous move- functional outcomes increasingly emphasize
ments, enabling surgical procedures that were high scores on validated quality-of-life (QOL)
impossible by conventional endoscopic meth- instruments. Several large-volume centers have
ods. Robotic surgery has been found to eliminate reported that the “functional and QOL” benefits
many problems encountered with conventional of robotic thyroidectomy include excellent cos-
endoscopic techniques [6–8]. metic outcomes, and reduced pain and voice and
The history of robotic thyroidectomy is short swallowing discomfort, when compared with
and the technique is still developing. The first conventional open surgery [23–26].
series, published in 2009, included 100 patients Robotic thyroidectomy, at present, compares
[9]. The shift toward robotic thyroidectomy has favorably with open thyroidectomy in surgical
reshaped the surgical approach to thyroid disease completeness, safety, and QOL outcomes,
in South Korea and some parts of Asia. Its impact including cosmetic results. Further analyses of
in the USA and Europe, however, has been some- surgeons’ experience with long-term follow-up,
what delayed and less widespread than in Asian as well as randomized controlled trials, remain
countries [4, 10–17]. In thyroid surgery, the da important. In this chapter, we review the recent
Vinci robotic system is being used in a wide surgery literature, with a focus on how the
range of specialties, including surgery for thyroid refinement of surgical techniques in robotic thy-
cancer and benign thyroid disease. Its aims are roidectomy and the development of robotic sur-
identical to those of conventional surgery, gical training will alter the future direction of
although its postoperative outcomes are better these procedures. We also discuss the impact of
and cosmetic satisfaction is improved. Therefore, these developments on thyroid cancer manage-
for patients, the potential advantages of robotic ment, including oncologic, safety, and QOL
surgery compared with conventional endoscopic outcomes.
procedures include greater precision, lower error
and bleeding rates, shorter hospital stay, more
rapid recovery, and less pain. For surgeons, the Indications and Contraindications
use of a robot, controlled via a master–slave for Robotic Thyroidectomy
interface, may improve visualization and surgical
ergonomics. For example, a surgeon may remain Patient selection is of the utmost importance
seated during the operation [4, 6–8]. when considering the use of newly developed
Complete oncologic resection of a tumor with techniques. Although there are no established
minimal disruption of the surrounding healthy guidelines on the limitations of robotic thyroid-
tissue is the overall aim of cancer surgery. The ectomy, most experienced specialized surgeons
development of new technologies has brought would consider a robotic approach for the
24 Robotic Thyroidectomy and Radical Neck Dissection Using a Gasless Transaxillary Approach 271

removal of a thyroid benign nodule <5 cm in size template for robotic thyroidectomy (two-incision
and for resecting a differentiated thyroid cancer technique and single-incision technique) [4, 5, 9,
without locally advanced features. 28–30]. Since it is important to avoid collisions
We have found that preoperative patient evalu- among robot instruments but also to provide free
ation, including accurate tumor staging, was the access to the thyroid bed, robot docking and port
most important factor in choosing a surgical (cannula) placement is of major concern for robot
method. Thyroid nodules were diagnosed preop- thyroidectomy. We briefly describe the main fea-
eratively based on the results of ultrasonography tures of the technique (Fig. 24.1).
(US)-guided fine needle aspiration biopsy. Patient
workup consisted of a physical examination and Patient Positioning
imaging analyses, including high-resolution US Patient Preparation. The patient under general
and neck-computed tomography (CT). Staging anesthesia is placed in a supine position on a
US was also utilized for preoperative clinical small shoulder roll with the neck slightly
staging, influencing patient selection and surgical extended. The arm is extended and a 5- and 6-cm
extent. Tumor characteristics assessed included vertical incision is marked in the anterior aspect
diameter, site, presence of extrathyroidal inva- of the ipsilateral axilla (Fig. 24.2a).
sion, multiplicity, bilaterality, and presence of The arm is then replaced into its natural posi-
cervical LN metastasis. tion to ensure that the incision will be hidden
Patients were considered eligible for robotic after the procedure is completed. The arm of the
surgery if they had (a) follicular proliferation lesion side is raised straight superiorly but natu-
with a tumor size ≤5 cm and (b) differentiated rally within the range of shoulder motion to avoid
thyroid cancer without the following contraindi- brachial plexus paralysis. The arm is fixed to
cations. Patients were excluded if they had (a) a afford the shortest distance between the axilla
history of previous head-and-neck surgery, (b) and the anterior neck. This setup rotates the clav-
severe thyrotoxicosis, (c) locally advanced thy- icle, lowering its medial aspect and providing
roid cancers featuring definite invasion to adja- excellent access to the thyroid. The alternative
cent structures, (d) distant metastasis, or (e) patient positing has been developed in the USA
lesions located in the dorsal thyroid area, espe- especially for the patients with some obstacles
cially in the region adjacent to the tracheoesopha- originated by a large body habitus [10–15]. The
geal groove, because of possible injury during lesion-side arm was extended to expose his/her
surgery to the trachea, esophagus, or recurrent axillary area at the shoulder and then flexed at the
laryngeal nerve (RLN). elbow an approximately 90° angle such that the
The extent of thyroidectomy was determined wrist is over the patient’s forehead with the palm
based on American Thyroid Association facing the ceiling. The arm is then padded and
Guidelines [27]. All patients with thyroid cancers fixed to an arm board overlying the forehead
also underwent prophylactic central compart- (Fig. 24.2b).
ment node dissection (CCND).
Creation of Working Space. After the patient is
prepped and draped, a 5- to 6-cm vertical skin
Overview of the Procedure incision along the lateral border of the pectoralis
major muscle is made in the axilla, and a working
Robotic Thyroidectomy Procedure space is then created in the plane between the
subcutaneous tissue and the pectoralis major
Refinements in the surgical technique during the muscle by electrical cautery under direct vision.
established steps of thyroid surgery have led to After exposure of the medial border of the sterno-
improved operative outcomes following robotic cleidomastoid (SCM) muscle, the dissection is
thyroidectomy. We use three robotic arms and a approached through the avascular space of the
single camera and recently formulated a standard SCM branches (between the sternal head and the
272 J. Lee and W. Chung

Fig. 24.1 Operating room set up (for a right-sided the location of the thyroid lesion. For a left-sided lesion,
lesion): An overhead view of the recommended operat- the patient and anesthesiologist should be rotated 180°
ing room configuration for a da Vinci thyroidectomy. and the scrub nurse should be on the left side of the
The patient cart should always be placed contralateral to assistant

clavicular head). The carotid sheath is separated positioned in the middle of the incision of the
down from the strap muscle, taking care not to patient’s axilla, the camera arm is in line with the
injure the internal jugular vein (IJV) and the camera cannula and center column of the patient
common carotid artery (CCA), and the omohyoid cart. The “sweet spot” should be confirmed to
muscle is retracted superficially and posterolat- maximize the range of motion for the instrument
eral. Then, the strap muscles are elevated muscle arms prior to docking. We have to align the blue
until the medial one-third portion of the contra- arrow within the blue marker on the second joint
lateral lobe of the thyroid is exposed. To maintain or assure a ~90° angle between the first and third
a working space, a spatula-shaped external joints on the camera arm. We also achieve a
retractor (Chung’s thyroid retractor) with a table straight line by aligning the clutch button, the
mount lift is placed under the strap muscles and third joint of the camera arm, and the gray dot in
secured to the lift. To achieve an adequate work- “da Vinci” on the center column. After then, the
ing space, the incision entrance should be main- patient cartwheel is locked once the correct loca-
tained to provide a height of >4 cm and the tion of the camera arm within its “sweet spot” is
retractor blade should be >1 cm from the anterior reached. The cart’s arms are extended over the
surface of the thyroid gland (Fig. 24.3a, b). patient, and the cannulas are placed in the inci-
sion site with the remote centers located just
Robot Positioning and Docking inside the skin edge.
Robot Positioning and Cannula Placement. The
camera arm is positioned set-up joint toward the Docking Stage (Two-Incision Technique).
patient’s head to insure maximum clearance for The novel method of robotic thyroidectomy
instrument arm. For the camera arm should be using a gasless transaxillary approach requires
24 Robotic Thyroidectomy and Radical Neck Dissection Using a Gasless Transaxillary Approach 273

Fig. 24.2 (a) Patient position and skin incision line. The tion. The lesion-side arm was extended to expose the axillary
incision was made along the axillary skin crease on the lateral area at the shoulder and flexed at the elbow at an approxi-
border of the pectoralis major muscle (b) Modified arm posi- mately 90° angle to avoid brachial plexus neuropraxia

two skin incisions, axillary incision for camera, It is important that the angle and position of the
first and second robot arm access, and an anterior da Vinci arm joints are optimized during this
chest incision for the third robotic arm [4, 5, 28, setup. The camera arm starts parallel with the
29]. In two-incision robotic thyroidectomy, a sec- retractor and centered above the thyroid. The
ond skin incision (0.6–0.8 cm long) is made on instrument arms should come in at the edges of
the medial side of the anterior chest wall to insert the incision and angle out away from the camera.
the third robot arm, 2 cm superiorly and 6–8 cm Once the thyroid is visualized with the endo-
medially from the nipple. A dual-channel tele- scope, the back end of the camera arm will form
scope is placed on the central arm, and harmonic an inverted triangle with the instrument arms,
curved shears, together with a Maryland dissec- while the instrument tips and endoscope tips will
tor, are placed on both lateral sides of the scope. form a normal triangle at the surgical site. During
A ProGrasp forceps is inserted through the the procedure, the robot arms and camera may
anterior chest wall incision (Fig. 24.4a, b) [4, 30]. need slight adjustments during the most extreme
274 J. Lee and W. Chung

Fig. 24.3 To achieve an adequate working space after least 4 cm and (b) the retractor blade should be >1 cm
retractor blade positioning, (a) the axillary incision from the anterior surface of the thyroid gland to provide
entrance should be maintained to provide a height of at enough space for movement of the robotic instrument

upper and lower pole dissections. After docking mies via a two-incision technique, we found that
procedure, we should check for any external col- we were able to perform robotic thyroidectomy
lisions and tweak arm position as necessary to without the second incision. According to single-
ensure that there is full access to the target anat- incision technique, all robotic arms with camera
omy. Our initial robotic thyroidectomy proce- are inserted through an axillary single incision. To
dures (about 700 cases) were performed using prevent collision between robotic arms, we realize
this novel method using two-incision approach. several tips and rules about there to place the
ProGrasp forceps and how to introduce the robotic
Docking Stage (Single-Incision Technique). After arms at appropriate angles and inter arm distances.
performing more than 700 robotic thyroidecto- For the conduit of the right-side robotic thyroidec-
24 Robotic Thyroidectomy and Radical Neck Dissection Using a Gasless Transaxillary Approach 275

Fig. 24.4 Two-incision robotic thyroidectomy. (a) side of the anterior chest wall to allow insertion of the
Schematic of a two-incision thyroidectomy docking. A fourth robotic arm (with ProGrasp forceps). (b) External
second 0.6–0.8 cm skin incision was created on the tumor view after port placement and instrument insertion

tomy via a single axillary incision, a 12-mm can- the target anatomy by clutching the camera
nula for the 30° dual-channel endoscopic camera and extending tilting the back of the arm toward
is placed in the center of the axillary incision. The the floor. With the 30° down scope, this provides
edge of camera cannula is inserted in an upward a good view of the thyroid. Before the 8-mm
direction and centered at the bottom of the inci- cannula is positioned in the incision, attach
sion. The tip of the camera is positioned to view the ProGrasp to the robot arm and insert the
276 J. Lee and W. Chung

Fig. 24.5 Single-incision robotic thyroidectomy. (a) through the axillary incision. (b) External view after port
Schematic of a single-incision thyroidectomy docking. placement and instrument insertion. All instruments
All four robotic instruments and the camera were inserted should be as far from each other as possible

instrument through the cannula until it is at full the ProGrasp forceps arm will form an inverted
insertion. The tip of ProGrasp forceps is then triangle externally with the insertion axis and
positioned as parallel and just to the right side of make a triangle internally with the instrument
the retractor blade at the top of the incision just tips. At this point, the ProGrasp forceps must be
above the thyroid. The 5-mm cannula of a located as close as possible to the ceiling of the
Maryland dissector is then positioned on the left working space (the retractor blade). Instruments
edge of the incision and the 5-mm cannula for should be as far apart as possible. The arms must
the Harmonic curved shears at the right side of be spaced and positioned in a manner mini-
the camera. Therefore, all three instruments and the mizing collisions between the instruments and
camera are inserted through the axillary incision the camera. If most movements could not be
(Fig. 24.5a, b) [4, 30]. at the wrists during single-incision technique,
If the setup has been performed correctly, the large internal movements may cause external
Maryland dissector arm, the Camera arm, and collisions.
24 Robotic Thyroidectomy and Radical Neck Dissection Using a Gasless Transaxillary Approach 277

Step-by-Step Review of Critical divided by Harmonic curved shear close to the

Elements of the Robotic Thyroidectomy thyroid capsule while retracting the contralateral
Console Stage. The general principle of operation lobe laterally and taking care to preserve the
proceeding for robotic thyroidectomy was the contralateral RLN. In patients with a prominent
same manner as a conventional open thyroidec- trachea and a deeply located contralateral thy-
tomy. The thyroid gland is retracted using a roid, the surgical table can be tilted by 10–15°,
ProGrasp forceps on the fourth robotic arm, and which provides optimal exposure of the contra-
dissection is performed employing a Harmonic lateral trachea-esophageal groove. The resected
curved shears and a Maryland dissector. specimen is removed through an axillary skin
This procedure allows the surgeon to use three incision. A 3-mm closed suction drain is inserted
robotic arms during thyroidectomy. We initiate through a separate skin incision under the axil-
the dissection of superior pole of the thyroid lary skin incision. Wounds are closed cosmeti-
gland using the ProGrasp forceps to retract the cally. The axillary incision scar is completely
thyroid downward and Maryland dissector to cre- covered when the arm is in its natural position
ate traction on the thyroid tissue. The superior (Fig. 24.7a, b). Apart from docking of the robotic
thyroid gland vessels are identified and individu- arms, during console stage, the two-incision and
ally ligated close to the thyroid gland to avoid single-incision robotic thyroidectomy procedures
injury of the external branch of superior laryn- are the same.
geal nerve using Harmonic curved shears. The
upper pole of thyroid gland is separated from the
cricopharyngeal and cricothyroid muscles until Robotic Radical Neck Dissection
the superior parathyroid gland is exposed and Procedure
preserved (Fig. 24.6a).
The thyroid gland is then pulled in a superior Although the papillary thyroid cancer (PTC)
and medial direction using the ProGrasp forceps, usually has shown a favorable prognosis and
and the lateral side of the CCND is performed relatively mild biological behavior, but fre-
from the CCA artery to the inferior thyroid artery quently, more than 30 %, metastasizes to regional
superiorly and to the substernal notch inferiorly. LNs [31–33]. In PTC patients with lateral neck
All dissections and ligations of vessels are per- node metastases (N1b) should undergo total thy-
formed using the Harmonic curved shears. After roidectomy with modified radical neck dissec-
exposing the CCA to the inferior thyroid artery, tion (MRND). Standard guidelines for thyroid
soft tissue and central compartment nodes are cancer treatment recommend that comprehen-
detached to the substernal notch until the anterior sive neck dissection for DTC patients with lat-
surface of trachea is exposed (Fig. 24.6b). The eral cervical LN metastasis is essential to address
inferior thyroid artery is divided close to the thy- all levels (levels II–V) due to the possibility of
roid gland using the Harmonic curved shears, and skip metastasis. Recently, we described in detail
the whole cervical course of the RLN is traced. In robotic MRND using a gasless transaxillary
the Berry ligament area, the thyroid gland is approach for PTC and demonstrated its feasibil-
meticulously detached from the trachea to avoid ity and provided details of operative techniques
direct or indirect thermal injury of the RLN. In and short-term operative outcomes [4, 5, 34, 35].
cases of bilateral total thyroidectomy, contralat- In robotic MRND technique, the complete ana-
eral lobectomy was usually performed after com- tomical neck LN dissection, matching that of the
pleting ipsilateral lobectomy. The removal of the open method, was found to be possible using
contralateral lobe was done by capsular dissec- excellent robotic instruments, such as magnified
tion through the thyroid capsule with adequate and three-dimensional operative field, a stable
retraction of the thyroid lobe and trachea. The camera platform, multi-articulated and tremor
blood vessels were divided close to the thyroid filtering system, and three accessible robotic
capsule. The contralateral Berry’s ligament was arms.
278 J. Lee and W. Chung

Fig. 24.6 Operative findings for robotic thyroidectomy. section with Harmonic curved shears. (b) Division of
(a) Dissection around the superior parathyroid gland Berry’s ligament to free the recurrent laryngeal nerve
(SPG) and its vessels using a Maryland dissector and dis- (RLN) from the trachea and CTM (cricothyroid muscle)

Patient Positioning away from the lesion. The lesion-side arm is

Patient Preparation. With the patient in the abducted by 80° from body to expose axilla and
supine positions and under general anesthesia, lateral neck, and the head is tilted and rotated to
the neck is extended slightly by inserting a soft face the non-lesion side (Fig. 24.8) [4, 5, 34]. The
pillow under the shoulder and the face is turned landmarks for flap dissection are bounded by the
24 Robotic Thyroidectomy and Radical Neck Dissection Using a Gasless Transaxillary Approach 279

sternal notch and the midline of the anterior neck

medially, the anterior border of the trapezius
muscle laterally, and the submandibular gland
superiorly.

Creation of Working Space. A 7–8 cm vertical

skin incision is made in the axilla along the ante-
rior axillary fold and the lateral border of the pec-
toralis major muscle. The subcutaneous flap from
the axilla to the midline of the anterior neck is dis-
sected over the anterior surface of the pectoralis
major muscle and clavicle by electrical cautery
under direct vision. After exposing the clavicle,
subplatysmal flap dissection proceeds to the mid-
line of the anterior neck medially, to the upper
point where the external jugular vein and greater
auricular nerve cross the lateral border of the SCM
muscle superiorly. The external jugular vein is
ligated at the crossing point of the SCM muscle.
Laterally the trapezius muscle is identified and
dissected upward along its anterior border. During
the flap dissection in the posterior neck area, the
spinal accessory nerve is identified and exposed
along its course. After subplatysmal flap dissec-
tion, the clavicular head of the SCM is divided at
Fig. 24.7 Postoperative outcomes. (a) Operative scar the level of its attachment to the clavicle to expose
3 months after robotic thyroidectomy. (b) Concealment of
an axillary scar by a patient arm by her side in the normal the junction area between the IJV and the subcla-
position vian vein, and the dissection proceeds upward

Fig. 24.8 Patient position for robotic MRND. The neck body to expose the axilla and lateral neck, and the head
was extended slightly and the face was turned away from was tilted and rotated to face the non-lesion side
the lesion. The lesion-side arm was abducted 80° from the
280 J. Lee and W. Chung

along with the posterior surface of the SCM to manner to the camera arm (to face downward).
expose the submandibular gland and the posterior Finally, the external three joints of the robotic
belly of the digastric muscle. The proximal exter- arms should form an inverted triangle. These
nal jugular vein is then clipped and divided at the proper positioning of angles are important to
crossing point of the SCM lateral border, and soft prevent collisions between robotic arms.
tissue detachment from the posterior surface of the
SCM is continued lateral to medial until the IJV Step-by-Step Review of Critical
and CCA are exposed. After flap dissection, the Elements of the Robotic MRND
patient’s head is returned to the neutral position. Console Stage. Actually, the robotic modified
A spatula-shaped wide external retractor (Chung’s radical neck dissection procedure is similar to
retractor) is then used to raise and tent the skin flap conventional open technique. Lateral neck dis-
at the anterior chest wall, the SCM, and the strap section is initiated from the level III and IV area
muscles to create a working space. The entire neck around the IJV. The IJV is handled medially
levels (level IIa, III, IV, Vb, and VI areas) are fully using the ProGrasp forceps, and soft tissues and
exposed by elevating the SCM muscle and the LNs are pulled laterally using a Maryland dissec-
strap muscles. A second skin incision (0.6–0.8 cm tor. Careful dissection is needed during the
long) is then made on the medial side of the ante- detachment of the LNs from the posterior aspect
rior chest wall to allow the fourth robotic arm to be of the IJV to avoid injury to the CCA and the
inserted (2 cm superiorly and 6–8 cm medially vagus nerve. Smooth, sweeping, lateral move-
from the nipple). ments of a Harmonic curved shears can establish
a proper plane and allow vascular structures to be
Robot Positioning and Docking differentiated from specimen tissues. The dissec-
Robot Positioning and Docking Stage. The tion of the IJV is progressed upward from level
robotic column is placed on the lateral side of the IV to the upper level III area. During this proce-
patient contralateral to the main lesion, and the dure, the superior belly of the omohyoid muscle
operative table is positioned slightly obliquely is cut at the thyroid cartilage level. Bundle of LNs
with respect to the direction of the robotic col- are then drawn superiorly using the ProGrasp for-
umn to allow direct alignment between the axis ceps, and the LNs are meticulously detached
of the robotic camera arm and the operative from the junction of the IJV and subclavian vein.
approach. Proper introduction angles are impor- In general, the transverse cervical artery as a
tant to prevent collisions between robotic arms. branch of the thyrocervical trunk courses laterally
Four robotic arms are used during the operation. across the anterior scalene muscle, anterior to the
Three arms are inserted through the axillary inci- phrenic nerve. Using this anatomic landmark, the
sion. A 30° dual-channel camera is placed on the phrenic nerve and transverse cervical artery can
camera arm through a 12-mm cannula which be preserved without injury or ligation. Further
should be placed in the center of the axillary skin dissection is followed along the subclavian vein
incision. In particular, the camera arm has to be laterally. The inferior belly of omohyoid muscle
inserted to face upward which means the external is cut where it meets the trapezius muscle. The
third joint should be placed in the lower portion distal external jugular vein is then clipped and
(floor) of the incision entrance, and the camera divided at its connection with the subclavian
tip should be directed upward. The 5-mm vein. Level VB dissection in the posterior neck
Maryland dissector is installed on the left side of area proceeds along the spinal accessory nerve in
the camera and the Harmonic curved shears on the superomedial direction, and is followed by
the right side through 8-mm cannula. A ProGrasp level IV dissection, while preserving the brachial
forceps is placed on the fourth arm and inserted nerve plexus, the phrenic nerve, and the thoracic
through the 8-mm anterior chest cannula. The duct. The dissection proceeds by making turns at
Harmonic curved shear and the Maryland dissec- levels VB, IV, and III and then by proceeding
tor arms should be inserted in the opposite upward to the level IIA area. The individual
24 Robotic Thyroidectomy and Radical Neck Dissection Using a Gasless Transaxillary Approach 281

nerves of the cervical plexus are sensory nerves,

and when encountered during dissection, some of
them might be sacrificed to ensure complete node
dissection, while preserving the phrenic nerve
and ansa cervicalis.
After performing the level III, IV, and VB node
dissection, re-docking is needed for a better oper-
ating view to dissect the level II LN. The external
retractor is then reinserted through the axillary
incision and directed toward the submandibular
gland. The operating table should also be reposi-
tioned more obliquely with respect to the direction
of the robotic column to allow the same alignment
between the axis of the robotic camera arm and the
direction of retractor blade insertion. Drawing the
specimen tissue inferolaterally, soft tissues and
LNs are detached from the lateral border of the
sternohyoid muscle, the submandibular gland, and
the anterior surfaces of the carotid artery and the
IJV. Level IIA dissection is advanced until the pos-
terior belly of the digastric muscle is exposed
superiorly. After removing the specimen, fibrin
glue is sprayed around the area of the thoracic duct
and minor lymphatics, and a 3-mm closed suction Fig. 24.9 Comparison of postoperative scars 6 months
drain is inserted just under the axillary skin inci- after (a) conventional unilateral (right) open MRND and
sion. Wounds are closed cosmetically. The incision (b) bilateral robotic MRND
scar in the axilla is completely covered when the
arm is in its neutral position (Fig. 24.9a, b) [5, 35]. lowing 1,000 consecutive robotic thyroidectomies
performed by a single surgeon was 0.8 %, whereas
the rate following robotic thyroidectomy in 1,043
Review of Perioperative Outcomes consecutive patients in several centers was 1.0 %
[38, 40]. These complication rates are comparable
Perioperative Outcome to those following open thyroidectomy performed
in experienced centers of excellence. However,
Over the past decade, robotic thyroidectomy has these results come from centers with the largest
gained considerable traction in thyroid surgery, worldwide experience with robotic thyroidec-
both locally in South Korea and abroad. tomy and may not be generalizable to less experi-
Perioperative results, including operation time, enced centers, especially during their early
volume of blood loss, length of hospital stay, adoption of this technique.
occurrence of perioperative complications, and A recent multicenter trial of 2,014 patients
recurrence rates following robotic thyroidectomy, with thyroid cancers showed that robotic thyroid-
are summarized in Table 24.1 [9, 11–14, 16, 17, ectomy yielded excellent postoperative out-
21, 28–30, 34–45]. The operative safety and fea- comes, including minimal complication rates, a
sibility of robotic thyroidectomy were demon- high degree of oncological safety, and superior
strated in studies of 100, 200, 338, and 1,000 ergonomic benefits for surgeons [40]. In this
procedures performed by a single surgeon [9, 28, study, surgeons completed a survey about neck,
29, 38] and of 1,043 procedures performed at sev- shoulder, and back muscle discomfort after open,
eral centers [40]. The major complication rate fol- endoscopic, and robotic thyroidectomies. These
Table 24.1 Clinical outcomes after robotic thyroidectomy (or robotic modified radical neck dissection) using a gasless transaxillary approach
Major
complicationsa
Pathology Operative time (Conversion Hospital stay
Author (year) Cases (patients) Operation type (Mean[±SD], min) to open) (Mean[±SD], days) Recurrence Character
Robotic thyroidectomy with/without central compartment node dissection
Kang et al. [9] 100 PTMC (100) TT and Total:136.5 ± 36.6 0/80(0 %) 3.0 ± 0.45 None Single surgeon
CCND (16) Console:59.9 ± 25.9 (None) experience (Chung’s
LTT and data)
CCND (84)
Kang et al. [28] 200 PTC (200) TT and Total:141.1 ± 38.8 1/200(0.5 %) 3.2 ± 0.6 None Single surgeon
CCND (45) Console:57.6 ± 23.8 (None) experience (Chung’s
LTT and data)
CCND (155)
Kang et al. [29] 338 PTC (332) TT and Total:144.0 ± 43.5 5/338 (1.5 %) 3.3 ± 0.8 None Single surgeon
Benign (6) CCND (104) Console:59.1 ± 25.7 (None) experience
TT and (Chung’s data)
CCND (234)
Ryu et al. [30] 1,047 PTC (1042) TT and Total:114.94 ± 27 5/1047 (0.5 %) 3.13 ± 0.58 None Single surgeon
FTC (2) CCND (371) Console:48.26 ± 11.88 (None) experience; single-
MTC (3) LTT and incision technique
CCND (676) (Chung’s data)
Landry et al. [11] 12 PTC (1) LTT (12) Total:142 0/12 (0 %) 1 None M.D. Anderson surgery
FTC (1) Completion (None) group; initial experience
Benign (9) TT (1)
Lewis et al. [12] 5 LTT (5) Total: 30–90 M.D. Anderson ENT
group; cadaver
dissection
Berber et al. [13] 2 TT (1) 0/2 (0 %) 1 (None) Cleveland surgery
LTT (1) group; initial experience
Berber et al. [36] 1 PTC (1) TT and 0/1 (0 %) 1 (None) Cleveland surgery
CCND (1) group; Surgical
completeness
Brunaud et al. [37] 1 Benign (1) TT (1) 0/1 (0 %) 1 (None) France; initial
experience
Kang et al. [38] 1,000 PTC (996) TT and Total: 136.7 ± 44.4 8/1000 (0.8 %) 3.0 ± 0.45 None Single center in Korea
FTC (1) CCND (337) (None)
HCC (1) TT and
MTC (2) MRND (36)
LT and
CCND (627)
Lee et al. [39] 1,043 PTC (1041) TT (366) LTT Total: 132.4 ± 48.5 10/1043 (1.0 %) 2.9 ± 0.8 None Multicenter study in
FTC (2) (677) Console:63.9 ± 39.5 (None) Korea
CCND (940)
MRND (35)
Lee et al. [40] 2,014 PTC (1947) TT (740) LTT Total:119.7 ± 61.8 21/2014 (1.0 %) 3.4 ± 2.3 None Multicenter study in
FTC (6) (1274) Console:65.8 ± 29.2 [(1/2014) Korea; surgeon’s
HTC (1) CCND (1865) (Conversion: one case) (0.05 %)] ergonomic consideration
MTC (5) MRND (61)
Benign (55)
Kuppersmith 31 PTC (3) TT (11), LTT(20) Total:196 →109 0/31 (0 %) 1 None M.D. Anderson ENT
et al. [14] Benign (28) Console:131→51 (None) group
Ishikawa et al. [16] 1 PTC (1) LT and CCND (1) Total:228 0/1 (0 %) 2 (None) Japan; initial experience
Lang et al. [17] 7 DTC (1) TT (4), LTT(3) Total:149 1/7 (14.3 %) 2 None Hong Kong; initial
Benign (6) Console:80 (None) experience
Kandil et al. [41] 5 Graves’ disease TT (5) Total:159 ± 17.82 0/5 (0 %) 1 (None) New Orleans: Graves
(5) disease
Kandil et al. [42] 50 TT (13), Total: 122.5 0/50 (0 %) 1 Console: 55.5 None New Orleans
LTT(37) (None)
Massasati et al. [43] 1 Benign LTT (1) Total: 69 0/1 (0 %) 1 (None) New Orleans; video
Console: 21 clip-neuromonitoring
Kandil et al. [44] 100 TT (22), Total: 108.1 ± 1/100 (1 %) 1 (Conversion: None New Orleans; BMI,
LTT (69) 60.5 Completion TT (9) two cases) learning curve
Tae et al. [21] 113 Benign (21) TT (44), LTT (69) TT (total): 0/100 (0 %) 5.9 None Single Surgeon in Korea
DTC (92) CCND (72) 184.5 ± 42.3 (None)
LTT (total):
147.9 ± 33.1
(continued)
Table 24.1 (continued)
Major
complicationsa
Pathology Operative time (Conversion Hospital stay
Author (year) Cases (patients) Operation type (Mean[±SD], min) to open) (Mean[±SD], days) Recurrence Character
Kiriakopoulos 8 Toxic TT (42), LTT (3) Total: 211 0/8 (0 %) 1.5 None Greece; initial
et al. [45] adenoma (3) TT and Console: 166 experience,
Multinodular CCND (1) postoperative visual
goiter (2) analogue score, cost
PTC (3)
Robotic modified radical neck dissection
Kang et al. [34] 33 PTC (33) TT and Total:280.8 ± 40.6 0/33(0 %) 5.4 ± 1.6 None Single surgeon
MRND (33) (None) (Chung’s data); initial
experience of robotic
MRND
Kang et al. [35] 56 PTC (56) TT and Total:277.4 ± 43.2 0/56(0 %) 6.0 ± 2.5 None Single center experience
MRND (56) (None) (Chung’s data) Robotic
MRND
PTMC papillary thyroid microcarcinoma, TT total or near-total thyroidectomy, CCND central compartment node dissection, LTT less than total thyroidectomy, PTC papillary thyroid carcinoma,
FTC follicular thyroid carcinoma, MTC medullary thyroid carcinoma, MRND modified radical neck dissection, HTC hurthle cell carcinoma, DTC differentiated thyroid carcinoma
a
Major complications were defined as those causing permanent damage, such as recurrent laryngeal nerve injury, permanent hypocalcemia, hematoma of the muscle flap requiring reoperation,
hemorrhage of a major vessel requiring reoperation, tracheal injury, Honor’s syndrome, major chyle leakage, and brachial plexus neuropraxia, but did not include minor complications such as
transient hypocalcemia, transient hoarseness, wound seroma, wound infection, and hematoma of the muscle flap requiring conservative management
24 Robotic Thyroidectomy and Radical Neck Dissection Using a Gasless Transaxillary Approach 285

three approaches involve different physical tasks, (or endoscopic) thyroidectomy, as well as any nota-
and the type and magnitude of musculoskeletal ble outcomes of these studies [17–26, 35, 45, 48,
stress vary. The results of the survey showed that 49]. Early measures of oncologic success, includ-
use of the robotic technique reduced musculo- ing postoperative 131RI scan and Tg concentra-
skeletal discomfort, compared with that experi- tions, as well as the number of harvested cervical
enced during open or endoscopic thyroidectomy. LNs, were similar in large groups of patients who
underwent robotic versus conventional thyroidec-
tomy. Several recent reports showed that robotic
Operation Time and Surgical thyroidectomy with or without radical neck dissec-
Learning Curve tion, when performed by experienced surgeons,
yielded excellent postoperative oncologic outcomes
Any new technology requires a learning curve compared with conventional techniques.
and a period of adaptation. Moreover, the rising A retrospective comparison of 192 patients
cost of health care requires a determination of who underwent robotic total thyroidectomy with
whether the advantages of a new technique merit 266 who underwent open thyroidectomy [20]
any increases in cost and time. Assessment of the showed no differences in oncologic outcomes,
learning curve for robotic thyroidectomy by a including postoperative 131RI scan and Tg con-
single pioneering surgeon showed that the actual centrations, and number of harvested cervical
operation (console) time for robotic thyroidec- LNs. Moreover, a comparison of 580 consecutive
tomy reached a standard of around 60 min after patients who underwent robotic thyroidectomy
approximately 40–45 operations [29]. A com- with 570 who underwent conventional endoscopic
parison of perioperative outcomes and surgical thyroidectomy found that the real operation time
learning curves for robotic and endoscopic thy- tended to be shorter and the mean number of
roidectomy by a single surgeon showed that retrieved central LNs greater in the robotic than in
robotic thyroidectomy resulted in a shorter oper- the endoscopic group [18]. Another retrospective
ation time and a more rapid learning curve (35– comparison of 96 thyroid cancer patients who
40 operations) than conventional endoscopic underwent conventional endoscopic and 163 who
thyroidectomy (55–60 operations) [22]. underwent robotic thyroidectomy, all performed
The learning curves for robotic thyroidectomy by a single surgeon, showed the number of
were evaluated in a multicenter trial by analyzing a retrieved cervical LNs was greater, the operation
range of perioperative parameters, including opera- time was shorter, and the surgical learning curve
tion time, complication rate, intraoperative blood was shorter, for robotic than for conventional
loss, length of hospital stay, number of dissected endoscopic thyroidectomy [22]. Together, these
LNs, and extent of complete resection [46, 47]. The findings indicate that the robotic technique was
study results indicated that to become proficient in superior to conventional endoscopy in thyroid
robotic total thyroidectomy with CCND and subto- cancer patients. Another retrospective comparison
tal thyroidectomy with CCND, a surgeon must per- of robotic and endoscopic thyroidectomies by a
form 50 and 40 operations, respectively. Moreover, single surgeon in South Korea found that the
beginning surgeons had acquired the necessary oncologic outcomes were better after robotic than
technical skills, similar to those of experienced sur- after conventional endoscopic thyroidectomy in
geons, once the learning curve was overcome. patients with thyroid cancer [21].

Oncologic Efficacy and Outcome Patient Perception and Satisfaction

After Robotic Thyroidectomy
Short-term oncologic data from large numbers of
patients have established the oncologic efficacy Several recent studies have evaluated patient per-
of robotic surgery. Table 24.2 summarizes the ception of and satisfaction with robotic thyroid-
results of studies comparing robotic and open ectomy (Table 24.2). Questionnaires evaluating
Table 24.2 Postoperative outcomes in patients undergoing robotic and endoscopic (or open) thyroidectomy
Author (year) Cases Operation time Complication rate Oncologic safetya Functional outcomes Comments
Open thyroidectomy (OT) vs. robotic thyroidectomy (RT)
Lee et al. [23] OT (43) vs. Operation time No difference No difference Cosmetic satisfaction (RT > OT), First comparative study of
RT (41) (RT > OT) hyper or paresthesia on neck functional outcomes
(OT > RT) Cosmetic outcomes, sensory
Voice handicap index (OT = RT) change
Swallowing impairment score Swallowing discomfort:
(OT > RT) RT > OT
Tae et al. [25] RT (41) vs. Operation time No difference No difference Cosmetic satisfaction (RT > OT), Cosmetic outcomes
OT (163) (RT > OT) Pain (OT = PT) RT > OT
Tae et al. [19] RT (75) vs. Operation time Transient - No difference Cosmetic satisfaction (RT > OT), Cosmetic outcomes, sensory
OT (226) (RT > OT) hypoparathyroidism hyper or paresthesia on neck change
(OT > RT) (OT > RT), hyper or paresthesia RT > OT
on chest (RT > OT)
Lee et al. [20] RT (192) vs. Operation time No difference No difference No data Oncologic safety, complication
OT (266) (OT > RT) rates: RT = OT
Landary et al. [48] RT (25) vs. Operation time Brachial plexus injury No difference No data Oncologic safety: RT = OT
OT (25) (RT > OT) (RT > OT)
Foley et al. [49] RT (11) vs. Operation time No difference No difference No data Safety: RT = OT
OT (16) (RT > OT)
Tae et al. [26] RT (50) vs. Operation time No difference No difference Voice function (RT > OT) Voice function: RT > OT
OT (61) (RT > OT) Swallowing function (RT = OT)
Lee et al. [24] RT (42) vs. No data No difference No difference Objective voice function Voice function recovery:
OT (46) (RT = OT) RT = OT
Endoscopic thyroidectomy (ET) vs. robotic thyroidectomy(RT)
Lee et al. [22] RT (163) vs. Operation time No difference Retrieved LN No data First comparative study of RT
ET (96) (ET > RT) (RT > ET) and ET, showing that RT was
Learning curve superior in operation time, LN
(ET > RT) retrieval, and learning curve
Advanced cancer
(RT > ET)
Lang et al. [17] RT (7) vs. Operation time No difference No data No data Reported initial experience of
ET (39) (RT > ET) RT in Hong Kong
Lee et al. [18] RT (580) Operation time Transient - Retrieved LN No data RT was superior to ET in
ET (570) (ET > RT) hypoparathyroidism (RT > ET) operation time, and number of
Advanced cancer (RT > ET) LNs retrieved
(RT > ET)
Kiriakopoulos RT (8) Operation No difference No data Visual analogue scale Comparative study of visual
et al. [45] ET (4) (ET > RT) (RT = ET) analogue scale and cost between
Cost (RT > ET) RT vs. ET
Tae et al. [21] RT (113) Operation time No difference Retrieved LN Neck and anterior chest RT was superior to ET for
ET (105) (RT > ET) (RT = ET) pain (RT = ET) performing TT, bilateral CCND.
Cosmesis (RT = ET) In terms of cost effectiveness,
ET was comparable to RT in
performing LTT
Open MRND vs. robotic MRND
Kang et al. [35] Robot (56) vs. No difference No difference No data First comparative study of
operation time Advanced stage robotic MRND and open
(RT > OT) (OT > RT) MRND, showing that robotic
Open (109) MRND was superior in cosmetic
outcome, and no difference in
complication rate and oncologic
safety between two groups
LN lymph node
a
Oncologic safety: Surgical completeness and radicality, representing the results of 131RI scans, serum thyroglobulin level, postoperative neck ultrasound, and number of retrieved lymph nodes
288 J. Lee and W. Chung

Table 24.3 Advantages and disadvantages of robotic compared with open (or endoscopic) thyroidectomy
Robotic Open Robotic Endoscopic
thyroidectomy vs. thyroidectomy thyroidectomy vs. thyroidectomy
Operation time Worse than Better than
or similar to
Cost Worse than Worse than
Morbidity Similar to Better than
or similar to
Cosmetic Much better NA*
satisfaction than
Pain Better than NA
or similar to
Neck discomfort Better than NA
Swallowing Better than NA
discomfort or similar to
Voice change Better than NA
or similar to
Learning curve NA Better than
Surgeon’s ergonomic Better than Much better than
consideration
*
NA no available data

patient satisfaction and regret found that robotic that QOL measurements, including pain, neck
thyroidectomy yielded better patient outcomes, discomfort, voice changes, swallowing changes,
including reduced pain, increased cosmetic satis- and cosmetic measurements, favored robotic thy-
faction, and improved QOL [21–26]. Moreover, roidectomy [4].
robotic thyroidectomy resulted in better postop- The relative advantages and disadvantages of
erative functional outcomes, as shown by lower robotic and open thyroidectomy on patient QOL
rates of hyperesthesia, paresthesia, and swallow- remain unclear. Moreover, because the robotic
ing discomfort. Robotic thyroidectomy does not technique was first introduced in late 2007, long-
involve midline dissection of the strap muscle term surgical outcomes are yet undetermined.
and is associated with a reduction in traction over Efforts continue to be made to modify the tech-
the paraesophageal area; this may prevent the nique to further improve patient satisfaction and
development of postoperative swallowing prob- QOL. Additional scientific studies are needed to
lems and voice impairment [4, 23]. critically compare the effectiveness of robotic,
Patients undergoing open surgery experienced open, and endoscopic thyroidectomy, with results
higher levels of dissatisfaction and regret than of these studies helping to define the role of
those undergoing robotic surgery, as shown by robotic thyroidectomy in patients with thyroid
the analysis of multiple QOL measurements [23]. disease. Endocrine surgeons are central to this pro-
Moreover, studies of early postoperative voice cess and should honestly counsel patients, providing
changes showed that patients undergoing robotic a realistic forecast of outcomes, based on our expe-
thyroidectomy had improved short-term voice rience and specific to each patient’s unique situation.
and swallowing outcomes than those undergoing Due to the current refinements of the conven-
conventional open thyroidectomy [21–26], with tional method, not all physicians will find robotic
the most obvious difference being satisfaction techniques worthwhile to pursue. Although the
with the postoperative scar. A systemic review of literature addressing the merits and demerits of
prospective trials comparing robotic thyroidec- robotic thyroidectomy is extensive, diversity of
tomy and open (or endoscopic) surgery found opinion predominates over consensus. Table 24.3
24 Robotic Thyroidectomy and Radical Neck Dissection Using a Gasless Transaxillary Approach 289

summarizes the published results comparing the

advantages and disadvantages of robotic thyroid- Limitations and Future Directions
ectomy with conventional open and endoscopic in Robotic Thyroidectomy
thyroidectomy.
Endoscopic thyroid surgery, although becoming
more popular in parts of Asia, has not been
Robotic Modified Radical Neck widely used because of limited technical feasibil-
Dissection Procedure ity. The limitations of conventional endoscopic
thyroidectomy led to the development of robotic
Our initial evaluation of outcomes after robotic surgical systems, and future telerobotic surgery is
modified radical neck dissection (MRND) in 33 not far away, enabling a surgeon to operate at a
patients with papillary thyroid carcinoma (PTC) distance from the operating table. Although
and lateral neck node metastasis (N1b) showed experience with robotics is very recent, it has
that robotic MRND was satisfactory, with no great potential in many areas of medicine.
serious postoperative complications observed Moreover, due to increased awareness of these
and that use of axillary incisions yielded maximal techniques by clinicians and patients, the popu-
cosmetic effects [34]. This technique allowed larity of robotics may become patient driven. As
the precise manipulation of robotic instruments robotic approaches to other types of general and
and complete compartment-oriented dissection urologic surgery become more feasible, robotic
without injuring major vessels or nerves or thyroidectomy and neck dissection will be more
compromising surgical oncologic principles. widely used and become accepted as an alterna-
Recently, early postoperative outcomes were tive to traditional open surgery.
compared in 56 patients who underwent robotic Before the widespread acceptance of this
MRND and 165 who underwent open MRND [35]. technology in thyroid surgery, however, its bene-
In that study, the mean tumor size was smaller, fits to patients must be carefully evaluated and
the mean age was lower, and the disease stage proven. In the absence of clear guidelines and
was earlier in the robotic MRND group. Although without proper training of operators, the applica-
the mean operation time was significantly longer tions of robotic surgery will be limited. A steep
in robotic than in open MRND, the complication learning curve, the relatively high costs of equip-
rates were similar. Taken together, the short-term ment and consumables, and the absence of a clear
oncologic effectiveness of thyroid surgery, as cost-benefit analysis hamper the widespread use
assessed by serum Tg concentration, 131RI scan, of robotic surgery. The loss of tactile sensation is
and cervical LNs retrieved, appears to show that often cited as a disadvantage of working with
robotic and open thyroidectomy are equivalent, robotic systems. Although most surgeons are
whereas mean hospital stay after robotic MRND able to compensate using the improved visual
was shorter. In contrast, long-term effectiveness, feedback afforded by the 3-D display, the absence
evaluated as lack of tumor recurrence, cannot of tactile feedback and the high cost of the tech-
yet be determined due to the relatively short time nology remain limitations to its adoption. New
the robotic technique has been in use. Together, generations of robotic surgical systems should
these findings indicate that the oncologic out- address these defects.
comes and safety of robotic and conventional Nations differ widely in financial models of
open MRND were similar, whereas robotic health care. South Korea has a combined model,
MRND provides more satisfactory cosmetic involving both national and private insurance.
outcomes compared with the long neck scar Recognition of the worth of robotic systems, and
resulting from open MRND. However, robotic agreement by insurance companies to reimburse
MRND remains at an early stage, and the advan- charges associated with its use, will significantly
tages and disadvantages of this new technique affect its utilization, as reflected by the expansion
require further evaluation. of its use in South Korea. Regardless of financial
290 J. Lee and W. Chung

model, however, only centers with substantial studies with long-term follow-up periods are
patient volumes can reduce the average cost of needed to determine whether the robotic proce-
robotic surgery procedures to more affordable dure is superior to endoscopic or open thyroidec-
levels. The sustainability of robotic systems in tomy in terms of patient satisfaction and QOL
some publicly funded systems and in many pri- outcomes.
vate care systems remains very challenging.
It is unrealistic to expect that patients will Author Disclosures All authors including Drs. Lee and
have a complete understanding of the literature Chung have no conflicts of interest or financial ties to
disclose.
and the results of QOL outcome analysis and
reporting. It remains the responsibility of clini-
cians to help patients gain a deeper appreciation
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 Robotic Adrenalectomy
25
Halit Eren Taskin and Eren Berber

formed as a left adrenalectomy using AESOP

General Overview [5]. While these studies were reported from
Europe, the first application of robotic system
After the initial reports by Gagner et al. [1] and for adrenalectomy was reported in pigs at the
Mercan et al. [2], the laparoscopic techniques Cleveland Clinic in the USA [6]. After the FDA
have been standard in the removal of adrenal approval of da Vinci system for use in general
tumors. Although accepted as a safe and effective surgical procedures in July 2000, Horgan et al.
procedure, laparoscopic approach has certain dis- reported 34 advanced general surgical cases
advantages including the two-dimensional view, (including single bilateral adrenalectomy) that
unstable camera platform, and rigid instrumenta- were performed with using this system [3]. Since
tion. Robotic technology can potentially provide then, numerous studies and case reports describ-
a solution to these drawbacks of minimally inva- ing RA have been published in the literature
sive surgery, owing to the three-dimensional (Table 25.1) [7–25].
view, wristed instrument, and stable camera plat- Both posterior retroperitoneal (PR) and lat-
form [3]. eral transabdominal (LT) adrenalectomies have
The first published robotic adrenalectomy been described robotically and demonstrated to
(RA) was by Piazza et al. [4], as a right adrenal- be feasible and safe [4, 7]. The indications for
ectomy in a patient with Conn’s syndrome using robotic adrenalectomy are the same as the lapa-
the ZEUS AESOP system. In the same year, roscopic procedure and comprise hormonally
Hubens et al. also reported a case that was per- active adrenal tumors, including pheochromocy-
toma, aldosteronoma, and Cushing’s, as well
large (>4–6 cm) or enlarging tumors suspicious
for malignancy [4, 8].

H.E. Taskin, M.D.

Research Fellow at Endocrine Surgery Division, Robotic Lateral Transabdominal
Cleveland Clinic, 9500 Euclid Avenue/F20, Adrenalectomy
Cleveland, OH 44195, USA
Department of General Surgery, Cleveland Clinic, Positioning
9500 Euclid Avenue/F20, Cleveland, OH, USA
e-mail: [email protected]
After intubation and administration of general
E. Berber, M.D., F.A.C.S. (*)
anesthesia the patient is placed in a lateral right
Department of General Surgery, Cleveland Clinic,
9500 Euclid Avenue/F20, Cleveland, OH, USA or left decubitus position according to the side of
e-mail: [email protected] the mass (Fig. 25.1).

K.C. Kim (ed.), Robotics in General Surgery, DOI 10.1007/978-1-4614-8739-5_25, 293

© Springer Science+Business Media New York 2014
294 H.E. Taskin and E. Berber

Table 25.1 Robotic adrenalectomy cases involving >30 patients reported in the literature
Average
Year Mean OR Conversions tm size Complications Hospital stay
Author published Approach n time (min) (%) (cm) (%) (days)
Winter 2006 LT 30 185 0 2.4 7 2 (median)
et al. [14]
Brunaud 2008 LT 100 99 5 2.9 ± 1.9 10 6.4 ± 3
et al. [11] (mean)
Giulianotti 2010 AT 42 118 ± 46 0 5.5 4.8 4 (median)
et al. [8]
Raman 2011 LT–AT 40 117 ± 50 4 6.97 10 3.2 ± 1.2
et al. [23] (mean)
Nordenstrom 2011 LT 100 113 7 5.3 13 –
et al. [22]
Agcaoglu 2012 PR 31 163.2 0 3.1 0 1 (median)
et al. [24]
Karabulut 2012 LT–PR 50 166 ± 7 1 3.9 ± 0.3 1 1.1 ± 0.3
et al. [25] (mean)
LT lateral transperitoneal, PR posterior retroperitoneal, AT anterior transperitoneal, VHL von hippel lindau, IVC inferior
vena cava

when necessary (Fig. 25.2). This is usually the

most medial port for right-sided and the most lat-
eral port for left-sided masses. In special circum-
stances such as obese individuals, or patients
with short stature, the position of the first assis-
tant port might need to be changed depending on
the anatomy.

Robot Positioning and Docking

The robot is docked coming to position from the

ipsilateral shoulder of the patient and robotic tro-
cars are connected (Fig. 25.3). The table might
need to be rotated clockwise according to the
patient’s anatomy. Close cooperation with an
Fig. 25.1 Intraoperative photo showing the position of experienced anesthesia team is very important for
the patient in robotic left LT adrenalectomy
a fast docking.

Trocar Placement
Steps of the Operation
The first optical 12 mm trocar is introduced mid-
way between the umbilicus and the costal mar- For right adrenal tumors, first, the liver is mobi-
gin. After CO2 insufflation, two 8 mm and one lized by dividing the right triangular ligament.
15 mm robotic trocars are placed beneath the cos- For left-sided tumors, the splenocolic and sple-
tal margin. The trocar placement should be con- norenal ligaments are divided using electrocau-
figured to give enough space for the first assistant tery (Fig. 25.4a, b). Then, laparoscopic
to use the suction-irrigator and the clip applier ultrasound is performed to identify the lesion
25 Robotic Adrenalectomy 295

Fig. 25.2 Intraoperative photo showing the position of the robotic trocars and first assistant port for a left LT
adrenalectomy

Fig. 25.3 Intraoperative image depicting the position of the robotic system in a robotic right LT adrenalectomy
296 H.E. Taskin and E. Berber

and establish its relationship with adjacent

organs. These steps are done laparoscopically.
Then the robot is docked. The dissection is per-
formed along the lateral and superior borders of
the mass initially, followed the inferior and
medial dissection (Fig. 25.5). The adrenal vein is
divided either using the harmonic scalpel or
between clips based on its size (Fig. 25.6). After
the dissection is completed, the robot is
undocked. The tumor is removed using a speci-
men retrieval bag and morcellated if >3 cm
(Fig. 25.7). The operative site is irrigated and
suctioned laparoscopically. Then, the trocars are
removed. Fascial holes for the 12 mm trocar
sites are closed, followed by skin closure.

Hybrid Versus Totally Robotic

Approach

The laparoscopic portion of the case includes the

hepatic/splenic mobilization and extraction of the
specimen steps. The robot is used for the dissec-
tion of the mass. We believe that this approach
saves time and also determines the exact angle of
Fig. 25.4 Intraoperative figure showing the division of approach for robotic docking.
the right triangular ligament on the right (a) and spleno-
colic ligament on the left (b) for robotic LT
adrenalectomy

Fig. 25.5 Intraoperative

picture showing the robotic
dissection of a right-sided
pheochromocytoma via LT
approach
25 Robotic Adrenalectomy 297

Gerota’s space, this optical trocar is replaced by

a balloon trocar and a potential space is created
by inflating this trocar under direct vision
(Fig. 25.9). The balloon dissector is then removed
and this space is insufflated with CO2. Two 5 mm
trocars are inserted medial and lateral to the ini-
tial trocar.

Robot Positioning and Docking

The robot is brought in from the head of the table,

between the shoulders, with the final alignment
Fig. 25.6 Intraoperative photo showing the division of
the adrenal vein in a robotic left LT adrenalectomy depending on the location of the adrenal gland
(Fig. 25.10). The operating table might need to
be rotated, depending on the patient’s anatomy.

Steps of the Operation

We use a robotic grasper from the lateral port

and the robotic Harmonic scalpel from the
medial port. Depending on the progress of the
case, these instruments may need to be swapped.
The dissection is started superiorly and laterally
first. The inferior border is dissected next and
the medial border last (Fig. 25.11). The adrenal
vein is identified and divided either using the
Harmonic scalpel or between 5-mm clips placed
Fig. 25.7 Intraoperative figure showing extraction of the by the first assistant through the medial port
specimen in a robotic right LT adrenalectomy (Fig. 25.12). This requires removal of the
Harmonic scalpel temporarily. Suctioning is
also performed by the first assistant through the
Robotic Posterior Retroperitoneal same port when necessary. The robot is
Adrenalectomy undocked after the completion of adrenalec-
tomy. The specimen is extracted using a speci-
men retrieval bag (Fig. 25.13). The fascial
Positioning incision for the 12-mm port and the skin inci-
sions are closed.
After the intubation and administration of anes-
thesia on a gurney, the patient is placed in prone
jackknife position on a Wilson frame (Fig. 25.8). Hybrid Versus Totally Robotic
Approach

Trocar Placement
In this approach, after the trocars are placed and
First, an optical trocar is inserted inferior to the the retroperitoneal space is exposed, the proce-
12th rib through a cm incision. Once in the dure is finished robotically.
298 H.E. Taskin and E. Berber

Fig. 25.8 Intraoperative photo showing the patient position in a robotic right PR adrenalectomy

approach if the distance between the skin and the

Gerota’s space is 7 cm and the 12th rib is rostral
to the renal hilum [26]. In these patients, there
would be ergonomic manipulation of the trocars
to perform the adrenalectomy. Also, in patients
with bilateral tumors and extensive upper
abdominal scarring from previous operations,
we prefer the PR approach. If these principles
are adhered to, the outcomes of PR and LT adre-
nalectomy will be similar, as shown by us as well
as other groups [25, 27].

Fig. 25.9 Intraoperative image showing the retroperito- Review of the Literature
neal space dissected using a balloon trocar
The first randomized prospective trial comparing
laparoscopic approach to robotic counterpart was
Discussion reported by Morino et al. in 2004. There were 40
patients randomized to laparoscopic versus
Although both the LT and PR techniques are robotic surgery groups. Operative time was lon-
viable options for removing adrenal glands, there ger in the robotic group (169 vs. 115 min). There
is still controversy and bias among surgeons were no conversions to open; however, conver-
about the procedure of choice in a given patient. sion to laparoscopy was necessary in 4 of 10
In our practice we utilize the LT technique in robotic patients. Perioperative morbidity was
patients presenting with tumors >6 cm. In those also higher in the robotic group (20 % vs. 0 %),
patients with tumors <6 cm, we prefer the PR but hospital stay was similar. The cost of the
25 Robotic Adrenalectomy 299

Fig. 25.10 Intraoperative photo depicting the position of the robot in a left robotic PR procedure

On the other hand, Branaud et al. evaluated

100 patients who underwent robotic LT adrenal-
ectomy. The mean operative time for robotic-
assisted adrenalectomy was 95 min and
conversion rate was 5 %. Pathology was aldo-
steronoma (n = 39), pheochromocytoma (n = 24),
nonfunctional adenoma (n = 19), Cushing ade-
noma or hyperplasia (n = 16), and cyst (n = 2).
Morbidity and mortality rates were 10 % and
0 %, respectively. The mean operative time
decreased by 1 min every 10 cases. Operative
time improved more for junior surgeons than for
Fig. 25.11 Intraoperative photo showing dissection of an senior surgeons (P = 0.006) after the first 50
adrenal mass in a right robotic PR adrenalectomy cases. By multiple regression analysis, sur-
geon’s experience (−18.9 ± 5.5), first assistant
level (−7.8 ± 3.2), and tumor size (3 ± 1.4) were
robotic procedure was significantly higher than independent predictors of operative time
the laparoscopic counterpart ($3,467 vs. $2,737). (P < 0.001 each). The robotic procedure was 2.3
The authors concluded that laparoscopic adrenal- times more costly than lateral transperitoneal
ectomy was superior to robot-assisted in terms of laparoscopic adrenalectomy (4,102 vs. 1,799€).
feasibility, morbidity, and cost [17]. In conclusion, they commented that robotic
300 H.E. Taskin and E. Berber

Fig. 25.12 Intraoperative image depicting the division of adrenal vein in a left robotic PR adrenalectomy. IVC inferior
vena cava

tomy and in eight of these patients PR approach

was preferred. There were no conversions to
either laparoscopy or open surgery. The mean
operative time was 214.8 min. There were no
complications and patients are discharged on first
24 h. In this study, we believed that the robot
overcame the limitations of laparoscopic surgery
and was a refinement of the technique [9].
Giulianotti et al. also later reported that robotic
adrenalectomy could be a safe and feasible option
in high volume centers. In their series of 42
patients who underwent robotic LT
adrenalectomy, the mean lesion size was 5.5 cm,
Fig. 25.13 Intraoperative image showing extraction of
the specimen in a robotic right PR adrenalectomy with a median blood loss of 27 mL. The postop-
erative morbidity was 2.4 % and mortality 2.4 %.
Median hospital stay was 4 days. They had no
approach provided significant advantages to the conversions but one intraoperative complication
surgeon, such as more ergonomics and better due to capsular tear in a case of 6 cm pheochro-
image quality, although it was not cheaper or mocytoma. They also underscored that robotic
safer than the laparoscopic counterpart [11]. adrenalectomy can be good option for patients
The same group also evaluated the perioperative with higher BMI. They did not have any techni-
quality of life in patients after laparoscopic ver- cal challenges in their series where the patients
sus RA, and reported similar results between had a mean BMI of 30 kg/m2 [8].
two groups [28]. We have recently published our perioperative
Our group reported the first case series of outcomes of robotic adrenalectomy compared to
robotic posterior adrenalectomy in 2010. In this the laparoscopic approach. Fifty patients who
study, 23 patients underwent robotic adrenalec- underwent robotic adrenalectomy (both LT = 32
25 Robotic Adrenalectomy 301

and PR = 18 approaches) were compared with 50 In another study, we compared the perioperative
(LT = 32, PR = 18) consecutive patients who outcomes of robotic PR adrenalectomy versus
underwent laparoscopic adrenalectomy. For the laparoscopic PR adrenalectomy. Thirty-one
LT approach, despite larger tumor size in the patients who underwent robotic PR adrenalec-
robotic versus the laparoscopic group (4.7 ± 0.4 tomy were compared with 32 consecutive laparo-
vs. 3.8 ± 0.4 cm, P = 0.05), the operative times scopic patients. The mean tumor sizes for the
were similar (168 min vs. 159 min, P = 0.5). robotic and laparoscopic groups were similar
Regarding the time spent for the individual steps (3.1 vs. 3.0 cm, respectively; P = 0.48). For all
of the operation, the results were similar between patients, the mean skin-to-skin operative times
both approaches. In the PR approach, with similar were similar in both groups (163.2 vs. 165.7 min,
tumor sizes (2.7 cm vs. 2.3 cm, P = 0.4), operative respectively; P = 0.43). When the last 21 patients
time was equivalent (166 min vs. 170 ± 15 min; who underwent robotic PR adrenalectomy were
P = 0.8). Also, time spent intraoperatively for each compared with the 31 patients from the laparo-
step was similar, except for shorter hemostasis scopic series, it was seen that the mean operative
time in the robotic group (23 min vs. 42 min, time was shorter for the robotic group than for
P = 0.03). Interestingly, the presence of two staff the laparoscopic group (139.1 vs. 166.9 min;
surgeons versus a staff and a fellow decreased P = 0.046). The mean estimated blood losses and
operative time for the robotic LT (P < 0.02), but hospital stays were similar between the groups.
not the robotic PR approach. The morbidity was The mean pain score on postoperative day 1 was
10 % and 2 %, respectively, for laparoscopic and lower in the robotic group than in the laparo-
robotic procedures. We concluded that the intra- scopic group (2.5 vs. 4.2; P = 0.008); however,
operative time use was similar between two the mean pain scores for the groups were similar
groups for both LT and PR approaches; however, on postoperative day 14 (P = 0.53). There were
the robotic procedures were more favorable no deaths or cases of morbidity in either group. In
because of lesser morbidity and shorter hospital conclusion, we commented that once beyond the
stay over the laparoscopic counterpart [25]. learning curve, robotic posterior retroperitoneal
Another study from our group compared the adrenalectomy could shorten the operative time
use of robot versus standard laparoscopy in the compared to the laparoscopic approach [24].
resection of adrenal tumors >5 cm. Perioperative Robotic cortical-sparing partial adrenalec-
outcomes of 24 patients with 25 tumors who tomy can be used in bilateral adrenalectomy cases
underwent robotic adrenalectomy were compared where patients would require lifelong steroid
with those of 38 patients with 38 tumors who had supplementation. Julien et al. reported a case of
laparoscopic adrenalectomy. Tumor size was robotic cortical-sparing adrenalectomy in a
similar in both groups [6.5 (robotic) vs. 6.2 (lapa- patient with VHL disease who developed a right-
roscopic), P = 0.661]. Operative time was shorter sided pheochromocytoma at age 18, 9 years after
for the robotic versus laparoscopic group (159.4 his initial open adrenalectomy for left-sided
vs. 187.2 min, respectively, P = 0.043), while pheochromocytoma. This tumor was managed by
estimated blood loss was similar (P = 0.147). The robot-assisted cortical-sparing adrenalectomy,
conversion rate to open was less in the robotic and the patient was gradually weaned off the ste-
(4 %) versus the laparoscopic (11 %) group; roid replacement following 1 year after the
P = 0.043. Hospital stay was shorter for the operation [30]. Asher et al. also reported on 12
robotic group (1.4 vs. 1.9 days, respectively, patients undergoing 15 robotic partial adrenalec-
P = 0.009). The 30-day morbidity was 0 in robotic tomy procedures for pheochromocytoma. They
and 2.7 % in laparoscopic group. As a result we had one conversion to open where an inferior
concluded that the robot facilitated the resection venacaval injury ocured due to severe adhesions
of large adrenal tumors >5 cm and that it could to the liver. During their follow-up of 17.5
shorten operative time and decrease the rate of months, there were no recurrences and only one
conversion to open surgery [29]. patient has required steroid supplementation [31].
302 H.E. Taskin and E. Berber

Robotic adrenalectomy can also be feasible in 4. Piazza L, Caragliano P, Scardilli M, Sgroi AV, Marino
G, et al. Laparoscopic robot-assisted right adrenalec-
the setting of pregnancy. Podolsyky et al.
tomy and left ovariectomy (case reports). Chir Ital.
reported a case of robotic LT adrenalectomy for a 1999;51:465–6.
right-sided pheochromocytoma in a patient dur- 5. Hubens G, Ysebaert D, Vaneerdeweg W, Chapelle T,
ing second trimester of her pregnancy. The Eyskens E. Laparoscopic adrenalectomy with the aid
of the AESOP 2000 robot. Acta Chir Belg.
reported operative time was 270 min and the esti-
1999;99:125–7.
mated blood loss was 350 mL. The hemody- 6. Gill IS, Sung GT, Hsu TH, Meraney AM. Robotic
namic parameters of the patient were stable remote laparoscopic nephrectomy and adrenalec-
during the operation. They reported an unevent- tomy: the initial experience. J Urol. 2000;
164:2082–5.
ful postoperative course, and the patient had a
7. Choi KH, Ham WS, Rha KH, Lee JW, Jeon HG.
successful cesarean delivery at 39 weeks of ges- Laparoendoscopic single-site surgeries: a single-
tation [32]. center experience of 171 consecutive cases. Korean J
Urol. 2011;52:31–8.
8. Giulianotti PC, Buchs NC, Addeo P, Bianco FM,
Ayloo SM, et al. Robot-assisted adrenalectomy: a
Conclusion technical option for the surgeon? Int J Med Robot.
2011;7:27–32.
Over the last decade feasibility and safety of 9. Berber E, Mitchell J, Milas M, Siperstein A. Robotic
posterior retroperitoneal adrenalectomy: operative
robotic adrenalectomy both through lateral
technique. Arch Surg. 2010;145:781–4.
transabdominal and posterior retroperitoneal 10. Boris RS, Gupta G, Linehan WM, Pinto PA, Bratslavsky
approaches has been reported. Although these G. Robot-assisted laparoscopic partial adrenalectomy:
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doi:10.1016/j.urology.2010.07.501.
using robot in terms of patient outcomes, more
11. Brunaud L, Ayav A, Zarnegar R, Rouers A, Klein M,
recent studies have documented advantages et al. Prospective evaluation of 100 robotic-assisted
over the laparoscopic technique for the PR unilateral adrenalectomies. Surgery. 2008;144:
approach and also for removing large adrenal 995–1001.
12. Wu JC, Wu HS, Lin MS, Chou DA, Huang MH.
tumors. In our opinion, the robotic approach is
Comparison of robot-assisted laparoscopic adrenalec-
safe and feasible in centers experienced both in tomy with traditional laparoscopic adrenalectomy – 1
laparoscopic adrenalectomy and robotic sur- year follow-up. Surg Endosc. 2008;22:463–6.
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 Part IX
Surgical Techniques: Solid Organ
 Robot-Assisted Splenectomy
26
Luciano Casciola, Alberto Patriti,
and Graziano Ceccarelli

Introduction Indications to Minimally Invasive

Splenectomy: When a Robot-
Laparoscopic splenectomy (LS) was first described Assisted Approach?
in 1991 by Delaitre, and in the last two decades, it
has progressively become the procedure of choice LS can be considered a well-accepted approach
for nontraumatic splenic lesions [1, 2]. for the differential diagnosis and staging of
LS can be performed with times comparable lymphoproliferative diseases; for restaging after
to those required for open splenectomy, as well as chemotherapy or radiotherapy in abdominal
minimal morbidity and less postoperative pain. lymphoma, as well as when diseases recurrence
The postoperative length of stay is also signifi- is suspected; for the treatment of cystic or solid
cantly reduced following LS, which in turn can splenic lesions; and for the surgical treatment of
lead to decreased hospital costs [3]. blood disorders. The most accepted indications
Laparoscopy does, however, have some disad- to LS for hematological diseases are idiopathic
vantages, including two-dimensional vision and thrombocytopenic purpura not responsive to
rigid instrumentation, which can make splenec- conventional treatments, autoimmune hemo-
tomy for splenomegaly challenging. Robotic sur- lytic anemia, spherocytosis, beta-thalassemia,
gery (da Vinci®; Intuitive Surgical, Sunnyvale, hairy-cell leukemia, chronic idiopathic myelofi-
CA) can overcome these limitations providing brosis, and splenic lymphoma. To date, studies
“wrist-like” action of the instruments and three- conducted to investigate the role of robot-
dimensional visualization, resulting in high- assisted splenectomy (RS) did not show any
resolution binocular view of the surgical field and significant advantage over LS [4]. Nevertheless,
more precise dissection of the splenic vessels the endo-wristed movements and three-dimen-
even in difficult situations [4]. sional view may result advantageous in case of
difficult splenectomies in order to reduce the
complication and conversion rate. Whether a LS
is considered demanding can be ascribed to four
factors. Anatomy of the pancreatic tail can make
demanding spleen pedicle dissection when a
bulky or “intrasplenic” pancreatic tail is pres-
L. Casciola, M.D. • A. Patriti, M.D., Ph.D. (*) ent. Anatomy of the splenic vessels is another
G. Ceccarelli, M.D. factor. Splenic artery and vein branching off in
Division of General, Minimally Invasive and Robotic
multiple, short vessels can hamper their identifi-
Surgery, Department of Surgery, San Matteo degli
Infermi Hospital, Via Loreto, 3, Spoleto 06049, Italy cation and ligation. Spleen volume and consis-
e-mail: [email protected] tency is the most common factor determining

K.C. Kim (ed.), Robotics in General Surgery, DOI 10.1007/978-1-4614-8739-5_26, 307

© Springer Science+Business Media New York 2014
308 L. Casciola et al.

conversion of LS and the only one that can be – Plastic locking clip applier, medium and large
easily determined in the preoperative setting. – Endoscopic bag
The last condition impairing the good outcome
of LS is iatrogenic conditions, such as previous
radiotherapy [5]. With the exception of spleno- The Procedure
megaly, it is not easy to predict preoperatively
the difficulties encountered during LS. Stage 1
Therefore, indications to RS should be accu-
rately evaluated during laparoscopic explora- Patient Positioning and Robot Docking
tion, restricting the robot use to cases not The patient is placed in the supine position. The
suitable for LS. On the other hand, RS remains right arm is padded and tucked at the side. The on-
a good teaching model due to the absence of a table surgeon stands on the right side. The scrub
reconstructive phase and could be used to train nurse and instruments are positioned lateral to the
naïve robotic surgeons in order to deal with right leg (Fig. 26.1). A Mayo stand positioned over
more difficult situations. the right leg holds the most commonly utilized
instruments. Reverse Trendelenburg and tilting the
table on the right as necessary to take advantage of
Technical Aspects gravity and the weight of the stomach and trans-
verse colon to improve exposure. The robot is
Essential Operating Room Equipment docked over the patient left shoulder.

The Laparoscopic Operating Room Port Placement

– All laparoscopic equipment must be state of Five trocars are placed after induction of
the art and in good working order 12-mmHg pneumoperitoneum by the Veress nee-
– An adjustable, remote controlled electric split- dle inserted in the left flank (Fig. 26.2):
leg table – 1 × 10–12-mm placed supra-umbilically for
– The four-arm da Vinci robot is prepared over the assistant
the patient head – 3 × 8-mm intuitive robotic trocars placed in
– One monitor for the on-table assistant is the right upper quadrant, in the epigastrium,
placed on the patient left side and in the left flank are the working ports
– CO2 insufflators maintaining a pneumoperito- – 1 × 10-mm port inserted in the middle point
neum of 12 mmHg between the left costal margin and the umbili-
– Energy vessel sealing device (Harmonic cus is used for the robotic camera
Ace—Ethicon Endo-Surgery, Cincinnati, OH) – 1 × 5-mm accessory trocar can be inserted in
– A set of conventional open instruments should the epigastrium, between the umbilical port
be readily available and trocar number 1

Necessary Laparoscopic and Robotic Inspection of the Peritoneal Cavity

Instruments A thorough inspection of the peritoneal cavity for
– 10-mm 30° robotic laparoscope gross pathology and accessory spleens is per-
– Robotic Cadiere forceps, precise bipolar for- formed. If identified, the accessory spleen should
ceps, monopolar scissors, permanent cautery be removed before splenectomy.
hook, and Harmonic Ace
– Atraumatic bowel graspers
– Laparoscopic scissors Stage 2
– Articulated vascular linear stapler (30-mm
and 45-mm vascular cartridges) Approach
– Suction-irrigator system RS can be performed from an anterior approach
– Titanium clip applier, small and medium (i.e., vessel division without posterior mobilization
26 Robot-Assisted Splenectomy 309

Fig. 26.1 Operating room setup

of the spleen). The stomach is retracted to the

right with the Cadiere forceps inserted through
trocar number 1. The precise bipolar forceps is
introduced through port number 2. Port number 3
is used to introduce alternatively the monopolar
and the Harmonic scissors. Splenic flexure is
mobilized only if necessary in order to expose
and divide the splenocolic ligament and the left
gastroepiploic vessels. Splenic flexure mobiliza-
tion can be useful as well to dissect the pancreatic
tail and identify the splenic vessels in obese
patients.

Short Gastric Vessels

The short gastric vessels are divided using the
Harmonic scissors till full exposition of the pan-
creatic tail and splenic vessels. Alternatively, the
short gastric vessels can be clipped and divided
with the monopolar scissors (Fig. 26.3).

Pedicle Dissection
The pancreatic tail is exposed using the fourth
robotic arm in trocar 1 to completely retract the
Fig. 26.2 Trocar position
310 L. Casciola et al.

Fig. 26.3 Section of the

short gastric vessels with the
Harmonic Ace

Fig. 26.4 Dissection of the

branch of the splenic
artery for the inferior
splenic pole

stomach on the right side and atraumatic bowel This phase of the operation is carried out with
grasper to retract caudally the transverse colon. the precise bipolar forceps in trocar number 2 and
The splenic artery is circumferentially dissected the monopolar scissors or permanent cautery hook
for a distance of 2–3 cm at the level of the distal in trocar number 3. After visualization of the vein,
portion of the pancreas. If the artery gives off the splenic artery or its branches are divided
long branches, they can be dissected separately between plastic locking clips inserted by the assis-
(Fig. 26.4). tant from the umbilical port. The vein is finally
26 Robot-Assisted Splenectomy 311

Fig. 26.5 After arterial

branches were selectively
clipped and divided, the vein
is fully dissected and divided

dissected. In order to fully encircle even the larger ligament are dissected in a caudal-to-cephalad
splenic veins, the vein can be gently grasped by the direction (Fig. 26.6).
precise forceps allowing a complete circumferen-
tial dissection using the monopolar scissor or per-
manent cautery hook (Fig. 26.5). Stage 4
The vein is finally transected between two
large plastic locking clips. Main advantage of the Specimen Extraction
robot over traditional laparoscopy is the possibil- A 10-mm endoscopic bag is inserted through the
ity also to ligate and suture splenic vessels in this umbilical trocar and the robot undocked. Once
phase of the operation (Fig. 26.3). the specimen is accommodated into the bag, the
abdomen is deflated. The umbilical incision can
be extended along the left circumference of the
Stage 3 umbilicus. When the subcutaneous connective
tissue is stretched apart, the linea alba becomes
Spleen Mobilization evident. A 3-cm incision is made in a cranial-to-
The assistant stretches the Gerota fascia caudally caudal direction. With dilation and a slight trac-
using the suction-irrigator and maintains the field tion on the bag, the removal is carried out
clean. The robotic arm in trocar number 2 is used aseptically without the risk of neoplastic seeding.
to lift up the spleen by gentle pressure, and by the The bag is opened and the spleen removed for
monopolar scissor in trocar number 3, the splenic morcellation. The closure is performed by layers
312 L. Casciola et al.

Fig. 26.6 The spleen is lifted

up and the posterior
ligaments dissected

2. Casaccia M, Torelli P, Squarcia S, et al. The Italian

with an interrupted suture. Generally, the skin Registry of Laparoscopic Surgery of the Spleen
(IRLSS). A retrospective review of 379 patients under-
incision is hidden by the umbilical scar with a
going laparoscopic splenectomy. Chir Ital.
good long-term esthetical result [6]. 2006;58:697–707.
3. Winslow ER, Brunt LM. Perioperative outcomes of
laparoscopic versus open splenectomy: a meta-
analysis with an emphasis on complications. Surgery.
Drains
2003;134:647–53. discussion 54–5.
A Jackson-Pratt drain is routinely inserted 4. Gelmini R, Franzoni C, Spaziani A, Patriti A, Casciola
through port number 3 and left in place. L, Saviano M. Laparoscopic splenectomy: conven-
tional versus robotic approach – a comparative study. J
Laparoendosc Adv Surg Tech A. 2011;21:393–8.
5. Giulianotti PC, Buchs NC, Addeo P, Ayloo S, Bianco
References FM. Robot-assisted partial and total splenectomy. Int J
Med Robot. 2011;7:482–8.
6. Casciola L, Codacci-Pisanelli M, Ceccarelli G, Bartoli
1. Delaitre B, Maignien B. Splenectomy by the laparo- A, Di Zitti L, Patriti A. A modified umbilical incision
scopic approach. Report of a case. Presse Med. for specimen extraction after laparoscopic abdominal
1991;20:2263. surgery. Surg Endosc. 2008;22:784–6.
 Robotic Donor Nephrectomy
and Robotic Kidney Transplant 27
Ivo G. Tzvetanov, Lorena Bejarano-Pineda,
and José Oberholzer

uncontrolled comorbidities. In addition, wait

Minimally Invasive Robotic-Assisted time until transplantation and time on dialysis
Kidney Transplantation can be minimized. These factors allow better
graft and patient survival rates as compared to
Living Donor Nephrectomy deceased donor transplantation. The main obsta-
cle of living donation is the exposure of healthy
Kidney transplantation is the best treatment for individual to the inherent risk of surgical inter-
patients with chronic renal failure. In 2010, a vention without a direct health benefit, besides
total of 116,946 patients began renal replacement the personal satisfaction for an altruistic action.
therapy, but only 2.4 % received a preemptive Therefore, reducing postoperative pain, achiev-
transplantation as their first treatment modality ing faster recovery, and minimizing the surgical
(2012 USRDS Annual Data Report, http://www. incisions have become significant factors to
usrds.org). The outcomes of transplanted patients increase kidney donation rates. The availability
in terms of life expectancy, quality of life, and of minimally invasive, laparoscopic surgical
rate of hospital readmissions per year are more technique greatly enhanced living donation rates.
favorable compared to patients treated with dial- The US Food and Drug Administration (FDA)
ysis. However, there is a continuously widening approved the da Vinci Surgical System (Intuitive
gap between demand and availability of kidney Surgical, Inc.) in 2000, and its use in living donor
grafts due to notorious donor shortage. To address nephrectomies was a logical extension of the
this problem, living kidney donation is the most widely adapted minimally invasive approach.
practical approach [1]. The elective nature of liv- After acquiring extensive experience with the
ing donor transplantation offers the opportunity technique in general surgery, the first worldwide
to have kidney grafts of excellent quality and the transabdominal hand-assisted robotic donor
option to perform the procedure when the recipi- nephrectomy was performed successfully at the
ent is in optimal condition, reducing the likeli- University of Illinois at Chicago Hospital within
hood of complications associated with the same year [2]. Since then, our institution has
performed over 700 robotic donor nephrectomies
with excellent outcomes [3, 4].
I.G. Tzvetanov, M.D. • L. Bejarano-Pineda, M.D.
J. Oberholzer, M.D. (*) Donor Selection and Preoperative
Division of Transplantation, Department of Surgery, Evaluation
University of Illinois at Chicago, College of Medicine,
Candidates for living donation can be related to
840 South Wood Street, CSB Rm 502,
Chicago, IL 60612, USA the patient as a first- or second-degree relative or
e-mail: [email protected] an unrelated donor as spouse or a close friend.

K.C. Kim (ed.), Robotics in General Surgery, DOI 10.1007/978-1-4614-8739-5_27, 313

© Springer Science+Business Media New York 2014
314 I.G. Tzvetanov et al.

In the USA, any potential donor should be at least

18 years of age. The workup for living kidney
donors has the following purposes:
• Assessment and confirmation of ABO and
human leukocyte antigen (HLA) compatibil-
ity between donor and recipient. Nowadays,
ABO incompatibility or pre-sensitization to a
given donor does not necessarily preclude
successful transplantation. Preoperative
desensitization protocols for cross-match pos-
itive or ABO incompatible pairs are increas- Fig. 27.1 Port placement in the donor
ingly successful (add paper by Thielke J as
first and me as last author).
• Medical evaluation of the candidate assessing position with a cushioned beanbag and axillary
the current medical status and determining the roll. The abdomen is prepped and draped in a
medical and surgical risks to the donor. Every standard sterile fashion. An adequate fixation of
medical condition should be discussed and the patient to the operative table is important,
clarified. because any instability after docking the robotic
• Anatomy and functional assessment of the system could jeopardize the safety of the
kidneys. procedure.
• Psychological evaluation to uncover any psy-
chiatric disorders and psychological or social
problems that may disqualify the candidate Incision and Port Placement
and resolve doubts or misinformation related (Fig. 27.1)
to the procedure and its implication.
A multidisciplinary team makes final approval The herein described robotic-assisted donor
of the potential donor. The decision regarding nephrectomy is a transabdominal procedure,
which kidney to be harvested is based on the which is usually done through four laparoscopic
function and anatomy. Usually the left kidney is ports and one 7-cm infraumbilical incision. A
procured, due to its anatomy (longer left renal longitudinal or transverse abdominal incision can
vein) and the lower complexity of the left be made, based on the patient’s preference. The
nephrectomy. most commonly performed incision even in male
donors, is a 7-cm transverse suprapubic
Pfannenstiel incision. This incision provides bet-
Surgical Procedure ter cosmetic appearance and is the optimal
approach for hand assistance. In very tall, male
Patient Preparation and Positioning donors, a lower midline incision will provide
more optimal distance between the incision and
The donor is admitted the day of the procedure. the hilum of the kidney. The incision should not
Administration of bowel preparation the night be made excessively close to the laparoscopic
before the surgery is used in some centers, but operative field, because it would limit the range
does not offer much advantage and even delays of motion of the assisting hand. Utilization of
postoperative recovery. During the induction of hand port is not mandatory. In our practice, the
general anesthesia, Foley catheter and oral gas- assistant’s hand, previously wrapped with protec-
tric tube are regularly placed. Prophylactic anti- tive, sterile foil around the wrist and forearm, is
biotics are administrated. Pneumatic compression inserted directly through the incision. This
stockings are mandatory. For a left nephrectomy, maneuver does not cause any problems with the
the patient is rolled into the right lateral decubitus maintenance of pneumoperitoneum and, according
27 Robotic Donor Nephrectomy and Robotic Kidney Transplant 315

paracolic gutter. The operating surgeon controls

the electrocautery hook with his right hand and
bipolar pickups with the left hand. The descend-
ing and the sigmoid colon are then fully mobi-
lized. The splenocolic ligament is also transected
and additionally cauterized with bipolar pickups.
Following the exact plain between the mesentery
of the left colon and the Gerota’s fascia allows
bloodless exposure of the anterior surface of the
left kidney even in cases with significant intra-
abdominal adiposity. Occasionally, if the lower
pole of the spleen overlays the upper pole of the
kidney, the posterior splenic attachments are
transected and the spleen is partially mobilized.
The operating surgeon has to be very cautions to
Fig. 27.2 Mobilization of the left colon avoid injury of the body and tail of the pancreas,
which may also be overlaying the upper pole of
to our observations, significantly decreases the the kidney.
incidence of wound infections.
Once the assistant’s hand is inserted in the
abdomen, the kidney to be harvested is palpated Identification of the Ureter (Fig. 27.3)
to identify the position of the hilum. This maneu-
ver allows precise robotic port placement. Under The mobilized left colon is retracted medi-
hand control from inside the abdomen, a 12-mm ally by the assisting surgeon, and the retroperi-
laparoscopic port is placed above the umbilicus, toneal space is exposed. The dissection is
close to the midline, at the level of the renal carried along the anterior surface of the left
hilum. This port is required for the 30° robotic psoas muscle, starting from lateral towards
camera system. To achieve good triangulations, medial until the left ureter is identified. The
the two 8-mm robotic working ports are placed three-dimensional (3D) view offered by the
along the left midclavicular line. They are located robotic system allows a quick and safe identifi-
proximal and distal, 10–12 cm apart from the cation of the left ureter. The ureter is circum-
camera port. Lastly, the 12-mm port is placed in ferentially dissected and mobilized distally to
the left lower quadrant to assist with suction, the point where it crosses the iliac vessels.
clipping, stapling, and cutting. At this point, the A generous amount of adipose tissue should be
robotic system is docked and integrated to the conserved around the ureter in order to pre-
ports, and pneumoperitoneum is achieved with serve its blood supply. A short Penrose drain is
12–14-mmHg CO2 insufflation. To obtain addi- introduced, placed around the mobilized ure-
tional working space, the robotic arms are used to ter, and clipped to itself to hold the ureter. This
give additional lift on the ports. technique allows atraumatic lateral retraction
of the ureter by the assisting surgeon using a
locking grasper. This maneuver keeps the ure-
Mobilization of the Left Colon ter in view and prevents injury during the dis-
(Fig. 27.2) section around the lower pole of the kidney. If
a lower polar artery, originating from distal
The assisting surgeon’s right hand is intro- abdominal aorta is present, this vessel needs to
duced into the abdominal cavity, and the descend- be identified and exposed carefully because its
ing colon is retracted medially and freed from unintentional injury would deprive the ureter
lateral peritoneal attachments exposing the left of blood supply.
316 I.G. Tzvetanov et al.

fied up to five lumbar veins, forming a venous

network and draining into the lower and posterior
surface of the renal vein. The precision during the
isolation and transaction of these veins cannot be
overemphasized. In these cases, the articulating
skills of the robotic system and the 3D vision
give significant advantage over conventional lap-
aroscopic instruments.

Dissection Around the Upper Pole

and Adrenal Gland
Fig. 27.3 Mobilization of the ureter
The adrenal gland is identified proximal to the
left renal vein. The plain between the gland and
upper pole of the kidney is followed, and the
adrenal is left intact. The adrenal artery, which
originates from the left renal artery, should be
divided between clips whenever it presents.
The upper pole of the kidney is then fully
mobilized; this maneuver can be facilitated by
the assisting surgeon exercising gentle distal
hand retraction of the kidney. If a sizable upper
polar artery is present, extra care should be
taken to preserve this vessel, since it could sup-
ply 20–30 % of the kidney mass. Small upper
polar arteries give <5 % of the parenchyma
Fig. 27.4 Dissection of the left adrenal vein
blood supply, and they are not involved in the
vascularization of the pelvis, therefore, can be
safely sacrificed.
Identification of the Renal Vein

The gonadal vein is identified medial to the ureter Transection of the Ureter
and dissected off superiorly until its junction with and Posterior Mobilization
the left renal vein. This maneuver allows safe
identification of the renal vein at the proper dis- The previously mobilized ureter is clipped with
tance from its bifurcation within the renal hilum. two robotic hem-o-lock clips where it crosses
The tissue in front of the vein is transected and iliac vessels and sharply transects right proximal
the vein exposed medially to its junction with the to the clips. Bleeding from the transected surface
inferior vena cava (IVC). In rare cases, with ret- is a desirable sign, and the small amount of free
roaortic left renal vein, the dissection is carried as urine flow in the retroperitoneal space has no
medial as possible. The gonadal vein is tran- consequences. The posterior attachments of the
sected between two robotically placed hem-o- kidney are divided with the assistance of the
lock clips. Along the upper border of the renal assisting surgeon’s hand, as well as the articu-
vein, the left adrenal vein is identified. It is cir- lated robotic instruments. During this maneuver,
cumferentially dissected, double clipped, and surgeons have to be cautious to avoid much ten-
transected (Fig. 27.4). sion on the hilar vessels or to unintentionally
In most of the cases, at least one lumbar vein rotate the kidney to 180°, which would lead to
will be joining the left renal vein. We have identi- strangulation and vascular injury.
27 Robotic Donor Nephrectomy and Robotic Kidney Transplant 317

quadrant port. Utilization of the Endo TA stapler

allows additional length of the artery to facilitate
the implantation of the graft. The renal artery is
stapled as close as possible to its origin from the
aorta. 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 3–4 mm distal from
the stapler line. If multiple arteries are present,
they are sequentially stapled and transected in a
similar fashion. After completing the artery divi-
sion, 50 mg of protamine is given intravenously
to the donor to counteract the effect of heparin.
Fig. 27.5 Transection of the renal artery Of note: It is not safe to only use a hem-o-lock
clip for securing the arterial stump. The use of a
stapler device is mandatory. We only use a hem-
Identification of the Renal Artery o-lock to avoid minimal bleeding at times
observed from the staple line.
After completed posterior mobilization, the The kidney is now placed in a lateral (natural)
kidney is gently retracted medially. This allows position and the renal vein exposed. The operat-
an easier identification of the renal artery. The ing surgeon exercises gentle lift and traction to
ganglionic and lymphatic tissues surrounding the the hilum, straitening the vein. The vessel is
renal artery need to be transected, allowing expo- divided as medial as possible with an Endo GIA
sure of the artery. The vessel needs to be circum- vascular stapler and, subsequently, inserted by
ferentially dissected at the level of its origin from the assisting surgeon through the left lower quad-
the aorta. Be very careful to not injure possible rant assisting port. Care should be taken to avoid
early arterial branches. If multiple arteries are engaging previously placed plastic clips into the
present, every vessel has to be dissected freely as stapler line. Using angulations of the shaft of the
described. After completion of the dissection, the stapler is helpful.
only connection of the kidney is the renal artery The kidney graft is rapidly removed from the
and vein. The precision during this part of the abdominal cavity and placed in a container with
operation cannot be overemphasized, and the cold solution with the temperature below 4 °C
advantages of the robotic system are evident. and flushed with cold preservation solution.

Division of the Hilar Vessels Field Inspection and Closure

and Kidney Graft Extraction
(Figs. 27.5 and 27.6) Once the kidney graft is removed, the cavity is
inspected for bleeding. The arterial and venous
After the kidney is completely mobilized and the stumps are visualized, and the condition of the
vascular dissection completed, 5,000 U of hepa- stapler line verified. If any doubt about the reli-
rin is given intravenously to the donor and left ability, it should be over sawn with 5-0 Prolene
circulating for 2–3 min. The kidney is supported suture, which is relatively easy with the articu-
medially by the assistant’s hand. The left robotic lated robotic arms. Some bleeding from left over
arm retracts the artery gently, while the right arm adipose capsule is controlled with electrocautery.
holds the robotic hem-o-lock clip ready. The Be cautious to the presence of chylous and lym-
assistant surgeon advances the Endo TA stapler, phatic leak. If any of these situations are identi-
with vascular load, through the 12-mm left lower fied, it should be controlled with suture ligation.
318 I.G. Tzvetanov et al.

solution until clear fluid is seen coming out from

the vein. The surface of the kidney should be
inspected, and if the flash is not uniform, the
hilum needs to be examined for an unintention-
ally transected arterial branch. The residual adi-
pose capsule is excised and ligated around the
hilum in order to prevent accumulation of lym-
phoceles, which mostly originate from the graft
(in our center, we have essentially eliminated the
incidence of lymphoceles by careful backbench
preparation). Part of the adipose capsule around
the lower pole, in proximity to the ureter, is left to
preserve the blood supply. If multiple arteries are
present, decision regarding vascular reconstruc-
tion or separate implantation depends on the
actual position of the vessels.
Fig. 27.6 Transection of the renal vein

Right Donor Nephrectomy

The anatomical features of the right kidney make

it less preferred for harvesting, mostly due to the
shorter length and greater fragility of the right
renal vein. The transplant team at our institution
prefers to remove the left kidney, even in the pres-
ence of multiple arteries. The main indication for
harvesting the right kidney is the presence of ana-
tomical defects compatible with transplantation
in the right kidney (e.g., small unique renal stone,
a large cyst) or a significant difference in function
between both kidneys. In this case, the rule is to
harvest the kidney with inferior function but with
Fig. 27.7 Port positioning in the donor after closure
a glomerular filtration rate within normal range.
For robotic-assisted right donor nephrectomy, the
patient is placed in left decubitus position. The
The robotic system is disengaged and ports 7-cm incision is performed the same way as
removed. Closure of the 12-mm port sides is not described for left nephrectomy, while the port
mandatory, but is recommended. The 7-cm inci- sites are placed in mirror image location.
sion is closed anatomically by layers. Skin inci- Occasionally, one additional port is placed in the
sions are closed cosmetically (Fig. 27.7). left upper quadrant for liver retraction, which
may be necessary during the mobilization of the
upper pole. After medial mobilization of the right
Graft Backbench Preparation colon, the ureter is identified and IVC is exposed.
Occasionally, Kocher maneuver may be neces-
After the kidney is removed and placed in cold sary. Following the IVC proximally, the right
storage, the stapler line from the vein is excised renal vein is identified and circumferentially dis-
and the artery cannulated. The graft is flushed sected free. The renal artery is localized after
with cold infusion using University of Wisconsin posterior mobilization and medial retraction of
27 Robotic Donor Nephrectomy and Robotic Kidney Transplant 319

the kidney. The articulated arms of the robot and Major vascular complications during
3D vision are extremely useful for the renal laparoscopic donor nephrectomy, although
artery dissection when located posterior to the uncommon, can be potentially fatal [5]. To avoid
IVC. The rest of the procedure follows the same major postoperative bleeding, we embraced the
steps as described for left nephrectomy. concept and reiterate it again that vascular clips
alone are inadequate for safe hemostasis after
Postoperative Donor Care transection of the main renal artery. Therefore, we
After completion of the operation, the patient is recommend using vascular staplers for transfixion
relocated in supine decubitus position and extu- in every vascular transaction involving the renal
bated. Pain control is achieved preferentially with artery and vein, in order to minimize the risk of
opioids. Under appropriate hydration, it is safe to early postoperative bleeding from the stumps of
use short term with i.v. NSAIDS. The patient is the renal vessels. Other limitations, such as pro-
encouraged to ambulate the same day, and a liq- longed setup time and difficult instrument
uid diet is started 4–5 h after the operation. The exchange, addressed to the robotic system, mainly
morning after surgery, a complete blood cell occur during the initial experience, and with
count and basic metabolic panel are performed. appropriate mentoring, are rapidly overcome [6].
Foley catheter is also removed. General diet is
given, and if no complications are experienced,
the donor is discharged home on the second or Recipient
third postoperative day.
While we use robotic technology for all donor
nephrectomies, the use in the recipient operation
Discussion is limited to overweight patients, otherwise
denied access to conventional kidney transplanta-
Currently, according to widely accepted consen- tion by most transplant centers. Obesity is a com-
sus, every transplant center, which performs liv- mon comorbidity among potential kidney
ing donor kidney transplantation, must offer the transplant recipients in the USA [7], causing a
donors some of the available minimally invasive longer time on the waiting list for kidney trans-
modalities for donor nephrectomy. Considering plantation as compared to nonobese recipients.
the experience in our institution, with over 700 Decreased graft and patient survival have been
cases performed in the last 11 years, we conclude demonstrated in obese renal transplant recipients
that robotic donor nephrectomy is a safe proce- experiencing wound infections [8]. Considering
dure with a minimal number of complications. the negative impact of obesity in outcomes and
The majority of observed complications have increased risk of complications, many centers are
occurred at the beginning of our learning curve. skeptic to list morbidly obese patients for renal
The most significant complications, requiring transplantation.
conversion to open procedure, include (1) three Recent studies suggest that body mass index
intraoperative renal artery stump bleeding and a (BMI) >30 kg/m2 is an independent risk factor
(2) single case of intraoperative renal vein lacera- for surgical site infection (SSI), which is directly
tion (all occurred at the beginning of our experi- correlated to decreased graft survival. However,
ence, last event was in late 2001). Other early obese recipients who avoid SSI have similar out-
postoperative complications include one symp- comes to nonobese recipients [9]. These results
tomatic chyloperitoneum and one intra-abdominal show the need to implement new surgical tech-
hematoma without an identifiable source, both niques in obese kidney transplant recipients that
treated laparoscopically. We also encountered prevent complications such as SSI.
three cases of bowel obstruction due to adhesions, Minimally invasive surgical technologies have
also treated laparoscopically. The superficial shown benefits that include reduced recovery
wound infection rate has been, overall, <2 %. period, fewer wound complications, and reduced
320 I.G. Tzvetanov et al.

surgical scars. However, complex procedures

such as kidney transplantation have been consid-
ered technically demanding by conventional lapa-
roscopy [10]. The introduction of precise surgical
robotic systems, such as the da Vinci Surgical
System (Intuitive Surgical, Inc.), expanded the
possibilities for more difficult surgeries and
became promising in kidney transplantation.
Based on our extensive experience applying
the robotic system for different procedures such
as pancreatectomies, donor nephrectomies, and
liver resections, we developed the robotic-
assisted kidney transplant procedure. One of the
goals with this new surgical approach was to
minimize the difficulties in providing kidney
transplantation for obese patients with ESRD Fig. 27.8 Port placement in the recipient
[11]. Over the last three and a half years at the
University of Illinois at Chicago Hospital, we
performed 70 kidney transplants on obese
patients using the da Vinci robotic surgical sys- were used to avoid sliding of the patient during
tem. Initial results showed the advantages and the operation. After the patient is prepped in the
feasibility of the robotic-assisted procedure [12]. sterile fashion, a 7-cm midline incision, approxi-
mately 5 cm below the xiphoid process, is made
for the placement of the hand access device
Surgical Technique (Lap Disc, Ethicon, Cincinnati, OH, or Gelfoam
or similar). Depending on the body habitus of the
Backbench Preparation of the Graft recipient, the location of this midline incision
could be closer to the umbilicus in order to allow
Regardless of the origin of the kidney graft, liv- easier access to the surgical field for the bedside
ing or deceased donor, backbench preparation for hand-assisting co-surgeon.
robotic implantation has some specific steps. The Pneumoperitoneum is achieved at 15-mmHg
purpose is to facilitate orientation of the organ CO2 insufflation. Laparoscopic ports are posi-
and minimize bleeding after the implantation. tioned in the following manner: (1) one 12-mm
The adipose capsule is meticulously ligated with port for the 30° robotic scope is inserted in the
3-0 silk during excision. The renal vein and artery right side of the umbilicus; (2) two 7-mm robotic
are dissected towards the hilum and marked with ports are inserted, one is placed in the right flank
a marking pen, depending on the site of implanta- and the other in the left lower quadrant; and (3) a
tion, right or left. Lastly, the ureter is appropri- 12-mm assistant port is then placed on the left
ately shortened and spatulated. side of the umbilicus between the camera and the
left lower quadrant robotic port. If it is needed, an
additional 5-mm port could be placed in the right
Patient Positioning and Port flank between the camera and the robotic port.
Placement (Fig. 27.8) Once the ports are located, the patient is
placed in 30° Trendelenburg position with the
After induction of general anesthesia, a three- right side elevated (for implantation to the right
way Foley catheter is placed to allow irrigation of external iliac vessels). The robot system is docked
the bladder. The patient is positioned supine with into position from the patient right leg site paral-
parted and flexed legs; shoulder block and tape lel and slightly diagonal to the body.
27 Robotic Donor Nephrectomy and Robotic Kidney Transplant 321

Fig. 27.9 Anastomosis of

the renal vein

Vascular Exposure parallel to the dissected iliac vessels. Venovenous

anastomosis is completed in an end-to-side fash-
The operation begins with minimal mobilization ion with running suture (Fig. 27.9).
of the right colon and exposure of the right exter- If needed, interrupted stitches of 5-0 Prolene
nal iliac artery and vein. The iliac vessels are dis- are used to reinforce the anastomosis. The exter-
sected freely using bipolar forceps and a hook nal iliac artery is then clamped between robotic
electrocautery. In order to facilitate the exposure bulldogs and an oval-shaped window; propor-
and the dissection around the external iliac vein, tional to the size of the renal artery of the graft is
a vessel loop is used to retract the artery upwards. made in the anterior wall of the artery using
Another vessel loop is placed around the iliac robotic scissors. To facilitate this maneuver, a 5-0
vein to allow the dissection on the posterior sur- Prolene stitch is placed through the anterior wall
face of the vein. Since the iliac vessels need to be of the artery, and gentle pulling is applied. The
completely mobilized at least 5 cm in length, any arterial anastomosis is completed in an end-to-
collateral vessels found need to be suture ligated side fashion with 12-cm double-needle 6-0 Gore-
with Prolene 5-0 and transected. Tex suture with a knot in the middle (Fig. 27.10).
Once the reconstruction is completed, venous
clamps are removed first, followed by immediate
Graft Implantation and Reperfusion removal of the arterial clamps. The reperfusion of
the organ and hemostasis are additionally veri-
Once the external iliac vessels are completely fied, and bleeding points secured with 6-0 Prolene
dissected free, two robotic bulldog clamps are suture. We routinely use robotic fluorescence
used to clamp the external iliac vein. Robotic camera and IV injection of 3 ml of indocyanine
Potts scissors are used to create a venotomy to green. This allows confirmation of the complete
about 15 mm in length. Twelve-centimeter, and homogenous reperfusion of the renal graft.
double-needle, 5-0 Gore-Tex suture with a knot At this point, the pressure of the pneumoperito-
in the middle is placed at the corner of the venot- neum is decreased to 8–10 mmHg to minimize
omy. The kidney graft is inserted in the abdomi- possible negative effect of high intra-abdominal
nal cavity by the assisting surgeon and positioned pressure on the graft perfusion.
322 I.G. Tzvetanov et al.

Fig. 27.10 Anastomosis of

the renal artery

Fig. 27.11 Ureteroneocystostomy

Ureteroneocystostomy nique suturing full thickness of the ureteral wall

with the mucosal layer of the bladder. Utilization
The bladder is distended with diluted methylene of ureteral stent is optional (Fig. 27.11). Upon
blue solution in order to facilitate its identifica- completion of the anastomosis, the seromuscular
tion. The muscular layers are incised, the bladder layer is closed over the ureteroneocystostomy
mucosa is prepared, and the muscular layers are with 3-0 Vicryl to create an antireflux mechanism.
detached laterally to facilitate the subsequent cre- At the end of the procedure, the minilaparot-
ation of an antireflux mechanism. The ureter is omy is closed with running 0 PDS, and the two
anastomosed to the bladder with running 5-0 12-mm port sites are closed with an endoclosure
Monocryl suture using typical antireflux tech- device and 0 Vicryl suture (Fig. 27.12).
27 Robotic Donor Nephrectomy and Robotic Kidney Transplant 323

Based on the experience in our institution, we

can state that robotic-assisted kidney transplanta-
tion for obese recipients is a safe and effective
operation. 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 transplan-
tation. Of note: This is a very advanced applica-
tion of robotic surgery and requires extensive
experience in robotic surgery. Surgeons attempt-
ing this procedure require the full armamentar-
ium of robotic surgical skills, including advanced
vascular suture techniques.
Fig. 27.12 Port positioning in the recipient after closure
Acknowledgments To Dr. Enrico Benedetti and Dr. Pier
Giulianotti for their expertise and great efforts in supervis-
ing and leading us to accomplish this program. Without
Discussion your contribution, it would not have been possible.

Applying this standardized technique, within the

last three and a half years, we performed more References
than 70 robotic-assisted kidney transplants in
obese recipients. The only selection criterion is 1. Levey AS, Danovitch G, Hou S. Living donor kidney
BMI >30 kg/m2, without an upper limit. The transplantation in the United States–looking back,
looking forward. Am J Kidney Dis. 2011;58(3):343–
highest BMI of transplanted patient was 58 kg/m2,
8. PubMed PMID: 21783290.
and the mean BMI of the group was 45 kg/m2. 2. Horgan S, Vanuno D, Sileri P, Cicalese L, Benedetti
High immunologic risk or multiple previous sur- E. Robotic-assisted laparoscopic donor nephrectomy
geries were not considered a contraindication to for kidney transplantation. Transplantation. 2002;
73(9):1474–9. PubMed PMID: 12023627.
perform a robotic-assisted procedure. The only
3. Gorodner V, Horgan S, Galvani C, Manzelli A,
exclusion criteria were severe atherosclerosis of Oberholzer J, Sankary H, et al. Routine left robotic-
the iliac vessels in the recipient and the graft assisted laparoscopic donor nephrectomy is safe and
vessels (in case the graft is from a deceased effective regardless of the presence of vascular anom-
alies. Transpl Int. 2006;19(8):636–40. PubMed
donor). We performed a case–control study
PMID: 16827680.
where we compared our first 28 robotic-assisted 4. Horgan S, Galvani C, Gorodner MV, Jacobsen GR,
kidney transplants to a frequency-matched retro- Moser F, Manzelli A, et al. Effect of robotic assistance
spective cohort of obese recipients who under- on the “learning curve” for laparoscopic hand-assisted
donor nephrectomy. Surg Endosc. 2007;21(9):1512–
went kidney transplantation by open technique.
7. PubMed PMID: WOS:000249555400008. English.
We observed one wound complication in this 5. Friedman AL, Peters TG, Jones KW, Boulware LE,
robotic group, which was a hematoma in a Ratner LE. Fatal and nonfatal hemorrhagic complica-
patient on anticoagulation. No SSI was observed tions of living kidney donation. Ann Surg.
2006;243(1):126–30. PubMed PMID: WOS:
in this sample of robotic-assisted kidney-trans-
000234311800020. English.
planted obese recipients as compared to 28 % in 6. Galvani CA, Garza U, Leeds M, Kaul A, Echeverria
the control group and up to 40 % in previous A, Desai CS, et al. Single-incision robotic-assisted liv-
studies [9]. Besides the advantages of minimally ing donor nephrectomy: case report and description of
surgical technique. Transpl Int. 2012;25(8):e89–92.
invasive surgery as early mobilization and high
PubMed PMID: WOS:000306273400001. English.
patient satisfaction, we have observed excellent 7. Friedman AN, Miskulin DC, Rosenberg IH, Levey
graft function [12]. AS. Demographics and trends in overweight and
324 I.G. Tzvetanov et al.

obesity in patients at time of kidney transplantation. 10. Rosales A, Salvador JT, Urdaneta G, Patino D,
Am J Kidney Dis. 2003;41(2):480–7. PubMed PMID: Montlleo M, Esquena S, et al. Laparoscopic kidney
12552513. transplantation. Eur Urol. 2010;57(1):164–7. PubMed
8. Aalten J, Christiaans MH, de Fijter H, Hene R, van PMID: 19592155.
der Heijde JH, Roodnat J, et al. The influence of obe- 11. Segev DL, Simpkins CE, Thompson RE, Locke JE,
sity on short- and long-term graft and patient survival Warren DS, Montgomery RA. Obesity impacts access
after renal transplantation. Transpl Int. 2006;19(11): to kidney transplantation. J Am Soc Nephrol.
901–7. PubMed PMID: 17018125. 2008;19(2):349–55. PubMed PMID: 18094366.
9. Lynch RJ, Ranney DN, Shijie C, Lee DS, Samala N, Pubmed Central PMCID: 2396750.
Englesbe MJ. Obesity, surgical site infection, and 12. Oberholzer J, Giulianotti P, Danielson K, et al.
outcome following renal transplantation. Ann Minimally invasive robotic kidney transplantation for
Surg. 2009;250(6):1014–20. PubMed PMID: obese patients previously denied access to transplan-
19779327. tation. Am J Transplant. 2013;13(3):721–8.
 Part X
Surgical Techniques: Hernias
 Robot-Assisted Ventral
and Incisional Hernia Repair 28
Brad Snyder

ary to large flaps in the abdominal wall layers,

General Overview as well as recurrence rates between 25 % and
63 % [3, 4]. The open ventral hernia repair with
When the abdominal contents are able to prosthetic mesh using a tension-free technique
eviscerate through a fascial defect, an hernia is has lowered the recurrence rate to 10–40 %
defined. This may lead to loss of domain, vis- [5, 6], but it also increased the incidence of sig-
ceral disproportion, bowel obstruction, and/or nificant wound complications including mesh
chronic pain. The umbilical hernias (a congeni- infections [5–7]. Laparoscopic repair of inci-
tal defect) and epigastric hernias (acquired sional hernias was introduced in 1992 [8, 9],
fascial decussation) make up what is known in leading to improvements in recovery time, hos-
general as ventral abdominal wall hernias. pital stay, complication rates, and cost. Published
Incisional hernias, on the other hand, are sec- recurrence rates have been reduced to 0–9 %
ondary to a surgical procedure. Most practicing [10–13]. These recurrences have been attributed
surgeons will find themselves evaluating these primarily to improper positioning of the mesh
hernias for repair. (with <3 cm overlap of mesh and fascia) and to
Ventral abdominal hernia (primary or inci- the use of tacking or stapling devices for fixa-
sional) repair is a common surgical procedure. tion rather than abdominal wall suturing using
About 90,000–100,000 repairs are performed suture passers [13, 14].
every year in the USA. There is a reported The primary complications of laparoscopic
incidence of 3–20 % in the 5-year period ventral hernia repair are seroma formation,
post-laparotomy [1, 2]. wound infection, ileus, and hematoma [10–13].
The principle idea for repair is to approxi- Although laparoscopic repair has been associ-
mate the fascial edges of the hernia and prevent ated with faster recovery, fewer complications,
recurrence. There are several techniques for and a lower recurrence rate compared to open
repairing these ventral hernias. The traditional technique, there continues to be a significant
ventral hernia repair, using an open technique incidence of postoperative pain associated with
with a simple suture closure, was associated the transabdominal wall sutures. Several authors
with a high rate of wound complication second- [2, 12, 15–17] have reported a 2 % incidence of
significant postoperative pain lasting more than
2–8 weeks after repair. Significant postoperative
pain has also been described in association with
B. Snyder, M.D. (*)
helicoids staples and tackers. Three exploratory
Department of Surgery, Memorial Hermann Texas
Medical Center, Houston, TX, USA laparotomies were required in such cases [2,
e-mail: [email protected] 18]. Additionally, a randomized controlled

K.C. Kim (ed.), Robotics in General Surgery, DOI 10.1007/978-1-4614-8739-5_28, 327

© Springer Science+Business Media New York 2014
328 B. Snyder

study showed a significantly higher pain level in Trocar Placement

suture placement compared to tackers for mesh
fixation [19]. The pain is described by patients The abdominal cavity is accessed right or left
as a single point of constant, sharp burning in a upper abdomen via a 5 mm subcostal incision
dermatome pattern at the points of transabdomi- and is later exchanged for a robotic 5 mm trocar.
nal sutures or tackers; this pain has been A 12 mm trocar is placed for the camera, and a
attributed to tissue and nerve entrapment. These final 5 or 8 mm robotic trocar is placed in the
suture sites require prolonged hospital stay, lower abdomen. These are placed in the lateral
local injections, and the occasional readmission abdomen under direct visualization as far lateral
for pain control. as possible to maximize distance away from the
The da Vinci Robot (Intuitive Surgical, fascial defect.
Sunnyvale, CA, USA) offers numerous advan-
tages over the open and traditional laparoscopic
approach. These include six degrees of motion, Robot Positioning and Docking
three-dimensional (3D) imaging, and superior
ergonomics, to name a few, that enable easy and The robot is docked to the patient immediately if
precise intracorporeal suturing [2]. This can serve there are no adhesions or there is a sufficient dis-
as a means to eliminate transabdominal fixation tance from the adhesions to safely visualize and
sutures and tacks all together. move within the peritoneal cavity. A 10 mm
In addition, the da Vinci Robot can be used to Intuitive robotic camera positioned 30° up is
primarily suture the fascial defect closed fol- used. The lysis of adhesions is performed with
lowed by circumferential fixation of the mesh. sharp and blunt dissection using limited electro-
Two reports of robotic ventral hernia repair did cautery or ultrasonic devices. Robotic instrumen-
not close the ventral hernia primarily nor did tation used for the adhesiolysis is typically the
they employ a continuous running suture; 8 mm monopolar shears. After reduction of the
instead, they used interrupted sutures to secure hernia contents, the peritoneal sac is generally
the mesh [20, 21]. However, closing the defect left in place. The hernia defect is measured, and
primarily will significantly increase the overlap an appropriately sized prosthetic mesh designed
of the mesh, and continuously running the for intra-abdominal use is prepared to overlap all
suture increases surface area of suture to the fas- margins of the defect or defects by 5 cm prior to
cia. Together, these changes eliminate the need primary closure of the fascial defect.
for transabdominal sutures or helicoid tackers If the defect is midline, the robot can be docked
that can cause significant postoperative pain at 90° to the bed from the opposite side of the tro-
while maintaining, if not improving, the strength car placement. If the defect favors a particular
of the repair. side, the robot is docked from that side with tro-
cars placed on the opposite side as the defect. It is
important to be familiar with the setup of the da
Procedure Overview Vinci Robot and to approximate the ideal place-
ment of the trocars so as to obtain the optimal
Patient Positioning range of motion for repair of larger ventral
hernias. Depending on the location of the ventral
Patients are placed in the supine position with both hernia, all efforts should be made to position the
arms tucked at their sides and the entire abdominal robotic camera and trocars as far away from the
wall exposed and prepped. In all cases, the bladder fascial defect as possible. Considerations for port
and stomach should be decompressed. An adhesive placement must be made to accommodate the
drape is used to cover the patient’s abdomen; this 3–5 cm overlap of mesh and fascia. In general, a
also facilitates marking the size, shape, and loca- 10–15 cm circumferential circle can be drawn
tion of the fascial defect (see Fig. 28.1). around the edge of the fascial defect. The robotic
28 Robot-Assisted Ventral and Incisional Hernia Repair 329

Fig. 28.1 Patient positioning and room setup for robotic ventral hernia repair

trocars can then be placed anywhere along the

semicircle outline as long as they are 8 cm apart
from one another along a perpendicular line to the
axis of the robot and the hernia (see Fig. 28.2).
As the external arms of the robot typically
articulate down with this repair, a docking
approach over the head or pelvis will be inade-
quate for arm movement. Optimally, one should
keep the side of the bed elevated where the trocars
insert to insure proper movement of the robotic
arms. The cart comes in directly in line with the
defect and the camera port. Also, a utility port
should be placed at the start of the operation for
delivering the mesh into the abdomen; however, a
utility port is not necessary for most patients. The
location of the robot cart must also accommodate
the bed, anesthesiologist, and bony prominences,
such as the shoulder and anterior superior iliac
spine, which may limit the range of motion. In
addition, the trocars should be placed at the most
extreme lateral, cranial, and caudal positions that
will still allow anterior work without interfering Fig. 28.2 Typical port placement along a 10 cm circum-
with the bed, anesthesiologist, and bony promi- ferential circle drawn around the primary ventral abdomi-
nences. The most lateral possible position of the nal wall defect
330 B. Snyder

Fig. 28.3 The primary defect

is closed primarily

two instrument arms will allow the most range of cern if the primary closure does not hold com-
motion and anterior abdominal wall suturing. The pletely or not since there will be an underlay of
extremes for instrument length must also be con- mesh to prevent the hernia recurrence. Simply
sidered prior to trocar placement. The current da put, the primary repair is to allow greater overlap
Vinci instruments have a 34 cm reach; however, and additional security to the repair.
close proximity to trocars and camera, especially Once the fascial defect is closed, the mesh is
in smaller, lower body mass index patients, is the positioned superiorly and inferiorly as it was out-
most common difficulty. side the abdomen, and a spinal needle is inserted
at each marked point through the abdominal wall
for verification of correct placement. A strong,
Critical Elements of the Procedure permanent suture already fixated at the 12 o’clock
and 6 o’clock positions of the mesh is then used to
The fascial defect is typically closed using the circumferentially suture the mesh to the abdomi-
running 0-absorbable suture (see Fig. 28.3). nal wall taking care to take bites of the posterior
Typically this suture is run from one end of the fascia with each pass (see Fig. 28.4). These bites
defect to the other and then back again in a con- are full thickness through the posterior fascia and
tinuous fashion. The suture is tightened periodi- into the abdominal wall musculature. While the
cally to remove any slack and afford fascial musculature does not add to the overall strength
approximation. The use of absorbable sutures is of the fixation, it is important to know that full-
to not leave any unneeded permanent material in thickness purchases of the fascial are being
the fascial that could cause chronic postoperative obtained. Care must be taken not to acquire too
pain. We feel that approximating the fascial edges big of a bite through the muscle because this may
allows us greater overlap for the mesh and its cause undue pain with little gain in repair strength.
fixation. Once the mesh is fixated underneath the If the defect is below the arcuate line, one must
defect, there is little to no tension on the primary obtain transversalis fascia with each bite. The
repair; therefore, there is less concern about ten- suturing is started at the 12 o’clock position on the
sion on this repair than if this would be a primary mesh, run to the 6 o’clock position, and then back
repair alone. Nonetheless, it is not our main con- to the 12 o’clock (see Fig. 28.5). It is easiest to
28 Robot-Assisted Ventral and Incisional Hernia Repair 331

Fig. 28.4 The mesh is

sewn in place with a
continuous, running,
nonabsorbable suture
using “baseball” stitch
conformity

Fig. 28.5 The suture is run

to each corner of the next
suture and tied to its tail to
secure the running suture and
mesh

start on the side of the mesh that is furthest away as not to tighten the mesh closely against the
from the camera. That is, if your ports are on the abdominal wall until the opposite suture is again
patient’s left side, the entire right side of the mesh started in a similar manner.
is sewn first. Once the suture from the 12 o’clock No trans-fascial or transabdominal sutures are
position is run to the 6 o’clock position and tied to placed. No drain is used. The 12 mm trocar site is
the next suture, the left side of the mesh, closest to then closed with absorbable suture using a suture
the camera, is run back up to the 12 o’clock posi- passer, pneumoperitoneum is released, and the
tion and tied to itself. The suture is kept loose so skin is closed.
332 B. Snyder

Hybrid Versus Totally Robotic The robot-assisted intracorporeal suturing tech-

Approach nique adds numerous advantages to the standard
technique for laparoscopic ventral hernia repair.
The robotic assisted ventral hernia repair should While previous reports have confirmed the need to
be considered a hybrid technique unless the suture the mesh at 2–5 cm intervals [12–14] as a
hernia is a primary defect with no adhesions or means of reducing the recurrence rates associated
contents to reduce. In this case, all sutures and with laparoscopic hernia repairs, we feel that
mesh can be placed before docking and the case continuous circumferential suturing applies those
can be completed with one dock. It may be principles while evenly distributing the tension
necessary at times, however, to perform lysis throughout the mesh. Mesh fixation with tacking
of adhesions laparoscopically or robotically and alone has been associated with higher recurrence
close the defect, at which time the robot is rates [14, 24]. Transabdominal sutures and tackers
undocked to assess the size and shape of mesh are often placed using measurements and fascial
to be used on the defect. In these particular defect approximation without direct visualization
cases, the arms are simply lifted off the trocars of the edge of the fascial defect. This method can
for measurement and placement of the mesh. result in incorrect placement and increases the risk
The robot does not need to be moved away from of recurrences. The robotic technique places the
the bedside. approximated fascial defect edges in the middle of
the mesh, thus maximizing the overlap of the mesh.
The transabdominal sutures and tackers have
Discussion of Advantages, been directly related to severe postoperative pain
Limitations, and Relative that lasts for months [11–13, 18, 25]. The pain is
Contraindications attributed to direct trauma, nerve impingement,
and soft tissue entrapment. Patients may require
Laparoscopic ventral hernia repair was introduced repeated local injections and occasionally read-
in the 1990s and since has gained wide acceptance mission for pain control [12, 13]. In our experi-
[8, 9]. With published data showing recurrence ence, the major source of pain has not been
rates equal or less than the open mesh repair, fewer tackers as much as transabdominal sutures. This
complications, shorter operative times, and has lead to multiple patients requiring prolonged
decreased lengths of stay [16, 22, 23], it has pain medication, frequent injections, and even a
become a readily used tool in the general surgeon’s surgery to remove the suture. Complications
arsenal. In the robotic technique for ventral hernia associated with tackers usually result from them
repair, the surgeon must adopt standard robotic being misplaced or incompletely placed. They
port placement to safely and successfully perform may dislodge, increasing the formation of adhe-
intracorporeal suturing of the fascial defect and sions directly to the tack and under surface of the
mesh fixation with circumferential fascial fixation. mesh. Exposed mesh has also been associated
The da Vinci Robot has been shown to have advan- with bowel erosion. This technique has a potential
tages over standard laparoscopy for suturing risk for future small bowel obstruction and septic
because of its instrument’s six degrees of freedom complications in the presence of a prosthetic
with the EndoWrist that utilizes intra-abdominal mesh. Our technique for the robot-assisted lapa-
articulations and true 3D imaging. This makes this roscopic repair of ventral hernia using intracor-
device the ideal tool for intracorporeal suturing of poreal suturing allows for stable suture fixation
mesh to the posterior layer of the anterior abdomi- under direct visualization and eliminates the need
nal wall for ventral hernia repair. In addition, there for tackers because a running suture is used for
is less abdominal wall trauma and postoperative circumferential fixation. The entire repair is per-
pain at the working trocar ports as the fulcrum is formed under direct visualization, with precise
not entirely at the abdominal wall but at the placement and confirmation of depth into the
EndoWrist instruments. posterior fascia for all sutures placed. The fascial
28 Robot-Assisted Ventral and Incisional Hernia Repair 333

sutures encompass 1 cm bites of fascia, minimiz- ous abdominal operations, size and number of
ing trauma to the abdominal wall. defects, ability to close defect primarily and type
Intracorporeal suturing of the fascia allows the of suture used, size and type of prosthetic mesh
midline to be re-approximated allowing for pos- implanted including suture used for circumferen-
sible primary repair, more physiologic abdominal tial suturing, operative time, laparoscopic time,
wall movement, and greater overlap of the mesh robotic docking time, robotic console time, anes-
to the defect fascial edges. Slick, nonabsorbable thesia time, estimated blood loss, number of tro-
sutures were used to minimize adhesion forma- cars required to complete surgery, length of
tion and provide adequate strength for a lasting hospital stay, operative and postoperative com-
repair without slippage of the mesh. In addition, plications, hernia recurrences, and duration of
this suture is easy to handle in the abdomen and follow-up were collected. American Society of
slides through the mesh allowing ease of tighten- Anesthesiologists (ASA) score over 3 and/or fas-
ing the suture along the circumference of the cial defects larger than 15 cm in any one dimen-
mesh. Robot-assisted laparoscopic ventral hernia sion assessed by clinical, radiology, or diagnostic
repair offers yet another advantage by providing laparoscopy were not repaired using robotic tech-
the suturing option under excellent visualization nique and therefore are not reported here.
for the repair of difficult hernias with bony or Of the 15 patients, all had robotic-assisted
muscular margins, such as lumbar, suprapubic, ventral hernia repair and were available for fol-
and subcostal hernias. Several of our patients had low-up. All the fascial defects were closed pri-
hernias on or near lateral borders of the abdomen marily before the mesh repair. Median follow-up
making mesh fixation with tackers difficult. This time was 23 months (range 2–33 months). Five
allows the surgeon to take very precise bites of had a BMI greater than 30 kg/m2, mean 31.53
tissue to anchor the mesh repair. (range 27–41.65). The mean ASA score was 2.4.
Limitations of this robot-assisted technique All but two patients (86 %) had previous surgery;
are obvious for large ventral hernias as they however, no one had previous attempts at hernia
approach the working ports and camera, making repair. Most hernias were in or near the midline.
this technique technically challenging. In addi- Multiple defects were found in five of the patients
tion, obese patients pose a challenge preopera- (33 %). The mean fascial defect size was
tively because it may be difficult to determine the 37.39 cm2 (range 6.28–117.75 cm2). The mean
ideal trocar placement. operative time was 114 ± 21 min and console time
was 74 ± 16 min (range 42–143). The mean
length of hospital stay was 2.4 ± 1.1 days (range
Outcomes Review 0.25–10). None of the patients required conver-
sion to open or traditional handheld laparoscopic
Between 2009 and 2011, these authors had a per- technique after the initial trocar insertion. There
son experience with this procedure, and we per- were no mortalities.
formed a retrospective review of 15 patients who One patient required a prolonged hospital
underwent robotic-assisted ventral hernia repair stay (6 days) for pain control, and one patient
with intracorporeal, primary closure of fascial had both prolonged hospital stay (10 days) for
defects with a running 0-absorbable suture, fol- pain control and postoperative urinary reten-
lowed by underlay mesh fixation using a continu- tion. Since there was no comparative laparo-
ous running, circumferential, nonabsorbable scopic arm, subjective patient pain scales or
suture. Standard laparoscopic ventral hernias narcotic usage was not measured specifically
were also performed during this time, but were within the retrospectively reviewed group.
not directly compared in a prospective fashion. There were no seromas, prolonged ileus, or
Data for age, gender, body mass index, American infections of the mesh or wound reported in this
Society of Anesthesiologists (ASA) score, previ- series. There was one recurrence diagnosed by
334 B. Snyder

physical exam. This recurrence was from the 3. LeBlanc KA, Heniford BT, Voeller GR. Innovations
in ventral hernia repair. Contemp Surg. 2006: 1–8
patient with a lumbar hernia that presented
4. Van der Linden FT, Van Vroonhoven TJ. Long-term
many difficult challenges with regard to port results after surgical correction of incisional hernia.
placement, patient positioning, mesh place- Neth J Surg. 1988;40:127–9.
ment, and fascial closure. 5. Stoppa RE. The treatment of complicated groin and
incisional hernia. World J Surg. 1989;13:545–54.
The average time for robot-assisted laparo-
6. Laber GE, Garb JL, Alexander AI, et al. Long-term
scopic ventral hernia repair using intracorporeal complications associated with prosthetic repair of
sutures (114 min) seems to be comparable to the ventral hernias. Arch Surg. 1998;133:378–82.
times reported in the literature for standard lapa- 7. White TJ, Santos MC, Thompson JS. Factors affect-
ing wound complications in repair of ventral hernias.
roscopic ventral hernia repair and previous
Am Surg. 1998;64:276–80.
robotic ventral hernia repair in pig models [2, 8. Heniford BT, Park A, Ramshaw BJ, et al. Laparoscopic
12–14]. Our series included lysis of adhesions of repair of ventral hernias: nine years’ experience with 850
the anterior abdominal wall while maintaining a consecutive hernias. Ann Surg. 2003;238:391–400.
9. Perrone JM, Soper NJ, Eagon JC, et al. Perioperative
comparable time to a previous report of robotic
outcomes and complications of laparoscopic ventral
ventral hernia in pigs without adhesions. The hernia repair. Surgery. 2005;138:708–15.
sizes of the defects in this study (6–118 cm2) 10. Carbajo MA, Martin del Olmo JC, Blanco JI, et al.
were comparable to those reported for standard Laparoscopic treatment vs open surgery in the solu-
tion of major incisional and abdominal wall hernias
laparoscopic repair [12, 13, 25].
with mesh. Surg Endosc. 1999;13:250–2.
11. Franklin ME, Dorman JP, Glass JL, et al. Laparoscopic
ventral and incisional hernia repair. Surg Laparosc
Conclusion Endosc. 1998;8:294–9.
12. Heniford BT, Ramshaw BJ. Laparoscopic ventral
hernia repair: a report of 100 consecutive cases. Surg
The robotic-assisted ventral hernia technique is Endosc. 2000;14:419–23.
feasible and may reduce postoperative pain by 13. Heniford BT, Park A, Ramshaw BJ, et al. Laparoscopic
eliminating trans-fascial sutures. Further evalua- ventral and incisional hernia repair in 407 patients.
J Am Coll Surg. 2000;190:645–50.
tion is needed and long-term data is lacking to
14. Sanders LM, Flint LM, Ferrara JJ. Initial experience
assess the benefit to the patient, but future studies with laparoscopic repair of incisional hernias. Am
are investigating this very thing. Randomized J Surg. 1999;177:227–31.
prospective trials to compare robotic versus lapa- 15. Earle D, Seymour N, Fellinger E, et al. Laparoscopic
versus open incisional hernia repair: a single-
roscopic ventral hernia repair where operative
institution analysis of hospital resource utilization for
time, hospital stays, objective measurements of 884 consecutive cases. Surg Endosc. 2006;20:71–5.
postoperative pain, chronic pain, and hernia 16. Harrell AG, Novitsky YW, Peindl RD, et al.
recurrence are measured. A study like this would Prospective evaluation of adhesion formation and
shrinkage of intra-abdominal prosthetics in a rabbit
be more appropriately poised to answer the ques-
model. Am Surg. 2006;72:808–13.
tion: is a robotic ventral hernia repair better than 17. McKinlay RD, Park A. Laparoscopic ventral
a laparoscopic repair? What is certain at this time incisional hernia repair: a more effective alternative to
is that robotic ventral hernia is feasible and safe conventional repair of recurrent incisional hernia.
J Gastrointest Surg. 2004;8:670–4.
and appears to be highly effective.
18. Berger D, Bientzle M, Muller A. Postoperative com-
plications after laparoscopic incisional hernia repair.
Surg Endosc. 2002;16:1720–3.
References 19. Bansal VK, Misra MC, et al. A prospective
randomized study comparing suture mesh fixation
versus tacker mesh fixation for laparoscopic repair
1. Mudge M, Hughes LE. Incisional hernia: a 10-year
of incisional and ventral hernias. Surg Endosc.
prospective study of incidence and attitudes. Br
2011;25(5):1431–8.
J Surg. 1985;72:70–1.
20. Tayar C, Karoui M, Cherqui D, et al. Robot-assisted
2. Schluender S, Conrad J, Divino CM, et al. Robot-
laparoscopic mesh repair of incisional hernias with
assisted laparoscopic repair of ventral hernia with intra-
exclusive intracorporeal suturing: a pilot study. Surg
corporeal suturing. Surg Endosc. 2003;17: 1391–5.
Endosc. 2007;21(10):1786–9.
28 Robot-Assisted Ventral and Incisional Hernia Repair 335

21. Ballantyne GH, Hourmont K, Wasielewski A. large community hospital. Arch Surg. 2003;138:
Telerobotic laparoscopic repair of incisional ventral 777–8.
hernias using intraperitoneal prosthetic mesh. JSLS. 24. LeBlanc KA, Booth WV. Laparoscopic repair of inci-
2003;7(1):7–14. sional abdominal hernias using expanded polytetra-
22. Dubay DA, Wang X, Kirk S, et al. Fascial fibroblast fluoroethylene: preliminary findings. Surg Laparosc
kinetic activity is increased during abdominal wall Endosc. 1993;3:39–41.
repair compared to dermal fibroblasts. Wound Repair 25. LeBlanc KA. The critical technical aspects of laparo-
Regen. 2004;12:539–45. scopic repair of ventral and incisional hernias. Am
23. Giulianotti PC, Coratti A, Angelini M, Sbrana F, et al. Surg. 2001;67:809–12.
Robotics in general surgery: personal experience in a
 Part XI
Surgical Techniques: Pediatric
 Pediatric Robotic Surgery
29
John J. Meehan

ning also must include ideal patient positioning,

General Considerations trocar placement, and trocar depth. Discussing the
envisioned progress of the case with all team
Most surgical equipment is designed for adults. members including anesthesia ahead of time can
Pediatric surgeons need to find ways of making help avoid difficulties later in the procedure.
the adult equipment and instrumentation fit in the
world of pediatric surgery. The da Vinci robotics Positioning
was no exception and was never designed with
children in mind. Since the start of the robotic With a height of about 6 ft, the current robot
era, very little has been done to redesign or add appears enormous hovering over a small child.
technology for kids. Pediatric surgeons are forced Access to patients becomes limited. The robotic
to find unique ways to make this technology work arms must have adequate clearance in regard not
in children. Despite the daunting size of this only to the patient but also to the OR table and in
500 kg robot next to a 5 kg infant, many simple relation to the other robotic arms. In order to
adjustments can be made in order to accommo- avoid instrument arm to OR table collisions, we
date the da Vinci system for minimally invasive recommend elevating the smaller patients using
procedures in children. foam padding (Fig. 29.1).
The first step in determining whether a pediat- This allows the robot arms a greater range of
ric procedure is possible with the da Vinci is to motion external to the patient as the arms of the
consider the diagnosis and anatomy in relation to robot are less likely to collide with the OR table.
the potential working region. Procedures, which Raising the patient off the main OR table with a
concentrate in a focused location have the highest compressible pad also affords better access to the
probability of success. Procedures that may need patient for the bedside assistant and anesthesiolo-
to sweep from one quadrant of a cavity to an oppo- gist. We routinely place children 10 kg or less on
site quadrant may need further consideration. two foam eggcrate style pads and one foam pad
Utilizing a hybrid approach incorporating laparos- for children between 10 and 20 kg in size. Larger
copy or even an open segment of an operation may children are usually fine without additional eleva-
be appropriate for some procedures. Careful plan- tion. An important additional consideration is
assuring adequate clearance of the external robot
arms over the patient. Serious injury could occur
J.J. Meehan, M.D., F.A.C.S. (*) if the robotic arms torque down onto a patient
University of Washington School of Medicine, Seattle
unchecked. We prefer placing a solid barrier
Children’s Hospital, 4800 Sand Point Way NE,
Seattle, WA 98105, USA securely mounted to the OR table to help protect
e-mail: [email protected] the patient. An example is shown in Fig. 29.2.

K.C. Kim (ed.), Robotics in General Surgery, DOI 10.1007/978-1-4614-8739-5_29, 339

© Springer Science+Business Media New York 2014
340 J.J. Meehan

Fig. 29.1 Foam padding (a) helps elevate the small patients off of the table which aids in gaining adequate access to
the child during a robotic procedure (b)

together create a new problem, namely, robotic

arm collisions. In fact, making the robot trocars
further apart can reduce robot arm external
collisions. But this benefit is only good up to a
certain point; if the trocars are too far apart, they
may be approaching the target at too shallow of
an angle and the external arm could make contact
with the patient or the OR table.

Trocar Depth

Fig. 29.2 A table-mounted barrier is helpful to prevent Available working space for the da Vinci robotic
the large robotic arms from making contact with the instruments is limited by the minimum require-
patient
ments that are needed for instrument articulation.
While this is almost never a problem in adult sur-
Trocar Location gery, this can be an enormous issue in the abdo-
men of a small child. The remote center of the
Trocar placement in robotic procedures may not robotic trocar is the point in three-dimensional
be the same as trocar placement in standard MIS space in which the robot arm will pivot around.
procedures. In standard MIS, ergonomic issues This location is represented on the da Vinci
influence how far apart the surgeon may place the robotic trocar with a thick black line (Fig. 29.3).
trocars. Sites that are too lateral will cause shoul- The distance from remote center to end of tro-
der and neck discomfort for the operating sur- car is a set length at a distance of 2.90 cm. The
geon and can make an otherwise easy case manufacturer recommends that the robotic trocar
somewhat tedious and physically taxing. is inserted inside the patient such that the remote
However, the ergonomic concerns are eliminated center is placed just at the inside edge of the body
in robotic surgery. Trocars placed too close cavity. Therefore, 2.90 cm of trocar length should
29 Pediatric Robotic Surgery 341

Fig. 29.3 The da Vinci 5 mm robotic trocar demonstrating the remote center (arrow)

be inside the patient. Next, we must consider the 5 mm scopes down the shaft of a single scope.
articulating instrument. The shortest 5 mm da But this 12 mm 3D scope simply will not fit in the
Vinci instrument is the needle driver. Measuring intercostal space of smaller children and is huge
the needle driver from the tip of the instrument to for abdominal procedures in neonates. In 2005,
the most proximal articulating joint is a distance Intuitive released a 5 mm 2D scope for use with
of 2.71 cm. Adding this distance to the articulat- the da Vinci Standard robot. This 5 mm scope
ing length yields a minimum distance of 5.61 cm. was a key improvement even though it was only
In other words, the target organ must be a mini- a 2D system. The 5 mm camera paved the initial
mum of 5.61 cm away from the abdominal or wave of neonatal cases and allowed robotic neo-
chest wall. Other instruments are even longer. In natal surgery to flourish for a few years. Numerous
small children, this distance is considerable and neonatal congenital anomalies were repaired
the amount of usable working space beyond this robotically for the first time in both the abdomen
minimum distance can disappear quickly. and the chest. These procedures included duode-
However, there is a potential adjustment nal atresia repairs in children as young as one day
which may allow for a little additional room in of age and a CDH repair in a 2.2 kg 6-day-old
selected patients. Although the remote center baby [1, 2]. Pulmonary lobectomies for congeni-
marking on the da Vinci trocar was originally tal cystic adenomatoid malformation (CCAM)
intended to be visible just inside the patient, we and pulmonary sequestration were also now pos-
can adjust the trocar so it is just outside the sible [3]. We also performed the first EA-TEF
patient instead. The entire abdominal or thoracic repair with da Vinci system in 2007 although this
wall of small children may only be 1 cm. was unpublished. Neonatal robotic surgery was
Therefore, by routinely extracting the trocar back off to a flying start.
such that the remote center is positioned just out- There is no question that the 5 mm 2D scope
side the patient instead of just inside the patient, opened up a tremendous variety of potential
we can effectively increase our workable domain robotic cases. Eventually, the 8.5 mm 3D scope
and potentially improve instrument maneuver- came available and is now available in HD.
ability. We have found that this simple adjust- However, the 8.5 mm can be a bit too large for
ment can have tremendous impact on our ability the intercostal space in some neonates. The
to perform a procedure. 5 mm 2D scope still had a significant place in
the pediatric robotic theater. Unfortunately, this
5 mm scope was only made for the Standard and
Scope S systems. Once the Si system was unveiled,
Intuitive Surgical announced that they would
While the optics of the 3D system has been a not make a compatible scope with the Si new
huge advantage for robotic surgery, it has also platform. Shortly thereafter, the company dis-
uncovered some limitations due to the diameter. continued support of the 5 mm 2D scope entirely
The 12 mm 3D da Vinci scope is essentially two (Fig. 29.4).
342 J.J. Meehan

robot’s current large size limits its usefulness in

children. We consider using the 4th arm if the
child is greater than 20 kg. The one exception is
the choledochal cyst resection with Roux-en-Y
reconstruction. We will describe that case later in
this chapter.

Specific Pediatric Procedures

Table 29.1 lists all of the robotic procedures we

Fig. 29.4 A comparison between the original robotic have performed in children.
scopes for the Standard da Vinci camera. (left, 12 mm 3D;
The list is quite extensive which demonstrates
middle, 8.5 mm 3D; right, 5 mm 2D). The 5 mm 2D scope
is no longer manufactured the diversity of the surgical problems in pediatric
patients. Many of these procedures such as chole-
cystectomy, Heller myotomy, adrenalectomy,
splenectomy, and colon resections are similar to
Instruments adult procedures and are discussed in detail else-
where in this text. Pediatric urology is covered
The 8 mm platform was launched in 2001. elsewhere as well. Describing the details of all of
Smaller diameter instruments were made avail- the procedures in this list is a book in itself so we
able in 2005 with the release of the 5 mm instru- will concentrate on selected cases that are ideal
ments. The smaller diameter was welcomed by robotic pediatric operations or deserve special
pediatric surgeons who had already become mention. Following the pediatric principles and
accustomed to using 5 and 3 mm laparoscopic adjustments outlined in the preceding sections
instruments. The 5 mm robotic instrument is a can help a surgeon adequately plan for nearly any
reasonable instrument diameter for small chil- pediatric robotic procedure.
dren. But these 5 mm instruments are not without
a new limitation: the articulating length is longer
than the 8 mm counterpart. As discussed in the Fundoplication
preceding sections, trocar depth can be adjusted
to offset this problem. Another disadvantage of The fundoplication is a key procedure in the
the 5 mm instruments is that selection is exceed- training of a pediatric surgeon new to robotics.
ingly limited with only a few types of 5 mm Along with the cholecystectomy, the fundoplica-
instruments being made. As of the beginning of tion is a familiar laparoscopic procedure and is
2013, the 5 mm instrument product line has gone one of the most common operations in pediatric
essentially unchanged with almost no new instru- general surgery. Therefore, we must emphasize
ment choices or improvements. that the fundoplication is an important procedure
in understanding the subtle differences between
robotic surgery and laparoscopic surgery and will
The 4th Arm help a new robotic surgeon learn the basics before
moving on to more complex procedures.
The da Vinci system has an option for an addi- Most pediatric fundoplications are performed
tional instrument arm. While potentially useful in via the transabdominal approach, and the Nissen
adults or larger children, the neighboring space fundoplication is the most common fundoplica-
external to a small child or neonate is already tion [4]. Other less common fundoplications are
limited and the additional arm may add addi- the Toupet and Thal partial wraps. The choice for
tional constraints. Although we occasionally use the type of fundoplication is the surgeon’s prefer-
the 4th arm for a handful of procedures, the ence, but all have been shown to be effective [5].
29 Pediatric Robotic Surgery 343

Table 29.1 Pediatric robotic procedures: a comprehen-

sive list of procedures we have performed using the da
Vinci surgical robot
• Abdomen
• Cholecystectomy
• Fundoplication
• Heller myotomy
• Pyloroplasty
• Adrenalectomy
• Neuroblastoma
• Splenectomy
• Small bowel resection
• Crohn’s
• Enteric duplication
• Meckel’s diverticulum
• Partial colon
• Left colectomy
• Ileocecectomy
• Right colectomy
• Sigmoid colectomy
• Total proctocolectomy with pull-through
• Kasai portoenterostomy
• Choledochal cyst
• Duodenal anomalies Fig. 29.5 The robotic trocar for a fundoplication. Notice
• Duodenal atresia the lateral placement of the working ports, which are more
• Duodenal web lateral than the standard laparoscopic locations. A 3 or
• Annular pancreas 5 mm retractor port for the liver is placed in the right
• Ladd’s procedure upper quadrant
• Jejunal or ileal atresia
• Puestow
• Gastrotomy with foreign body retrieval
• Congenital diaphragmatic hernia (Morgagni) Laparoscopically, the fundoplication procedure
• Nephrectomy
has been performed regularly since the mid-
• Ovarian cystectomy
• Ovarian teratoma
1990s with good results [6]. The learning curve
• Urachal remnant for the laparoscopic approach has been estimated
• Utricle somewhere between 25 and 30 cases [7].
• Chest Although many well-trained laparoscopic sur-
• Pulmonary resections geons will argue about the futility of the robot for
• CCAM
this procedure, we have found that it is an excel-
• Pulmonary sequestration
• Thymectomy
lent training case. More importantly, the learning
• Cystic hygroma curve is much shorter, perhaps as short as five
• Mediastinal masses cases [8].
• Congenital anomalies Trocar locations are slightly modified from
• Bronchogenic cyst the laparoscopic approach (Fig. 29.5).
• Esophageal duplication
While the camera location is still at the umbi-
• Tumors
• Ganglioneuroma
licus, the left and right working ports are slightly
• Neuroblastoma more lateral in comparison to the laparoscopi-
• Ganglioneuroblastoma cally placed trocars. The more lateral placement
• Germ cell tumor avoids robotic arm collisions between the instru-
• Teratoma ment arms and the camera arm external to the
• Esophageal atresia with tracheoesophageal fistula
patient. The retracting port for the liver is in
• Congenital diaphragmatic hernia (Bochdalek)
the same location as is customarily placed along
• Eventration of the diaphragm
the patient’s right flank. The robot cart is positioned
344 J.J. Meehan

Ladd’s Procedure

Malrotation results from a failure of the intestine

to return to the abdomen in the proper orientation
during embryology. In normal embryogenesis, the
bowel has two rotational axes that result in the
proper orientation of the bowel. The rotations
occur outside the abdominal cavity early in gesta-
tion. As the bowel reenters the abdomen, the
small bowel becomes fixed along its most proxi-
mal segment to form the C-loop of the duodenum,
which terminates with the ligament of Treitz.
Meanwhile, the large bowel becomes fixed to the
Fig. 29.6 The fundoplication is constructed using inter-
retroperitoneum by attachments along the right
rupted nonabsorbable sutures
gutter. Most importantly, the mesentery to the
small and large bowel lies in a long fan of mesen-
teric attachments that extend from the right lower
quadrant all the way to the left upper abdomen
and the ligament of Treitz. This fixed long fan of
mesentery is why normally rotated bowel usually
does not twist. However, in malrotation, the mes-
entery is very narrow. Upon return of the bowel to
the abdomen, the small bowel that did not rotate
properly usually has the majority of the small
bowel off to the right of the abdomen. The duode-
nal loop never properly forms and the duodenum
can often go straight inferiorly instead of making
the proper C-loop. The ascending colon is often to
the left of the small bowel and duodenum so the
Fig. 29.7 Unable to close the hiatus primarily, patch clo- retroperitoneal attachments that were supposed to
sure of the large congenital hiatal defect was required
tether the ascending colon to the right gutter now
prior to this fundoplication
grab onto anything in the right abdomen, usually
the small bowel but in a random fashion. These
directly over the patient’s head. Dissection attachment bands are called Ladd’s bands in refer-
begins by exposing the hiatus and taking down ence to the pediatric surgeon William Ladd who
the short gastric vessels. We prefer both a mini- first described the operation that also bears his
mal hiatal dissection as well as a minimizing the name [9]. Ultimately, a patient can present with
number of short gastric we sacrifice. The wrap either partial or complete obstruction from these
is constructed with nonabsorbable suture and bands, and a chronic condition that is hard to
generally should be at least 3 cm in length diagnose may exist for years without an upper GI
(Fig. 29.6). study. The biggest worry, however, is the develop-
Suturing the completed wrap to the underside ment of a volvulus. This occurs as a result of the
of the diaphragm is optional and we recommend narrow vascular pedicle, and rapid operative inter-
this additional step if the patient had a large hiatal vention is critical before the bowel is lost from
defect that required repair. Occasionally, a patch ischemia.
for a congenital diaphragmatic hiatal hernia may The Ladd’s procedure has four steps: (1)
be needed (Fig. 29.7). Results are similar to the Detorse the bowel. The volvulus always occurs in
laparoscopic approach. a clockwise fashion, and the bowel must be
29 Pediatric Robotic Surgery 345

Fig. 29.9 Intraoperative photo of a Ladd’s procedure

showing the numerous Ladd’s bands

The key area of work is the right upper

Fig. 29.8 Port locations for the robotic Ladd’s procedure quadrant. Begin by taking down all Ladd’s bands,
usually starting laterally and working medially
turned counterclockwise until the mesentery is (Fig. 29.9). The entire course of the duodenum
straight (remember the phrase “turn back time”). should be freed along its lateral aspect. On the
(2) After the torsion has been reduced, the Ladd’s medial aspect of the duodenum, the anterior
bands are taken down freeing all adhesions. (3) sleeve of mesentery is incised longitudinally and
The most important step in reducing the risk of a blunt dissection is used to widen the mesentery.
recurrence is widening the mesentery. The Finally, the appendix is taken at the conclusion of
peritoneal surface of narrow pedicle between the the procedure.
duodenum and the ascending colon is incised on
one side and the mesentery splayed out in order
to widen it. (4) Finally, the appendix in a malro- Kasai Portoenterostomy
tated patient is never in the right lower quadrant,
so an appendectomy is part of the procedure to Patients with biliary atresia require a Kasai
reduce the possibility of diagnostic confusion if procedure for biliary drainage where a Roux limb
appendicitis ever developed in such a patient. of intestine is brought up to the portal plate to
Malrotation can present with or without volvu- facilitate drainage of the bile. The key step in the
lus. The patient with malrotation and midgut vol- open Kasai operation is the precise dissection of
vulus is a true surgical emergency, and we do not the portal plate for the best chance of obtaining
advocate attempting a minimally invasive proce- adequate biliary drainage. This procedure was
dure in these patients. However, the patient who done laparoscopically for several years, but the
has chronic abdominal pain or partially obstructive results were less than optimal [10]. A voluntary
symptoms who is found to have malrotation on moratorium was placed on the MIS Kasai proce-
upper GI but no evidence of volvulus or acute dures by the International Pediatric Endoscopic
obstruction may be a good candidate for an elec- Group (IPEG) at their annual scientific meeting
tive minimally invasive procedure. Besides chil- in Buenos Aries in September of 2007 [11]. The
dren, these patients could also be adults who have lack of precision in the technique was suspected,
a long history of abdominal pain or emesis and although some data suggested that CO2 insuffla-
have gone through a multitude of doctor visits over tion may have also played a role [12]. This fail-
the years. The diagnosis is confirmed by an upper ure suggests that the Kasai procedure has no
GI as stated previously. The robotic trocar loca- margin for error and exposes the deficiencies in
tions for a Ladd’s procedure are shown in Fig. 29.8. standard laparoscopy for a procedure that
346 J.J. Meehan

Fig. 29.10 Port locations for the robotic Kasai portoen- construction. Note: This port placement scheme is also
terostomy. Note that a 12 mm scope is preferred for the used for the duodenal atresia repair except an 8.5 mm
Kasai to take advantage of an extracorporeally Roux limb scope is preferred for the umbilical camera port

requires precision like the Kasai for biliary the porta hepatis. The remnants of the cystic duct
atresia. Robotic surgery offers a level of preci- are dissected back to the fibrosed common
sion and improved optics that may be the solu- hepatic and bile ducts. We recommend leaving a
tion. The robotic approach allows the surgeon to portion of the gallbladder attached to the liver
dissect the portal plate at the appropriate angle bed and to use this as a handle for liver retraction
and with absolute precision. The port placement through the remainder of the case. The atretic
for the robotic Kasai is shown in Fig. (29.10). extrahepatic biliary system is then dissected up to
Despite the small size of these children at 4–8 the bifurcation of the portal vein (Fig. 29.11).
weeks and usually only about 4 kg, we recom- It is very important to avoid cauterization at
mend using the 12 mm scope for the robotic the portal plate as this may inadvertently damage
Kasai. This camera size is selected because the critical biliary drainage channels. The portal
neonatal bowel can easily be extruded through a plate should be separated from the atretic extra-
12 mm umbilical incision to create an extracor- hepatic biliary tissue using the scissors at a pre-
poreal Roux-en-Y limb, whereas trying to con- cise angle such that potential biliary channels
struct one intracorporeally in such a small child is have the highest probability to drain (Fig. 29.12).
difficult. The patient is supine in a slight reverse After the portal plate has been precisely dis-
Trendelenburg position and rotated slightly to the sected, the Roux-en-Y jejunojejunostomy is
left. After gaining access to the abdomen, a chol- created extracorporeally. The small bowel is
angiogram should be attempted before the robot marked about 15–20 cm distal to the ligament of
is docked to confirm the diagnosis. The rudimen- Treitz. The robot is then undocked from the tro-
tary gallbladder is retracted cephalad to expose cars and the 12 mm umbilical trocar removed.
29 Pediatric Robotic Surgery 347

Fig. 29.11 Robotic dissection at the bifurcation of the Fig. 29.13 Constructing the hepaticojejunostomy
portal vein and exposure of the portal plate

gallbladder are removed from the liver bed

concluding the operation. Initial results are
encouraging [13, 14]. A multi-institutional study
is needed to investigate if a robotic Kasai
procedure is the answer to the MIS approach in
neonates with biliary atresia.

Choledochal Cyst

The choledochal cyst resection with reconstruc-

tion is a complex procedure that is very challeng-
ing with standard laparoscopic instruments. The
Fig. 29.12 Dissection of the portal plate challenging dissection and significant suturing
required in the reconstruction make this an ideal
The neonatal bowel easily comes through the robotic case. Choledochal cysts are more preva-
12 mm umbilical port with no need to extend the lent in females and Asian populations [15].
incision. The marked bowel is then brought up Patients can present with right upper quadrant
through the umbilical wound, and a 30 cm Roux pain, fever, and jaundice. Ultrasound often dem-
limb is constructed using interrupted absorbable onstrates the cyst, and a CT scan will demon-
sutures extracorporeally. The Roux limb is then strate a more detailed anatomical picture for
dropped back into the abdomen and the trocar surgical planning. Alternative radiographic
reintroduced and the pneumoperitoneum rees- images can be obtained from ERCP or MRCP.
tablished. The robot is re-docked to the same The age of presentation can be as young as just a
trocars and a retrocolic portoenterostomy is few months of age up through young adults.
created (Fig. 29.13). Similar to the Kasai, smaller children may be
We use 4-0 absorbable suture to anchor the candidates to have their Roux limb constructed
anastomosis on each side of the portoenteros- extracorporeally through the 12 mm umbilical
tomy followed by interrupted 5-0 or 6-0 PDS port incision if their abdominal wall is thin
sutures to complete the anastomosis. Next, the enough. Larger children may have an abdominal
gap in the colonic mesentery where the Roux wall that is too thick to allow a Roux limb con-
limb passes is closed to prevent an internal her- struction extracorporeally. Intracorporeal Roux
nia. Finally, the last portions of the rudimentary limb construction is a better option for these
348 J.J. Meehan

Fig. 29.14 Port locations for

the robotic choledochal cyst
resection and Roux-en-Y
choledochojejunostomy
reconstruction

patients, and the robot helps to facilitate this step. portal vein. The biliary tree is dissected proxi-
Trocar placement is shown in Fig. (29.14). mally to the duodenum as close as possible and
A cholangiogram can be done at the onset of ligated. The cyst is then dissected towards the
the procedure prior to robot docking and is gener- liver until the entire cyst has been isolated.
ally recommended. If the child is more than Transection of the common duct cephalad to the
20 kg, we opt for using the 4th arm of the robot to cyst completes the resection and reconstruction
retract the gallbladder upwards to expose the begins. A Roux-en-Y limb is created as described
porta hepatis. In smaller children, we find the 4th in the Kasai procedure, and the choledochojeju-
arm too cumbersome due to the small size of the nostomy anastomosis is accomplished with PDS
patient. Retraction of the gallbladder and dissec- suture (Fig. 29.16).
tion of the cystic duct is the first task. The cystic Preliminary laparoscopic data suggests that
duct is identified, ligated, and divided and the reconstruction can be done via a choledochoduo-
dissection carried towards the common bile duct, denostomy without the need of a Roux limb [16].
leaving the gallbladder attached to the liver bed. This type of reconstruction significantly shortens
The gallbladder is used through the remainder of the length of time of the case, but long-term data
the case as a grasping handle to retract the liver. regarding potential complications is lacking.
Once the junction from the cystic duct to com-
mon bile duct has been identified, the extrahe-
patic biliary dissection is performed to fully Duodenal Atresia
expose the choledochal cyst (Fig. 29.15).
We sometimes elect to open the cyst on the The repair of the newborn with duodenal atresia
anterior surface in order to see the back wall bet- (DA) is a very difficult laparoscopic proce-
ter as these cysts are often densely adherent to the dure. Only a few pediatric surgeons routinely
29 Pediatric Robotic Surgery 349

Fig. 29.15 Robotic

dissection of the choledochal
cyst

Fig. 29.16 Robotic

construction of the Roux-
en-Y choledochojejunostomy

perform this procedure using laparoscopic With the baby supine in reverse Trendelenburg
instrumentation simply because the technique position and rotated slightly to the left, the tro-
is too challenging to suture the small diameter cars are identical as the Kasai arrangement
bowel in such a tight space. A novel approach already shown in Fig. (29.10). However, there is
using permanent material has been performed no need to use the large 12 mm scope in the duo-
laparoscopically using nitinol U-clips denal atresia case and we opt for the 8.5 mm
(Medtronic Surgical, Minneapolis, MN, USA), scope instead. A 5 mm accessory port is placed
but is not in widespread use [17]. The robot on the right flank just above the liver edge and
offers the significant suturing advantages. The about 1 cm below the costal margin. This port is
youngest patient to have robotic surgery was used to retract the liver with the aid of a fan
the first duodenal atresia ever performed with retractor as necessary or could also be used for a
the da Vinci robot, a 1-day-old newborn that suction device by the bedside assistant once the
weighed only 2.4 kg. proximal and distal bowel segments are opened.
350 J.J. Meehan

Fig. 29.17 Dissection

demonstrating the proximal
and distal duodenum in a
baby with duodenal atresia.
The pancreas is also visible
as well as the separation
between the two segments of
bowel

The 5 mm robotic instrument ports must be stra- the entire length should be avoided as this may
tegically placed to allow for adequate internal encourage a stricture. The front row should be
movement as the patients are often only about constructed in an interrupted fashion (Fig. 29.18).
3 kg or less. The robot is brought in over the
patient’s right shoulder at about a 45° angle. A
needle driver or Maryland is used in the surgeon’s Mediastinal Mass
left hand and the hook cautery in the right hand.
The procedure begins by taking down the hepatic This is a broad category of diagnoses and includes
flexure of the colon in the right upper quadrant, both benign and malignant tumors as well as con-
thereby exposing the duodenum. The dilated genital anomalies. The congenital anomalies
proximal duodenum is usually easy to locate, but include bronchogenic cyst and esophageal dupli-
finding the small distal duodenum may take some cation. Bronchogenic cysts are often located at
time during dissection (Fig. 29.17). the carina but can be in other locations as well.
Care should be taken during the dissection to Esophageal duplications can occur anywhere
avoid the common bile and pancreatic ducts as along the tract of the esophagus and may present
they enter the duodenum. This junction could be with dysphagia or reflux. Resection may require
in either the proximal or distal segment. Once the reconstruction of the esophageal wall or even a
proximal and distal extents of the duodenum are protecting fundoplication if they are located low
exposed, the proximal segment is opened trans- in the chest. Mediastinal tumors can occur in a
versely and the distal longitudinally. We recom- number of locations depending on their cell line
mend constructing the duodenal anastomosis in a of origin. The location in either the anterior or
diamond configuration whenever possible, as posterior mediastinum often helps predict the
described in the open procedure by Kimura [18]. diagnosis.
If desired, the anesthesiologist can help pass a The differential diagnosis of a posterior mass
small NGT tube into the stomach, which can be includes ganglioneuroma, ganglioneuroblas-
fed into the distal bowel and flushed with saline, toma, and neuroblastoma. These tumors arise
looking for possible downstream webs or atre- from the sympathetic chain and may even tra-
sias. Interrupted suturing is preferable, but a run- verse the diaphragm. Ganglioneuromas are
ning locked configuration in short runs is benign tumors that are slow growing or may have
acceptable on the back row. A running suture for arrested in growth completely (Fig. 29.19).
29 Pediatric Robotic Surgery 351

Fig. 29.18 Nearing the end

of the diamond duodenoduo-
denostomy in duodenal
atresia. The 5 mm robotic
instrument is placed down the
narrow distal limb to prevent
back-walling the anastomosis

Fig. 29.19 Resection of a

ganglioneuroma. The 3D
vision of the da Vinci system
helps to see how these tumors
dive in between the ribs

Primary resection is the only therapy required The anterior masses include teratomas, germ
for these tumors. Neuroblastomas are malignant cell tumors, and thymomas. Teratomas are more
and can be quite large on initial presentation. commonly benign and may be asymptomatic for
Confirming the diagnosis with a biopsy followed years (Fig. 29.20). However, they can also be
by chemotherapy is the best option for large malignant, and it is important to draw serum val-
lesions, while smaller lesions may be amenable ues for alpha fetoprotein (AFP) and beta human
to a primary resection. Proper staging will chorionic gonadotropin (beta-HCG) levels prior
include bone marrow aspiration and biopsy, and to resection. Elevation of these serum markers is
chemotherapy is tailored based on tumor biol- highly suggestive a malignant tumor. Subsequent
ogy. Ganglioneuroblastomas carry an intermedi- measurements after resection are helpful to mon-
ate classification due to their occasional itor for potential recurrence in patients with
propensity to recur locally but require primary malignant teratomas [19]. If the serum levels are
resection only. normal, the teratomas are almost certainly mature
352 J.J. Meehan

Fig. 29.20 A mediastinal

teratoma

Fig. 29.21 A large

10 × 11 cm germ cell tumor
adherent to the pericardium.
Note the proximity of the
phrenic nerve (arrow)

teratomas and benign. Finally, the tumors of thy- placing the robot cart wherever the tumor is
mic origin include thymomas and germ cell situated. For example, if the mass is anterior and
tumors. Germ cell tumors may also have superior, the robot will come in from an anterior
increased beta-HCG and AFP, often originate in and superior angle. Likewise, if the mass is pos-
thymic tissue, and can grow to an enormous size terior and inferior, the robot will be bought in
(Fig. 29.21). from a posterior and inferior angle (Fig. 29.22).
The robotic articulations are particularly use-
ful for navigating around mediastinal masses
reducing the need for additional trocars. We often Congenital Diaphragmatic Hernia:
can accomplish the entire resection of just about Bochdalek Hernia
any mediastinal mass with only 3 trocars; one
camera port and 2 instrument ports. The simple The posterolateral Bochdalek CDH occurs due to
rule for setting up the case can be remembered by the failure of the diaphragm to close properly in
29 Pediatric Robotic Surgery 353

Fig. 29.22 Example trocar locations and robot cart positioning for mediastinal masses: (a) anterior and superior mass
and (b) posterior and inferior mass

embryology. The defect is always posterior and procedure need the robot. Viscera reduction is
lateral, but the size of the defect can be quite vari- better accomplished using standard thoraco-
able. The most posterolateral rim may have no scopic instruments. Large sweeping movements
diaphragm at all making it difficult to find ade- from one section of the chest to another are nec-
quate tissue to complete the repair. Moreover, essary for reducing the viscera, and the da Vinci
this anatomic location is hard to reach in standard is not very adept at moving in this manner.
thoracoscopy as it is deep in the sulcus of where Therefore we reduce the viscera thoracoscopi-
the diaphragm should be and the suturing angles cally before docking the robot. Defects that are
thoracoscopically are less than ideal. The abdom- too large for a primary repair will require a patch
inal approach is even more challenging but not closure. The material is brought in through a
because the region is hard to reach, in fact it is 5 mm trocar rolled up like a carpet. Once inside,
fairly easy to reach. But these children have a it can be easily unrolled and sewn in place. In
scaphoid abdomen with a lack of domain because patients with a tight primary closure, the patch
the viscera developed inside the chest. Moreover, material can be used as a reinforcement sewing it
bringing the viscera back into the abdomen directly over the repair.
crowds the very tight abdominal compartment The patient is placed in a lateral decubitus
even further adding to the problem regarding lack position. The robot will come in from the patient’s
of domain. Therefore, most pediatric surgeons feet, at a slight angle towards the patients back
agree that the thoracoscopic approach is pre- (Fig. 29.23). This means that the robot arms will
ferred. It should be noted, however, that we have be maneuvering over the patient’s head during
occasionally done the abdominal approach robot- the case. It is critically important to place a pro-
ically for very small patients when the articulat- tective solid barrier over the baby’s head to pre-
ing instruments are too long from the chest [1]. vent the robot arms making inadvertent contact
Regardless, the thoracoscopic approach to the with the patient. We prefer a table-mounted
Bochdalek CDH remains our preferred approach. laryngoscopy holder commonly used in head and
Non-robotic thoracoscopic failure rates have neck procedures (Fig. 29.24).
been alarmingly high in some series [20, 21]. The The robotic trocars need to be placed perfectly in
articulating instrumentation used in robotics may a neonatal repair as the small neonatal chest has very
solve this problem [22]. But not all aspects of the little additional room for the articulations. Cheating
354 J.J. Meehan

Congenital Diaphragmatic Hernia:

Morgagni Hernia

Repair of the Morgagni CDH is another ideal

robotic case and relatively easy. The foramen of
Morgagni is anterior and essentially midline on
the diaphragm although it is often skewed slightly
to the right side. The defect occurs as a result of
failure of the fusion of the pleuroperitoneal sur-
face of the diaphragm at the costosternal trigone.
Unlike the Bochdalek CDH, which often presents
at birth with respiratory compromise, these
patients may go years or even decades without
Fig. 29.23 Trocar placement for the robotic Bochdalek the diagnosis suspected. The defect may be found
CDH repair incidentally during a chest X-ray for unrelated
issues. Occasionally, a patient may present with a
bowel obstruction from viscera trapped in the
the remote center to the outside of the chest helps hernia. More commonly, patients complain of
gain important additional articulating length. mild substernal chest pain or indigestion. Because
The procedure begins by first reducing the vis- of its anterior location, the angles for suture
cera by using laparoscopic peanuts and gentle repair of this defect using the standard laparo-
traction. Once the viscera are reduced, the robot scopic instrumentation are challenging. Primary
can then be docked. Mobilize the diaphragmatic repair is preferred although a patch closure may
edge of the defect as it fuses with the posterolat- be necessary for larger defects. Port placement is
eral chest wall as best as possible (Fig. 29.25). shown in Fig. (29.27).
This mobilized rim of tissue can help attain a Typically, only one camera port and two
primary closure, which is preferred over patch instrument ports are required without the need
closure. Close the defect using interrupted hori- for an accessory port. The viscera reduction is
zontal mattress sutures (Fig. 29.26). performed first followed by resection of the her-
We prefer to work from lateral to medial but nia sac, which is usually, but not always, present.
either direction is acceptable. Pledgets help dis- A rim of tissue on the anterior abdominal wall is
tribute the tension on the diaphragm and may mobilized with the hook cautery, and repair is
reduce tearing of the muscle. Occasionally, clos- performed using horizontal mattress sutures
ing the most posterolateral aspect can be particu- (Fig. 29.28).
larly difficult because no rim of tissue is available Pledgets can be used if desired. Prosthetic
for mobilization. In these patients, consider pass- material can be rolled up like a carpet and brought
ing the suture out of the chest and around a rib, in through one of the instrument trocars for larger
making a small external skin incision to assist defects if a patch closure is needed.
with this maneuver. Usually only one or two
sutures around the rib are required. We have not
needed this rib stitch very often using the robot Thymectomy
because we can often get adequate mobilization
and proper suturing angles without it. Once the Myasthenia gravis (MG) is a poorly understood
posterolateral section is closed, the repair pro- autoimmune disorder where the body produces
ceeds medially. Patch closure, if necessary, is antibodies that block muscle cells from receiv-
accomplished by suturing the lateral aspect first ing neurotransmitters from the nerve cell. This
and proceeding medially. A chest tube is usually leads to muscle weakness of voluntary muscles.
not necessary following closure. Patients can present with fatigue, generalized
29 Pediatric Robotic Surgery 355

Fig. 29.24 A protective

barrier is positioned over the
baby’s head. This is a
critically safety precaution in
the CDH repair as the robot
arms will maneuver over the
patient’s head during the
operation

Fig. 29.25 Mobilizing tissue

to create a suitable diaphragm
rim for suturing

weakness, facial paralysis, or even breathing results in hospitalization during acute exacerba-
difficulties from weakness of the chest wall mus- tions. Patients with refractory symptoms are
cles. The muscles around the eye are often candidates for thymectomy as this may alleviate
affected first leading to the classic eyelid droop the need for medications.
or even double vision. While the weakness may The robotic thymectomy is an ideal approach
be noticed on physical exam, reflexes are often to the thymus which often extends beyond the
normal. The diagnosis is confirmed by nerve mediastinum and up into the neck. Preliminary
conduction studies and detection of acetylcho- studies are already in print and the initial robotic
line receptor antibodies. Steroids that can help results are encouraging [23]. We prefer a left tho-
reduce the immune response and pyridostig- racic approach. A dual lumen endotracheal tube
mine, which may improve the communication is preferable and will assist with collapse of the
between nerves and muscles, are the mainstay of left lung. The patient is placed in a supine posi-
medical therapy. Respiratory compromise often tion rolled slightly to the right with a small bump
356 J.J. Meehan

reside in the right chest or the right neck but is all

easily accessible from the left chest using the
robotic instruments. The innominate vein is iden-
tified and care taken to fully dissect the entire
gland out of the neck holding adequate retraction
to pull the cephalad tail of the thymus down into
the mediastinum (Fig. 29.31).
A complete resection is critical for the best
chance for resolution of symptoms. A postopera-
tive chest tube is rarely necessary. At the comple-
tion of the operation, we automatically send all
patients to the pediatric ICU as a precaution
because of their baseline weakness but have
never had any postoperative respiratory issues.
Most patients are discharged in 24–48 h follow-
ing surgery.
Fig. 29.26 Closure of the Bochdalek CDH using inter-
rupted horizontal mattress sutures and pledgets
Esophageal Atresia with
Tracheoesophageal Fistula

Repair of the neonate with a TEF is considered

the Holy Grail in pediatric surgery, and absolute
precision is required for the esophageal anasto-
mosis. Using a minimally invasive approach is
slowly gaining popularity but has not gained
wide acceptance. The first MIS TEF repair was
reported in 2001 [24]. Several series have been
reported since then, but the procedure is still
being done by only a small subset of pediatric
surgeons. One of the problems is the rarity of this
Fig. 29.27 Port placement for the Morgagni CDH repair condition in relation to a problematic learning
curve in order to become familiar with the proce-
under the left scapula. The left arm is positioned dure. Initial stricture and leak rates are relatively
over the face and trocars are placed as shown in high but eventually approach those of open sur-
Fig. (29.29). gery [25]. Despite this shortcoming, advantages
The entire procedure can be accomplished such as avoiding of a thoracotomy are of great
with only three ports although an assistant port benefit as profound scoliosis is a major concern
can be added for lung retraction if necessary. The for neonates that undergo a thoracotomy [26].
scope selection is a 30° scope and alternating Theoretically, the robot could solve the prob-
between an upward and downward look is help- lem of the precision with 3D vision and more
ful throughout the case. The phrenic nerve is accurate placement of the sutures. Unfortunately,
identified early in the procedure, and care should this is a procedure, which is still a bit difficult for
be employed when dissecting near this sensitive the current robotic da Vinci system because of
structure (Fig. 29.30). the size of the instrumentation in relation to the
Dissection is followed cephalad and then patient. Most newborns with TEF are quite small,
medially. A significant portion of the gland may often under 3 kg in size. The robotic 8.5 mm
29 Pediatric Robotic Surgery 357

Fig. 29.28 Repair of the

Morgagni CDH

Fig. 29.29 Positioning and

trocar placement for the
robotic thymectomy. The da
Vinci robot will come in over
the patient’s right shoulder

scope is a very tight fit between the rib space of improvements are made. As a guideline, The
such a small baby, and the lack of workable space TEF baby generally needs to be above 3 kg and
for the articulating instruments makes this opera- very few TEF babies are that large. We did our
tion extremely challenging. These constraints are first TEF repair in 2007 with a da Vinci Standard
potentially compounded if the newborn has any system and the 2D 5 mm scope which is no lon-
one or more of the numerous others associated ger available. This procedure can also be accom-
anomalies often seen with TEF as part of the plished with the 8.5 mm scope but the rib space is
VACTERL association (V, vertebral; A, anorectal very tight. However, in the hopes that this tech-
malformation; C, cardiac; TE, tracheoesophageal nology will eventually improve with diameter
fistula; R, renal; L, limb). Therefore, the robotic equipment and shorter articulating lengths, we
TEF repair is unlikely to be a common procedure will go on to describe the steps to robotic repair
with the current da Vinci robot unless significant of the TEF. Although there are five different
358 J.J. Meehan

Fig. 29.30 Identification of the phrenic nerve (arrow) is the first task in the robotic thymectomy

Fig. 29.31 Dissection of the thymus around the innominate

types of TEF, we will describe repair of the most The first step is identification and division
common variant, the proximal esophageal atresia of the azygos vein. The vessel can be taken
with distal tracheoesophageal fistula. down and divided using a thermal sealing
Bronchoscopy is strongly recommended at the device such as the LigaSure. Alternatively,
beginning of the procedure to confirm the sus- clips can be used to ligate the vessel and scis-
pected anatomy. The trocar placement is shown in sors brought in for division. Dissection then
Fig. 29.32 and a transpleural approach is required. begins in the mediastinum with identification
29 Pediatric Robotic Surgery 359

using interrupted anastomosis 4-0 or 5-0 suture.

The first suture may not bring the two ends
together all the way but can be regarded as a trac-
tion suture lining up the repair for the remainder
of the anastomosis. Subsequent sutures can be
used to pull the two ends completely together. We
recommend placing the knots on the inside of the
lumen for the back row and on the outside for the
front row. Have the anesthesiologist gently slide
Fig. 29.32 Trocar placement for the robotic esophageal a NG tube past the completed back row and down
and TEF repair into the distal esophagus before completing the
front row (Fig. 29.34).
of the proximal esophagus, the distal esopha- The surgeon may have to help guide the tube
gus, the trachea, and the fistula connecting the with a grasper or needle driver. The NG tube then
trachea to the distal esophagus. The anesthesi- serves as a stent or sizer for the repair. Although
ologist can assist the surgeon by manipulating some surgeons prefer to leave it in place, it can be
a nasogastric (NG) tube to help demonstrate removed at the completion of the procedure.
the upper pouch. The fistula is often just a cou- Complete the front row of sutures over the NG
ple of tracheal rings inferior to the upper pouch tube with the knots on the outside of the esopha-
and usually attaches just 1 or 2 mm proximal to gus. A chest tube is left in place following the
the carina (Fig. 29.33). repair and should stay in place until a swallowing
The fistula takedown is the next important step study is performed about 7 days postoperatively.
that can be done in a variety of ways. One recently The chest tube can be removed and feeds initi-
advocated method is to simply clip the fistula ated once there is no evidence of a leak.
close to the origin at the trachea using an endo-
scopic clip applier [27]. Alternatively, the fistula
can be divided in a piecemeal fashion to mini- The Future
mize the leak from the trachea and closed sequen-
tially with interrupted absorbable sutures. The wide range of procedures that can be done
Another choice would be to come across the fis- robotically in children is huge as the combination
tula all at once with the scissors, but this may of acquired and congenital anomalies creates an
cause significant airway pressure loss until the enormous variety of surgical pathology. The da
open trachea is closed. We prefer the piecemeal Vinci has gained tremendous popularity in adult
approach, suturing the trachea as the fistula is urology, gynecology, and more recently in adult
divided. Once control of the fistula has been general surgery. Enthusiasm is now also growing
established, attention is turned at bringing the in pediatric general surgery. However, improve-
two ends of the esophagus together with mobili- ments in the technology are needed in order to
zation of the esophagus. Mobilization needs to be gain widespread acceptance. Downsizing the
adequate to bring the two ends together without diameter is an important step as the 5 and 8 mm
undue tension, but this needs to be balanced with robotic instruments are competing against 3 mm
avoiding overdissection and potential esophageal laparoscopic instrumentation. The articulating
ischemia. Grasping the friable neonatal esopha- length is also an issue, as space becomes a sig-
gus with robotic instrumentation poses another nificant issue in smaller patients. This can be
challenge and should be done with a minimum of accomplished either in the instrument itself or by
trauma. Once again, it is often helpful to utilize shortening the length of the robotic port from
the assistance of the anesthesiologist by manipu- remote center to the end of the cannula. The tis-
lating the NG tube to aid in the proximal pouch sues of newborns and premature babies are very
mobilization. The anastomosis is performed fragile, and instrumentation with delicate but fine
360 J.J. Meehan

Fig. 29.33 Exposure of the

tracheoesophageal fistula
(arrow). The proximal
esophagus (PE), distal
esophagus (DE), and trachea
(T) are also visible

Fig. 29.34 The NG tube is

passed distally to assist with
the anastomosis in the repair
of the esophageal atresia

tips is another item for the future as we expand nal atresia, choledochal cysts, Ladd’s procedure,
this technology to smaller and smaller babies. the Kasai portoenterostomy, thymectomy, medi-
There are many laparoscopic procedures that astinal masses, and all forms of congenital dia-
are often too challenging for the standard hand- phragmatic hernia. The introduction of the Tissue
held instruments, and the robotic approach has the Sealer in 2012 may prove to be a major game
potential to overcome the deficiencies of laparos- changer as this device has the potential to be use-
copy in children. Cholecystectomies and fundo- ful for pulmonary lobectomies in children with
plication are excellent training cases, and surgeons pulmonary sequestrations and CCAMs. Animal
new to robotic surgery should start their experi- testing for this application is still needed but could
ence with these simple cases before moving on to lead to a revolution in the way pediatric surgeons
more challenging procedures. There are many view the robotic technology. Additionally, devel-
operations where we feel the current robot is opment of pediatric specific instrumentation with
already superior to laparoscopy including duode- finer grasping qualities could help expand the
29 Pediatric Robotic Surgery 361

realm of procedures for neonates and perhaps 13. Dutta S, Woo R, Albanese CT. Minimal access porto-
enterostomy: advantages and disadvantages of stan-
even premature kids. Finding ways to utilize the
dard laparoscopic and robotic techniques. J
Firefly technology for neuroblastoma, rhabdo- Laparoendosc Adv Surg Tech A. 2007;17(2):258–64.
myosarcoma, and other pediatric tumors could 14. Meehan JJ, Elliott S, Sandler A. The robotic
help pave the way for a whole new perspective for approach to complex hepatobiliary anomalies in
children: preliminary report. J Pediatr Surg. 2007;
pediatric oncological surgery. The possibilities
42(12):2110–4.
are endless and there is plenty of room to grow as 15. Huang CS, Huang CC, Chen DF. Choledochal cysts:
pediatric robotic surgery is literally in its infancy. differences between pediatric and adult patients. J
Gastrointest Surg. 2010;14(7):1105–10.
16. Liem NT, Pham HD, le Dung A, Son TN, Vu HM.
Early and intermediate outcomes of laparoscopic sur-
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Should open Kasai portoenterostomy be performed thoracoscopic surgery. J Laparoendosc Adv Surg
for biliary atresia in the era of laparoscopy? Pediatr Tech A. 2011;21(5):439–43.
Surg Int. 2008;24(8):931–3. 26. Sistonen SJ, Helenius I, Peltonen J, Sarna S, Rintala
11. Gundeti MS. Pediatric robotic and reconstructive RJ, Pakarinen MP. Natural history of spinal anomalies
urology: a comprehensive guide. Oxford: Wiley- and scoliosis associated with esophageal atresia.
Blackwell; 2012. Pediatrics. 2009;124(6):e1198–204.
12. Laje P, Clark FH, Friedman JR, Flake AW. Increased 27. Rothenberg SS. Thoracoscopic repair of esophageal
susceptibility to liver damage from pneumoperito- atresia and tracheo-esophageal fistula in neonates:
neum in a murine model of biliary atresia. J Pediatr evolution of a technique. J Laparoendosc Adv Surg
Surg. 2010;45(9):1791–6. Tech A. 2012;22(2):195–9.
 Part XII
Surgical Techniques: Microsurgery
 Robotic-Assisted Microsurgery
for Male Infertility and Chronic 30
Orchialgia

Jamin V. Brahmbhatt, Ahmet Gudeloglu,

and Sijo J. Parekattil

sperm granuloma at the anastomosis [2]. Also in

General Overview of Current 2004, Fleming et al. reported excellent patency
Applications on two patients that underwent the first bilateral
robotic-assisted vasovasostomy (RAVV) [3]. The
The introduction of the operative microscope in first robotic-assisted subinguinal varicocelec-
the 1920s revolutionized surgery of microscopic tomy (RAVx) was described in 2008 [4, 5]. Since
structures. Today another revolution is upon us then the techniques and outcomes have improved
with the incorporation of robotic technology into significantly with robotic assistance for male
microsurgery. The advantages of robotic assis- infertility [6, 7].
tance include high-resolution three-dimensional Chronic orchialgia (CO) is a common clinical
optics, enhanced precision with elimination of condition that is often under diagnosed. The con-
tremor and 5:1 motion scaling, improved surgeon dition may affect over 100,000 men annually [8, 9].
ergonomics, and ability to control multiple instru- CO is defined as intermittent or constant, unilat-
ments without need for a skilled assistant. These eral or bilateral testicular pain lasting more than
benefits have led to its utilization for treatment of 3 months [10]. The pain can be idiopathic or
male infertility and chronic orchialgia through caused by nerve irritation or hyposensitivity
vasectomy reversal, subinguinal varicocelec- through vasectomy, hernia repair, sports injury,
tomy, testicular sperm extraction, and targeted abdominal surgery, or any intervention that can
denervation of the spermatic cord. irritate the genitofemoral or ilioinguinal nerves.
In 2004 Kuang et al. performed the first Although the exact mechanism for CO is not well
robotic-assisted andrological procedure with an understood, one common theme is a two-hit the-
ex vivo vasovasostomy [1]. The first randomized ory (Fig. 30.1). There is a baseline inflammatory
prospective study comparing the robotic-assisted or genetic process that leads to Wallerian degen-
vasovasostomy (RAVV) and pure microsurgical eration (Fig. 30.2) of the peripheral nerves. This
vasovasostomy (MVV) showed advantages in leads to hypersensitivity of the ilioinguinal and
terms of decreased operative time and decreased genitofemoral nerves. A second inciting event,
trauma, surgery, or irritation of these nerves then
leads to chronic neuropathic pain in this area.
J.V. Brahmbhatt, M.D. • A. Gudeloglu, M.D.
S.J. Parekattil, M.D. (*) Prevalence can range up to 33 % of men after
Department of Urology, Winter Haven Hospital and vasectomy [11] and 63 % after inguinal hernia
University of Florida, 199 Avenue B NW, Suite 310, repair [12–14]. After hernia repair the pain can
Winter Haven, FL, USA
be neuropathic or non-neuropathic secondary to
e-mail: [email protected];
[email protected]; mesh. Even with such a high prevalence after her-
[email protected] nia repair, only 1 % of patients who suffer from

K.C. Kim (ed.), Robotics in General Surgery, DOI 10.1007/978-1-4614-8739-5_30, 365

© Springer Science+Business Media New York 2014
366 J.V. Brahmbhatt et al.

Fig. 30.1 Two-hit theory on cause of chronic orchialgia

Fig. 30.2 Nerve fiber with and without Wallerian degeneration on H&E staining

CO may be referred for further evaluation [15]. within the spermatic cord [16]. The three primary
Parekattil et al. in 2008 reported on the advan- locations for abnormal nerves (highest to lowest)
tages of robotic-assisted targeted microsurgical are cremasteric nerve fibers, perivasal tissue and
denervation of the spermatic cord (RMDSC) for vasal sheath, and posterior lipomatous/posterior-
chronic groin and testicular pain [7, 8]. The tech- arterial tissue.
nique targets denervation at specific nerves found In this chapter we will highlight specific
to have abnormal fibers (Wallerian degeneration) procedures for the management of male infer-
30 Robotic-Assisted Microsurgery for Male Infertility and Chronic Orchialgia 367

tility and chronic orchialgia: robotic-assisted

Robotic-Assisted Microsurgical
microsurgical vasovasostomy, vasoepididymos-
Vasovasostomy
tomy, subinguinal varicocelectomy, and targeted
denervation of the spermatic cord.
Technique

Preoperative Preparation The proximal and distal vas deferens (beyond the
previous vasectomy site) is palpated through the
Anticoagulant medications or supplements are scrotal skin. Through the skin the distal vas is
generally held 5–7 days prior to the procedure. fixed into place with a towel clip (Fig. 30.7).
A broad-spectrum antibiotic is administered at Local anesthetic is infiltrated into this area.
least 30 min prior to skin incision. Mechanical A 1–2 cm vertical incision is made over the vas
lower extremity compression stockings are used starting inferiorly from the previously placed
for deep venous thrombosis prophylaxis. towel clip (Fig. 30.8). Using fine electrocautery
and sharp dissection, the distal and proximal ends
of the vas are dissected free. The distal vas is dis-
Operative Setup and Patient sected to allow a tension-free anastomosis to the
Positioning proximal vas. The proximal vas is carefully tran-
sected with a #11 blade. Microscopic examina-
The patient is placed in a supine position and tion of the proximal vas fluid is performed. If no
prepped and draped in a standard surgical fashion. sperm is present in this proximal fluid,
Skin incisions are made and appropriate operative robotic-assisted microsurgical vasoepididymos-
tissues are exposed. The robot is brought in from tomy (RAVE) is performed. If sperm is found,
the right side of the patient for the microsurgical then RAVV is performed. The adventitia from
portion of the case (Fig. 30.3). Figure 30.4 illus- either end of the vasa is now secured together
trates the trocar robotic arm placement. Trocars with a 3-0 prolene suture to allow a tension-free
are loaded to allow the instruments to function anastomosis.
and to stabilize their movements outside the The robot is now positioned from the right of
patient’s body. Instruments are advanced 4–5 cm the patient to perform the microsurgical vasova-
beyond the tip of the trocar to optimize range of sostomy. Black diamond micro-forceps are
motion. A 0° camera lens is used to optimize the inserted on the right and left robotic arms. The
visual field during procedures. micro Potts scissors are inserted onto the fourth
Figure 30.5 illustrates our utilization of the robot arm. The 0° camera lens is inserted onto the
VITOM (Karl Storz Inc., Tuttlingen, Germany) robot camera arm. The two ends of the vas are
camera system for enhanced 16–18× magnifica- placed over a 1/4 in. Penrose drain. The assistant
tion with a nitrogen powered fifth arm (Point set- passes the 9-0 nylon suture that is kept in its inner
ter arm, Karl Storz Inc., Tuttlingen, Germany). packaging to the surgical field. The suture is
The real-time video images from VITOM are grasped using the black diamond right-hand
transported to the surgeon console utilizing the grasper and cut to about 2 in. length using the
TilePro (Intuitive Surgical, Sunnyvale, CA) micro Potts scissors. The 9-0 nylon suture is held
robotic surgical console software system to pro- and manipulated using the black diamond for-
vide simultaneous real-time images to the micro- ceps in both left and right arms as needle drivers.
surgeon. Figure 30.6 illustrates the cockpit view The posterior muscularis layer of the two ends of
of the surgeon console (1) the da Vinci Si 3D HD the vas is now approximated (Fig. 30.9). Two or
camera view, (2) the VITOM optical 16–18× three double-armed 10-0 nylon sutures are now
camera lens system view, and (3) a 40–100× placed inside out to reanastomose the posterior
optical microscopic view from the intra-op mucosal lumen of the vas (Fig. 30.10). Three
andrology laboratory microscope (Nikon Inc., double-armed 10-0 nylon sutures are used to
Tokyo, Japan). close the anterior mucosal lumen of the vas
Fig. 30.3 General robotic position and setup for microsurgery cases

Fig. 30.4 Robotic arm and trocar placement for microsurgery cases

(Fig. 30.11). Five to six 9-0 nylon sutures are sitioning the robotic arms. The Penrose drain is
used to approximate the anterior muscularis layer gently removed from under the repair. The vas is
of the vas (Fig. 30.12). The same procedure is placed back into the scrotal cavity and the tissue
now performed on the contralateral side by repo- and skin are closed with absorbable suture.
Fig. 30.5 Positioning of VITOM on nitrogen powered fifth robotic arm

Fig. 30.6 Cockpit view of surgeon console with TilePro software

370 J.V. Brahmbhatt et al.

The testicle is delivered and the tunica is incised to

Robotic-Assisted Microsurgical
expose the epididymis. The adventitial layer of the
Vasoepididymostomy
epididymis is incised above the level of epididy-
mal obstruction (blue/gray zone with dilated epi-
Technique didymal tubules above this area). A 3-0 prolene
suture is used to attach the testicle to the adventitia
The RAVE procedure starts from above when there of the vas to prevent tension between the anasto-
is no sperm in the fluid from the proximal vas. The mosis. The vas is stripped off the adventitia and
scrotal incision is enlarged by 1–2 cm inferiorly. flipped towards the epididymal tubules. The robot
is now positioned similar to above. Two 10-0 nylon
double-armed suture needles are placed longitudi-
nally through a single epididymal tubule to expose
the tubule (Fig. 30.13). This tubule is then incised
longitudinally using the micro Potts scissors
between the two suture needles to create a lumen
in the tubule (Fig. 30.14). The fluid is then aspi-
rated and examined under a separate phase con-
trast microscope for the presence of sperm.
When sperm is confirmed, two double-armed
10-0 nylon needles in the epididymal tubule are
advanced through and then all four of the needles
are brought inside out on the vas mucosal lumen
to involute the epididymal tubule lumen into the
vas lumen (Fig. 30.15). Five to six 9-0 nylon
sutures are placed circumferentially to approxi-
mate the muscularis of the vas to the adventitia of
the epididymal tubule (Fig. 30.16). The testicle
and anastomosis are carefully delivered back into
Fig. 30.7 Skin and vas under towel clip for robotic
vasectomy reversal the scrotum. The dartos layer and skin are closed.

Fig. 30.8 Midline skin incision for robotic vasectomy reversal

30 Robotic-Assisted Microsurgery for Male Infertility and Chronic Orchialgia 371

Fig. 30.9 RAVV posterior muscular anastomosis

Fig. 30.10 RAVV posterior luminal anastomosis

372 J.V. Brahmbhatt et al.

Fig. 30.11 RAVV anterior luminal anastomosis

RAVV/RAVE Outcomes Review sal serial and appears to be safe and feasible. The
advantages such as a stable microsurgical plat-
Between July 2007 and March 2013, 147 robotic- form, ergonomic surgeon instrument controls,
assisted vasectomy reversals (90 bilateral RAVV, elimination of tremor, magnified immersive 3D
57 RAVE) were performed by a single fellowship- vision, and simultaneous tri-view ability all con-
trained microsurgeon. Twenty of these patients tribute to reach comparable patency rates with
had chronic scrotal pain after vasectomy and the experienced standard microsurgery centers.
rest wished to regain fertility. Median patient age Further evaluation and longer follow-up is needed
was 42 years and median duration from vasec- to assess its clinical potential and the true cost-
tomy 7 years for RAVV and 11 years for RAVE. benefit ratio.
Median OR setup duration was 30 min and
median robotic OR duration was 120 min and
150 min for RAVV and RAVE, respectively. Robotic-Assisted Microsurgical
After 23 months median follow-up, patency rates Varicocelectomy
(more than one million sperm per ejaculate) were
97 % in the RAVV group and 60 % in the RAVE Technique
group. Pain relief occurred in 88 % of the patients
who underwent RAVV or RAVE for chronic A 1–2 cm subinguinal incision is made over the
scrotal pain related to vasectomy. external inguinal ring. A tongue depressor is placed
To our knowledge this is the world’s largest underneath the cord to keep the cord elevated.
robotic-assisted microsurgical vasectomy rever- The robot is positioned from the right of the patient.
30 Robotic-Assisted Microsurgery for Male Infertility and Chronic Orchialgia 373

Fig. 30.12 RAVV anterior muscular anastomosis

A zero degree camera lens is utilized. The black lowing conditions: azoospermia in 18 patients,
diamond micro-forceps are used in the right robotic oligospermia in 53 patients, and chronic orchi-
arm, the micro bipolar forceps in the left arm, and algia with or without oligospermia in 109
the curved monopolar scissors in the fourth arm. patients. The median duration per side was
The anterior cremasteric sheath of the spermatic 20 min (10–80). Median follow-up was 34
cord is now incised to separate the cord structures. months (1–57). Seventy-eight percentage with
The artery(ies) is identified using real-time oligospermia had a significant improvement in
micro-Doppler (Vascular Technology Inc, sperm count or motility, 28 % (five patients)
Nashua, NH). All dilated veins are isolated and with azoospermia converted to oligospermia,
tied using 3-0 silk (Fig. 30.17). Vein mapper may and 92 % of the testicular pain patients had a
be used to help enhance identification of veins significant reduction in pain (84 % of these
(Fig. 30.18). Vessels are cut with curved monopo- patients had targeted denervation of the sper-
lar scissors. The cord is placed back into the inci- matic cord in addition to varicocelectomy). Two
sion and the deep tissue and skin are now closed. recurrences or persistence of varicocele
occurred, one patient developed a small
postoperative hydrocele, and two patients had
RAVx Outcomes Review postoperative scrotal hematomas (treated con-
servatively). The fourth robotic arm allowed the
From June 2008 to March 2013, 211 RAVx surgeon to control one additional instrument
cases were performed in 180 patients. during the cases decreasing reliance on the
Indications for the procedure were the presence microsurgical assistant. The fourth arm also
of a grade two or three varicocele and the fol- enabled the surgeon to perform real-time
Fig. 30.13 RAVE exposed epididymal tubule

Fig. 30.14 RAVE incision of epididymal tubule

Fig. 30.15 RAVE involution vasoepididymostomy

Fig. 30.16 RAVE vas muscularis to epididymal adventitia approximation

376 J.V. Brahmbhatt et al.

Fig. 30.17 Isolation and ligation of dilated vein

Fig. 30.18 Vein mapper assistance during robotic varicocelectomy

intraoperative Doppler mapping of the testicular Robotic-Assisted Microsurgical

arteries while dissecting the veins with the other Testicular Sperm Extraction
arms if needed.
RAVx appears to be a safe, feasible, and Technique
efficient alternative to pure microsurgical varico-
celectomy. The preliminary human results appear A vertical 4–5 cm incision is made in the scrotal
promising. Further evaluation and comparative median raphe. The incision is carried down to
effectiveness studies are warranted. the tunica vaginalis that is incised to allow
30 Robotic-Assisted Microsurgery for Male Infertility and Chronic Orchialgia 377

Fig. 30.19 Exposure of larger seminiferous tubules

delivery of the scrotum. The robot is now posi- robotic arm can be very helpful in deep dissec-
tioned from the patient’s right side as described tion to help retract the superficial lobules out of
earlier. Black diamond micro-forceps are placed the way as the surgeon is evaluating the deeper
in the right and fourth robotic arms. Curved lobules. Once adequate sperm has been retrieved
monopolar scissors are placed in the left robotic or adequate sampling has been performed, the
arm. Once the testicle is isolated, a 2–3 cm tunical incisions in the testicle are closed with
transverse incision over the tunica exposes the 6-0 prolene running suture. The testicle in placed
seminiferous tubules. The tunica of the testicle back into the tunica vaginalis cavity within the
is everted to fully expose all the tubules in the scrotum and closed in layers.
testicle. The testicular lobules are carefully dis-
sected through to find areas that appear to have
larger seminiferous tubules (Fig. 30.19). These Robotic-Assisted Targeted
areas are sampled and the specimens are exam- Denervation of Spermatic Cord
ined immediately with phase contrast micros-
copy by a trained embryologist. Sampling is Technique
performed until sperm sufficient for multiple-
assisted reproductive technique cycles are A 1–2 cm transverse subinguinal incision is
collected. made. The incision is carried down until the sper-
In cases where no sperm are readily found, the matic cord is reached. Spermatic cord is brought
testicle is thoroughly evaluated. Dissection up to the surface. Posterior medial and lateral dis-
through the deeper lobules of the testicle is per- section and cauterization are performed to ligate
formed and sampling is performed. The addi- branches of the ilioinguinal and genitofemoral
tional black diamond micro-forceps in the fourth nerves in this area.
Fig. 30.20 Standard robotic instrumentation for targeted denervation

Fig. 30.21 Flexible CO2

laser instrumentation during
targeted denervation

The robot is positioned from the right of the tively (Fig. 30.20). If a flexible CO2 laser fiber
patient. A 0° camera lens is utilized. The right, (Omniguide, Cambridge, MA) dissection is used,
left, and the fourth robot arms are loaded with then the fourth arm is replaced with a black dia-
black diamond micro-forceps, Maryland bipolar mond micro-forceps to hold the Flexguide laser
grasper, and monopolar curved scissors, respec- holder (Fig. 30.21).
30 Robotic-Assisted Microsurgery for Male Infertility and Chronic Orchialgia 379

Fig. 30.22 Confirmation of testicular artery using micro-Doppler

Fig. 30.23 Hydrodissection

of residual nerve fibers on
perivasal tissue

The anterior cremasteric muscle is divided. component are ablated. The vas is isolated and
The presence of a testicular artery is confirmed generally the artery and vein to the vas are dis-
(Fig. 30.22) with real-time intraoperative micro- sected away from the vas. The perivasal tissue is
Doppler (Vascular Technology Inc, Nashua, NH). now ablated. Hydrodissection of the perivasal tis-
The posterior cremasteric fibers and posterior fat sue is now performed (Fig. 30.23) using the
380 J.V. Brahmbhatt et al.

Fig. 30.24 Secured axoguard around spermatic cord

ERBEJET2 hydrodissector (ERBE Inc., Atlanta, arteries and one vasal injury were all repaired
GA) to ablate residual nerve fibers. intraoperatively with robotic-assisted microsurgical
The cord is now wrapped with axoguard techniques without any further sequel.
(Axogen Inc., Gainesville, FL) bio-inert wrap to The fourth robotic arm allowed the surgeon to
prevent neuroma formation and irritation of ligated control one additional instrument (micro-Doppler
nerve ends. The wrap is loosely secured using 6-0 or hydrodissector) leading to less reliance on the
prolene interrupted sutures (Fig. 30.24). The robot microsurgical assistant. Targeted robotic-assisted
is now undocked. The cord is placed back into the microsurgical denervation of the spermatic cord
incision and the deep tissue and skin are now closed. seems safe and feasible, and the preliminary
results appear promising. Further follow-up and
further evaluation is warranted.
RMDSC Outcomes Review

Between October 2008 and March 2013, 496 Conclusion

RMDSC procedures have been performed. The pain
was assessed utilizing a standardized validated pain The use of robotic assistance is rapidly expand-
assessment tool: PIQ-6 (QualityMetric Inc., Lincoln, ing in many fields that perform microsurgery.
RI). Pain scores and physical exam were performed The advantages include a stable microsurgical
preoperatively and then postoperatively at 1, 3, 6, 9, platform, ergonomic control of microsurgical
and 12 months. At 28 months median follow-up instruments, elimination of tremor and magnified
(1–54 months), 86 % of the patients had a significant 3D vision with cockpit view, and less reliance on
decrease in their pain (70 % complete response and a surgical assistant. As techniques evolve robotic-
additional 16 % greater than 50 % reduction in their assisted microsurgery can provide endless oppor-
pain score) by 6 months post-op. The procedure tunities for more efficient and less morbid
failed to provide pain relief in 55 patients. Median procedures. The use of these technologies needs
operative duration was 15 min (10–150). to be assessed for its true cost–benefit ratio.
Complications included one testicular ischemia, Hopefully, this technology will only further pro-
nine hematomas, and two seromas. Two testicular vide benefits for our patients.
30 Robotic-Assisted Microsurgery for Male Infertility and Chronic Orchialgia 381

9. Levine LA. Microsurgical denervation of the

References spermatic cord. J Sex Med. 2008;5(3):526–9. Epub
2008/02/29.
1. Kuang W, Shin PR, Matin S, Thomas Jr AJ. Initial 10. Costabile RA, Hahn M, McLeod DG. Chronic orchi-
evaluation of robotic technology for microsurgical algia in the pain prone patient: the clinical perspec-
vasovasostomy. J Urol. 2004;171(1):300–3. Epub tive. J Urol. 1991;146(6):1571–4. Epub 1991/12/01.
2003/12/11. 11. McMahon AJ, Buckley J, Taylor A, Lloyd SN, Deane
2. Schiff J, Li PS, Goldstein M. Robotic microsurgical RF, Kirk D. Chronic testicular pain following vasec-
vasovasostomy and vasoepididymostomy: a prospec- tomy. Br J Urol. 1992;69(2):188–91. Epub 1992/02/01.
tive randomized study in a rat model. J Urol. 2004; 12. Alfieri S, Amid PK, Campanelli G, Izard G, Kehlet H,
171(4):1720–5. Epub 2004/03/17. Wijsmuller AR, et al. International guidelines for pre-
3. Fleming C. Robot-assisted vasovasostomy. Urol Clin vention and management of post-operative chronic
North Am. 2004;31(4):769–72. Epub 2004/10/12. pain following inguinal hernia surgery. Hernia.
4. Corcione F, Esposito C, Cuccurullo D, Settembre A, 2011;15(3):239–49. Epub 2011/03/03.
Miranda N, Amato F, et al. Advantages and limits of 13. Hakeem A, Shanmugam V. Current trends in the diag-
robot-assisted laparoscopic surgery: preliminary nosis and management of post-herniorraphy chronic
experience. Surg Endosc. 2005;19(1):117–9. Epub groin pain. World J Gastrointest Surg. 2011;3(6):
2004/11/19. 73–81. Epub 2011/07/19.
5. Shu T, Taghechian S, Wang R. Initial experience with 14. Poobalan AS, Bruce J, King PM, Chambers WA,
robot-assisted varicocelectomy. Asian J Androl. 2008; Krukowski ZH, Smith WC. Chronic pain and quality
10(1):146–8. Epub 2007/12/19. of life following open inguinal hernia repair. Br J
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logical surgery. Asian J Androl. 2013;15(1):67–74. 15. Hindmarsh AC, Cheong E, Lewis MP, Rhodes M.
Epub 2012/12/18. Attendance at a pain clinic with severe chronic pain
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gery. Curr Opin Urol. 2011;21(6):493–9. Epub 16. Parekattil SJ, Gudeloglu A, Brahmbhatt JV, Priola
2011/09/22. KB, Vieweg J, Allan RW. Trifecta nerve complex –
8. Parekattil SJ, Cohen MS. Robotic surgery in male potential anatomic basis for microsurgical denerva-
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 Part XIII
Education and Training
 Developing a Curriculum
for Residents and Fellows 31
Brian Dunkin and Victor Wilcox

Introduction Needs Assessment

This chapter is designed as a resource for anyone The first step in curriculum design is to perform a
seeking to develop a curriculum for surgical resi- thorough needs assessment. This requires deter-
dents and fellows in robotic surgery. It is orga- mining the learning needs of the target audience,
nized in the same fashion as a curriculum is identifying gaps in their current learning, and
developed covering the topics of needs assess- setting priorities. In 2005, there were 25,000
ment, goals and objectives, didactic and skills robotic cases reported; that number grew to
educational methods, outcome measures, and 355,000 in 2011 and is on pace to surpass 400,000
evaluation and feedback. The chapter outlines the cases in 2012 (Fig. 31.1) [1]. Over 1,000 hospi-
currently available resources to provide cognitive tals now boast a robotic surgery platform, and the
and technical skills training, highlighting the robot is becoming commonplace in gynecologi-
advantages to each and the barriers to their imple- cal, urological, thoracic, and general surgery pro-
mentation. It also provides examples of current cedures. The robot holds particular importance to
best practices for each part of the curriculum certain subspecialties such as urology where the
identified either in the literature or through per- public knowledge of and demand for robotically
sonal communication with experts in the field. performed radical prostatectomies have led to an
The chapter focuses on training for use of the da increasing centralization of cases in hospitals
Vinci® Surgical System (Intuitive Surgical Inc., equipped with robots where 85 % of all of these
Sunnyvale, California, USA), the only FDA- procedures are currently performed in the USA
approved surgical robot available in the USA, but [2]. As the use of the robot in surgery becomes
the principles for training are the same for any ever more prominent, the need for residents and
robotic platform. fellows to be trained on the system becomes
greater. Adding to this clinical demand are the
unique aspects of robotic surgery in regard to
patient safety and team communication that are
not part of other surgical procedures. These fac-
B. Dunkin, M.D., F.A.C.S. (*) tors and the complexity of the robotic system
Department of Surgery, Houston Methodist Hospital indicate that robotic surgery training is ideally
6550 Fannin Street, Suite 1661A, Houston,
introduced during residency and fellowship to
TX 77030, USA
allow for a longitudinal training experience over
V. Wilcox, M.D
a significant period of time. Despite this need, a
Research Fellow, Department of Surgery, Houston
Methodist Hospital, 6550 Fannin Street, Suite 1661A, minority of training programs offers a structured
Houston, TX 77030, USA curriculum for robotic surgery. Additionally, a

K.C. Kim (ed.), Robotics in General Surgery, DOI 10.1007/978-1-4614-8739-5_31, 385

© Springer Science+Business Media New York 2014
386 B. Dunkin and V. Wilcox

Fig. 31.1 Rapid rise in robotic surgical procedures with extrapolated estimates through 2012

lack of accepted clinical measures of competency this curriculum the learner will be able to…”
in robotic surgery has led to great variability in Goals are determined based on the needs analysis
credentialing requirements for use of the robot at and objectives created for each goal that are spe-
different hospitals. The end result is a failure to cific actionable items. For example, one goal is to
guarantee that any particular training curriculum teach residents and fellows to be proficient in
will provide all the evidence of competency that robotic surgery. An objective to meet this goal
an institution requires for the graduating resident might be that after completion of the curriculum,
or fellow to practice [3]. Clearly, the increasing the resident will be able to describe the compo-
volume of robotic surgery across multiple spe- nents of the da Vinci Si robotic system.
cialties, coupled with the unique aspects of Expertise in a surgical domain requires both
robotic procedures, complexity of the platform, knowledge and technical skill. Interestingly, of
and variability in training opportunities is strong all the curricula reviewed for this chapter, many
evidence that there is a need for more structured had written overall goals and specific objectives
curricula introduced as early as possible into sur- for what was to be achieved technically, but few
gical residency and fellowships. had specific cognitive objectives. In developing a
meaningful curriculum with measurable out-
comes, it is essential to pay particular attention to
Goals and Objectives well-developed goals and objectives.

Once a formal needs analysis is performed, the Knowledge

next step in curriculum development is to All medical device manufacturers are committed
determine the goals and objectives of the curricu- to the safe use of their products and take mea-
lum. Goals are general ideas of what the curricu- sured steps to achieve this by their users. Intuitive
lum needs to accomplish such as “provide Surgical Inc., the manufacturer of the da Vinci
residents and fellows with a comprehensive Surgical System (dVSS) is no different. As a
robotic education to make them more proficient result, the company has developed the da Vinci
in robotic surgery.” Objectives are more specific Surgery Training Pathway and the da Vinci
action items often worded as “After completing Residency/Fellowship Training Program. The
31 Developing a Curriculum for Residents and Fellows 387

Surgical Training Pathway is focused on practic- site, but no suggested articles, structure of review,
ing physicians who want to learn to perform or goals and objectives for this component are
robotic surgery, while the Residency/Fellowship available.
program is focused on “senior” level residents Step 2 of the da Vinci Residency/Fellowship
(those in the last 2 years of training) and fellows Training Program is focused on residents and fel-
across multiple specialties. Both programs utilize lows who are beginning their participation in
online modules and assessments developed dVSS surgery. It has six components (1) energy
specifically for each da Vinci platform (Si, Si-e, control lab for da Vinci Si users, (2) da Vinci port
S, and Standard) coupled with live in-person placement philosophy, (3) dVSS docking practi-
hands-on training using the actual robotic system cum, (4) dVSS skills training, (5) procedure
and either inanimate or animate models. The observation, and (6) literature review. Components
online modules for both are available for free 1–4 are all done with an instructor using the real
through the da Vinci Surgery Online Community dVSS platform in an inanimate lab, and while
accessed through Intuitive’s website (http://www. instructions for how to set-up and conduct the
intuitivesurgical.com) [4]. labs are provided, there are no goals and objec-
The da Vinci Residency/Fellowship Training tives described. Components 5 and 6 are identical
Program is arranged into three steps: Step 1— to that describe for components 3 and 4 in Step 1.
preclinical phase, Step 2—clinical preparation Step 3 of the da Vinci Residency/Fellowship
phase, and Step 3—online modules and assess- Training Program entails online modules and
ments. Step 1 is focused on residents and fellows assessments for each of the available dVSS mod-
who are not yet prepared to operate the dVSS els on the market. The components of each mod-
clinically—either as a patient-side assistant or as ule and the goals of each component are shown in
a console surgeon. There are four components to Table 31.1. There are extremely comprehensive
this step (1) online dVSS courses and exams for descriptions of the dVSS system with profession-
each system, (2) hands-on dVSS overview, (3) ally edited videos and images coupled with self-
procedure observation, and (4) literature review. assessment quizzes within each module and a final
The first component consists of professionally comprehensive “Staff Assessment” test at the end.
developed on-line video modules with a self- As a result, this material is frequently incorpo-
assessment quiz to be completed after viewing. rated into curricula developed by individual train-
There are four goals for this component (1) ing programs to satisfy the cognitive component.
describe the features and benefits of the dVSS, The most comprehensive industry agnostic cur-
(2) review the surgeon console components, (3) riculum is the Fundamentals of Robotic Surgery
review the patient cart components, and (4) (FRS) Curriculum being developed under the
review the vision cart components. No objectives direction of three co-principle investigators
are listed to achieve these goals. It is anticipated (Satava, Smith, and Patel) with funding from
to take approximately 2 h to review the material, industry and government [5]. The FRS program
and residents/fellows who complete the module has brought together experts from multiple surgi-
and take the self-assessment quizzes will receive cal societies and in the fields of education and per-
an online certificate of completion. There is no formance metrics to build a basic curriculum in
description of what is entailed in the second com- robotically assisted surgery that could be adopted
ponent of Step 1—hands-on dVSS overview. For by multiple specialties. Since 2011 there have
the third component, procedure observation, it is been four FRS conferences focused on identifying
suggested that this can be accomplished by view- the essential components of knowledge and skill
ing live cases or recorded cases from the da Vinci required to perform robotic surgery. The vision is
online video library. No goals or objectives are to create didactic content coupled with hands-on
described for this component and no suggested skills practice and team training that lead to mea-
cases. The fourth and final component of Step 1 surable competence. A high stakes written exami-
is a literature review. Multiple robotic surgery nation and hands-on skills test are also planned to
articles are available through the Intuitive web- serve as validated measures of knowledge and
388 B. Dunkin and V. Wilcox

Table 31.1 Components and goals for da Vinci online modules

Intuitive da Vinci online training modules
Module Training goals
da Vinci Si (or Si-e, S, Standard) system
Overview • Provide an overview of the features and benefits of the dVSS
• Review the surgeon console components
• Review the patient cart components
• Review the vision cart components
OR setup and system connections
OR configuration • Demonstrate how to arrange the system components into a basic OR configuration
System connections • Review the steps for properly connecting all the system cables
Start-up • Demonstrate the start-up process
Shutdown • Demonstrate the shutdown process
Vision system
Components • Introduce the components of the vision system
– CORE
– Camera assembly
– CCU
– Illuminator
– Touch screen monitor
Vision system controls • Review vision system controls available on the touch screen monitor and camera
head
White balance • Explain the white balancing procedure
Endoscope calibration • Review the steps for endoscope and camera calibration
Draping
Patient cart • Review the patient cart components that require draping
• Demonstrate the steps required to drape the patient cart
Camera assembly • Provide an overview of the camera assembly components
• Demonstrate the steps required to drape the camera
Touch screen monitor • Demonstrate the steps required to drape the touch screen monitor
Docking
Port placement • Review the basic da Vinci port placement philosophy
• Discuss the accessories needed for port placement
• Explain remote center technology
Camera arm positioning • Summarize the steps for setting up and aligning the camera arm to maximize range
of motion
Instrument arm positioning • Summarize the steps for setting up and aligning the instrument arms to maximize
range of motion
Docking • Review the steps for docking the patient cart
• Explain the guidelines for minimizing trauma to the incision site
• Provide tips for retaining correct position of the camera and instrument arms during
the docking process
Endoscope insertion and • Review the correct procedure for inserting and removing the endoscope and camera
removal assembly
Instrument insertion and • Review the procedure for inserting and removing the EndoWrist instruments
removal manually
• Demonstrate the correct procedure for removing and inserting the EndoWrist
instruments using the guided tool exchange (GTE)
Safety features
Fault modes and error • Review recoverable and non-recoverable fault modes
handling • Discuss basic safety features and error handling procedures
• Explain the battery back-up feature
• Discuss the process for contacting customer service
• Review the process for accessing the events logs
(continued)
31 Developing a Curriculum for Residents and Fellows 389

Table 31.1 (continued)

Intuitive da Vinci online training modules
Module Training goals
Emergency switches • Review the function and purpose of the emergency stop button
• Review the function and purpose of the emergency power off switches
Energy control • Review the system energy and control features
Procedure conversions • Review the procedure steps for converting to an open or laparoscopic procedure in
an emergency situation
Final OR staff assessment
Da Vinci Si OR staff • Quiz covering the material in all of the modules
assessment

Network robotic surgical training curriculum for

residents is to train all OB-GYN and general sur-
gery residents to be competent bedside assistants
in complex robotic surgery. The curriculum has
two phases—bedside training and console train-
ing. Within bedside training, there are five com-
petencies with clearly identified goals and
objectives in both knowledge and skill.

Technical Skill
Most curricula focus on the technical skills
required to perform robotic surgery. For the da
Vinci Residency/Fellowship Training Program,
technical skills are rehearsed using the actual
dVSS in either an inanimate or animate labora-
tory setting and under the guidance of a trained
Fig. 31.2 The Sweet tree of curriculum templates proctor. While the Program provides suggested
“scripts” of what should be done in the lab and
what measures should be recorded, there are no
skill at the completion of the curriculum. The pro- specific goals or objectives outlined.
gram is arranged into three phases—preoperative, The FRS Curriculum sought to develop a
intraoperative, and postoperative—and the goals deconstructed task list essential for all special-
and objectives of this curriculum are evolving. ties. Participating expert surgeons engaged in a
FRS is meant to serve as the core knowledge and 2-day workshop using the Delphi method where
skills required by any specialty to perform robotic ideas from each institution’s curriculum were
surgery, with more advanced modules left to be evaluated and then ranked by anonymous vote.
developed by specific specialties (Fig. 31.2). The guiding principles in selecting tasks were
Another example of a curriculum with clear that they be oriented around three dimensions,
goals and objectives in the knowledge domain has incorporate as many elements of real surgical
been created at the Lehigh Valley Health Network skills as possible, be cost effective, easy to
under the direction of Dr. Mario Martino. This administer and reliably evaluate, utilize physical
curriculum is available through the “The Medicine models that could be placed under any robotic
Network” website which serves as a central platform, and preferably already have validating
repository for curricula and resources for robotic evidence supporting their use. After the first
training for medical students, residents, and fel- selection round, tasks were organized into a
lows [6]. The goal of the Lehigh Valley Health matrix and then another round of voting
390 B. Dunkin and V. Wilcox

performed to assign importance. Tasks falling or traditional classroom training. For skills training,
two standard deviations below the mean task the choices include working with inanimate
score were eliminated. The resulting task list models, participating in animal or cadaver surger-
(Table 31.2) serves as a basis for training objec- ies, and working with virtual reality simulators.
tives for a core global curriculum.
The Lehigh Valley Health Network curricu-
lum requires skills practice using the Didactic Educational Methods
Fundamentals of Laparoscopic Surgery (FLS—
http://www.flsprogram.org) as well as inanimate As described in the section “Goals and Objectives,”
and simulator training on the robotic platform but many training programs currently leverage the
does not provide details of this practice or outline online content provided by Intuitive Surgical Inc.
goals and objectives. through their da Vinci Residency/Fellowship
Dulan et al. from the University of Texas Training Program to serve as the didactic portion of
Southwestern Medical Center have developed their curriculum. These modules include high-quality
and published a comprehensive, proficiency- multimedia presentations, and the trainee can select
based curriculum [7]. While this curriculum uses training specific to the robot model available to
the da Vinci Residency/Fellowship Training them (Standard, S, Si, or Si-e). Each of the six
Program for its didactic content, it systematically modules takes approximately 2 h to complete and
created goals and objectives for developing tech- includes self-assessment questions. There are cer-
nical skills. This process brought together six tificates of completion for each individual module
experienced experts from various disciplines to and for completing a comprehensive written exam
identify the skills necessary to perform robotic at the end of the entire online program. Many cur-
surgical procedures for any specialty. From this ricula require trainees to print out these certificates
discussion, they developed a deconstructed task and submit them to their training director prior to
list that served as the basis for their objectives in embarking on skills training or working as a bed-
the skills curriculum (Table 31.3). side assistant. Directors may want to require each
Lyons et al. from the Methodist Institute for trainee to complete more than one or even all of the
Technology, Innovation, and Education model-specific modules depending on the genera-
(MITIESM) have used a similar consensus confer- tion of robot(s) in use at their institution. Intuitive
ence of experts to deconstruct robotic surgery also has a large library of procedure videos that can
skills into a somewhat shorter list of tasks which serve as a source of training material during the
then served as a basis for developing a proficiency- didactic phase of training. Although this library is
based skills curriculum using the da Vinci Skills comprehensive in scope, the value of the videos for
Simulator (Table 31.4) [8]. helping residents and fellows to independently
learn about robotic procedures may be limited as
they are highly edited; usually do not review patient
Didactic and Skills Educational selection, room setup, or port placement; and often
Methods are without audio.
While the intuitive online modules are well
After deciding on the objectives that will best designed and freely available, some feel that the
achieve the learning goals of the curriculum, the didactic portion of a curriculum should be devel-
next step is to identify available content and edu- oped and validated independent of a vendor. This
cational methods and select those that will maxi- not only allows content to be directly targeted at
mize the impact of the curriculum on the target the curriculum’s learning objectives but also
learners. In the case of robotic surgery, training allows for ongoing evolution and refinement of
objectives require both didactic and skills training. the content to meet evolving needs and improve-
For didactic content, training can be in the form of ment of the program based on feedback and out-
computer-based modules, reading of the literature, comes evaluations. The Lehigh Valley Health
31 Developing a Curriculum for Residents and Fellows 391

Table 31.2 FRS task list in order of decreasing importance

Task Description
Situation awareness Aware of status of team, equipment essential to the procedure, and patient status;
maintains effective communication
Eye–hand instrument Learn to accurately and efficiently manipulate the bedside instruments with
coordination economy of motion; pass objects between instruments
Needle driving Accurately and efficiently pass needle through targeted tissue without tearing,
damaging adjacent structures, or dropping the needle
Atraumatic handling Manipulating tissue with graspers without causing avulsion or crush injuries;
understanding of haptics
Safety of operative field Appropriate placement and positioning of instruments so as to avoid injury to
tissues from instrument collision outside of the field of view
Camera Effectively maneuver the camera in a controlled manner maintaining focus, proper
orientation and angle, and avoiding tissue contact
Clutching Maintaining full range of motion in an efficient, ergonomic manner without
collision of console controls; efficient, accurate use of pedals
Dissection, fine and blunt Accurately utilizes instruments to bluntly or precisely dissect tissue in correct
plains maintaining traction and countertraction and adequate exposure without
injuring surrounding structures
Closed loop communication Maintain effective communication with team members using names, clear requests,
and using callbacks as per TeamSTEPPS®
Docking Guides team in docking the robot efficiently with proper positioning and
alignment, attaches arms to trocars, avoids moving OR table
Knot tying Accurately and efficiently ties secure knots with economy of motion and without
causing tissue damage or ischemia
Instrument exchange Efficiently, accurately, and safely removes
Cutting Efficiently and accurately cuts the right structure without collateral damage or
going past-point
Energy sources Applies energy appropriately without collateral damage
Foreign body management Safely removes all foreign bodies from the patient with the appropriate
instruments, confirming removal and instrument counts
Robotic Trocars Safely inserts trocars with correct orientation and spatial orientation relative to the
target; uses direct visualization after first trocar
Suture handling Efficiently, accurately, and safely places running and interrupted sutures to
adequate appose tissues avoiding suture breakage or tissue damage
Wrist articulation Efficiently uses all degrees of freedom in full range of motion
Ergonomic positioning Maintains good posture with comfortable position of body and limbs during the
entire procedure
System settings Can properly configure console settings for scope angle, magnification, and motion
speed and scaling
Multiple arm control Can efficiently activate and employ the fourth arm in the procedure without collisions
OR setup Properly arranges bedside cart where most accessible and safe while maintaining
sterile field
Robot system errors Understands and troubleshoots system errors to correct them when possible
avoiding unnecessary conversion
Undocking Efficiently and safely removes robotic equipment and trocars and inspects port sites
Transition to bedside assist Safely and efficiently removes instruments and ports performing port site
inspections

Network created such content that is freely robotic surgery as well as the future expectations
available online [9]. It incorporates multimedia- for the field. They also learn the benefits, indica-
and computer-based training with live video and tions for, and recent advancements in the robotic
animations. Trainees learn about the history of platforms. The program teaches about the surgeon
392 B. Dunkin and V. Wilcox

Table 31.3 Deconstructed robotic surgery curriculum tasks list from UT southwestern
Task Description
Cognitive skills
Console setup Setting up and adjusting console settings as needed during surgery
Docking Surgeon guides OR nurse in positioning bedside robot and attaches arms to trocars
Robotic trocars Appropriate port location strategies and placement technique
Robotic positioning Placing the bedside cart in the location where the operative field is most accessible
Communication Closed loop communication between console surgeon, bedside assistants and OR team
Robot component names Knowledge of robotic component terminology
Instrument names Knowledge of instrument terminology
Technical skills
Energy sources Activation and control of cautery or other energy sources
Camera Maneuvering the camera to obtain a suitable view
Clutching Maintaining comfortable range of motion for manual controls
Instrument exchange Changing out instruments used in the operation
Fourth arm control Activating the fourth arm through clutching and using it in the operation
Basic eye–hand coordination Using manual controls to accurately manipulate bedside instruments and perform
tasks
Wrist articulation Understanding and using the full range of motion of the EndoWrist (Intuitive Surgical)
Depth perception Appreciating spatial relationships of instruments and tissue
Instrument to instrument Passing objects between the instruments
transfer
Atraumatic handling Using graspers to hold tissue or surgical material without crushing or tearing
Blunt dissection Using instruments to separate tissues bluntly
Fine dissection Using instruments to perform precise dissection of delicate structures
Retraction Holding tension on an object to facilitate surgical manipulation
Cutting Using the scissors to cut at a precise location
Interrupted suturing Suturing single stitches with the robot
Running suturing Suturing continuous stitches with the robot

Table 31.4 MITIE deconstructed task list for robotic surgery

Task Description
1 Pick and place Pick up an object and set it down in a specific location
2 Two-handed transfer Transfer an object from one hand to another in space
3 Wrist manipulation Use wristed instruments to advantage
4 Camera control Manipulate camera for optimal view
5 Clutching Use clutch control to optimize position of hands at surgeons console and minimize
working space
6 Third arm Use of third arm for retraction and manipulation
7 Suturing Suturing efficiently and accurately
8 Energy Use of energy—monopolar and bipolar

console, vision cart, bedside cart, and instrumen- which requires passage at a rate of 80 % in order
tation. In addition, trainees learn safety measures to receive a completion certificate. While this
and what to consider when selecting patients for material was developed with medical students as
robotic versus laparoscopic surgery. There is a the target audience, it is well done and clearly
self-assessment test at the end of the program applicable to residents and fellows as well.
31 Developing a Curriculum for Residents and Fellows 393

After successful completion of the Lehigh ing to dock the robot safely. It then progresses to
Valley online modules, the trainee is prescribed skills rehearsal using inanimate models. The
mentored learning time in the laboratory to Chamberlain Group (Great Barrington, MA)
learn more about port placement, docking, and offers a number of inanimate surgical skills mod-
working as a first assistant. Patient manage- els that are commonly used for this purpose (see
ment skills are also mentored both in the clinic Table 31.5) (Figs. 31.3, 31.4, 31.5, and 31.6)
and on the hospital wards as trainees learn to [12]. They also offer kits with multiple models
identify good candidates for robotic surgery that may prove more economical (see Figs. 31.7
and manage patients postoperatively. Trainees and 31.8). Unfortunately, there are no validated
are also mentored on systems-based practice in metrics of performance on these tasks that can be
which they review robotic cases to identify used for formative or summative feedback.
variation in quality and areas for improvement. In contrast, Genevieve et al. from the
In addition, mentors teach professionalism and University of Texas Southwestern (UTSW) have
demonstrate effective communication between developed the most comprehensive and vali-
the trainee and members of the robotic surgery dated series of inexpensive, inanimate exercises
team and the Lehigh program has developed in a fashion similar to the Fundamentals of
in-house evaluation tools for measuring Laparoscopic Surgery (FLS) [13]. Using the
performance in these areas. deconstructed task list in Table 31.3, these
The FRS Curriculum has also developed an investigators set out to develop tasks on physi-
outline to create vendor agnostic didactic content cal models that would incorporate these desired
matched to the deconstructed educational tasks skills. Care was taken to minimize cost and use
identified through expert consensus conferences. durable materials that could standup to repeti-
It is planned for this material to be developed tive practice. Through this development pro-
with input from multiple specialty societies and cess, nine exercises (Table 31.6) (Figs. 31.9,
made available through an online host. 31.10, 31.11, 31.12, 31.13, 31.14, 31.15, 31.16,
and 31.17) were chosen to be used in a box
trainer utilizing standardized templates, the
Skills Educational Methods Standard da Vinci system, a zero degree camera,
and various 8 mm articulating robotic instru-
In addition to the online didactic training module, ments. The tasks were ordered according to
the da Vinci Residency/Fellowship Training increasing level of complexity. Prior to the per-
Program outlines technical skills rehearsal using formance of each exercise, the manual controls
the actual dVSS and is meant to be administered of the console unit were placed in an optimal
by trained Intuitive proctors at approved training neutral position by the proctor; for tasks 1, 3,
sites. Currently this program is not readily avail- and 4, no clutching or camera adjustments were
able and residents or fellows who want this type allowed, whereas clutching and camera adjust-
of experience must go through the da Vinci ments were encouraged for the other tasks.
Surgery Training Pathway at an approved ani- Tasks 1, 4, 5, 8, and 9 used FLS models (http://
mate lab for a fee. www.flsprogram.org), including a pegboard,
A number of institutions have published suture block, slitted Penrose drains, and pre-
robotic skills curricula, including the depart- marked gauze. Modifications of the FLS models
ments of Obstetrics and Gynecology at the included creation of a hexagonal pegboard for
University of Alabama, the University of North task 5 and extension of the Penrose drain slit to
Carolina at Chapel Hill, and the Lehigh Valley 2 cm with placement of 5 target pairs for task 9.
Health Network. Each teaches the same set of Commercially available models (Manipulation
skills using in-house robots and inanimate mod- Skill Drill Pod, The Chamberlin Group, http://
els either home grown or acquired from a third www.thecgroup.com) were used for tasks 3 and
party vendor [10, 11]. Practice begins with learn- 6 and modified by placing them on standardized
394 B. Dunkin and V. Wilcox

Table 31.5 Inanimate models used in intuitive skills training

Chamberlain
group model Skill session instructions
Item 4068 Manipulation
(Fig. 31.3) Trainees take a ring from the center, transfer it to the other hand, and place it on the corresponding
outer peg. After moving all four rings, they then reverse the process
Instruments
Two large needle drivers
Evaluation
Trainees are timed and suffer time penalties of 5 s for dropping rings and 5 s for omitting any
hand-offs
Item 4072 Dissection
(Fig. 31.4) Trainees use blunt or sharp dissection to dissect through the superficial layer of the model and dissect
out the embedded vessel, mobilizing it across a specified length (should be marked)
Instruments
Two Maryland bipolar forceps
Evaluation
Trainees are timed and suffer time penalties of 5 s for injuries to vessels and 10 s for avulsions of the
vessels from the proximal or distal attachments
Item 4075 Transection
(Fig. 31.5) Trainees take grasp the model with the ProGrasp™ forceps at the indicated spot, then transect the
tissue beginning at the lowest numbered area 1 and proceeding one at a time to area 6
Instruments
Large needle driver, curved scissors, and ProGrasp™ forceps (with third arm)
Evaluation
Trainees are timed on each wave transected and suffer time penalties of 5 s for transecting outside of
the marked boundaries
Item 4073 Suturing
(Fig. 31.6) Trainees use the 20cm length suture to close the “I” using running suture and 4 knots; they then repair
the “S” defect using the three 10cm lengths of suture with figures of eight through marked areas on the
model and tied with four knots each
Instruments
Two Large Needle Drivers w/ 3 × 10cm lengths and 1 × 20cm length of 3-0 Vicryl™ RB-1
Evaluation
Trainees are timed and suffer time penalties of 5 s for dropping a suture, 10 s for breaking a suture, 5 s
for driving needle outside of the marked zone, and 5 s for incomplete tissue approximation

templates. Tasks 2 and 7 were created de novo. graphically (task 8). Based on observation of
Task 2 used freehand drawings of polygons and expert and novice performance, cutoff times
error markings such that when targets were (maximal allowable task duration) were assigned
appropriately acquired by the camera, a uniform for each task. The following formula was used:
rectangular shape was visible on the monitor as Score = (cutoff time) − (completion time) −
witnessed by the proctor. Task 7 used a rubber (weighting factor × sum of errors); to heavily
band with inked targets placed at 1 cm intervals. penalize suboptimal performance, errors were
A video illustrating the appropriate technique as weighted by a factor of 10 (tasks 1–7, 9) or 50
well as pitfalls to avoid was created for use as a (task 8, Pattern Cut, requiring all cuts to be
standardized tutorial. within the marked line). A higher score indicated
Objective scoring based on the previously superior performance. A score of zero was
validated FLS approach [14–16] was used and assigned if a negative value was derived.
included time and carefully defined errors Similarly, if a protocol violation occurred, such
(Table 31.6); for example, accuracy was mea- as using the wrong technique, as witnessed under
sured in mm (tasks 4, 7, and 9), and surface area direct observation by the proctor during testing,
of cuts outside of the circular line was measured a score of zero was assigned.
31 Developing a Curriculum for Residents and Fellows 395

Fig. 31.3 Chamberlain Group Item 4068 Fig. 31.5 Chamberlain Group Item 4075

Fig. 31.4 Chamberlain Group Item 4072 Fig. 31.6 Chamberlain Group Item 4073

A robotic expert (extensive prior clinical expe- components of the curriculum, including three
rience) performed five consecutive repetitions of consecutive repetitions of tasks 1–9 as a measure
each task and the mean −2 s.d. values were chosen of baseline performance; the baseline novice and
as preliminary proficiency levels; data were suit- expert scores were compared to evaluate construct
ably homogeneous and there were no outliers (>2 validity, defined as the ability of a test to measure
s.d.). A normalized score was defined as the task the trait that it purports to measure. The novice
score divided by the proficiency score; a compos- then practiced the nine tasks until proficiency was
ite score was defined as the sum of all nine normal- reached on two consecutive repetitions for each
ized task scores. A robotic novice (no prior robotic task and underwent proctored post-testing (one
and minimal laparoscopic exposure) performed all repetition per task).
396 B. Dunkin and V. Wilcox

Fig. 31.7 Robotic system skills kit from the Chamberlain Group

supporting overall construct validity. For the

individual tasks, novice and expert performance
was significantly different for tasks 1, 3–7, and 9
but not for tasks 2 and 8.
The novice reached proficiency on all 9 tasks
after performing 111 practice repetitions.
Significant pretest to posttest improvement was
noted according to the composite scores (500.8 vs.
839.2, p = 0.004), thus supporting overall curricu-
lar effectiveness in terms of skill acquisition. From
a resource standpoint, curriculum development
materials (models, supplies, and box trainer) cost
$2,227 excluding the cost of the robotic system
and instruments and suture. Incremental cost for
training the novice was minimal (<$10), since the
only consumable materials included Penrose
Fig. 31.8 Robotic skills kit from the Chamberlain Group drains, rubber bands, and pattern cut gauze.
Hung et al. developed a more simplified set of
The novice completed inanimate training in 7 physical models (Fig. 31.18) and established
h. Baseline novice and expert performance were both construct validity (i.e., experts performed
significantly different according to composite better on the models than novices) and superior
scores (546 ± 26 vs. 923 ± 60, p < 0.001), thus training benefit when compared to a virtual reality
31 Developing a Curriculum for Residents and Fellows 397

Table 31.6 UTSW data w/prelim construct data

Task Model Instructions
I Peg transfer (Fig. 31.9) Model FLS peg board
Instruments Two large needle drivers (left and right)
Description The six pegs are picked up in turn by a large needle driver from
a pegboard on the surgeon’s left, transferred in space to a needle
driver in the right hand instrument, and then placed on the
corresponding right side of the pegboard. After all pegs are
transferred to the right, the process is reversed
Errors Dropping peg out of the field of view
Cutoff time 300 s
Proficiency score 234 (66 s with no errors)
II Clutch and camera Model Flat template with geometric shapes
movement (Fig. 31.10) Instruments None
Description Using the camera, follow the path from shape A to B and
continue on clockwise from shape to shape until arriving back
at shape A. At each shape, the camera must freeze and the
trainee must verbalize that they have their final image. Error
dots and lost corners will be counted and the trainee will
continue on to the next shape
Errors Visualization of the red error dots or lack of visualization of the
corners of the geometric shape
Cutoff time 300 s
Proficiency score 248 (52 s with no errors)
III Rubber band transfer Model Curved wire posts on custom template
(Fig. 31.11) Instruments Two large needle drivers (left and right)
Description Two rubber bands are picked up in turn by a large needle driver
from the curved wires on the surgeon’s left, transferred in space
to a needle driver in the right hand and then placed on the
curved wire on the corresponding right-hand side. After the two
rubber bands are transferred from left to right, the process is
reversed
Errors Dropping rubber band out of the field of view or avulsion of
wire hooks
Cut-off Time 300 s
Proficiency Score 229 (71 s with no errors)
IV Simple suture Model FLS suture block with penrose drain
(Fig. 31.12) Instruments Two large needle drivers (left and right) and one curved scissors
(fourth arm)
Description Use the 12 cm 2-0 silk suture to suture through the two targets
on the Penrose drain, tie one surgeon’s knot and two square
knots, and then cut the tails to approximately 1 cm
Errors Inaccuracy, suture breakage, knot slippage, air knot, incorrect
tail length, frayed suture, model avulsion, bunny ears
Cutoff time 600 s
Proficiency score 509 (91 s with no errors)
V Clutch and camera peg Model Hexagon peg board (6.5 cm between posts)
transfer (Fig. 31.13) Instruments Two large needle drivers (left and right)
Description The peg starts at post A and is moved by the left hand to post B.
At post B, pick up the peg with the right hand, position the
camera to view post C, and then move the peg to post C.
Continue in like fashion until returning to post A
Errors Dropping peg out of the field of view
Cutoff time 300 s
Proficiency score 251 (49 s with no errors)
(continued)
398 B. Dunkin and V. Wilcox

Table 31.6 (continued)

Task Model Instructions
VI Stair rubber band Model Curved wire post on pedestals and custom template
transfer (Fig. 31.14) Instruments Two large needle drivers (left and right)
Description With the left hand instrument, pick up the rubber band on post
A and place it on post B. The right hand picks up the rubber
band on post B and places it on post C. Then, with the left hand,
transfer it back to post A. The camera should follow the
movement of the instruments from post to post
Errors Dropping a rubber band outside the field of view, avulsion of
the wire hooks
Cutoff time 300 s
Proficiency score 242 (58 s with no errors)
VII Run and cut rubber Model 10 cm rubber band with 1-cm inked targets
band (Fig. 31.15) Instruments Two large needle drivers (left and right), one curved scissors
(fourth arm)
Description Grasp the rubber band at every other black mark and cut the
intervening black mark. Repeat this until every black target is
cut
Errors Cutting outside of the black marks
Cutoff time 300 s
Proficiency score 202 (98 s with no errors)
VIII Pattern cut (Fig. 31.16) Model FLS pattern cut testing gauze
Instruments One Maryland forces (left), one curved scissors (right), and one
cadiere forceps (fourth arm)
Description Activate the fourth arm to hold the free inferior portion of the
gauze. Activate the third arm and cut the circle making sure to
have black lines on both sides of the cut gauze showing that all
cuts were made on the black line and not outside of it
Errors Cuts outside of the black line
Cutoff time 300 s
Proficiency score 147 (153 s with no errors)
IX Running suture Model FLS suture block with penrose drain with five black targets on
(Fig. 31.17) each side of the 2-cm slit
Instruments Two large needle drivers (left and right), one curved scissors
(fourth arm)
Description Using a 16-cm 2-0 silk suture, suture through the first set of
targets and tie one surgeon’s knot and two square knots. Place
running sutures through the next three pairs of inked targets and
tie one surgeon’s knot and two square knots on the last pair of
targets. Cut the tails to approximately 1 cm
Errors Inaccuracy, breakage of suture, slippage of knot, air knot,
incorrect tail lengths, frayed suture, avulsion of the model, and
bunny ears
Cutoff time 600 s
Proficiency score 340 (260 s with no errors)

simulator as measured in an animate lab setting and testing. A modified Delphi process is being
[17]. utilized for this process with a goal of goal of cre-
The Fundamentals of Robotic Surgery ating three-dimensional tasks than incorporate all
Curriculum is in the process of developing the of the deconstructed FRS skill sets (Table 31.2),
tasks and metrics it will require for skills rehearsal be cost effective, have high fidelity at least for
31 Developing a Curriculum for Residents and Fellows 399

testing purposes, be easy to administer with good virtual reality environments (Table 31.7). These
inter-rater reliability, use physical models, and platforms offer another way to provide a longitu-
focus on tasks that have prior validation when dinal training experience for residents and fel-
possible. The committee is also considering tasks lows. Mimic Technologies Inc. (Seattle,
to practice docking and trocar insertion. Washington, USA) founded in 2001 with depart-
ment of defense funding has developed two sim-
ulators, one with a stand-alone simulated console,
Virtual Reality Skills Training and another that docks and works with the dVSS
surgeon console. The simulated console, called
There are a number of simulator platforms that the Mimic dV-Trainer™, uses a relatively small
provide training options for robotic surgery with booth and cable-suspended controls to provide
practicing surgeons with the hands-on feel of a
real robotic platform (Fig. 31.19). The system
incorporates a comprehensive set of validated
exercises to take aspiring robot surgeons from
novice to intermediate skill level. Trainees on the
console learn basic arm control, then use of three
arms, camera control, energy usage, suturing,
and knot tying. Multiple validation studies have
confirmed its face, content, and construct valid-
ity. It also has validated orientation and skills
training modules (see Figs. 31.20 and 31.21) as
well as a validated performance analysis and
scoring system called MScore™ (see Fig. 31.22).
The system costs in the ballpark of $100,000
with an additional annual service fee. It is fairly
compact, fitting on a table or desk with a set of
Fig. 31.9 UTSW task 1—peg transfer pedals for the floor. It also requires an attached

Fig. 31.10 UTSW task 2—Clutch and Camera MOvement

400 B. Dunkin and V. Wilcox

Fig. 31.11 UTSW task 3—rubber band transfer

da Vinci Skills Simulator (Fig. 31.23). This

“backpack” utilizes the real da Vinci surgeon
console with a computer-generated environment.
Its cost is comparable to the MIMIC simulator,
and multiple studies have been published estab-
lishing a difference in performance between nov-
ices and experts on this simulator. Because the
dVSS is often packaged as part of the sale of a
new da Vinci Si platform, there are now over 400
“backpack” simulators in institutions around the
world. Despite this unprecedented availability,
however, a well-defined and validated
proficiency-based skills curriculum on this plat-
form has yet to be developed.
Fig. 31.12 UTSW task 4—simple suture The HOST™ (Hands-on Surgical Training) is
a haptic enabled augmented reality system avail-
able on the RoSS (Robot Surgical Simulator,
desktop computer. MIMIC has sought to aid the Simulated Surgical Systems, LLC, Williamsville,
development of curriculum by adding an NY) and is another option for simulated robot
“MShare” section to their website where curricu- training (Fig. 31.24). It comes with basic skill
lum developers can share their work with other modules for camera control, arm movement,
Mimic users to foster collaboration among vari- clutch, three-arm control, suturing, tying,
ous institutions [18]. clipping, and suture cutting. There have been
Intuitive has collaborated with Mimic since limited studies to show face and content validity,
2003, and in 2011, licensed some of the software and the training modules are currently being
of the Mimic simulator to be incorporated into a assessed for validity. Its size is comparable to a
stylized computer module that connects to the da Vinci surgeon console, and its cost ranges
back of the da Vinci Si platform and is called the from $100,000 to $125,000. HOST features a
31 Developing a Curriculum for Residents and Fellows 401

Fig. 31.13 UTSW task 5—clutch and camera peg transfer

Fig. 31.14 UTSW task 6—stair rubber band transfer

mode that uses a novel reversal of the master– modules that would benefit general surgeons
slave relationship where the trainee watches a such as adrenalectomy and nephrectomy.
surgery taking place, and the trainee’s hands are The least expensive option currently available
moved by the simulator so that he or she can feel for virtual reality robotic surgery is the SEP-
himself performing the same surgery. The system Robot simulator from SimSurgery (Boston, MA;
includes modules mostly suited to training urolo- Fig. 31.25). Priced between $40,000 and $45,000
gists and gynecologists but also includes a few plus an annual service plan, this system has no
402 B. Dunkin and V. Wilcox

console and rather depends on arm boards, a

monitor, and a turnkey computer. This simulator
provides modules to simulate a cholecystectomy
and other minimally invasive procedures. It is
currently, the cheapest, most mobile simulator
option in use.

Team Training

All surgery requires a team to work together in a

coordinated fashion, but robotic surgery is
unique in that the surgeon is not “scrubbed” into
Fig. 31.15 UTSW task 7—run and cut rubber band the surgical field and is immersed in a visualiza-
tion environment that limits his or her situation
awareness. In addition, if an intraoperative crisis
should occur that requires converting from
robotic surgery to an open approach, the robotic
instruments and platform must be removed
and “undocked” in a coordinated fashion. As a
result, precise communication within a well-
coordinated team is paramount to a successful
robotic surgery program. At the Methodist
Institute for Technology, Innovation, and
Education (MITIE, Houston, Texas), intraopera-
tive robotic surgery crisis scenarios have been
developed which require the operating surgeon
and circulating nurse to work in a coordinated
fashion to convert from robotic to open surgery.
Studies are being conducted to validate the
Fig. 31.16 UTSW task 8—pattern cut metrics of these performances with plans to
incorporate this type of experience into not only
resident and fellow training but also into hospi-
tal quality initiatives.

Outcome Measures

The ultimate measure of a curriculum is to

determine if it has enabled trainees to achieve the
outlined goals and objectives. For robotic surgery,
the ultimate goal is for a resident or fellow who
successfully completes the curriculum to have
the knowledge and skills required to safely and
effectively perform robotic surgery. Ideally, this
outcome would be measured in the clinical
Fig. 31.17 UTSW task 9—running suture domain during real surgical procedures.
31 Developing a Curriculum for Residents and Fellows 403

Traditionally, validated measures of clinical attending surgeon to perform a surgery while a

performance have been difficult to come by in resident or fellow observes and to selectively
surgery. More recently, however, one such tool allow the trainee to perform parts of the proce-
has been developed in the laparoscopic domain dure. There is very limited data on the efficacy of
called GOALS (the Global Operative Assessment the dual-console system. Smith et al. recently
of Laparoscopic Skills) [19]. This simple tool can published a series of 50 cases done on the dual
be used to reliably differentiate between novice console in which they used the second console for
and expert surgeons performing laparoscopic sur- observation and verbal assistance [22]. They
gery. Using GOALS as a template, Goh et al. found no compromise in patient outcomes or
developed a similar clinical assessment tool for operative times and felt the platform provided a
robotic surgery called GEARS (the Global feasible way to train residents with varying levels
Evaluative Assessment of Robotic Surgery) of experience.
(Fig. 31.26) [20]. This validated global assess-
ment form uses a 5-point Likert scale with
descriptive anchors at 1, 3, and 5 to evaluate per- Evaluation and Feedback
formance in six domains—depth perception,
bimanual dexterity, efficiency, autonomy, force In order to facilitate ongoing improvement of the
sensitivity, and robotic control. This clinical curriculum and to ensure it evolves to meet the
assessment tool has been shown to reliably dif- changing needs of trainees, a mechanism to gar-
ferentiate the performance of novice, intermedi- ner evaluation and feedback about curriculum
ate, and experts during robotic surgery with performance is crucial. This is usually done by
excellent consistency and inter-rater reliability. having trainees complete a survey about their
Such a powerful clinical assessment tool can be experience. It is important to gain feedback from
used to validate robotic training curricula and curriculum moderators and technicians as well.
prove their effectiveness. As an example, in their curriculum development,
Another measure of clinical performance is the Dulan et al. used a 5-point Likert scale to ask
ability for a trainee to independently complete a trainees how well they felt the curriculum trained
step of a surgical procedure. The Lehigh Valley them in each of the deconstructed tasks they iden-
Health Network curriculum breaks down roboti- tified [7]. This feedback cycle can be further
cally assisted hysterectomy into ten steps with improved by surveying trainees after they have
time limits assigned to each (Table 31.8) [21]. The completed residency or fellowship and moved
trainee is allowed to progress as far as possible into practice. In this way it can be determined how
within the time limit for each step and scored on a well the curriculum prepared graduates to meet
3-point Likert scale with a minimum total score the credentialing requirements of their new insti-
established for proficiency. While this tool may tutions and how prepared they felt for indepen-
not have been tested for high-stakes validity, it is dently performing robotic surgery in practice.
practical and appears powerful in giving residents
formative feedback on their performance.
Finally, the da Vinci Si dual-console robotic Conclusion
platform may be an additional aid for training. It
allows for two surgeons (i.e., expert and trainee) to The resources and examples described in this
sit at their own surgeon console connected to the chapter describe a number of options for
patient-side robotic platform. Both participants program directors wishing to provide robotic
can view the surgery in three dimensions, and con- surgery training to their residents or fellows.
trol of the instruments can be “passed” back and The right approach for any program will be dic-
forth between the two consoles. This may allow an tated by their own needs assessment and goals
404 B. Dunkin and V. Wilcox

Fig. 31.18 Hung et al. inanimate exercises for fundamentals of robotic surgery

as well as the availability of robotic platforms for constructed curricula coupled with validated
training and financial and personnel resources measures of knowledge and skill is the best way
(Fig. 31.27). Ideally, after implementing a cur- to assure that graduating residents and fellows
riculum, trainees would be objectively measured will be well equipped to become credentialed to
in their clinical performance using validated perform robotic surgery and provide optimal
tools such as GEARS. Implementing well- care to their patients.
31 Developing a Curriculum for Residents and Fellows 405

Table 31.7 Virtual reality robotic surgery simulators

Simulator Advantages Disadvantages Price estimate
Mimic • Fits on table top • Proprietary surgeon console $100,000 + annual
• Feels like the console interface maintenance fee
• No need for robot console
• Validated MScore™ system
da Vinci skills simulator • Fits on back of robotic • Requires use of robot for $100,000 + annual
console non-operative purposes maintenance fee
• Uses actual console • Less validation available of
scoring system
RoSS HOST • Includes video of many • Requires space equivalent to $100,000–$125,000
surgeries a da Vinci console
• No need for robot console • Limited training material for
general surgeons
• Limited validation studies
available
SEP robot • Low cost • Limited validation studies $40,000–$45,000
• Compact and mobile available
• No need for robot console • Uses disconnected EndoWrist
without similar haptic feedback

Fig. 31.19 MIMIC console

406 B. Dunkin and V. Wilcox

Fig. 31.20 MIMIC advanced arm manipulation

Fig. 31.21 MIMIC needle driving

31 Developing a Curriculum for Residents and Fellows 407

Fig. 31.22 MIMIC MScore display

Fig. 31.23 da Vinci Si skills simulator backpack on

robot console Fig. 31.24 RoSS HOST robotic simulator system
408 B. Dunkin and V. Wilcox

Fig. 31.25 SEP robotic simulator system

31 Developing a Curriculum for Residents and Fellows 409

Fig. 31.26 GEARS evaluation form

 410

Table 31.8 Lehigh valley health network clinical assessment of robotic hysterectomy
Needs improvement Good Excellent
Task 1 2 3
Procedure preparation (50 min)
Patient positioning Patient required repositioning > 3 times Patient required repositioning 2–3 times Patient properly positioned the first
time
Equipment setup, port placement, and Required considerable assistance (> 50%) Required assistance Accurately performed with little or
docking no assistance
Incision Does not use landmarks, poor incision Appropriate incision in terms of location and Handled scalpel expertly
placement, or poor handling of scalpel size, comfortable handling of scalpel
Anatomic landmarks and boundaries Did not accurately identify required Identified required landmarks and boundaries Identified all known structures,
landmarks and boundaries landmarks, and boundaries
Procedure (10 min)
Transect round ligaments and open Does not use surface landmarks to transect Appropriate incision in terms of location and Expert handling of instruments to
broad ligament accurately, inappropriate incision placement, size for accurate transection, at ease with the transect ligaments
and poor instrument handling instruments
Identify pararectal and paravesical Did not identify spaces accurately Identified the spaces with minimal assistance Identified the space without
spaces assistance
Procedure (10 min)
Isolate, seal, and transect the Did not identify the ligament or failed to Identified the ligament, transected the ligament, Identified all known structures and
infundibulopelvic ligaments properly transect or seal it and appropriately sealed it accurately transected and sealed the
ligament
Identify the ureters Unable to accurately identify required Required assistance to identify required Accurately identified all required
landmarks and boundaries landmarks and boundaries landmarks and boundaries
Bladder procedure (10 min)
Dissection of the bladder Appears unsure and excessively hesitant Controlled and safe dissection using correct Superior atraumatic dissection using
while dissecting anatomical plane; minimal trauma to tissues correct anatomical planes while
handling instruments confidently
during the dissection
Procedure (20 min)
Isolate uterine artery, cardinal Did not accurately identify required Identified required structures, landmarks, and Identified all known structures,
ligaments, and uterosacral ligaments structures, landmarks, and boundaries boundaries landmarks, and boundaries
Transect ligaments Does not use surface landmarks to transect Appropriate incision in terms of location and Handled instruments expertly to
accurately, inappropriate placement of size to transect accurately; looked at ease with transect ligaments
incision, or poor handling of instruments instruments
B. Dunkin and V. Wilcox
 Needs improvement Good Excellent
Task 1 2 3 31
Procedure (20 min)
Perform vaginal colpotomy Does not use surface landmarks; Appropriate incision in terms of location and Performed without hesitation, limited
inappropriate incision placement size; purposeful movements with delivery of cautery with ease of specimen
specimen if applicable delivery if applicable
Procedure (10 min)
Closure of cuff Poor quality closure, insecure ends, air knots Incisions reapproximated without visualization Cuff closed securely, purposeful
identified, poor handling of suture of air knots, ends of cuff closed, and safe suture placement, superior closure
instruments, and suture cut during tying maneuvering of instruments with hemostasis, and no suture
breakage
Procedure (20 min)
Undocking, removal of ports, and Unsafe practices such as undocking before Safely undocks and removes ports with Efficiently undocks without
cystoscopy removing instruments, pneumoperitoneum, minimal guidance; safe performance of guidance; skilled and purposeful
or overdistention of the bladder cystoscopy manipulation of cystoscope
Procedure (20 min)
Incision closed to out of room time Poor quality of knot tying, knots the slip Competent knot tying, minimal trauma to tissue Superior knot tying, atraumatic tissue
frequently, or excessive trauma to tissues or and vessels, and minimal blood loss and vessel handling, and secure knots
vessels without slippage
Postoperative procedure (20 min)
Developing a Curriculum for Residents and Fellows

Assist with room turnover No assistance with room turnover Assists anesthesia with waking and transferring Assists with all aspects of room
turnover
Resident performance
Equipment handling Looks awkward Confident handling of the scope Skilled, competent handling of the
scope
Movement of hands-on controls Many unnecessary movements Some unnecessary movements All purposeful movements
Flow of procedure Hesitated often unsure of what to do Usually confident with occasional hesitation Confident and sure of what to do at
all times
Score
Overall performance rating Needs improvement Pass Competent
(8–18) (20–36) (39–54)
411
412 B. Dunkin and V. Wilcox

Fig. 31.27 Robotic

surgery curriculum
development flowchart

3. Erickson BK, Gleason JL, Huh WK, Richter HE.

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 Challenges and Critical Elements
of Setting Up a Robotics Program 32
Randy Fagin

regardless of whether their surgeons are demanding

Background or supportive, whether their staff has unions or
they work with residents, there is a clear and
There are currently thousands of da Vinci surgical common pathway to success in setting up, main-
systems at hospitals around the world. They are taining, and growing a da Vinci surgery program.
being used by surgeons on every continent except This common pathway contains six elements:
Africa and Antarctica, and when it comes to setting 1. A clear noble purpose
up, maintaining, and growing a successful 2. The right leadership structure
daVinci surgery program, I can say with com- 3. Consistent communication pathways
plete confidence that most of these hospitals con- 4. Standardization
sider themselves unique in the challenges they 5. Parallel tasks
face. Most feel quite strongly that the culture and 6. A continuous improvement cycle
size of their hospital, the resources they have Before we explore these six elements, we must
access to, the politics of medicine where they start by acknowledging a few truths:
live, the size of their city, the number and person- 1. Just because your hospital owns a da Vinci
ality of the surgeons they work with, and the surgical system, and there are surgeons who
presence of unions or residents or both all pose come to that hospital to use, it does not mean
unique challenges that are unlike any other pro- you have a da Vinci surgery program. It is
gram. I’ve heard it so often that there must be possible that all you have is a surgical tool that
some statistic like “every 8 s a healthcare team surgeons come to use.
member involved in daVinci surgery says…Well 2. If your hospital has successfully increased the
that may work for THEM, but you don’t under- number and type of da Vinci surgeries it per-
stand, things are different here.” forms, it still does not mean that you have a da
However, when you examine successful da Vinci surgery program. It is possible that all
Vinci surgery programs across the globe, you you have is a surgical tool that more surgeons
find that regardless of the size of the hospital or are choosing to use as more surgeons and
city, no matter what the politics and competitive patients see the value in da Vinci surgery.
forces are at play in their medical community, A daVinci surgery program exists only when
elements 1, 2, and 3 exist
1. A clear noble purpose
R. Fagin, M.D. (*) 2. The right leadership structure
Texas Institute for Robotic Surgery, Hospital 3. Consistent communication pathways
Corporation of America, Austin, TX, USA and its success is dependent on its ability to apply
Intuitive Surgical International, Austin, TX, USA elements 4, 5, and 6

K.C. Kim (ed.), Robotics in General Surgery, DOI 10.1007/978-1-4614-8739-5_32, 415

© Springer Science+Business Media New York 2014
416 R. Fagin

4. Standardization need to define who you are as a program, find

5. Parallel tasks your noble purpose, before you can achieve true
6. A continuous improvement cycle and lasting success.
In the following pages I will detail for you a This noble purpose must be what is referred to as
straightforward and reproducible plan for creating a S.M.A.R.T. goal. It must be Specific, Measurable,
a da Vinci surgery program at your hospital and Attainable, Relevant, and Time-bound.
driving its success using the above six elements
and the resources you already have in place.
Specific

A Clear Noble Purpose Your goal must be clear and unambiguous. It

must tell you who will be involved, what you
We are in the business of helping people, treating wish to accomplish, and why you are doing it.
diseases, and changing lives for the better. We all
would like to see our volumes and revenue increase
and often, our success is judged by our ability to Measurable
achieve those goals. However, increases in revenue
and surgical volume can be the result of work You need well-defined criteria that you will use
towards your goal, but they cannot be the goal to measure your progress towards the goal.
itself. To create a da Vinci surgery program every
team member must come to work with a common,
clear, and noble purpose beyond the fulfillment of Attainable
their job’s responsibilities and beyond the achieve-
ment of increasing volume and revenue. The goal you choose should not be easy to
To find your program’s noble purpose, start by achieve but realistic enough that you can attain it.
having your surgeons and administrative leader-
ship answer the following questions:
“What do we want our da Vinci surgery program Relevant
to achieve?”
“How are we going to measure that success?” Your goal must be something that matters and
Do you want to achieve the best clinical out- will help drive your organization forward.
comes in your city? Then you need to define what
a “best clinical outcome” is for each surgery and
specialty, decide how you will measure for these Time-Bound
“best clinical outcomes,” and determine the path
towards achieving that goal. Maybe you want to You must set a deadline for completing mile-
be at the leading edge of new surgical innova- stones on the way to your goal. Without a dead-
tions. Then you need to define what will count as line, achieving these critical milestones can be
an innovation, decide who your surgeon champi- overtaken by day-to-day challenges.
ons are that will be developing these innovations,
determine how you will prioritize which innova-
tions your program will support, and agree on The Right Leadership Structure
how you will measure the success of using these
innovations and how you will share your innova- Once you have determined your noble purpose,
tions with others. Is your program centered you need to put into place a leadership structure
around a small number of key surgeons or is it that will facilitate your achieving the goals you
structured to accommodate a diverse population have set. To develop the right leadership structure
of surgeons from practices across your city? You you need to first ensure that you are looking
32 Challenges and Critical Elements of Setting Up a Robotics Program 417

Fig. 32.1 Building a house

beyond the da Vinci surgical system as a tool that includes your surgical techs, nurses, anesthesia
your surgeons use and are treating all da Vinci sur- providers, surgeons, housekeepers, and your da
gery in your hospital as its own service line. This Vinci coordinator. Remember, since we agree that
means you cannot think of da Vinci surgery as part da Vinci surgery is its own service line, we need to
of your urology service line, part of your GYN ser- ensure that we have a nurse coordinator that is spe-
vice line, part of your general surgery service line, cific to this service line—our da Vinci coordinator.
etc. da Vinci surgery must be its own service line The second floor of the house is where your
with leaders and leadership that attend to its needs operational oversight team lives. This is typically
and are accountable to its noble purpose across a member of your operating room leadership
surgical specialties, as we would traditionally team, your da Vinci coordinator, and one of your
describe them. This is a unique thought for a hos- surgeon leaders. If the da Vinci service line were
pital that is used to creating silos of leadership a company, the operational oversight team would
around surgical specialties that are defined by the be the Chief Operating Officer. Their role is
residency a surgeon completed (Urology, OB/ focused on the establishment and optimization of
GYN, General Surgery, etc.). Once we accept that day-to-day operations in the program. They
da Vinci surgery is its own service line, and that it advise the program management team (see next
is a service line that crosses many surgical special- section) on key planning issues and make recom-
ties, then we are ready to look at the leadership mendations on planning and resource allocation.
structure that will support it. Think about building Based on the noble purpose of your program,
the leadership structure for your da Vinci surgery they set operational and/or performance goals,
service line like building a house. The house we establish processes for improvement, ensure
are going to build has three levels (Fig. 32.1). quality control, and inform all the other “floors of
The ground floor of the house is literally the the house” of their progress and achievements. In
ground floor of your da Vinci surgery program. It is short, they look at what happens in every da Vinci
the boots on the ground support you depend on in surgery, ensure that all team members learn from
your operating room for day-to-day operations. It what happens in every room and not just their
418 R. Fagin

room, and use that knowledge to create, implement, a level of the house. To have an effective
and measure improvements that bring the pro- communication pathway we need to build stairs
gram closer to achieving its noble purpose. for our house (see Fig. 32.2).
The third floor of the house is the program Notice that the stairs only go up one floor at a
management team. This team consists of an time. So the surgeon and anesthesiologist who do
administrative leader (typically someone with a not agree on positioning need to bring their con-
“C” in their title CEO, COO, CAO, CNO, CFO, cerns to the operational oversight team, one level
CMO,…) and surgeon champions representing up. This operational oversight team that lives on
each of your surgical specialties performing da the second floor can then perform a review of
Vinci surgery. If we go back to our company anal- best practices and literature. They can then bring
ogy, the program management team serves as the their findings to the program management team
Chief Executive Officer. Their role is focused on for modification and/or approval (one level up).
looking to the future, aligning and directing their The program management team’s approval then
team members, interfacing between the hospital travels one level down to operational oversight,
leadership/board and the program team members, who can then implement safe and standardized
and managing the allocation of financial and patient positioning for ALL the da Vinci operat-
physical resources. In short, they are the visionary ing rooms (one level down). Problem solved. If
leader who ensures that the program’s human and the surgeon is unhappy with the support in his
physical resources are allocated and aligned to operating room, skipping a level and going to the
work towards achieving their noble purpose. CEO does not help. The CEO can’t fix the operat-
ing room. The surgeon needs to be directed to the
operational oversight team (one level up), who
Consistent Communication will address the concerns and create a solution
Pathways that will be implemented in ALL da Vinci operat-
ing rooms (one level down) so no matter which
In order for the leadership structure to function team member is supporting the surgeon’s case,
effectively in driving the program towards their the support will be correct and consistent.
noble purpose, consistent communication pathways Be prepared, people aren’t used to this and will
must be created and enforced. Unfortunately, the try to circumvent the system on a regular basis.
typical communication pathways are ineffective Someone will ask a team member in the room to
at solving problems. Typically, people communi- solve a problem, or someone will call an executive
cate with those who are either geographically team member to complain. It takes time, but be
closest to them, or who possess the highest “rank.” consistent and direct people one level up to solve
A surgeon and an anesthesiologist work out how their problems and hold each level responsible for
they will position the patient in a way that satisfies making sure that solutions are implemented across
both of them only to have a new combination of team members only one level down.
surgeon and anesthesiologist the next day forcing So now we have successfully created the foun-
them each to go through the exercise all over dation of our da Vinci surgery program by putting
again. Or maybe a surgeon is unhappy with the into place elements 1, 2, and 3:
support he is getting in the operating room so he 1. A clear noble purpose
marches up to the CEO’s office to tell him how 2. The right leadership structure
important he is to the hospital and why the CEO 3. Consistent communication pathways
needs to fix “his” operating room. If we go back Next we need to create success within our
to our house analogy, this means people are trying program, so it’s time to move on to elements 4,
to solve problems within a single level of the 5, and 6:
house, or they are skipping a level of the house. 4. Standardization
This simply does not work. Problems cannot be 5. Parallel tasks
solved within a level of the house or by skipping 6. A continuous improvement cycle
32 Challenges and Critical Elements of Setting Up a Robotics Program 419

Fig. 32.2 Build stairs

miss a detail? Way too often. One of the beauties

Standardization of da Vinci surgery for the surgeon and the operat-
ing room team is its ability to facilitate standard-
There is variability everywhere in our operating ization. With da Vinci surgery we need fewer
rooms, from pick lists and room setup to equip- instruments because da Vinci instruments articu-
ment and personnel. We live in a world where a late and can be used for multiple purposes, by
single surgeon will have a 5–10 page printout that almost all surgeons, for almost all cases. The
outlines what they want for a particular case. For equipment (the patient side cart and console), as
a medium-sized da Vinci program, that can mean well as its setup, breaks down, and sterilization is
a few dozen surgeons who perform a few dozen common to all surgeons and procedures. Our da
different types of operations with the da Vinci sur- Vinci programs, however, have not fully taken full
gical system, each with a unique 5–10 page print- advantage of this great opportunity for standard-
out. It may seem like a good idea, giving each ization. In a room where we have the same equip-
surgeon what they request, but it’s actually very ment and instruments, set up in exactly the same
bad for the surgeon, the team, and the patient. way, for all surgeons, and all surgical cases, how
Let’s do a little math. If there are just 10 da Vinci often do you think a team member will miss a
surgeons, 6 surgical technologists, 8 circulator detail? Not very often. This is good for the team,
nurses, and 15 anesthesiologists, there will be a 1 good for the surgeon, and good for the patient.
in 7,200 chance that if you were to walk into that There are three simple ways you can take
operating room twice in 1 year, you would see the advantage of the opportunity for standardization
same group of 4 people. And that doesn’t take into in daV inci surgery.
account the differing pick lists for each type of 1) Room setup
case as preferred by each surgeon. In this environ- 2) Personnel
ment, how often do you think a team member will 3) Instrumentation
420 R. Fagin

Room Setup Instrumentation

The da Vinci operating room should have a standard Because da Vinci surgeries across specialties use
setup that works for as close to 100 % of your da the same core open, laparoscopic, and da Vinci
Vinci surgeries as possible. Depending on your instrumentation, we have a great opportunity to
OR size, shape, and the types of cases your hospi- minimize and standardize the instruments we use
tal performs, this setup may vary slightly from across surgeons, surgeries, and specialties. You
hospital to hospital. But whatever setup you can begin by simply looking across the pick lists
choose, you want it to be the standard for nearly all for all of your da Vinci surgeries and find the
your da Vinci cases. To find your standard setup, items that are common to a single procedure or
start by clearing out any unnecessary items from all procedures. By taking these common instru-
the room. These unnecessary items are both visual ments and making a single tray that will be used
and physical barriers to communication and work- for many or all da Vinci surgeries, the frequency
flow. Next, using just the items you need every of use of this single tray will improve the effi-
day, work with your team to create a configuration ciency of setup, breakdown, and sterilization and
that keeps the sterile field in one area and the non- improve the likelihood that you will have 100 %
sterile field in another. Doing this will improve the of what you need 100 % of the time.
efficiency and flow of patients and personnel on Standardizing the instruments used by your
the non-sterile side and the performance of surgi- surgeons also allows you to standardize how you
cal tasks on the sterile side. set up the back table. By standardizing back table
setup, your team will be able to function more
consistently no matter which team member is
Personnel scrubbed in the room and no matter who is giving
relief.
As we saw from the example in the opening para-
graph, even a small core team can present prob-
lems with standardization. Despite these Parallel Tasks
challenges, we must work to standardize our da
Vinci team. By designating a core da Vinci team Traditionally, in the operating room tasks are per-
that is highly familiar and proficient in the setup, formed in series (Fig. 32.3). First the team works
use, breakdown, and care of the daVinci surgical together to set up the back table, then they work
system, we can improve the quality of patient together to drape the robot, then the patient is
care, the consistency with which that care is brought back. The reality is tasks like these can
delivered, and the efficiency of the team’s perfor- and should be performed by one person. With
mance. When you are looking to reduce the vari- one person performing these tasks they can then
ability in your team you need to be sure you look be done simultaneously (Fig. 32.4).
beyond the surgical tech and circulating nurse For example, one person can set up the back
and include anesthesia. Anesthesia is the often table at the same time that another person
forgotten, but critical member of the da Vinci drapes the robot. By executing tasks in parallel
team. Their involvement as a core team member you will reduce the time it takes to get all these
is critical to the smooth and safe performance of tasks finished. In addition, if you also take ele-
da Vinci surgery. Designating and utilizing a core ments that are traditionally done while the
team of anesthesia providers that are familiar operating room is “down” (the “red zone” on
with the unique needs of da Vinci surgery includ- Figs. 32.3, 32.4, and 32.5) and convert them to
ing things like patient positioning, ventilation tasks done while the patient is still in the room
requirements, and fluid needs improve patient you will reduce the number of tasks that need to
safety, quality of care, consistency of care deliv- be done in the “red zone” and will reduce you
ery, and operational efficiency. room turnover time (Fig. 32.5).
32 Challenges and Critical Elements of Setting Up a Robotics Program 421

Fig. 32.3 Old approach

Fig. 32.4 New approach

Operating Room Efficiency: Parallel in the operating room. We are going to go step by
Task Model step with each figure depicting the roles and par-
allel tasks for the five critical people in the room:
Now that you know the basics lets apply these Surgeon, Nurse Circulator, Scrub Tech, Surgical
key concepts in a model that you can implement Assistant, and Anesthesia. Under each heading I
422 R. Fagin

Fig. 32.5 New approach

will list the specific parallel task that is critical Step 2: Patient Enters the OR (Fig. 32.7)
for that step in the robotic procedure. Parallel Task: Drape the Robot While
the Patient Is Being Intubated
Step 1: Setting Up the Back Table When the patient enters the room the surgeon and
(Fig. 32.6) the circulator should be focused on positioning
Parallel Task: Go Get the Patient Before and prepping the patient while the scrub tech is
the Back Table Is Set Up focused on draping the robot. Remember, anes-
The key for efficiency at this stage of the pro- thesia still needs to intubate the patient then the
cedure is that once the back table is opened the patient will need to be positioned, prepped, and
circulator and anesthesia representative go to draped. These activities will take 5–15 min,
get the patient. The back table may look like a which gives the scrub more than enough time to
giant pile at this point but it takes 5–10 min to drape the robot while the patient is in the room
go to pre-op holding and return with a patient and these other activities are being performed.
and that is more than enough time for the scrub
(and in some places first assistant) to com- Step 3: Patent Draped (Fig. 32.8)
pletely set up the back table. There is no need Parallel Task: Team Members Need
to wait for the back table to be setup to go get to Anticipate the Surgeon’s Needs
the patient. In addition, to make back table set not React to Them
up more efficient, you should work to mini- Once the patient is draped, the surgeon will make
mize the instruments you open. You do not his initial incision, insufflate the abdomen with
need a full open set opened and counted. If you CO2 and place the ports. While the surgeon is
choose, an open set can be in the room left doing this, the team should be anticipating his/
unopened next to the back table and opened her needs. The circulator should connect the
only in the case of the rare emergency. bovie, then the gas in that order since this is the
32 Challenges and Critical Elements of Setting Up a Robotics Program 423

Fig. 32.6 Step 1: Setting up the back table

order in which the surgeon will need it (first members can change from day to day, the ability
incision, then insufflation). The assist’s role at of the surgeon to complete simple tasks like this
this time is to clean and prepare the scope since will reduce variability and improve efficiency and
this is the next item needed. These steps are the consistency. Once the robot is docked, the surgeon
same every case so anticipating the needs of will move to the console and it is at this point that
the surgeon should be easy and routine. By antic- the circulator should begin his/her paperwork. In
ipating surgeon needs instead of reacting to many operating rooms the circulator will disrupt
requests efficiency is further improved. the workflow up to this point by trying to complete
paperwork or make computer entries. The sur-
Step 4: Ports Placed (Fig. 32.9) geon’s time at the console will provide more than
Parallel Task: Docking Should Be a Team enough opportunity for the circulator to complete
Effort That Includes the Surgeon the necessary paperwork and make all the required
The surgeon is the only consistent person in the computer entries. By completing charting while
operating room so he/she needs to be as facile with the surgeon is at the console, workflow is not
the docking procedure as the team. Because team disrupted and efficiency is improved.
424 R. Fagin

Fig. 32.7 Step 2: Patient enters the OR

Step 5: Surgeon off the Console patient is still in the room. The surgeon will take
(Fig. 32.10) 10–20 min to remove the specimen and close the
Parallel Task: While the Surgeon Closes abdomen, which gives plenty of time for the team
the Patient the Robot Should Be Undraped to begin stripping the room of unnecessary items.
and the Back Table Cleared
When the surgeon stands up from the console, Step 6: Patient Exits the OR (Fig. 32.11)
they are telling the room that they are done using Parallel Task: While the Patient Heads
the robot and all of the equipment associated with to Recovery the Scrub and Assist Complete
it. This means the robot should not just be rolled the Room Cleanup and Begin to Open
back but it should also be undraped and the for the Next Case
robotic equipment (reposables, ports, etc.) should With the operation complete, the surgeon heads out
be cleaned up and removed from the room. By to talk the family of the patient he just operated on
removing the drapes, cleaning up the robotic and the patient who they will be operating on next.
equipment and sending it to central sterilization While the circulator and anesthesia are bringing the
you are performing part of the turnover while the patient to recovery, the scrub and assist should be
32 Challenges and Critical Elements of Setting Up a Robotics Program 425

Fig. 32.8 Step 3: Patent draped

completing what little is left of room clean up and notes you are playing are correct. When you
then should immediately open for the next case. swing your golf club you know right away if you
With the back table already cleared and the robot sliced it into the woods or hit it straight down the
already undraped all that is left to do is take out the fairway. When you throw a football you know
garbage, mop, and open for the next case. These few immediately if you connected with or overthrew
remaining tasks take less than 15 min and should be your receiver. But in the operating room you can
the only “red zone” items to complete minimizing find people who have been doing their job for a
the time turnover should take. long time and still aren’t very good at it. Why is
working in the operating room any different from
being a quarterback? Because unlike the quarter-
A Continuous Improvement Cycle back who knows the second he throws the ball if
it was a good throw or not, members of the oper-
We all recognize that practice makes perfect. ating room team do not get any feedback on their
Whether you are playing the piano, swinging a task performance. How much could a golfer
golf club, or throwing a football, we recognize improve if he was only allowed to see where his
that to get better at it, you have to do it, and do it ball landed 3 months later? How about a basket-
often. When playing the piano you can hear if the ball player who would be told how many of the
426 R. Fagin

Fig. 32.9 Step 4: Ports placed

shots he took were baskets only at an annual per- Standardize an Operation

formance review. Practice only makes perfect and the Activities That Support It
when the feedback given is timely, frequent, and
relevant and we need to apply this feedback to We learned during the section on reducing vari-
our operating room teams if we want them to ability that standardization of simple items like
improve. We can provide this feedback to our room layout, personnel, and instrumentation can
operating room teams using a five-step process: improve team performance and drive quality and
1. Standardize an operation and the activities efficiency simultaneously. As we look beyond
that support it these items and focus on the processes our team
2. Measure the standardized operation members engage in, the same benefits hold true.
3. Gauge measurements against requirements So it is up to us to give our team members the
4. Innovate to meet requirements and increase responsibility of identifying areas of variability
productivity and working to create standardized methods for
5. Standardize the new, improved operations performing activities.
32 Challenges and Critical Elements of Setting Up a Robotics Program 427

Fig. 32.10 Step 5: Surgeon off the console

Measure the Standardized Operation record those measurements. Because the

processes we are measuring are performed by our
It isn’t enough, however, to merely standardize a day-to-day team members on the ground floor of
process. We need to know if all our team mem- our “house,” we must record these measurements
bers are following the standardized method and on the ground floor. Measurements should be
we need to be able to gauge how effective this taken at the point closest to where a task being
method has been at improving care and effi- measured is being performed. Doing this will
ciency. The only way to do that is to measure provide you with the most accurate information.
what we are doing. So, for any process we cur- This means, to measure performance, you will
rently perform or intend to perform, we must need to assign the job of collecting these mea-
identify a way to measure the performance of the surements to members of your day-to-day team
task in an objective way, and implement a way to on the ground floor.
428 R. Fagin

Fig. 32.11 Step 6: Patient exits the OR

Gauge Measurements Against Innovate to Meet Requirements

Requirements and Increase Productivity

Once you have standardized a process and Although it will be team members on the second
measured the performance of the tasks within floor of your house (operational oversight) that
that process, you need to know if your results will be responsible for the first three steps, it is
meet your performance goals. To gauge your the responsibility of your ground floor day-to-
measurements against your goals, you will day personnel that are charged with step 4; inno-
need to enlist members of your operational vating the role they play to improve efficiency
oversight team on the second floor of the and productivity. Because team members, who
house to review the data collected, and com- perform a given role, know that role the best, you
pare your current performance to your perfor- need to give them the responsibility of finding
mance goals. innovative ways to work smarter, not harder.
32 Challenges and Critical Elements of Setting Up a Robotics Program 429

Standardize the New, Improved purpose, building your “house” and setting in
Operations place the right leadership structure and commu-
nication pathways, working to reduce variability
So you’ve standardized tasks, measured perfor- in tasks, focusing on parallel tasks, and engaging
mance of that task, met your performance goal in a continuous improvement cycle you can join
for that operation, and improved the efficiency of the hundreds of daVinci surgery programs across
performing the task. Now you need to standard- the country that have used this model to create
ize this new, optimized task and continue to mea- growth and success. The results achieved can be
sure performance to maintain this higher level of dramatic and sustainable and the performance
functioning. improvements are significant and reproducible.
When you successfully enact a continuous After reading this, if you still believe that your
improvement cycle, you will find that the benefits situation is unique, or you cannot implement this
extend beyond improvements in quality, produc- entire model because of (insert your reason here)
tivity, and revenue. A continuous improvement I want you to share with you one more pearl.
process, when done correctly, improves engage- One of the unique aspects of this model is the
ment of your staff/team, eliminates inefficient ability to implement various fragments of it in
work, and teaches people to perform experiments part or in total. Regardless of the limitations and
on their work to spot and eliminate waste. challenges your program faces, you can imple-
ment those part(s) of this model that you choose,
eliminate those part(s) you simply cannot imple-
Conclusion ment due to your unique situation, and still
achieve significant benefits in program develop-
Although there are many challenges in setting up ment and success. So use this model and begin
a successful daVinci surgery program, a clear, enjoying the improvements in quality, revenue,
reproducible path to success is within every pro- and success it can bring your program, your
gram’s reach. By defining your clear and noble practice, and your patients.
 Professional Education:
Telementoring and Teleproctoring 33
Monika E. Hagen and Myriam J. Curet

While a pool of experienced senior surgeons

Background are usually available in large tertiary hospitals to
monitor and mentor their inexperienced
The change in modern technique for general surgery colleagues as they learn how to use new technol-
from traditional open procedures to minimally ogies or even new procedures, this process can be
invasive techniques has been driven by technologi- a bottleneck in the dissemination of new tech-
cal advances, which require effort to master on the niques and their availability to the general popu-
part of trainee surgeons [1, 2]. Besides learning the lation. As a result, telementoring or teleproctoring
technical aspects of these new technologies for is becoming an increasingly familiar and wel-
routine standard surgery, new approaches to the come part of the modern surgical milieu [3, 4].
anatomy and even entirely new procedures might The goal of telementoring is to provide
be necessary when applying minimally invasive surgeons with real-time, “over-the-shoulder”
techniques. Examples include changing to a guidance from distant, more experienced col-
medial to lateral dissection during laparoscopic leagues as they perform unfamiliar or challenging
colonic mobilization or the work in new anatomical procedures or use new technology [5 ]. Using
spaces for procedure such as minimally invasive Internet- enabled cameras, microphones, teles-
totally extraperitoneal hernia repair. Therefore, the tration (technology to draw illustrations on
technical mastering of laparoscopic instruments is the surgeon’s monitor), and speakers in the
often insufficient for the successful performance operating theater, telementors are able to
of procedures that are already mastered with an observe and guide their mentees as necessary.
open approach and each individual laparoscopic This approach is particularly well suited to
procedure requires specific learning. minimally invasive procedures, which already
mostly rely on cameras to visualize the
operating field; thus, there is less situational
M.E. Hagen, M.D., M.B.A. awareness to be gained by the physical pres-
Intuitive Surgical International, Sunnyvale, CA, USA
ence of the mentor. When efficiently scheduled,
Department of Digestive Surgery, University Hospital telementoring might maximize the number of
Geneva, 14, rue Gabrielle-Perret-Gentil, Geneva
1211, Switzerland
procedures mentors are able to proctor,
e-mail: [email protected] increasing the overall training rate. This is
M.J. Curet, M.D. (*)
particularly important for uncommon or
Intuitive Surgical International, Sunnyvale, CA, USA newly developed surgical procedures using
Department of Surgery, Stanford University School
new tools and techniques such as robotics
of Medicine, Stanford, CA, USA where the global supply of sufficiently expe-
e-mail: [email protected] rienced mentors may be limited.

K.C. Kim (ed.), Robotics in General Surgery, DOI 10.1007/978-1-4614-8739-5_33, 431

© Springer Science+Business Media New York 2014
432 M.E. Hagen and M.J. Curet

Barbara, CA), Karl Storz OR1 Smartconnect

Value and Limitations (Karl Storz, Tuttlingen, Germany), and Stryker’s
of Telementoring Video Network Hub (Stryker, Kalamazoo, MI).
Details of the systems can be reviewed on the
The major advantages of telementoring are in webpages of the respective company. The most
convenience and throughput. A telementor does important prerequisite for operating these sys-
not need to scrub in or move from one operating tems in a telementoring context is bandwidth,
room to another; they can remain in their office which must be adequate to carry the images and
with all their reference material. Their time is sound in both directions with low latency and
used only when it is needed—thus increasing the high resolution [6]. Generally these systems
efficiency of supervision. Trainee surgeons any- transmit the laparoscopic camera output from
where around the world with equipment and the surgical field, as well as audio and visual
bandwidth can perform telementored surgery. feeds from the operating theater to the mentor,
This can drastically increase the availability of while transmitting audio feeds from the men-
procedures at community and rural hospitals tor’s office to the theater. In some systems the
equipped for telementoring and decreases the mentor is able to draw and make indications on
distances that patients are forced to travel in order the camera feed view to show the trainee what
to receive the best care. Most importantly, tele- is being discussed (telestration), and there may
mentoring allows training in and enhances per- be a monitor with a video feed from the men-
formance of complex surgeries when mentors are tor’s office as well. The telementoring appara-
not physically present. Telementoring also makes tus may be installed in the operating room or on
it easier to extend the period of mentoring; a a mobile cart so it may be shared between oper-
trainee might go from needing a great deal of ating rooms. Patient information confidentiality
attention in the beginning to only calling in their regulations also require the use of encryption to
telementor for particularly difficult presentations. protect privacy. A minimum setup would utilize
Because mentors’ time is not wasted in transit or a virtual private network (VPN) running on an
scrubbing, their attention costs less and they are asymmetrical digital subscriber connection
able to spend more time with their own patients. (ADSL) capable of >1 Mbps, encrypted using a
Telementoring does have its disadvantages. 256-bit advanced encryption standard (AES)
A mentor who is physically present is able to step [4]. As a simplified alternative, Parker et al.
in and complete the procedure if there is a reported on ten clinical cholecystectomies dur-
complication; obviously this is not possible in ing which mentors communicated with trainees
telementoring. This underscores the need for over the phone and received short videos of the
strong preparation of the trainee beforehand. surgery via Blackberry to comment on the pro-
Telementors also must address issues around cedure [7]. This or a similar system (e.g., Skype
licensing, credentialing, and privileging ahead of or Google video chat through a laptop) has the
time. Additionally, relying on two-dimensional potential to provide an effective low-cost
images can make it difficult to detect or indicate backup and allow successful guidance during
anatomical features. Some or all of these prob- surgical procedures.
lems may be rendered irrelevant in the future.

Applications of Telementoring
Systems and Technical in General Surgery
Requirements
Reports on telementoring during general sur-
There are a variety of telepresence and tele- gery procedures as part of advanced laparo-
mentoring systems currently available, among scopic training can be found in the literature
them RP-Vantage (In Touch Health, Santa for a variety of procedures such as colorectal
33 Professional Education: Telementoring and Teleproctoring 433

resections [8, 9]. Rosser et al. reported that definition of telementoring as well. During
intraoperative problems were solved successfully dual console da Vinci surgery, two surgical
by remote guidance for colon resections and consoles are connected to a single patient side
fundoplications [10]. Telementoring also may cart. Two surgeons can control different func-
enable care in austere and environments. For tions of the da Vinci Surgical System simulta-
example, the US Navy has experimented with a neously. Console adjustments can be made
successful implementation of telementoring independently including the image and instru-
aboard an aircraft carrier for inguinal hernia ment control mode. Instrument control is indi-
surgery when far from port [6]. Telementoring vidually assigned to either one of the two
has else been applied to delivery health-care surgeons, and this setup might be switched at
needs in remote areas: Sebajang et al. reported any time during the procedure. Camera control
telementoring for 19 laparoscopic general sur- can be performed in the usual way by either
gery procedures which were performed by sur- surgeon. All instruments lock as usual during
geons with no formal minimally invasive camera movements. A virtual pointer—a three-
training [11]. Byrne et al. demonstrated in 34 dimensional graphical object that appears
laparoscopic cholecystectomies that the overlaid to the video image when activated—
amount of required telesupport increases with can be used by either surgeon when masters are
difficulty of the surgical case and physical not assigned to instruments.
attendance of the mentor was need in 2 of the In the most common scenario, a proctor
34 cases. Sawyer et al. compared operating surgeon, sitting at one of the consoles, controls
times and complications of six age- and sex- no, one, or two instrument arms and provides
matches cases of laparoscopic cholecystec- guidance to a surgeon being proctored at the
tomy with live or telementoring. This group other surgeon console, who controls two, three,
observed no significant differences in operat- or four instrument arms. The four arms are
ing time and concluded that telementoring is a divided between the proctor and the proctee
safe and effective training method for laparo- depending on who is performing which tasks.
scopic cholecystectomy. In addition, two The proctor surgeon would use one or two unas-
reports can be found on successful telementor- sociated masters to activate one or two pointers
ing for laparoscopic adrenalectomy without and then use each pointer to refer to anatomical
technical difficulties [12, 13]. features or to demonstrate movements of the
instruments while speaking with the surgeon
being proctored. During this setup, the mentor
Robotic Surgery and Telementoring can demonstrate as well as facilitate the surgery
at the same time.
While the da Vinci Surgical System (Intuitive The dual console da Vinci Surgical System
Surgical International, Sunnyvale, CA, USA) is therefore currently a valuable tool for
offers all technical requirements that are needed “short- distance” telementoring and its future
for “long-distance” telementoring, currently no potential, as a “long-distance” mentoring tool
such application is available on the market (as of via online data transmission seems evident. In
July 2012). Teleproctoring and remote case its present version, it appears most valuable in
observation for robotic procedures with the da a teaching setting and the second surgical
Vinci Surgical System was investigated by console might serve as a platform for simula-
Intuitive Surgical International but remains off tion use when not required for clinical cases.
the market until its value and legal implications Clinical procedures have been performed in
are clear (as of July 2012). the abovementioned setup and described
Besides classical “long-distance” telemen- in the literature [ 14 ], but its value for surgical
toring, teaching using a dual console setup in education has not yet been scientifically
the same room or same hospital falls under the established (as of July 2012).
434 M.E. Hagen and M.J. Curet

2. Rosser Jr JC, Murayama M, Gabriel NH. Minimally

Conclusion and Future Perspective invasive surgical training solutions for the twenty-first
century. Surg Clin North Am. 2000;80:1607–24.
Telementoring offers advantages over the 3. Rosser Jr JC, Gabriel N, Herman B, Murayama M.
Telementoring and teleproctoring. World J Surg.
physical-presence model of surgical training. 2001;25:1438–48.
As the cost of telementoring equipment 4. Antoniou SA, Antoniou GA, Franzen J, Bollmann S,
decreases and its use as a teaching modality Koch OO, Pointner R, Granderath FA. A comprehen-
spreads, decentralized surgical training will sive review of telementoring applications in laparo-
scopic general surgery. Surg Endosc.
become more feasible. Additionally, telemen- 2012;26(8):2111–6.
toring enhances the capabilities of general sur- 5. Senapati S, Advincula AP. Telemedicine and robotics:
geons operating in remote locations on patients paving the way to the globalization of surgery. Int J
with complex problems. Once the pool of tele- Gynaecol Obstet. 2005;91:210–6.
6. Cubano M, Poulose BK, Talamini MA, Stewart R,
mentors for a given surgical procedure is ade- Antosek LE, Lentz R, Nibe R, Kutka MF, Mendoza-
quately large, someone will always be available Sagaon M. Long distance telementoring. A novel tool
to provide an emergency consult. It is to be for laparoscopy aboard the USS Abraham Lincoln.
hoped that telementoring receives legislative Surg Endosc. 1999;13:673–8.
7. Parker A, Rubinfeld I, Azuh O, Blyden D, Falvo A,
support, which protects and promotes the avail- Horst M, Velanovich V, Patton P. What ring tone
ability of qualified telementors. should be used for patient safety? Early results with a
With the development of telepresence and Blackberry-based telementoring safety solution. Am J
telerobotics in medicine, the disadvantages of tele- Surg. 2010;199:336–40. discussion 340–1.
8. Schlachta CM, Lefebvre KL, Sorsdahl AK, Jayaraman
mentoring may be superseded. Telerobotic surgery S. Mentoring and telementoring leads to effective
is ideally suited to telementoring because the incorporation of laparoscopic colon surgery. Surg
telemetry and controls are easily shared between Endosc. 2010;24:841–4.
trainee and mentor. If complications arise, a telep- 9. Schlachta CM, Sorsdahl AK, Lefebvre KL, McCune
ML, Jayaraman S. A model for longitudinal mentor-
resent mentor would be able to complete the sur- ing and telementoring of laparoscopic colon surgery.
gery, obviating the need for physical presence. Surg Endosc. 2009;23:1634–8.
Telementoring is still in its infancy, and 10. Rosser JC, Wood M, Payne JH, Fullum TM, Lisehora
evidence-based support for its use to impact GB, Rosser LE, Barcia PJ, Savalgi RS. Telementoring.
A practical option in surgical training. Surg Endosc.
learning curves and patient outcome is sparse but 1997;11:852–5.
promising. The convenience of telemedicine is its 11. Sebajang H, Trudeau P, Dougall A, Hegge S,
great selling point especially as the demands McKinley C, Anvari M. Telementoring: an important
upon the time of physicians increase. As the price enabling tool for the community surgeon. Surg Innov.
2005;12:327–31.
of equipment goes down and telementoring’s 12. Bruschi M, Micali S, Porpiglia F, Celia A, De Stefani
legal status is clarified, expect it to become a S, Grande M, Scarpa RM, Bianchi G. Laparoscopic
common feature of surgical practice, particularly telementored adrenalectomy: the Italian experience.
in a robotic setup. Surg Endosc. 2005;19:836–40.
13. Ushiyama T, Suzuki K, Aoki M, Takayama T,
Kageyama S, Ohtawara Y, Fujita K, Uchikubo A.
Laparoscopic adrenalectomy using telementoring sys-
tem. Nihon Hinyokika Gakkai Zasshi. 2003;94:582–6.
References 14. Smith AL, Krivak TC, Scott EM, Rauh-Hain JA,
Sukumvanich P, Olawaiye AB, Richard SD. Dual-
1. Abboudi H, Khan MS, Aboumarzouk O, Guru KA, console robotic surgery compared to laparoscopic sur-
Challacombe B, Dasgupta P, Ahmed K. Current status gery with respect to surgical outcomes in a
of validation for robotic surgery simulators – a sys- gynecologic oncology fellowship program. Gynecol
tematic review. BJU Int. 2013;111:194–205. Oncol. 2012;126(3):432–6.
 Part XIV
Evolving Platforms
 Single-Incision Platform
34
Giuseppe Spinoglio

tectomy (SILC) was in 1997 by Navarra et al. [2]

General Overview followed by others; it showed the feasibility of
this approach for cholecystectomy [3, 4]. This
In the last 20 years, surgical techniques have technique required the introduction of multiple
moved toward a less invasive approach from open trocars through separate fascia stabs within the
to laparoscopic surgery, to natural orifice translu- same skin incision.
minal surgery (NOTES) and to single-incision The evolution was the diffusion of the “multi
laparoscopic surgery (SILS). The new emerging single-port access devices” that have different
techniques have been developed to reduce the shapes and types of embodiment (plastic filled with
number of ports in order to limit the invasivity of port holes, glove-form plastic platforms with the
the surgical access, to improve better cosmesis outer surface gel, etc.) [5, 6] but have the common
and to decrease parietal and body image trauma. feature of allowing the introduction of multiple lap-
The main limitation of NOTES is the lack of aroscopic instruments, simultaneously, through a
instruments for flexible endoscopes, which single fascia and skin incision. The advantage con-
allows the same performance of laparoscopic sists of being more similar to laparoscopy but with
ones. Furthermore, this technique necessitates important conceptual differences.
passing through hollow organs with risk of con- As known, the founding technical principles
tamination and of dehiscence [1]. of good manipulation in laparoscopic surgery are
fulcrum and triangulation.
The fulcrum is placed on the abdominal wall,
SILS and the instruments have a favourable or unfa-
vourable leverage depending on their length
Almost always the SILS technique uses the inside and outside of the abdomen. When the
umbilicus as access: it can be considered as a external arm is longer, we get greater precision
NOTES with the opening of a naturally closed because a wide movement of the surgeon’s hands
orifice and truly scarless surgery because an inci- reflects a short movement of the instrument tip. If
sion is made in a scar that already exists. The first the internal arm is long, we get a better ergon-
report of single-incision laparoscopic cholecys- omy. The triangulation is obtained with the
appropriate distance between the trocars in order
to achieve different angles between the instru-
G. Spinoglio, M.D. (*) ments. We have to consider three different angles:
Department of General and Oncological Surgery,
azimuth angle, elevation angle and the manipula-
City Hospital SS. Antonio e Biagio, Via Venezia 16,
Alessandria 15121, Italy tion angle. The azimuth angle is the optimal
e-mail: [email protected] angle between optical axis and instruments plane

K.C. Kim (ed.), Robotics in General Surgery, DOI 10.1007/978-1-4614-8739-5_34, 437

© Springer Science+Business Media New York 2014
438 G. Spinoglio

Fig. 34.1 The azimuth angle

Fig. 34.3 The manipulation angle

instruments: the lateral movements can only be

achieved by an inversion of instruments; the tool
that comes from the right side can only pull on
the left and vice versa. Therefore, the traction is
inverted compared to the movement of the hands.
The loss of triangulation results in less accu-
rate manoeuvres. The inversion of the hands
causes external crossing of instruments and hands
with a consequent internal “sword fighting” and
left/right inversion of direction [3, 9].
By using curved, articulated or instruments of
different lengths and flexible scopes, we can
Fig. 34.2 The elevation angle reduce incidents, but it does not avoid this issue.
For these reasons, SILS is still a demanding
technique with manoeuvres that are not easy to
and has to be between 0° and +15°, with the cam- do and sometimes inaccurate.
era from above (Fig. 34.1).
The elevation angle reflects the optimal eleva-
tion angle between the instrument and the hori- Robotic Assisted SILS
zontal plane and has to be 60° (Fig. 34.2).
The manipulation angle reflects the best ergo- A robotic platform appears to be particularly
nomic layout for laparoscopic surgery which is in suitable to overcome some of these limitations
a range from 45° to 75° between the instruments with technological advantages such as stable 3D
with equal azimuth angles [7, 8] (Fig. 34.3). views, tremor filtration, precise and delicate
Once obtained, the triangulation allows one to movements, and software that automatically
reach the target surgical field correctly, and the ergo- associate the surgeon’s hands to the ipsilateral
nomics and accuracy are a function of the length of instrument tips to restore intuitive control. First
the lever arms with an optimal ratio between internal attempts were made using traditional robotic
and external length of the instruments. EndoWrist® instruments and homemade or lapa-
In SILS, there is only one port with the loss of roscopic monoport.
all the correct angles described above. Fixed The most frequently used was the GelPort/
direction and fulcrum force the parallelism of the GelPOINT™ (Applied Medical, Rancho Santa
34 Single-Incision Platform 439

Fig. 34.4 (a, b) The flexible instruments are introduced through the curved cannulae. The remote centre is at the level
of the abdominal wall into the port

Margarita, California, USA) with the possibility side to the side of introduction, restoring the correct
of introducing the instruments in more lateral triangulation. The shape of the curved cannulae,
position to reduce external conflict [10, 11]. The externally, keeps the da Vinci arms separated to
robotic software assigns each instrument to the avoid external collisions and instrument crowding.
contralateral hand in order to offset their crossing The intra-abdominal instrument position is reversed:
inside the abdomen. The triangulation achieved the instrument that enters the abdomen from the left
only by the articulated tips of EndoWrist® is only reaches the operative field on the right and vice
a few centimetres, whereby the internal and versa. The da Vinci software automatically reas-
external conflicts of the instruments are not yet signs the surgeon’s hands to the ipsilateral instru-
resolved. In addition, the force of the robotic ment tips restoring the intuitive control.
arms can displace the port from its seat causing Keeping the remote centre at the level of the
loss of pneumoperitoneum. abdominal wall and the curvature of the cannulae
with consequent convergence of the instruments
ensures that there is an optimal focal distance of
The Single-Site™ Platform work allowing the instruments to converge cor-
rectly on the anatomical target (Fig. 34.5).
The recent new Single-Site Robotic Platform (da If the target is closer or further away with
Vinci Surgical System, Intuitive Surgical Inc., respect to the optimum focus, it will be necessary
Sunnyvale, CA) allows one to overcome the to advance or retract the cannulae causing an
issues previously described [12]. incorrect positioning of the remote centre.
The main features of this platform are the use These modifications could cause excessive
of instruments with flexible shafts, rigid curved stress on the port and on the abdominal wall
cannulae that cross at level of the abdominal wall resulting in improper working of the instruments
(remote centre) and restoration of the correct hand/ and loss of CO2. Moreover, if the instruments
instrument correlation achieved by reassigning come out too far from the cannulae to reach a dis-
control of the instrument arms (Fig. 34.4a, b). tant target, more of the flexible shaft extends
The curvature of the cannulae, crossing inside a beyond the rigid support of the curved cannulae
dedicate port, increases the distance between the and loses traction strength. The availability of
instruments tips allowing each to reach the target two sets of robotic curved cannulae of different
anatomy in a convergent way, from the opposite lengths mitigates this issue.
440 G. Spinoglio

Fig. 34.5 The optimal focal distance of work allows the instruments to converge correctly on the anatomical target

The single-site platform was primarily 5-mm straight accessory cannula

designed to work in a narrow operative field and 10-mm straight accessory cannula
with a discrete anatomical target such as during a 10-mm straight blunt obturator
cholecystectomy; however, recently it has also Dock Assist Tool
been used for colonic surgery. 8.5-mm endoscope cannula
8-mm blunt obturator
5-mm blunt obturator
Instruments and Accessories Intuitive surgical 30° 8.5-mm endoscope
Intuitive surgical 0° 8.5-mm endoscope
Single-Site™ Port

The Single-Site™ port is made of silicone and Robotic Flexible Instruments

has a target anatomy arrow indicator and five
lumens (Fig. 34.6). Maryland dissector
Three of these are straight: for the scope, for the Crocodile grasper
insufflation adaptor and for assistant instruments. Fundus grasper
The two more lateral lumens are curved and cross Cadiere forceps
in the midline of the monoport with the outlet Curved scissors
holes on the opposite side of entry. The curved Monopolar cautery hook
robotic cannulae are inserted into these channels. Hem-o-Lok® clip applier
Hem-o-Lok ML clips
Suction irrigator
Single-Site™ Accessories Needle driver
All of the Single-Site™ instruments are
5 × 300-mm curved cannula “1” flexible in order to allow introduction into the
5 × 300-mm curved cannula “2” curved cannulae and rotate on their own axis at
5 × 300-mm flexible blunt obturator 360°. The flexibility, however, does not allow,
5 × 250-mm curved cannula “1” in the current version, the possibility of having
5 × 250-mm curved cannula “2” EndoWrist® technology, as in traditional
5 × 250-mm flexible blunt obturator robotic instruments.
34 Single-Incision Platform 441

Fig. 34.6 The Single-

Site™ port

In this chapter, we described the techniques of

robotic Single-Site™ cholecystectomy (SSRC)
and robotic Single-Site™ right colectomy.

SSRC Procedure Overview

The patient is placed in a supine position with both

arms tucked away as required. The patient cart
should approach the patient 45° (from perpendicu-
lar) over the right shoulder (Fig. 34.7) ensuring that
the target anatomy is in line with the centre col-
umn, umbilicus and arrow on the port. Only three
robotic arms are used: arms 1, 2 and camera arm.
Robotic arm 1 is placed to the left of the patient,
and its instruments reach the surgical field from the
right (i.e. from the lateral side of the gallbladder);
robotic arm 2 is placed to the right of the patient,
and its instruments reach the surgical field from the
left (i.e. from the medial side of the gallbladder).
The camera arm is in line with the centre of the
column bent at an angle of 45° (sweet spot). The
assistant surgeon is to the left of the patient, and the
scrub nurse is positioned at the patient’s feet. The
main assistant monitor is located at the patient’s
right within view of the assistant (Fig. 34.8). Fig. 34.7 Patient chart set-up
442 G. Spinoglio

Fig. 34.8 O.R. set-up for Single-Site™ cholecystectomy

Using standard surgical techniques, a 2.5–2.8- reverse Trendelenburg (10–15°) and is rotated to
cm midline incision is created intraumbilical. After the left (5°) for better exposure of the gallbladder.
opening the peritoneal cavity, it is necessary to per- After abdominal exploration, the assistant retracts
form a digital exploration of the abdominal wall in the fundus of the gallbladder cephalad with a lapa-
order to exclude the presence of adhesions. roscopic grasper to expose the infundibulum. This
The Single-Site™ port can be placed through procedure is performed to assess port alignment
the umbilical incision using an atraumatic clamp and to ensure an adequate working space for the
(e.g. Mayo Guyon clamp or Pean forceps) with cannulae and to assure the cannulae length chosen
two different techniques: unfolded or folded is the appropriate length. The laparoscopic grasper
clamp technique (Figs. 34.9 and 34.10). In the and accessory cannulae are then removed. Curved
first technique, it is easier to clamp the port, but it cannulae are lubricated by dipping in sterile solu-
has a larger surface area for entry into the abdo- tion and inserted by sight to avoid visceral injury.
men. The second technique reduces the insertion The robot is then docked. With the cannulae tips in
profile of the port; however, clamping the port view, the Cadiere forceps are inserted into the
can be more challenging. The arrow marking on robotic arm 1, and the monopolar cautery hook is
the port must be aligned with the theoretical ana- inserted into robotic arm 2. The assistant then
tomical target (gallbladder) (Fig. 34.11). The top grasps the fundus of the gallbladder to expose the
port flanges should lay flat against the abdominal hepatoduodenal ligament. The scope is retracted,
wall. If the port seems to be higher than the skin repositioned under the grasper and pushed for-
or bulging, the inner rim of the silicone port is ward. This lifts the grasper (and the fundus of the
likely not completely below the level of the fas- gallbladder) upwards (Fig. 34.13). The surgeon at
cia, or the incision may be too small. the console retracts the gallbladder infundibulum
The endoscope and the accessory cannulae are laterally using the Cadiere forceps to open the
inserted (Fig. 34.12). The table is placed in slight Calot’s triangle, as in the four-trocar laparoscopy.
34 Single-Incision Platform 443

Fig. 34.9 Unfolded clamp technique

Fig. 34.10 Folded clamp technique

The instrument positions from top to bottom formed with Hem-o-Lok ML clips (clip applier
are as follows: the assistant grasper lifting the gall- arm 2) (Fig. 34.16), and the transection is per-
bladder, the 30° scope is in the centre of the oper- formed with curved scissors (instrument arm 2).
ating field and Cadiere forceps and monopolar The gallbladder liver bed detachment is performed
hook are at the level below the examination scope. using the Cadiere forceps (instrument arm 1) and
The monopolar hook is used to incise the perito- monopolar cautery hook (instrument arm 2)
neum close to the gallbladder neck (Fig. 34.14). (Fig. 34.17). During this step, the scope is reposi-
The cystic duct and artery are identified and tioned above the grasper to lift the liver and expose
skeletonised (Fig. 34.15). The ligation is per- the surgical field. If bleeding requires suction, the
444 G. Spinoglio

cautery instrument is removed and the suction/ inspected for evidence of bleeding or bile leaks.
irrigation instrument is inserted. Before comple- After complete dissection of the gallbladder, the
tion of the gallbladder detachment, the liver bed is specimen extraction is performed by exchanging
the 5-mm assistant trocar to a 10-mm trocar and
introducing a laparoscopic specimen extraction
bag (Fig. 34.18). All the instruments are then
removed, including the single-site port and the
specimen bag. The fascia defect is closed with
adsorbable stitches, and the umbilicus is restored
to its physiological position, suturing the dermis at
the fascia below. The skin is then closed.
If necessary, it is possible to perform an intra-
operative cholangiography using a dedicated
percutaneous balloon set during the procedure.
The catheter is introduced percutaneously in the
right upper quadrant of abdomen, so that
the robotic instruments can grasp and insert the
catheter into the cystic duct. During cholangiog-
raphy, the instruments and the endoscope are
removed, the robotic arms are undocked from
the cannulae and the robotic cart is moved away
from the patient. The curved cannulae are
retracted in a safe position, 3 cm below the
remote centre, but left in the port.
After performing the cholangiography, the
Fig. 34.11 The arrow marking on the port is aligned robot is redocked. The balloon catheter is removed
with the anatomical target by sight, and the procedure is completed as usual.

Fig. 34.12 Curved cannulae inserted into the port at the end of docking procedure
34 Single-Incision Platform 445

Fig. 34.13 The scope is retracted, repositioned under the grasper and pushed forward

Fig. 34.14 Incision of the peritoneum close to the gallbladder neck

Discussion of Advantages, The first step for assessment of the biliary tract
Limitations and Relative anatomy toward safer laparoscopic cholecystec-
Contraindications tomy was the introduction in 1995 by Strasberg
et al. [13] of the “critical view of safety” (CVS)
Advantages [14]. Following this approach, Calot’s triangle is
The lateral traction of the infundibulum is essential dissected to achieve the proximal third of the gall-
in the four-trocar cholecystectomy to open the bladder free from the liver bed and the triangle of
Calot’s triangle surface, to identify the anatomic Calot cleared of fat with the liver segment V visible
landmarks and to avoid biliary and artery damage. through the window. Then the cystic artery and
446 G. Spinoglio

Fig. 34.15 Identification and skeletonisation of cystic duct and artery

Fig. 34.16 Ligation with Hem-o-Lok ML clips

cystic duct must be the only two tubular structures traction is achieved by crossing the instruments
remaining between the gallbladder and the hepato- inside the abdomen and the surgeon’s
duodenal ligament. hands outside: thus, the surgical performance
During SILS cholecystectomy, because of the decreases and the surgeon fatigue and stress
parallel alignment of the instruments, lateral levels increase.
34 Single-Incision Platform 447

Fig. 34.17 Liver bed detachment

Fig. 34.18 Specimen extraction

The robotic Single-Site™ platform allows a o-Lok® clip applier, with its 360° rotation on its
perfect triangulation to open the Calot’s triangle as axis, allows for easy and safe ligation of the struc-
in a four-trocar laparoscopic cholecystectomy to tures prior to cutting them with the robotic scissor.
achieve the CVS with the added benefits of stable These manoeuvres require frequent changes of the
three-dimensional high-definition view, the added tools that are easily and safely made possible by
precision and dexterity and the ease and safety in the assisted tool change feature enabled by the da
changing instruments. The Cadiere forceps allow Vinci system software that automatically puts the
a gentle and steady traction on the gallbladder instrument introduced into the same position as
infundibulum, and the monopolar cautery hook that extracted. Moreover, the 3D high-definition
enables the surgeon to perform a meticulous skel- vision allows precision in controlling any bleeding
etonisation of the artery and cystic duct. The Hem- and/or bile leaking if needed [15].
448 G. Spinoglio

Other advantage, recently added to single-site Contraindications

platform for increase safety during a cholecystec- There are no absolute contraindications to the
tomy, is the near-infrared fluorescent vision sys- technique, but the presence of adhesions and of
tem [16, 17]. The system components include a active inflammatory process could require fre-
surgical 8.5-mm endoscope capable of visible quent rotations and realignments of port and can-
light and near-infrared imaging, a 3DHD stereo- nulae to obtain a proper workspace. For these
scopic camera head that couples to the endoscope reasons, the intrinsic limitations of the single-site
and an endoscopic illuminator that provides visi- platform cannot be recommended in cases of
ble light and near-infrared illumination through acute cholecystitis, biliary pancreatitis and previ-
the surgical endoscope via a flexible light guide. ous upper abdominal surgery.
The surgeon can quickly switch between nor-
mal (visible light or VIS) mode and fluorescence
(near-infrared or NIR) mode. A dose of 2.5 mg of Outcomes Review
indocyanine green (ICG) is administered intrave-
nously during patient preparation to visualise the In our experience of 100 SSRC, the indication for
biliary tree structures switching from white light surgery was symptomatic gallstones and gall-
to fluorescence whilst always keeping an eye bladder polyposis. Overall, SSRC mean opera-
fixed on the surgical field. This permits one to tive time was 68 (range, 35–125) min, mean
obtain an intraoperative dynamic fluorescent docking time was 3.8 (range, 3–8) min and mean
cholangiography that could substitute the classic console time was 23.4 (range, 10–61) min; there
X-ray cholangiography for a safer Calot’s dissec- were no conversions, and all procedures were
tion [18, 19]. performed robotically.
Usually, patients were discharged within 24 h
Limitation of the surgical procedure. There were no early
A crucial aspect is the correlation of the move- postoperative complications or readmissions.
ments of the assistant instrument and the scope. Two incisional hernias (2 %) were observed.
Because of the close relationship between the We compared operative times of first 25 SSRC
scope and the assistant grasper, it is important to with operative times of our first 25 SILC per-
consider the reciprocal interactions whenever the formed by the same surgeon to assess the learn-
grasper or scope is moved (at the beginning of ing curve differences. We report that our average
the procedure, the scope is positioned above the overall operative time for the 25 robotic proce-
assistant grasper and then is retracted and rein- dures was significantly lower than the average
serted under the grasper, and during the detach- operative time for our first 25 SILC cases (62.7
ment of the gallbladder, it is repositioned above vs. 83.2 min, P = 0.001) [20].
the grasper). The assistant cannula is close to the During our experience with the SILC, operat-
camera cannula on the left side of the port and ing time decreased with increasing number of
can only be parallel to the scope: for this reason, procedures. In contrast, SSRC operative times
it is the surgeon at the console that drives the were lower than those of SILC since the begin-
assistant instrument moving the camera. ning; robotic technique seems to be more
Moreover, if the instruments protrude too far intuitive and does not require a specific learning
from the cannulae to reach a distant target, during curve.
the lateral traction, they could flex excessively A possible explanation is the close analogy of
with a potential bullwhip effect and consequent the single-site robotic approach with the four-
risk of damage to the gallbladder wall. Current trocar laparoscopic cholecystectomy; an expert
limits of the flexible instruments are the lack of surgeon in four-trocar laparoscopic cholecystec-
EndoWrist® technology and the current absence tomy might need a very short training period in
of monopolar scissors. Bipolar coagulation SSRC to achieve good and steady operative times
device has been recently introduced. with no major complications.
34 Single-Incision Platform 449

SSRC is a safe and feasible option especially with suprapubic access and intracorporeal
for a trained surgeon in four-trocar laparoscopic anastomosis.
cholecystectomy [21].

Procedure Overview
Robotic Single-Site Right Colectomy
The patient is placed in a supine position with the
Current scientific literature has demonstrated arms along the body. The robotic cart is posi-
that SILS application in colonic surgery is safe tioned at a 40° angle over the patient’s right
and feasible in selected patients. The main diffi- hemithorax, the assistant is at the patient’s left
culties were related to problems of triangulation, side and the scrub nurse at the patient’s feet. The
internal and external instrument collision and main assistant monitor is placed at the patient’s
anatomical exposition. The most frequently right side (Fig. 34.19a, b).
reported SILS in colorectal surgery has been the The single port is introduced through a 3-cm
right hemicolectomy with umbilical access [22, transversal left paramedian sovrapubic incision.
23]. After our experience in SSRC, we decided The last ileocolic loop is then retracted laterally
to use the robotic Single-Site™ platform to test with the Cadiere grasper tenting up the ileocolic
the feasibility and safety also in this surgical vessels (Fig. 34.20). The peritoneum is dissected
procedure, trying to replicate the same tech- up to visualise the duodenum creating a window
niques we perform with a standard laparoscopic (Figs. 34.21 and 34.22). The ileal branch of
or robotic approach, ready to convert to multi- ileocolic vessels is clipped and cut (Figs. 34.23
port in case of our inability to maintain the stan- and 34.24).
dard of safety and oncological radicality. In our The ileocolic vessels are followed as a road
laparoscopic and robotic technique, the over- map to reach the superior mesenteric vessels;
view of mesenteric root, to perform “en bloc” they are then clipped and sectioned exposing the
lymphectomy exposing the mesenteric vessel superior mesenteric vein surface. Proceeding
anterior aspect, is achieved by placing the scope upward, along this plane, the middle colic vessels
in the left iliac fossa in the middle of the line are recognised and the right branch is dissected
joining the umbilicus and anterior superior iliac between clips (Fig. 34.25). Mobilisation of the
spine [24]. colon is performed in medial to lateral direction
The extraction of a specimen is done in the avascular plane between Gerota’s and
through a Pfannenstiel incision enlarging the Toldt’s fasciae keeping down the right ureter and
existing access of the suprapubic trocar. The the gonadic vessels. The segment of transverse
advantages of the Pfannenstiel incision com- colon chosen for the section is skeletonised, and
pared to vertical incisions include improved the vessels of the mesentery are clipped and cut;
cosmesis and decreased pain and rate of incisional then the gastrocolic ligament and the omentum
hernia [25]. are divided.
In our initial experience, we planned to The hepatic flexure is then mobilised, and the
place the Single-Site™ port in Pfannenstiel detachment of the right colon is completed by the
incision in order to get a correct approach to dissection of the right peritoneal groove.
the mesenteric root, similar to our standardised The ileum and the transverse colon are joined
laparoscopic and robotic approach. The extrac- at the point chosen for anastomosis with a 3-0
tion of the specimen, usually really bulky, is absorbable monofilament suture. The traction on
performed through the same incision avoiding this stitch keeps vertical and parallel both the
a median supra- and infraumbilical laparotomy. intestinal tracts in order to perform an intracorpo-
We describe below our early experience with real side-to-side termilised anastomosis using a
three robotic single-site right colectomies flexible stapler (Echelon Flex) 60 blu cartridge.
450 G. Spinoglio

Fig. 34.19 (a) O.R. set-up for Single-Site™ right colectomy. (b) Patient chart docked for SS right colectomy

Fig. 34.20 Lateral retraction of the last ileal loop with the Cadiere grasper

The stapler is introduced by a 15-mm right para- The transverse colon and the last ileal
median sovrapubic trocar, at the side of the loop, including the bowel defect, are finally tran-
robotic port, medially to the rectum muscle sected by stapler performing the classical
without any added incision. side-to-side terminalised mechanical anastomo-
sis, with assessment of correct perfusion of the
34 Single-Incision Platform 451

Fig. 34.21 Dissection of the peritoneum visualising the duodenum

Fig. 34.22 Dissection of the peritoneum visualising the duodenum

stumps by fluorescence imaging (Figs. 34.26, Outcome Review

34.27, 34.28, and 34.29).
Then, the port and the 15-mm trocar are Between January 2012 and April 2012, three
removed, and the specimen is extracted with an patients underwent single-site robotic right col-
endobag through a Pfannenstiel, which is sutured ectomy. The indication for surgery was caecal
in the standard fashion. carcinoma or severe dysplasia (one case). The
Anastomosis may also be performed extracor- mean patient age was 70 years and mean BMI was
poreally through the Pfannenstiel incision. 21.7. Overall Single-Site robotic right colectomy
452 G. Spinoglio

Fig. 34.23 Ileocolic vessels clipped and cut

Fig. 34.24 Ileocolic vessels clipped and cut

operative time was 240 min, mean docking time day. Patients were discharged within 5 days of
was 6 min and mean console time was 180 min. the surgical procedure. There were no early
There were no conversions, and all procedures postoperative complications or readmissions.
were performed robotically. Oncological principles have been satisfied, the
The mean skin incision length was 8 cm. The distal and proximal margins were negative and
mean first flatus time was 1.6 days, and all the mean number of harvested lymph nodes
patients resumed feeding in first postoperative was 24.
34 Single-Incision Platform 453

Fig. 34.25 Section of the right branch of middle colic vessels

Fig. 34.26 Bowel perfusion assessment by fluorescence imaging

Discussion of Advantages, absence of tremor and lack of internal and

Limitations and Relative external conflicts compared to the SILS.
Contraindications Monopolar scissors and bipolar forceps, not
currently available, will make this technique
The robotic Single-Site platform allows sur- simpler and safer.
geons to perform an easier and more accurate The advantages of the Pfannenstiel incision as
lymphadenectomy due to a stable 3D vision, the site of single-port insertion include decreased
454 G. Spinoglio

Fig. 34.27 Side-to-side anastomosis

Fig. 34.28 Bowel perfusion assessment by fluorescence imaging

pain, improved cosmesis and optimal view of the the ICG fluorescence for better evaluation of the
mesenteric axis like to that achieved in the multi- stump perfusions [26] (procedure details
port technique. described in Cap. VIII).
Moreover, it is possible, by this way, to After our initial experience, we believe that the
perform an intracorporeal anastomosis using robotic Single-Site right colectomy is a safe and
34 Single-Incision Platform 455

Fig. 34.29 Side-to-side anastomosis terminalised

feasible technique that should be applied in 6. Romanelli JR, Mark L, Omotosho PA. Single port
selected patients with low BMI and small tumours. laparoscopic cholecystectomy with the TriPort sys-
tem: a case report. Surg Innov. 2008;15:223–8.
In the future, prospective, randomised trials will 7. Hanna GB, Shimi S, Cuschieri A. Influence of
be needed to further evaluate the benefits of this direction of view, target-to-endoscope distance and
approach compared with SILS right colectomy manipulation angle on endoscopic knot tying. Br J
with regard to potential complications, oncological Surg. 1997;84(10):1460–4.
8. Patil PV, Hanna GB, Cuschieri A. Effect of the angle
radicality, patient’s quality of life and cosmesis. between the optical axis of the endoscope and instru-
ments’ plane on monitor image and surgical perfor-
mance. Surg Endosc. 2004;18:111–4.
References 9. Rawlings A, Hodgett SE, Matthews BD, Strasberg
SM, Quasebarth M, Brunt LM. Single-incision
laparoscopic cholecystectomy: initial experience with
1. Tomikawa M, Xu H, Hashizume M. Current status and critical view of safety dissection and routine intraop-
prerequisites for natural orifice translumenal endoscopic erative cholangiography. J Am Coll Surg. 2010;
surgery (NOTES). Surg Today. 2010;40(10):909–16. 211:1–7.
2. Navarra G, Pozza E, Occhionorelli S, Carcoforo P. 10. Ragupathi M, Ramos-Valdes DI, Pedraza R, Haas
Donini I One-wound laparoscopic cholecystectomy. EM. Robotic assisted single-incision laparoscopic
Br J Surg. 1997;84:695. partial cecectomy. Int J Med Robot. 2010;6(3):
3. Mutter D, Callari C, Diana M, Dallemagne B, Leroy J, 362–7.
Marescaux J. Single port laparoscopic cholecystec- 11. Stein RJ, Wesley WM, RajGoel RK, Irwin BH, Haber
tomy: which technique, which surgeon, for which GP, Kaouk JH. Robotic laparoendoscopic single –site
patient? A study of the implementation in a teaching surgery using GelPort as the access platform. Eur
hospital. J Hepatobiliary Pancreat Sci. 2011;18:453–7. Urol. 2010;57(1):132–6.
4. Prasad A, Mukherjee KA, Kaul S, Kaur M. 12. Kroh M, El-Hayek K, Rosenblatt S, Chand B, Escobar
Postoperative pain after cholecystectomy: conven- P, Kaouk J, Chalikonda S. First human surgery with a
tional laparoscopy versus single-incision laparoscopic novel single port robotic system: cholecystectomy
surgery. J Minim Access Surg. 2011;7:24–7. using the da Vinci Single-Site platform. Surg Endosc.
5. Hayashi M, Asakuma M, Komeda K, Miyamoto Y, 2011;25:3566–73.
Hirokawa F, Tanigawa N. Effectiveness of a surgical 13. Strasberg SM, Hertl M, Soper NJ. An analysis of the
glove port for single port surgery. World J Surg. problem of biliary injury during laparoscopic chole-
2010;34(10):2487–9. cystectomy. J Am Coll Surg. 1995;180(1):101–25.
456 G. Spinoglio

14. Strasberg SM, Brunt M. Rationale and use of the criti- robotic cholecystectomy (SSRC) versus single-
cal view of safety in laparoscopic cholecystectomy. incision laparoscopic cholecystectomy (SILC): com-
J Am Coll Surg. 2010;211:132–8. parison of learning curves. First European experience.
15. Konstantinidis KM, Hirides P, Hirides S, Chrysocheris Surg Endosc. 2012;26:1648–55.
P, Georgiou M. Cholecystectomy using a novel 21. Pietrabissa A, Sbrana F, Morelli L, Badessi F, Pugliese
Single-Site® robotic platform: early experience from L, Vinci A, Klersy C, Spinoglio G. Overcoming
45 consecutive cases. Surg Endosc. 2012;26:2687–94. the challenger of single-incision cholecystectomy
doi:10.1007/s00464-012-2227-2. with robotic single-site technology. Arch Surg.
16. Tagaya N, Shimoda M, Kato M, Nakagawa A, Abe A, 2012;147:709–14. http://archsurg.jamanetwork.com.
Iwasaky Y, Oishi H, Shirotani N, Kubota K. Accessed April 16, 2012.
Intraoperative exploration of biliary anatomy using 22. Patel CB, Ramos-Valadez DI, Ragupathi M, Haas
fluorescence imaging of indocyanine green in experi- EM. Single incision laparoscopic-assisted right hemi-
mental and clinical cholecystectomies. J Hepatobiliary colectomy: technique and application. Surg Laparosc
Pancreat Sci. 2010;17:595–600. Percutan Tech. 2010;20(5):e146–9.
17. Ishizawa T, Tamura S, Masuda K, Aoki T, Hasegawa 23. Ostrowits MB, Eschete D, Zemon H, De Noto G. Robotic-
K, Imamura H, Beck Y, Kokudo N. Intraoperative assisted single-incision right colectomy: early experience.
fluorescent cholangiography using indocyanine green: Int J Med Robotics Comput Assist Surg. 2009;5:465–70.
a biliary road map for safe surgery. J Am Coll Surg. 24. Spinoglio G, Summa M, Priora F, Quarati R, Teasta S.
2009;208(1):e1–4. Robotic colorectal surgery: first 50 cases experience.
18. Buchs NC, Hagen ME, Pugin F, Volonte F, Bucher P, Dis Colon Rectum. 2008;51(11):1627–32.
Schiffer E, Morel P. Intra-operative fluorescent chol- 25. Orcus ST, Ballantine CJ, Marshall CL, Robinson CN,
angiography using indocyanine green during robotic Anaya DA, Arminian SS, Awed SS, Berger DH, Alba
single site cholecystectomy. Int J Med Robot. 2012; D. Use of a Pfannenstiel incision in minimally inva-
8:436–40. doi:10.1002/rcs. sive colorectal cancer surgery is associated with a
19. Spinoglio G, Marano A. Is the routine use of intraop- lower risk of wound complications. Tech Coloproctol.
erative cholangiography during laparoscopic chole- 2012;16(2):127–32.
cystectomy really the key to lowering bile duct 26. Kudszus S, Roesel C, Schachtrupp A, Hoer JJ.
injuries? Surg Endosc. 2013 Aug 14. Epub ahead of Intraoperative laser fluorescence angiography in
print. colorectal surgery: a noninvasive analysis to reduce
20. Spinoglio G, Lenti LM, Maglione V, Lucido FS, the rate of anastomotic leakage. Langenbecks Arch
Priora F, Bianchi PP, Grosso F, Quarati R. Single-site Surg. 2010;395:1025–30.
 TilePro
35
Woo Jin Hyung and Yanghee Woo

makes it possible to deliver information to the

Introduction surgeon during the operation without interruption
of the operative process. All the information and
TilePro™ is a multi-input display system of da the view at the console can be shared by all the
Vinci surgical system. TilePro™ allows the sur- staff in the OR and outside the OR. Herein,
geon and the OR team to view a 3D video of the current applications of TilePro during robotic
­
operative field along with up to two additional surgery and future perspectives are described.
video or digital sources. Additional sources can
be various types of digital data having informa-
tion, which can facilitate the operative proce- How to Use TilePro™ System
dures [1]. Digital data can be images of radiology
such as plain radiography, computed tomography The setup and use of TilePro are different in da
(CT), and magnetic resonance images (MRI) as Vinci S and da Vinci Si system. To set up and use
well as video inputs such as ultrasound and the TilePro at da Vinci Si system, digital output of
endoscopy. Not only radiographic images but any any devices such as ultrasound, endoscopy, and
digitalized information can be used such as elec- computer systems is connected to the S-video con-
trocardiography, vital status of the patient, and nections or digital video interface (DVI) inputs in
hospital electronic medical records [1, 2]. the back of the surgeon console (Fig. 35.1).
TilePro™ has been suggested as a tool for During the operation, the surgeons can acti-
data integration during robotic surgery. TilePro™ vate the video input by turning on the multi-input
TilePro™ system using the touch pad panel at
the surgeon’s console (Fig. 35.2). Surgeons are
W.J. Hyung, M.D., Ph.D. (*)
Department of Surgery, Yonsei University College able to display the digital input images on the con-
of Medicine, 50 Yonsei-ro Seodaemun-gu, Seoul sole monitor and other monitors as picture-on-
120-752, Republic of Korea picture mode and to switch on and off the TilePro
e-mail: [email protected]
display by tapping the camera foot pedal. By
Y. Woo, M.D. using the size control bar, the touch pad panel at
Division of GI/Endocrine Surgery, Center for
Excellence in Gastric Cancer Care, Columbia
the surgeon’s console, the size of the TilePro
University Medical Center, New York, NY, USA image can be adjusted as needed. To control the
Department of Surgery, Columbia University College
images of the digital inputs, wireless mouse can
of Physicians and Surgeons, New York, NY, USA be used when the inputs were from the computer
Department of Surgery, New York Presbyterian
systems or a special 3D motion controller was to
Hospital, New York, NY, USA manipulate the stereoscopic volume-rendered
e-mail: [email protected] image by the surgeons [3, 4].

K.C. Kim (ed.), Robotics in General Surgery, DOI 10.1007/978-1-4614-8739-5_35, 457

© Springer Science+Business Media New York 2014
458 W.J. Hyung and Y. Woo

Reconstructed CT images provide vital information

during surgery, in particular, a vascular map that
is critical for surgical guidance during lymphad-
enectomy, and it minimizes the risk of vessel
injury, especially of small- or deep-seated ves-
sels. This approach used intraoperative vascular
images to depict vasculatures around the stomach
(Fig. 35.4), and through it, surgeon could identify
important vascular variations [6].
During a totally robotic right colectomy,
tumor location and vascular supply were
­confirmed. During this procedure, surgeon con-
trolled the augmented stereoscopic volume-ren-
dered reconstruction images using 3D mouse.
This was the first application of 3D projection of
the images via TilePro during surgery. Thus, sur-
geon can have two 3D images simultaneously:
operative view and 3D reconstructed images [4].
Another possible application of TilePro in
general surgery area is using various types of
intraoperative endoscopy. Intraoperative upper
Fig. 35.1  TilePro inputs in the back of the surgeon console endoscopy is an option for the surgeon to localize
a tumor especially for early lesions. Intraoperative
colonoscopy can also be used not only for tumor
Current Applications of TilePro™ positioning but also for confirming anastomotic
System During Robotic Surgery line. Intraoperative choledochoscopy may also be
a necessary tool for liver and biliary surgery. For
Urology Application liver surgery, laparoscopic ultrasound can be
used as was in renal surgery.
The first reported application of TilePro was dur-
ing an urologic procedure [1–3, 5]. It was used
along with a Doppler technology in renal surgery. Other Applications
Laparoscopic ultrasound probe can be controlled
by the surgeon as well as an assistant at the patient Besides urology and general surgery applications,
side. By using Doppler ultrasound, the renal hilum TilePro can be applied in various other areas. For
could be identified and aberrant vessels were iso- example, echocardiographic images can be trans-
lated. It was also useful to confirm ischemia before ferred during cardiac surgery. Nerve function
resection. Surgeons can also correlate the ultra- monitoring may also be a good area of TilePro use.
sound images with preoperative CT scan images to
localize the tumor by using triple image display.
Limitations

General Surgery Application Transmission failure caused by a cabling issue

was reported. Testing the system in advance to
In general surgery, TilePro was used in various ensure that all data sources are capable of trans-
types of surgery. During radical gastrectomy for mission can prevent this type of failure. Data
gastric cancer, patient-specific vascular images transmission delay that led to alternative and tra-
were reconstructed during operation by the radi- ditional methods of data integration outside the
ologist and transferred to the surgeon console TilePro system (e.g., audible conveyance of infor-
using TilePro (Fig. 35.3). mation) was also reported [1]. More importantly,
35 TilePro 459

Fig. 35.2  TilePro can be activated by using the touch pad panel at the surgeon console. The surgeon can control the
video input on and off by tapping the foot pedal for the camera

Fig. 35.3  Intraoperative vascular reconstruction by a radiologist during radical gastrectomy for gastric cancer.
Reconstructed images are transferred to the surgeon console through TilePro

lack of comparison with and without TilePro Another limitation of TilePro is problems
application limits the evaluation of clinical impact related to operating TilePro and manipulating
of TilePro. However, the more information the image sources [3]. To manipulate the radiologic
surgeon has, results of the surgery may improve images, surgeon has to use mouse. Currently the
provided unless TilePro causes trouble to precede radiologic images cannot be manipulated on the
the operative procedures. console. The control of the images are on a device
460 W.J. Hyung and Y. Woo

Fig. 35.4  An intraoperative TilePro view at the surgeon console showing operative view and vascular image during
radical gastrectomy for gastric cancer

connected to the external image source and References

requires the surgeon to look away from the opera-
tion if any change in the images are necessary. 1. Bhayani SB, Snow DC. Novel dynamic information
This results in a break in the operation as the sur- integration during da Vinci robotic partial nephrec-
geon is unable to perform the operation simulta- tomy and radical nephrectomy. J Robot Surg.
2008;2:67–9.
neously. However, this limitation can be overcome 2. Hyams ES, Kanofsky JA, Stifelman MD. Laparoscopic
by an assistant who can manipulate the images at Doppler technology: applications in laparoscopic
the surgeons request. In addition, the endoscopy pyeloplasty and radical and partial nephrectomy.
must be performed by another endoscopist. Urology. 2008;71(5):952–6.
3. Rogers CG, Laungani R, Bhandari A, Krane LS, Eun
D, Patel MN, Boris R, Shrivastava A, Menon M.
Maximizing console surgeon independence during
Conclusions robot-assisted renal surgery by using the fourth arm
and TileProTM. J Endourol. 2009;23:115–21.
4. Volonté F, Pugin F, Buchs NC, Spaltenstein J, Hagen
TilePro is a useful additional tool of the current M, Ratib O, Morel P. Console-integrated stereoscopic
robotic surgery system. Although currently lim- OsiriX 3D volume-rendered images for da Vinci
ited, its applications during robotic surgery have colorectal robotic surgery. Surg Innov. 2013;20(2):
demonstrated satisfactory and favorable out- 158–63.
5. Yuh B, Muldrew S, Menchaca A, Yip W, Lau C,
comes after robotic surgery. In the near future, Wilson T, Josephson D. Integrating robotic partial
TilePro may be positioned as an essential tool for nephrectomy to an existing robotic surgery program.
surgery. Although it is complicated to use TilePro Can J Urol. 2012;19(2):6193–200.
so far, better surgeon-friendly system will be 6. Kim YM, Baek SE, Lim JS, Hyung WJ. Clinical
application of image-enhanced minimally invasive
developed in the near future. The more informa- robotic surgery for gastric cancer: a prospective
tion we can integrate using TilePro, the better the observational study. J Gastrointest Surg. 2013;17(2):
surgical outcomes will be. 304–12.
 ICG Fluorescence
36
Giuseppe Spinoglio

For more than 40 years, the technique of and 1 or 2 h later, it reaches the regional lymph
fluorescence imaging has been widely used for the nodes where it remains for about 24–48 h.
study of the blood flows and microcirculation [1]. The ICG has the ability to absorb light in the
Indocyanine green (ICG) is a vital dye that binds near-infrared wavelengths of between 600 and
to plasma proteins when injected into the blood- 900 nm. The amplitude of the spectrum depends
stream, and conveyed by the proteins, it reaches on the type of solvent used and its concentration.
all the organs and body regions. Its routine use has When it binds to plasma proteins, the maximum
spread throughout different specialties (cardiac absorption of infrared light is around 830 nm.
surgery, neurosurgery, ophthalmology, hepatol- If its molecules are excited with infrared laser
ogy, etc.), and this has been facilitated by its light at a frequency of 780 nm, they emit a very
excellent tolerability, few side effects, extremely intense fluorescent signal. At this wavelength, it is
low toxicity, and few allergic reactions (1/10,000 possible to suppress the excited laser light
as reported by the manufacturer) [1–3]. The dose through filters and dedicated cameras and detect
used for normal diagnostic procedures is between only the fluorescence signal.
0.1 and 0.5 mg/kg. The near-infrared light with wave amplitude
After intravenous injection, in a time interval of between 700 and 900 nm (NIR) has the ability
that lies between 5 and 50 s, the ICG reaches the to penetrate deep into tissue (from several
arterial and venous vessels; after about a minute, millimeters to several centimeters in depth) with
it reaches the kidneys where it remains for about low autofluorescence, thus providing a sufficient
20 min; and after about 2 min, it reaches the liver contrast [5].
from where it is eliminated via the bile without Recently there has been developed and inte-
being subject to enterohepatic recirculation [4]. grated to the da Vinci 3DHD robotic system an
The persistence in the liver, before the excre- optical system that is capable of emitting laser
tion is complete, is approximately 1–2 h. light that is closer to infrared light with the ability
When injected intradermally, subcutaneously, to switch between white light and near-infrared
subserosally, or submucosally, it is drained (NIR) light view in real time, creating the ability
through the network of lymphatic vessels; within to perform fluorescence-guided surgery. There
15 min, it reaches the first lymph nodes (SLNs); are many fields of application in general surgery,
some still experimental and evolving, ranging
from intraoperative cholangiography (IOC) to
G. Spinoglio, M.D. (*) define biliary anatomy; the study of bowel stump
Department of General and Oncological Surgery,
perfusion, especially in colonic resections; and
City Hospital SS. Antonio e Biagio, Via Venezia 16,
Alessandria 15121, Italy sentinel node and lymph node mapping in cancer
e-mail: [email protected] surgery. In addition, ICG fluorescence can be

K.C. Kim (ed.), Robotics in General Surgery, DOI 10.1007/978-1-4614-8739-5_36, 461

© Springer Science+Business Media New York 2014
462 G. Spinoglio

Fig. 36.1 ICG NIR fluorescence explanation

used to endoscopically mark colonic, rectal, and Single-site robotic cholecystectomy (SSRC)
gastric lesions [6–9]. allows easier and safer surgical procedures, similar
The fluorescence vision system of the da Vinci to those of multiport laparoscopic cholecystec-
HD robot comprises an endoscope that is able to tomy, with good exposure of the Calot’s triangle.
provide visible light and near-infrared light However, the difficulty in visualizing the bili-
images, a 3DHD stereoscopic camera connected ary structures can still remain in SSRC, although
to the endoscope, and an endoscopic illuminator to a lesser extent with respect to the SILC. This is
that through a flexible cable provides the console due to a reduced field of vision and to a forced
surgeon with both near-infrared and visible light- position of the instruments [15].
ing (Fig. 36.1). The surgeon can quickly switch Routine IOC to evaluate the biliary anatomy is
between normal viewing mode (visible light) and still recommended by many authors [16], but it
fluorescence (NIR) by pressing the pedal of the has several disadvantages such as a longer oper-
surgical console. ating time, requirement for a multidisciplinary
In this chapter, we describe current applica- team, staff and patient exposure to radiation,
tions in general surgery: fluorescent cholangiog- interruption of the workflow, and, in the case of
raphy, lymph node mapping, and assessment of robotic surgery, the need to undock and redock
the perfusion of the colonic stumps, colorectal, the robot.
and gastric tattooing. ICG NIR cholangiography is a noninvasive
method that requires no X-rays or bulky equip-
ment such as the C-arm and permits viewing of
Cholangiography Fluorescence the bile duct in real time by alternating between
of Indocyanine Green the white light and NIR fluorescent light with a
simple switch system.
Bile duct injury (BDI) is a rare but serious Recently, several authors have reported the
complication of cholecystectomy. The incidence of benefits of cholangiography with fluorescence
these lesions increased from 0.1–0.2 % at the detection of the biliary tract in real time during dis-
time of open cholecystectomy to 0.4–0.7 % in the section of the Calot’s triangle with no requirement
era of laparoscopic cholecystectomy. The primary for catheterization of the biliary tract [17, 18].
cause of BDI is the misinterpretation of biliary
anatomy (71–97 % of cases) [10–14].
The single-incision laparoscopic cholecystec- Technique
tomy (SILC) may be associated with an increased
risk of bile duct injuries because of insufficient The first dose of 2.5 mg of ICG is administered
exposure of Calot’s triangle compared to tradi- intravenously during the preparation of the patient,
tional multiport cholecystectomy. about 30–45 min before surgery. A second dose
36 ICG Fluorescence 463

aberrant ducts of Luschka (Figs. 36.6, 36.7, 36.8,

and 36.9).
After the procedure, a final fluorescence view
of the operative field may be prudent.

Discussion of Advantages,
Limitations, and Relative
Contraindications

Advantages
Fluorescent cholangiography, especially during
the SSRC, allows safe viewing and immediate
Fig. 36.2 White light view before Calot’s dissection and real-time anatomy of the biliary tract and
is a further aid to prevent BDI during the
procedure.
of 2.5 mg ICG is once again administered First, Ishizawa and then Buchs demonstrated
intravenously if fluorescence is not detected in the the technical feasibility of fluorescent cholangi-
liver about 60 min after the injection of the first ography during multiport laparoscopic cholecys-
dose. The surgery begins in the usual manner for tectomy, SILC, and SSRC [17, 18].
SSRC cholecystectomy. Once a view of the In our experience, 70 patients underwent
Calot’s triangle is established, the camera is put SSRC with ICG NIR cholangiography (initial
into fluorescence mode for an initial attempt to data submitted to Surg Endosc).
identify the biliary anatomy (Figs. 36.2 and 36.3). We visualized at least 1 biliary duct in 100 %
Then the dissection of the Calot’s triangle begins of cases before the dissection of the triangle of
with the incision of the peritoneum and continues Calot and two biliary ducts in 97 % of cases after
as described in the SSRC chapter, alternatively dissection. The operative time of SSRC with
switching from white to NIR light allowing views fluorescence compared with that of our SSRC
of the fluorescent bile ducts in real time. In this experience without fluorescence was not statisti-
way, the surgeon can follow a road map for a safe cally significant.
skeletonization of the cystic duct and cystic artery Mean hospital stay was 1.1 days. There were
(Figs. 36.4 and 36.5). The cystic duct may be no conversions, bile duct injuries, other major
clipped under fluorescence before sectioning, complications, or adverse events.
especially if it is very short and if there are prob- The advantages of this method compared to
lems in the biliary confluence. the traditional radiological IOC are many:
If there are problems with the vascular • There is no interruption of the workflow in
anatomy during the cystic artery skeletonization, that the images are highlighted on the surgical
it is possible to proceed with a further injection of field during the normal progress of the opera-
2.5 mg of ICG and, after 10–20 s, obtain a view tion and the surgeon can operate both in white
of the hepatic and cystic arteries and their light and fluorescence.
divisions and avoid any damage to anomalous • The interpretation of images is simpler
branches, especially the branch to the sixth because they appear in real time and can be
hepatic segment. checked with surgical maneuvers of moving
During the detachment of the gallbladder structures whilst they are in view. This is in
from the liver bed, use of fluorescence to define contrast to the traditional IOC images that
the boundary between the gallbladder and liver are fixed on the screen of the radiology equip-
bed is useful, especially in cases of thin or an ment with the surgeon working with static
intrahepatic gallbladder and to visualize any information.
464 G. Spinoglio

Fig. 36.3 NIR light view before Calot’s dissection

Fig. 36.4 White with light view after Calot’s dissection (cyst duct and artery sectioned)
36 ICG Fluorescence 465

Fig. 36.5 NIR light view after Calot’s dissection (cyst duct and artery sectioned)

Fig. 36.6 White light view of Luschka duct before sectioning

• It is possible to control the clipping and section- • The fluorescent bile that usually comes out of
ing of the cystic duct with a clear distinction of the stump of the cut cystic duct or of the
the bile ducts. gallbladder in case of perforation is always
• During the detachment of the gallbladder clearly visible; therefore, the system could
from the liver bed, its wall can be better potentially highlight any bile leaks. This use
highlighted and any aberrant ducts of Luschka of the ICF fluorescence, however, has not yet
easily found. been reported.
466 G. Spinoglio

Fig. 36.7 NIR light view of Luschka duct before sectioning

Fig. 36.8 White light view of Luschka duct after sectioning

• When needed, the vascular anatomy of the multidisciplinary teams, does not expose patients
hepatic artery and cystic artery can be shown. and staff to radiation, and is not burdened by
• C-arm or other equipment is not needed, thus adverse reactions.
avoiding the undocking and redocking of the
robotic system. Limitations
• The procedure does not require any additional The current limitations are mainly two:
time compared to normal SSRC. • So far the procedure has not been tested in cases
We can conclude that the procedure is safe of an emergency cholecystectomy performed
and inexpensive; it requires no interaction of for suppurative cholecystitis or gangrenous
36 ICG Fluorescence 467

Fig. 36.9 NIR light view of Luschka duct after sectioning

cholecystitis. The ability of NIR light to reach • Intraoperative lymph node mapping
the deeper, edematous, and inflamed tissues • Tattooing for the localization of tumors of the
must be studied. colon, rectum, etc.
• ICG NIR fluorescent cholangiography is opti-
mal for the definition of biliary tree anatomy.
The capability of the current system to recognize The Evaluation of Perfusion
biliary gallstones or other obstructions has not of the Intestinal Stumps
yet been investigated.
The anastomotic leakage is one of the most feared
Contraindications complications in colorectal surgery [19, 20]. The
Pregnancy, adverse reaction, or allergy to ICG, causes of and pathogenic mechanisms underlying
iodine, shellfish, or iodine dyes. anastomotic leakages have not been fully clari-
fied, but it is considered that the perfusion of
the intestinal stump is an important factor [21].
Fluorescence for Near-Infrared The evaluation of the adequacy of perfusion of
Imaging During Colorectal Surgery the stumps is usually based on the subjective
impression of the surgeon that includes parame-
The advantages of the robotic platform in ters such as active bleeding edge of the section,
colorectal cancer surgery have been extensively the pulsatility of the mesentery vessels, and lack
described in previous chapters. The fluorescence of discoloration of bowel segments [22].
viewing system of the da Vinci HD is able to The loss of tactile feedback, typical of mini-
increase the potential of robot technology in mally invasive surgery, can make this assessment
terms of safety and oncologic extent of more difficult compared to open surgery.
dissection. Many different solutions have been proposed:
The use of fluorescence in colorectal surgery laser Doppler flowmetry, visible light spectros-
can be useful for some currently developing copy, fluorescence laser angiography, narrow
applications: band laser imaging techniques, and near-infrared
• The evaluation of perfusion of the intestinal reflection spectroscopy.
stumps The fluorescence system of the da Vinci
• Real-time identification of vascular anatomy robot allows HD viewing in real time both for
468 G. Spinoglio

Fig. 36.10 Transection line assessment during left colectomy

macroscopic vascular anatomy of and perfusion paler because the vascularization of the tenia is
of the microcirculation. less intense due to thickness of the muscle tissue.
This device can be used to assess the intestinal The perfused segments gradually become
perfusion and reassure the surgeon in their choice green until they assume a bright green color, in
of point section of the bowel during left and right contrast with the gray segments that are not well
hemicolectomies and anterior resection of the vascularized (Fig. 36.10). The stapler can be
rectum. It can also be useful in nonstandardized placed following a well-perfused transaction line
colic resections such as the resection of the trans- (Fig. 36.11).
verse and left colonic angle in which vascular If the site chosen for the section does not
abnormalities can impair the blood supply. appear to be sufficiently perfused, the section line
can be moved. In case of doubt, the test can be
repeated after waiting a few minutes to allow the
Technique dye to wash out.
Further checks may be carried out before and
After having performed surgery with the da Vinci after performing the anastomosis (Figs. 36.12
surgical system following the usual technique of and 36.13).
vascular control and preparation of intestinal seg- With regard to the rectal stump, the pelvic
ments, the chosen location for colonic resection wall turns green first (as does the uterus in
is evaluated with white light, and an intravenous women) because it is highly vascularized. After a
dose of 5.0–10 mg mg of ICG is administered. few seconds, the rectal stump colors up allowing
Approximately 30–45 s after the infusion, the the assessment of perfusion at the selected point
operative field is viewed under fluorescence. (Figs. 36.14 and 36.15).
Depending on the tissues, the green fluorescent The ends of the section lines of the rectum in
intensity appears different and at different times. Knight-Griffen anastomosis or of the colon
With regard to the colonic stumps, the vessels of in latero-lateral anastomosis are often referred to
the epiploic appendices and mesentery turn green as critical points of leakage: particular attention
first, and then the green spreads across the intesti- should be paid to their perfusion, and today
nal wall. The antimesenteric side of the descend- fluorescence is the only tool we have to evaluate
ing colon and transverse colon is always a little it objectively.
36 ICG Fluorescence 469

Fig. 36.11 Bowel transection during left colectomy

Fig. 36.12 White light view of side-to-side anastomosis during splenic flexure resection

Discussion of Advantages, This work also demonstrated that the leak rate
Limitations, and Relative was reduced from 7.5 to 3.5 %; therefore, it
Contraindications seems this technology might be very impactful
for the reduction of anastomotic leaks in colorec-
The potential advantages of bowel perfusion tal surgery [9].
assessment using fluorescence appear interest- In most cases, visual inspection, combined
ing and are the subject of several multicenter with caution, is sufficient to perform a well-
studies. vascularized anastomosis, especially for experi-
Currently there is only one paper regarding enced surgeons. However, there are difficult
this topic. Kudszus et al. reported a 13.9 % rate of cases, both for patient conditions such as obesity,
change in stapling location after fluorescence diabetes, and inflammatory disease and for the
perfusion assessment. types of anastomosis such as in ultra-low rectal
470 G. Spinoglio

Fig. 36.13 NIR light view of side-to-side anastomosis during splenic flexure resection

Fig. 36.14 NIR light view of rectal transection

resection, especially in the presence of a thick The contraindications are those described in
mesocolon and a short mesentery, and in left angle general for ICG fluorescence.
resections, in which the evaluation of the perfu-
sion is important, even if only as confirmation.
Accidental spillage in the course of injection Lymph Node Mapping
for tattoo or lymph node mapping may pose a
limitation on the use of this method for assess- The prognosis and quality of life of patients with
ment of perfusion. In this case, it may be difficult colorectal cancer depend on the extent of the tumor,
to appreciate the fluorescence of the stump the characteristics of onset, and the quality of sur-
associated with perfusion as distinct from the gical care. In particular, a correct local-regional
fluorescence resulting from impregnation of the lymphadenectomy is mandatory for staging and
tissue. treatment of the tumor.
36 ICG Fluorescence 471

Fig. 36.15 White light view of rectal transection

Colorectal resections (colectomy and partial NIR fluorescent light permits real-time imaging
colectomy and anterior resection of the rectum) of lymph flow and identification of the SLN in
are governed by identical pathophysiological colon and rectal cancer specimens [8].
principles: cancers and colonic segments are
resected en bloc with their relative lymph nodes.
Although in most cases all the lymph nodes of Technique
the segment of colon affected by cancer are included
in the surgical specimen, in some cases, the lym- When injected intradermally, subcutaneously,
phatic spread may extend beyond these. Examples subserosally, or submucosally, the ICG is drained
of this abnormal extension are represented by through the network of lymphatic vessels; within
lateral pelvic lymph nodes in rectal cancer or 15 min, it reaches the first lymph nodes (SLNs);
by periaortic lymph nodes in left colon cancers. and 1 or 2 h later, it reaches the regional lymph
These lymph nodes may be the cause of recurrence nodes where it remains for about 24–48 h.
and should be removed. The technique differs in the timing of injection
For these reasons, over the years, the indica- of the ICG to assess the lymph node mapping
tions have often changed from standard rather than to identify the sentinel lymph node.
lymphadenectomy for cancer of the rectum to In the case lymph node mapping, 1 or 2 cc of
extensive lymphadenectomy, such as pelvic lat- a solution of 0.5 % ICG (5–10 mg) is injected
eral lymphadenectomy. endoscopically around the tumor in the submu-
On the other hand, in recent years, surgical cosa 3–24 h before surgery. The injection should
oncology is evolving towards less aggressive be done by introducing the needle tangentially to
approaches thanks to early diagnosis, which the wall and not perpendicularly in order to avoid
allows one to perform limited but oncologically any risk of perforation of the intestinal wall with
correct resections together with the development consequent diffusion of ICG in the peritoneum or
of techniques for the identification of the sentinel in the surrounding tissues.
lymph node. The SLN procedure is regarded as Operating in NIR light shows the first lymph
standard of care in the treatment of breast cancer node before the peritoneal dissection, and following
and melanoma [23, 24]. Although its value in the dissection, all lymph nodes are highlighted
colorectal cancer has not yet been established, the from where the ICG has been drained (Figs. 36.16,
recent study of Hutteman et al. demonstrated that 36.17, and 36.18). The lymph nodes are removed
472 G. Spinoglio

Fig. 36.16 White light view of periaortic lymph nodes during robotic rectal resection

Fig. 36.17 NIR view of periaortic lymph nodes during robotic rectal resection

en bloc if present in typical sites by a standard the bedside assistant. The surgeon at the console
lymphadenectomy; however, they are removed guides and inserts the needle tangentially into
with the “berry-picking” technique when present the subserosa or submucosa on 4 sides of the
in unusual locations (periperiaortic and pericaval in tumor, and the infusion is made by the assistant
the left colon, pelvic side walls in the rectum). surgeon at the table (Figs. 36.19 and 36.20). The
To locate the sentinel lymph node, the dye is needle is removed while maintaining suction to
injected intraoperatively into the subserosa. If prevent leakage of ICG into the peritoneum;
the location of the tumor cannot be identified the dose of ICG is identical to that injected
laparoscopically, the dye is injected into the sub- endoscopically.
mucosa by the endoscopist. The intraoperative After a few minutes after the injection, one or
technique involves the insertion of a butterfly two fluorescent lymphatic channels are displayed
infusion set connected to a syringe containing which run beneath the serosa and then drain the
the ICG solution of 0.5 % through the trocar by sentinel lymph node (SLN).
36 ICG Fluorescence 473

Fig. 36.18 NIR view of dissected periaortic lymph nodes during robotic rectal resection

Fig. 36.19 White light view of subserosal ICG injection during right colectomy

Discussion of Advantages, fluorescence has an important staging significance

Limitations, and Relative rather than surgical therapy and, therefore, may
Contraindications be performed with a “berry-picking” technique
that, guided by the fluorescence view, can be
The advantages of the definition of a lymph node more precise, meticulous, and certainly less trau-
map that permits sometimes a more extensive but matic than the regional lymphadenectomy.
guided lymphadenectomy could be the compro- With regard to the sentinel lymph node, we
mise solution, based on objective data, between know that some studies have been published in
extended and standard lymphectomy with the colorectal surgery, especially with the radio-
aim of a “tailored surgery.” The removal of lymph guided technique, but the role of the biopsy for
nodes outside of the typical sites shown by the the detection of micrometastases and their
474 G. Spinoglio

Fig. 36.20 NIR view of subserosal ICG injection during right colectomy

clinical significance has not yet been defined surgeon with a rigid sigmoidoscope and a long
[25–27]. spinal needle. On the other hand, the possibility
The sentinel node biopsy guided by ICG of viewing the sentinel lymph node in subperito-
fluorescence imaging has been shown to increase neal rectal neoplasms, even if subjected to neoad-
the detection rate with a low rate of false nega- juvant radiotherapy, is limited by the capacity of
tives in breast cancer, melanoma, and cancer of penetration of the NIR light that decreases drasti-
the anus and in the stomach [24, 28–30]. The cally with tissue thicknesses >0.5 mm.
application of fluorescence in colorectal surgery Likewise, the intraoperative butterfly needle
for sentinel lymph node is still limited to experi- injection can be difficult and often remains too
mental studies. One of the limitations of the superficial and spreads the dye into the peritoneum.
application is the rapid diffusion of ICG. For this An important caveat in the removal of lymph
reason, solutions of ICG with binding protein nodes with the “berry-picking” technique is to
able to slow down the diffusion such as albumin maneuver the instruments with great delicacy and
are under investigation. not to use vigorous movements on the lymph
In any case, the feasibility of the method nodes; even without breaking the lymph nodes,
during left colonic resections has already been the dye can spread easily and stain the robotic
demonstrated [8]. forceps and consequently taint neighboring
The limit of lymph node visualization tech- tissues with green fluorescence with each subse-
niques with ICG fluorescence is determined by quent touch.
its diffusibility. The peritumoral injection tech-
nique must be precise and submucosal, with a
small dose. Excessive penetration into the intesti- Colonic Tattooing
nal wall can result in diffusion into the tissues or
peritoneum that can cause an extended coloriza- In minimally invasive surgery, the localization
tion that masks the lymph nodes. For this reason, of small or flat tumors or those that were
the best results are obtained in rectal tumors removed endoscopically can be difficult to estab-
where the injection can be done directly by the lish. In colorectal robotic surgery, this problem is
36 ICG Fluorescence 475

colon, making the operation difficult or impossible.

An alternative solution could be intraoperative
endoscopy, closing the colon upstream with a
bowel clamp, so as to perform a tattoo visually
guided by the surgeon. This matter is a subject of
discussion for the generation of further studies.

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Part XV
Future
 Robotics and Remote Surgery:
Next Step 37
Jacques Marescaux and Michele Diana
“All glory comes from daring to begin.”
Eugene F. Ware

surgeon to perform more complex procedures

Introduction while concurrently reducing surgical risks.
Throughout the evolution of surgery, the physical
Surgery has been practiced for thousands of presence and the real tactile abilities of the oper-
years, and there is evidence of some embryonic ating surgeon have been a constant.
form of surgery that goes back to prehistory, with The advent of minimally invasive endoscopic
clues of rudimental procedures such as skull burr surgery (MIES) techniques in the mid-1980s is
holes. Hippocrates (480–390 BC) defined sur- considered one of the most groundbreaking sur-
gery as the therapeutic activity performed by gical innovations. MIES has been the first step
means of the “hands.” As a character, the surgeon towards a successful surgeon-patient distancing
has been surrounded by some sort of mysticism process. MIES respects the therapeutic principles
since he/she would “touch” the sacred and secret of open surgery with reduced surgical trauma
nature of the human body, with his/her bare since the surgical field is created through small
hands. In the Middle Ages, surgery was banned skin incisions and visualized by high-definition
by medical academies in Europe, and surgical cameras and the organs are manipulated with
acts were pursued only by men whose activities micro-instruments. With the hands of the surgeon
required craftsmanship (e.g., barbers, butchers, away from the patient’s body, surgical trauma is
bonesetters) with outstanding manual skills but reduced, and outcomes are undeniably better
who were often ignorant about anatomy or physi- with fewer surgical site infections [1, 2], less pain
ology. Nineteenth-century discoveries in the fun- and fewer hernias [3], and improved cosmetic
damental fields of antisepsis and anesthesia outcome. However, MIES is not straightforward,
enabled the wider use of surgery to treat diseases. and the surgeon is faced with some totally new
The twentieth century has seen the addition of challenges [4] for (1) reduced depth perception
thrilling new technologies to the operating room due to the 2D vision offered by the flat screen,
such as electrocautery. They have enabled the (2) loss of haptic proprioception due to hand-eye
disconnection, (3) limited field of view, and
(4) reduced tactile sensation which is possible
with laparoscopic instruments. Robotic science
J. Marescaux, M.D., F.A.C.S., (Hon.) F.R.C.S., offers specific innovations to facilitate MIES.
(Hon.) J.S.E.S. (*) • M. Diana, M.D. The da Vinci® system (Surgical Intuitive) is a
Department of Digestive and Endocrine Surgery, commercial surgical robotic platform equipped with
IRCAD (Research Institute against Digestive Cancer),
a binocular camera that provides a stereoscopic,
1, place de l’Hôpital, 67091 Strasbourg, France
e-mail: [email protected]; tenfold magnified, and high-resolution view. It also
[email protected] offers a haptic interface, which allows the surgeon

K.C. Kim (ed.), Robotics in General Surgery, DOI 10.1007/978-1-4614-8739-5_37, 479

© Springer Science+Business Media New York 2014
480 J. Marescaux and M. Diana

Fig. 37.1 Operative setup with the master–slave surgical unit). This is the basic configuration of a surgical robot
robotic platform. The surgeon and control panel (master that enables telesurgery
unit) are separate from patient and robotic arms (slave

to be comfortably seated. The surgeon can com- the OR was designed to perform image-guided
mand the instruments with movements very simi- precision tasks but was limited by basic computer
lar to that of natural hand movement, while interfaces. Of note is the PUMA 200 industrial
effectors exactly replicate the movements into a robot used since 1985 for CT-guided brain biopsy
precise and downscaled fashion, hence eliminat- [5] or the ultrasound-guided PROBOT, intro-
ing physiological tremors (Fig. 37.1). Additionally, duced in 1988 and used to perform prostate
at the turn of the twenty-first century, robotics has resections [6]. The first commercially available
yielded technology facilitating surgeon-patient medical robot was manufactured in 1992 and was
distancing, taking this to extremes, and, as a known as the ROBODOC (Integrated Surgical
result, breaking up the frontiers of “telesurgery.” Systems, Sacramento, CA), which was approved
to guide the surgeon during hip prosthetic
replacements. The evolution of surgical robots
Robotics and Remote Surgery: has led to a current generation of real-time tele-
Expanding Boundaries manipulators where robotic effectors reproduce
the surgeon’s hand motion in a “master–slave”
The idea to apply robotic technologies to configuration. In these units, the “master” control
surgery dates back to the 1970s when a military console, from which the surgeon operates, is
project of the National Aeronautics and Space physically separated from the “slave” unit, com-
Administration (NASA) aimed to provide surgi- posed of the robotic arms performing surgery on
cal care to astronauts with remotely controlled the patient. Two FDA-approved surgical robots
robots and to replace the surgeon’s physical pres- originated from the DARPA (Defense Advanced
ence in situations of mass casualties in hostile Research Project Administration)-funded projects:
environments such as war or natural catastrophes. the da Vinci® Surgical System (Intuitive Surgical,
The first generation of surgical robots that entered Inc., Sunnyvale, CA) and the Zeus® system
37 Robotics and Remote Surgery: Next Step 481

(Computer Motion, Goleta, CA). Intuitive global telesurgery [15]. In the Lindbergh opera-
Surgery absorbed Computer Motion in 2003, and tion, a combination of high-speed fiber-optic
the only robotic platform available on the market connection was used with an average delay of
today is the da Vinci® System. 155 ms with advanced asynchronous transfer mode
Robotic surgery has been used in a vast array (ATM) along with the Zeus® telemanipulator.
of surgical procedures, and although clinical ben- Now that one expert surgeon can operate from
efits are not yet clear, the ability to perform across continents, what is the next step?
remote surgery is certainly unique to the robotic The ultimate application for robotic telesurgery
interface. is probably the one that was initially conceived by
The data transmission speed is the primary the NASA: to provide surgical care to astronauts
difficulty with teleoperations, especially over during long-lasting, extreme distance space
large distances or in the presence of insufficient explorative missions in which self-sufficiency of
retransmission infrastructures. Early systems, in the space crew to face surgical emergencies is
fact, required the surgeon to be in the same room mandatory.
as the patient. However, with the use of high- The challenges that must be overcome to
speed telecommunications, both telementoring and make this possible are still manifold: the ability
telemanipulation were attempted from remote to perform surgery in reduced gravity conditions,
locations [7, 8]. portable and light equipment, and, most impor-
Telementoring is the possibility for expert tantly, the possibility of cosmic distance data
surgeons to mentor local surgeons through telep- transmission.
resence [9]. Telementoring programs that offer The feasibility of Zero-Gravity surgery has
rural hospitals the possibility to gain full benefit been demonstrated with a cyst removal on a
of specialist advice are being established world- human subject onboard the European Space
wide. One early report from 1996 demonstrated Agency (ESA) Airbus A-300 Zero-G Aircraft.
the ability of a surgeon located in the same city Weightlessness phases were achieved performing
to successfully mentor another surgeon as well as parabolic curves [16]. Similarly, experimental
to manipulate an endoscopic camera [10]. laparoscopic surgery on a pig model is feasible in
Cubano et al. [7] reported the efficacy of tele- weightlessness [17], with only minor distur-
mentoring laparoscopic hernia repairs to surgeons bances due to lack of gravity.
operating on the Maryland-USS Abraham Lincoln In addition, intensive research in miniaturiza-
Aircraft Carrier. Further reports have shown that tion of surgical telemanipulators is under way, and
specialist surgical skills can be disseminated a number of prototypes have been built with the
effectively through telementoring [11]. aim to extend the possibilities for telesurgery,
Network latency affects the surgical perfor- offering a lighter and more practical platform. The
mance with a longer task completion time of a Raven (University of Washington, BioRobotics
factor of 1.45 and 2.04 in the presence of delays Lab) is a portable 22 kg mass robotic tool with
of data transmission of 250 ms and 500 ms, two articulated arms. It has been conceived for
respectively, when compared to no time delay both open and MIES [18], and it integrates long-
[12]. However, operators may still perform surgi- distance remote control links. Another prototype
cal training with a low error rate even at delays of under evaluation is the M7. It is also a light and
approximately 1,000 ms [13]. Initially, latency in portable device, developed by Stanford Research
data transmission limited telemanipulation to a International, equipped with two arms with 7
distance of a few 100 km [14]. Degrees of Freedom (DOF), and which integrates
In September 2001, the first transatlantic haptic feedback [19]. The software of the M7 is
surgical procedure (Operation Lindbergh) covering suitable for teleoperations, and in September
the distance between New York (United States) 2007, it was successfully tested in the NASA first
and Strasbourg (France) was performed by our Zero-Gravity robotic experience during parabolic
team. This is considered to be the milestone of flights [20].
482 J. Marescaux and M. Diana

Fig. 37.2 Interactive spacecraft operating room: view of Medical Imaging facilities offers the remotely located
an interactive operating room. The integration of Virtual surgeon an immersive and informative environment that
Reality and Augmented Reality monitors and on-site enables Image-Guided Telesurgery

Internet-based communication speed and Imaging and Communication in Medicine

quality are sufficient to practice telesurgery on (DICOM) format images. This 3D virtual model
planet Earth, with reasonable delays of around enables to navigate through the human body and
400 ms, but it is not suitable for space missions. to perform a virtual exploration, highlighting
Telesurgery in extremely remote locations anatomical details, which might be underesti-
requires more advanced telecommunications mated on a customary image [23, 24]. The virtual
[21, 22]. The ability to provide real-time interac- exploration can assist the preparatory phase of
tion between the spacecraft and the ground is the surgical procedure through interactive and
obviously inversely related to distance. Taking visual planning of the strategy and simulation.
advantage of satellite-based transmissions, with Subsequently, during the intraoperative phase,
signals propagating at light speed (300,000 km/s), the 3D VR model may be superimposed onto
approximately 1-s delay would be experienced real-time patient images providing Augmented
for an Earth-Moon distance, which is still reason- Reality. This fusion of live images and synthetic
able for simple remotely controlled procedures. computer-generated patient-specific images may
For very large distances, as an example, for an provide the surgeon in space with an enhanced
average orbiting distance between the Earth and navigation tool, highlighting target structures and
Mars (72 million km), the delay would be around anatomical variations through a modular virtual
6 min, which means that remotely controlling organ transparency. Through this computer-assisted
real-time procedures would not be possible, nei- surgery, ground-spacecraft communication lag
ther would be telementoring. The limitations for time would be less important (Fig. 37.2).
effective telementoring are probably below a 60-s At the IRCAD, AR guidance was pioneered in a
delay. Beyond this range, a trained surgeon series of laparoscopic adrenal tumor resections
should be onboard and able to perform “solo.” [25], using customary software (VR RENDER®) to
The development of preoperative simulation construct the virtual model of the patient. The sys-
using Virtual Reality (VR) patient models, and tem allowed a very accurate navigation with a
real-time guidance systems based on Augmented maximum error of 2 mm. Subsequently, we have
Reality (AR), could well provide invaluable applied the same concept to liver surgery [23] and,
support to solve the issue of semi-real-time moni- more recently, to minimally invasive parathyroid
toring of the surgical act. surgery [24]. We are currently working on a system
VR medical software programs may elaborate to improve “registration,” which is the ability to
a 3D virtual model of the patient from Digital exactly superimpose 3D preoperative model to live
37 Robotics and Remote Surgery: Next Step 483

images and, secondly, to develop an automatic

registration process. Our aim is to establish a blue- References
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 The Future of Robotic Platforms
38
Mehran Anvari

As the use of robotics in surgery advances past

Introduction the investigational stage, and reaches routine
practice in many disciplines, the cost will con-
Since its inception, minimally invasive surgery tinue to decrease. Technological advances
has proven to be advantageous in terms of continue to be made with minimized entry ports
improved cosmosis, reduced risk of infection, and improvements in haptic feedback, and visu-
shortened recovery time post-surgery, and alization with the implementation of magnified
reduced pain [1, 2]. These techniques are not imaging, 3D resolution, global positioning and
without limitations, however, albeit most being real-time imaging.
technical constraints including a lack of haptic There are three distinct architectures of surgical
feedback and loss of dexterity (degrees of free- robotics: the master–slave configuration, the image-
dom). Robotic systems have been developed to guided targeted robots, and the micro robots.
address these limitations and are continually
being advanced to expand on the benefits of
minimally invasive surgery and enhance the sur- Master–Slave Robots
geons’ ability. Although robotic-assisted surgery
continues to develop and has been shown to The “master–slave” surgical systems are not a
reduce hospital stay, pain, and recovery time robot in the pure sense of the word, but rather com-
when compared to conventional surgery [3], the puterized systems, consisting of the console where
main disadvantages are cost and bulk of current the surgeon controls the robot (the “master”) and
systems, the learning curve associated with the the robotic arms holding the instruments being
use of current models, and the limited number of controlled (the “slave”). Major improvements
cost-effective clinical applications. have been made over the years to the master–slave
Progression in research and design aims to systems since the era of the Zeus and early da
resolve these limitations by reducing the size, Vinci models.
improving functionality, and increasing application. The da Vinci surgical system (Intuitive
Surgical, CA, USA) (Fig. 38.1a, b) was the first
operative robotic system approved by the US
M. Anvari, M.B.B.S., Ph.D., F.R.C.S., F.A.C.S. (*) FDA in 2000 [4]. While used in a number of
Department of Surgery, McMaster University,
surgical specialties and procedures worldwide,
Hamilton, ON, Canada L8N 4A6
its use in prostatectomy still dominates its appli-
St. Joseph’s Healthcare Hamilton, Room G805,
cation. The most recent version of the surgical
50 Charlton Avenue East, Hamilton, ON,
Canada L8N 4A6 system, the da Vinci Si HD (Intuitive Surgical
e-mail: [email protected] Inc., CA, USA), includes improved features of

K.C. Kim (ed.), Robotics in General Surgery, DOI 10.1007/978-1-4614-8739-5_38, 485

© Springer Science+Business Media New York 2014
486 M. Anvari

Fig. 38.1 (a and b) The da Vinci Si HD surgical system: surgeon console and patient cart (© 2009 Intuitive Surgical,
Inc., with permission)

3D high-definition visualization, 7 degrees of data, telesurgery, and training [5, 7]. It has been
freedom of movement (DOF), 90 degrees of artic- indicated that clinical testing will be initiated in
ulation, intuitive motion finger tip control and the next 2 years [8]. Titan Medical is also devel-
tremor, and motion reduction; however, it does oping a single incision robotic surgical platform
not provide haptic feedback, and the system is with 25 mm access, 3D visualization, and inter-
costly (approximately £1.7 million, 2011 [5]), active micro-instruments (Fig. 38.2). Projected
cumbersome, and bulky. This deficient sense of release of the platform is 2015 [7].
touch has been explored, with recent develop- ALF-X (SOFAR S.p.A, Italy) (Fig. 38.3a, b)
ments to restore haptic feedback. The Verro is a new surgical system undergoing testing in
Touch is a device being developed by Europe. It enhances surgical dexterity with a real-
Kuchenbecker et al. [6] which can be added to the istic tactile-sensing capability due to a patented
current da Vinci system and emits feedback in the approach which measures tip/tissue forces, with a
form of high-frequency vibrations and sound in sensitivity of 35 g and advanced eye tracking to
real time. control view [9]. The robotic system contains
Other master–slave systems currently being four independent arms with adaptable surgical
developed include: instruments for clinical use in gynecology, urol-
The Amadeus by Titan Medical Inc. (Canada) ogy, and thoracic surgery. With animal trials
which is a robotic surgical system with multi- complete, and indicating significantly reduced
articulating arms and single-site and multi-port procedural time for cholecystectomy compared
platform capabilities with infrared and ultrasound to the conventional telesurgical system (average
imaging and enhanced 3D visualization. of 31.75 min versus 91 min) [10], the ALF-X has
Additional features include force feedback and now received CE mark and is set to reach market
advanced communication technology for patient soon [11].
38 The Future of Robotic Platforms 487

Fig. 38.2 Titan single incision surgery platform, reprinted with permission

Fig. 38.3 (a and b) The ALF-X Telelap robot, reprinted with permission
488 M. Anvari

Fig. 38.4 Three DLR MIROs in a setup for minimally invasive surgery (from DLR Institute of Robotics and
Mechatronics with permission)

The DLR MIRO system (the Institute for cable-based, articulated aluminum dual arms
Robotics and Mechatronics, Germany) incorpo- with 7 DOF, with exterior motors, reducing the
rates haptic feedback through force and tactile size and weight. The robotic prototype is capable
feedback or optical tracking [5]. The MiroSurge of teleoperation and has been released to research
(Fig. 38.4) is compact and lightweight, consist- labs, with initial application in cardiac surgery,
ing of three of the MIRO robotic arms; generally aspiring to include beating heart procedures, with
two are used for surgical tools and one for visual- motion compensation and 3D ultrasound imaging
ization. Each arm has seven torque-controlled capabilities [14, 15].
joints for flexible movement designed to mimic The NeuroArm (developed at the University
the human arm. Presently this platform is used of Calgary, AB in collaboration with MacDonald,
for research purposes. Technical advances may Dettwiler and Associates Ltd) was one of the first
include compensation for heartbeat and motion MRI-compatible surgical robotic systems. The
to allow cardiac surgery without stopping the master–slave design of this system does not allow
heart [12]. freedom of movement by the operating surgeon,
Similarly, developed but not yet available but force feedback and real-time imaging
commercially is a remote-operated robotic surgi- combined with preoperative diagnostic images
cal system named “Sofie”: Surgeon’s Operating do provide effective tools for reference during the
Force-feedback Interface Eindhoven developed procedure [16]. Used in clinical trial for dissec-
by the University of Technology in Eindhoven. tion during microsurgery, successful results were
The 4D manipulators (surgical arms and a reported with the 34 cases, with one adverse
camera) are mounted on the operating table and event due to uncontrolled motion of the arm and
include a distinctive tactile force feedback sys- one conversion to the standard procedure due to
tem of counter pressure through the joystick con- reduced access and trouble with positioning dur-
trollers [5, 13]. Although this prototype has not ing the procedure (Sutherland et al. [17]). The
yet been released to market, it is anticipated that NeuroArm technology was acquired by IMRIS
an advantage of this compact system will be a Inc. (NASDAQ: IMRS; TSX: IM) in 2010, after
reduced cost to larger current models [13]. which the SYMBIS neurosurgical robot system
The RAVEN II (the University of Washington was released in 2012 (by IMRIS), pending FDA
and UC Santa Cruz) (Fig. 38.5) consists of two approval [18].
38 The Future of Robotic Platforms 489

Fig. 38.5 The Raven II, The University of Washington Platform for Surgical Robotics Research, The Hamlyn
(from: Jacob Rosen, Mika Sinanan, and Blake Hannaford, Symposium on Medical Robotics, July 1–2 2012, London,
Objective Assessment of Surgical Skills, Chapter 25 in UK; H. Hawkeye King, Blake Hannaford, Ka-Wai Kwok,
Surgical Robotics, Systems, Applications, and Visions, Guang-Zhong Yang, Paul Griffiths3, Allison Okamura, Ildar
Jacob Rosen, Blake Hannaford, Richard M. Satava Farkhatdinov, Jee-Hwan Ryu, Ganesh Sankaranarayanan,
(Editors), 1 ed. Springer 2011; Zhi Li, Daniel Glozman, Venkata Arikatla, Suvranu De, Kotaro Tadano, Kenji
Dejan Milutinovic, and Jacob Rosen, Maximizing Kawashima, Angelika Peer, Thomas Schuß, Martin Buss,
Dexterous Workspace and Optimal Port Placement of a Levi Miller, Daniel Glozman, Jacob Rosen, Thomas Low,
Multi-Arm Surgical Robot, ICRA 2011, Shanghai, China, Plugfest 2009: Global Interoperability in Telerobotics and
May 2011; H. Hawkeye King, Lei Cheng, Philip Roan, Telemedicine, IEEE International Conference on Robotics
Diana Friedman, Sina Nia Kosari, Ji Ma, Daniel Glozman and Automation, ICRA May 2010, Alaska, USA with
Jacob Rosen, Blake Hannaford, Raven II™: Open permission)

The Robin Heart 2 robot (developed by the larization, and possible future utilization in drug
Foundation for Cardiac Surgery Development, delivery and robotic-assisted artificial organ sur-
Zabrze, Poland) consists of two or more arms for gery [20].
tools and a camera, allowing the surgeon to Continued research and development efforts
essentially perform three roles (of two surgeons into the master–slave surgical robotic system and
and an endoscopic assistant) [19]. Future devel- the application of Laparo-Endoscopic Single-
opment includes computer simulation and opera- Site Surgery (LESS) and Natural Orifice
tive planning with application in cardiac surgery Translumenal Endoscopic Surgery (NOTES) to
for valve repair and replacement, laser revascu- further reduce surgical invasiveness, and decrease
490 M. Anvari

Fig. 38.6 (a and b) The robotic slave manipulator with Barbera, Antonella Tauro and Philipp Emanuel
two steerable articulating arms and controller Cosentino (2011). Robotic Colonoscopy, Colonoscopy,
(MASTER) (From Felice Cosentino, Emanuele Tumino, Paul Miskovitz (Ed.), ISBN: 978-953-307-568-6, InTech
Giovanni Rubis Passoni, Antonella Rigante, Roberta with permission)

port and trocar access, have brought forth new A computer-assisted robotic technology system,
robotic prototypes. Ideally, robotic platforms for the NeoGuide (NeoGuide Systems Inc., San Jose,
LESS should have the desired instrument maneu- CA, USA), has been developed and approved for
verability, dexterity, and freedom of movement application during colonoscopy [26]. The system
and restored triangulation without instrument incorporates a tip sensor that continually records
clashing for precise movement [21]. Designs to the steering commands and an external sensor
current systems have been improved to include that records the insertion depth to guide the
pre-bent curved, flexible, and articulating arms to scope along the natural shape of the colon [27].
increase maneuverability. Clinical application of A compact endoscopic robot ViKY (EndoControl
robotic-assisted NOTES has been demonstrated Medical, France) has been developed, recently
in preclinical and clinical study using various obtaining CE mark and FDA approval [28]. The
approaches. Transgastric, transvesical, and trans- system can be voice controlled or foot switch
colonic approaches have been used in abdominal operated to robotically control the laparoscopic
surgery, colonoscopy, and endoscopy [22]. camera with an innovative instrument tracking
An agile transluminal endoscopic robot system [29].
(Master And Slave Transluminal Endoscopic Advances in surgical robotic systems have
Robot, MASTER) (Fig. 38.6a, b) was developed generated the integration of preoperative and
by Singapore’s Nanyang Technological intraoperative imaging for procedural guidance
University and National University Hospital to and tracking of tools during surgical intervention
overcome some of the limitations of standard while accounting for organ movement [30].
endoscopic devices, including the lack of trian- A body-global positioning system for navigation
gulation [23]. The controller of this system and organ tracking has been pioneered by
attaches to the wrist and fingers of the operating Ukimura and Gill [30]. This ability to integrate
surgeon, allowing for 9 DOF. Animal trials using preoperative imaging can also be beneficial in
the MASTER for endoscopic submucosal dissec- pre-planning, training, and mentoring. Many sys-
tion (ESD) with NOTES have been conducted tems utilize the overlaid images obtained through
with promising results [24], and early results computerized tomography (CT), magnetic reso-
from human trials showed evidence of a short- nance imaging (MRI), or ultrasound for proce-
ened procedure time [25]. This system is dural guidance. A system for the 3D imaging of
anticipated to be released to market in the near tissue in real time using fluorescence imaging has
future. been developed by Intuitive Surgical Inc. for the
38 The Future of Robotic Platforms 491

da Vinci system and is currently in trial, imaging identifies the position of the patient, making
renal cortical tumors to determine the optimal continual adjustments for movement. Established
dose of ICG fluorescence for visualization using use in brain tumors as well as lesions of the spine,
the SPY scope [31]. lung, pancreas, liver, and prostate has been
reported [33].
The commercially available, FDA-approved,
Direct Image-Guided Robots miniature robot, Spine Assist (Mazor Robotics Ltd,
Israel) (Fig. 38.8), is a bone-mounted hexapod
Robotic systems designed for intervention under robot which assists in navigation and guidance for
image guidance are an exciting development, thoracic and lumbar pedicle screw drilling and
providing targeted therapy with clinical applica- implantation, vertebral biopsies, and kypho- and
tion in oncology, urology, gynecology, general vertebroplasties [34]. Future possible developments
surgery, neurology, and cardiology. may include application in craniocervical surgery
The Cyberknife system (Accuray, Inc., and cervical and lumbar total disc replacement [34].
Sunnyvale, CA) (Fig. 38.7) was the first image- Based on experience with the SpineAssist, Mazor
guided robotic technology for noninvasive Robotics has introduced the Renaissance platform
radiation procedures, receiving FDA approval in (Mazor Robotics Ltd) which creates a 3D preopera-
October of 2001. The system consists of a large tive blueprint of the procedure, synchronizing with
robotic arm that can quickly and accurately deliver the instrumentation to provide an implant proce-
targeted radiation with converged beams from dure within 1 mm of accuracy [35]. The Renaissance
multiple angles, reducing radiation exposure to platform received CE mark in 2011 and US FDA
surrounding tissue [32]. A real-time image guid- marketing clearance in 2012 to be used for applica-
ance system and respiratory tracking system tion in brain and spinal surgery [35].

Fig. 38.7 CyberKnife system, Accuray Inc., reprinted with permission

492 M. Anvari

Fig. 38.8 The SpineAssist (Mazor Robotics Ltd, Israel) applications and future developments. Acta Neurochir
(From Stüer C, Ringel F, Stoffel M, Reinke A, Behr M, Suppl. 2011;109:241–5 with permission)
Meyer B. Robotic technology in spine surgery: current

The RIO (Robotic Arm Interactive Orthopedic ing surgeon, utilizing MR images and Innomotion
System) (MAKO Surgical Corp., USA) received software [40].
FDA clearance in 2008, for knee joint resurfacing An MRI-compatible, image-guided, pneumatic,
during partial knee and total hip replacement pro- remotely operated robot, the MrBot, has been
cedures, providing patient-specific pre-planning designed to employ high-precision, image-guided
[36]. The application uses pre-procedure imaging access of the prostate gland, accommodating
data to create a cutting guide, with integrated various needle drivers for different percutaneous
digital tracking of the procedure and constant interventions such as biopsy, thermal ablations,
monitoring utilizing visual, tactile, and auditory and brachytherapy [41]. Early results show good
feedback. The robotic system does not require accuracy with the image-guided needle and seed
bone fixation [36], and the feedback resistance placement during testing in a 3 T MRI scanner
system restricts the surgeons’ movement to within [42], but no information on commercial availabil-
the planned cutting area [36]. ity can be found.
While magnetic resonance (MR)-guided Pfleiderer et al. [43] investigated the feasibility
percutaneous interventions, such as biopsies and of the ROBITOM II [Institut für Medizintechnik
ablation, have been clinically demonstrated with und Biophysik (IMB), Forschungszentrum
open-bore systems [37, 38], the closed-bore MR Karlsruhe und Institut für Diagnostische und
imaging (MRI) scanners provide superior resolu- Interventionelle Radiologie (IDIR), Jena], a
tion, but offer limited access during imaging and robotic system for MR-guided biopsy and inter-
therefore limited feasibility for intervention other ventional therapy of mammary lesions with the
than robotic [39]. Innomotion (Innomedic, potential to reduce pain, scarring, radiation expo-
Herxheim & FZK Karlsruhe Germany & TH sure, as well as time and cost when compared to
Gelsenkir), a CT and MR-compatible robotic surgical biopsy. Improvements to the first model
instrument-guiding system, was developed to were made, including a dedicated double breast
provide precise and reproducible instrument coil, which featured an open design for easy
positioning inside the magnet [39]. The access during breast interventions, and a high-
Innomotion robotic arm is mounted on specifi- speed trocar setting unit [43]. Designed for real-
cally designed bed rails, with the transducer time biopsy procedures within the magnetic
attached to the robotic arm guided by the operat- bore, with possible future application of therapeutic
38 The Future of Robotic Platforms 493

Fig. 38.9 Conceptual rendering of the IGAR system in clinical use with the patient lying prone on a patient support
system

treatments during the same procedure, animal

and small human feasibility trials have proven Miniature Robots
successful [43]. No information on commercial-
ization can be found. Minimizing both the robotic platform and
MRI-compatible robots continue to be reducing the access needed, while overcoming
explored in research and development, with issues of instrument collision and ergonomic
promising goals in oncology of improving challenge, are important issues facing current
accuracy and precision for biopsy, radiation, and surgical platforms. Recent research and develop-
treatment, with focus on small lesions previously ment has been focused on the miniaturization of
not easily treated. Image-guided robots provide surgical robotics. Miniature robots are either
precise, targeted treatment with better cosmosis, surgically placed or intracorporeally deployed,
reduced pain, and shorter recovery than tradi- consisting of fixed-based systems and mobile
tional methods and have future implication in robots, controlled remotely, performing various
many disciplines including neurosurgery, ortho- tasks. To date, clinical use has been focused on
pedics, and urology. screening for colon cancer, esophageal disorders,
In Hamilton, Ontario, Canada, current devel- and celiac disease [44], with miniature autono-
opment and testing of an image-guided automated mous robots being used for endoscopic imaging
robot (IGAR) (Fig. 38.9) for MRI-guided inter- and colonoscopy application.
vention is in progress by the Centre for Surgical Video capsule endoscopy (VCE) has been
Invention and Innovation and MacDonald, developed and used in clinical application for
Dettwiler and Associates Ltd (MDA). This will small bowel disease, intestinal disorders, and
be a base technology for image-guided proce- colon disease. The endoscopic capsule is swal-
dures and medical interventions, with the first lowed by the patient and used to photograph the GI
clinical application of IGAR employed during tract. The VCE capsule contains a video camera,
MRI-guided breast interventions. Future develop- a sensing system, a data recorder, and a battery.
ments will expand to other medical imaging The capsule moves through the GI tract by vis-
modalities and other clinical applications, includ- ceral peristalsis and gravity; therefore, a major
ing image-guided intervention and ablation of limitation is the lack of control of movement and
lesions of the lung, liver, kidney, and prostate. control of imaging. These limitations have led
494 M. Anvari

Pittsburgh, PA) (Fig. 38.10), moves along the

epicardium in an inchworm fashion and has
proven capability of ambulating and deploying
pacing leads and delivering dye injection to the
anterior and posterior surfaces of the heart in
animal studies [52]. This technology will hope-
fully be transferable to human interventions,
with ablative procedures and regenerative myo-
cardial interventions.
Magnetic anchoring and guidance systems
(MAGS) developed by the investigators from
University of Texas are micro robots which are
fixed to the abdominal wall with external mag-
Fig. 38.10 Wire-driven HeartLander model
nets for tissue retraction, cautery, and dissection.
Future application may include use in NOTES, as
to exploration of automated, remotely controlled MAGS has proven feasible in animal trials for
systems. transvaginal cholecystectomy [53, 54].
A miniature in vivo robot developed at the Miniature robots address many of the limita-
University of Nebraska Medical Center’s Center tions of large master–slave systems used for SILS
for Advanced Surgical Technology (CAST) is and NOTES procedures, such as size and the
engaged into the abdominal cavity and operated collision of instruments in the limited space
remotely using laparoscopic-type handles. (fulcrum effect). The SPRINT (Single-Port lapa-
Surgical tasks such as tissue grasping, manipula- Roscopy bImaNual roboT) (The BioRobotics
tion, cautery, and intracorporeal suturing are per- Institute, Scuola Superiore Sant’Anna, Italy)
formed with two arms which have been designed platform is a teleoperated miniature robot,
to mimic the human arm [45]. The system has inserted through the umbilicus. Consisting of two
been tested successfully in a porcine model, with arms with 6 DOF, the handheld manipulators
an intestinal anastomosis procedure and a vessel allow translation of the surgeon’s hand move-
ligation (Petroni et al. [46]), but has not yet ments to the end effectors [55].
undergone human testing [47]. The technology employed in miniature robot-
A similar compact, in vivo prototype, the ics is under continual development to overcome
Insertable Robotic Effectors Platform (IREP), limitations of function, due to size, and power.
can be folded and deployed into a 15 mm port to Wireless systems, relying on battery life, are lim-
perform surgical tasks and consists of two dexter- ited to an operating time of less than an hour, mak-
ous arms, with eight joints for 7 DOF and 3D ing their use appropriate in limited situations [56].
stereo vision [19, 48]. The system was developed Size limitations often result in not being able to
at Colombia University with the capability of implement all desired surgical functions such as
microsurgery, with future development in the visualization, movement, imaging, manipulation,
application of energy and drug delivery [49]. The and treatment in the same device. Advancements
technology was acquired by Titan Medical Inc. in in propelled movement and biopsy functions are
early 2012 [7]. in development [57, 58]. The Korean IMC
Mobile in vivo robots are remotely controlled (Intelligent Microsystems Center) is developing a
and are generally propelled with movements micro-electro-mechanical systems (MEMS) pro-
based on principles of either the inchworm or totype which integrates micro-optical imaging,
the earthworm [50, 51]. A miniature mobile physiological sensors, and a micromechanical
robot for cardiac intervention, the HeartLander arm for biopsy, drug delivery, and microsurgery
(Robotics Institute, Carnegie Mellon University, with advanced movement capabilities [59].
38 The Future of Robotic Platforms 495

Future direction of miniature robotics may Conflict of Interest

include the use of multiple robots to be employed This work was not externally funded; the author
simultaneously, each with a separate function has not received any financial support.
(e.g., one each for imaging, biopsy, resection, and
suturing). Micro robots may also incorporate
flexible engineering, as has been shown with References
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 Index

A ALF-X Telelap robot, 486, 487

Abbas, A.E., 25–32, 69–84 Al Jazari, 4
Abdalla, R.Z., 131 Allgrove’s syndrome, 55
Abdominoperineal resection (APR) American Society for Metabolic and Bariatric Surgery
circumferential resection margin, 247 (ASMBS), 121
da Vinci robot, 241 American Society of Anesthesiologists (ASA) score, 333
hybrid laparoscopic-robotic technique, 241 Anderson, C., 105
indications, 241 Anthone, G.J., 121
laparoscopic, 241 Antoniou, S.A., 191
rectal cancer, 241 Anvari, M., 485–495
robotic approach APR. See Abdominoperineal resection (APR)
clinical outcomes, 246–247 Archytas, 4
extralevator abdominoperineal resection, 245, 246 Aristotle, 4
perineal procedure and stoma creation, 245–246 Arthrobot, 5
robotic positioning and docking, 242 Asher, K.P., 301
robotic setup and instrument selection, 242, 244 Asimov, I., 3, 5
sigmoid colon and ligation, 242–243 4A syndrome, 55
total mesorectal excision, 244 Atallah, S., 261–266
trocar placement, 242, 243 Atraumatic graspers, 243
Abdul-Muhsin, H., 3–8 Ayloo, S., 122, 131
Achalasia
clinical findings, 55–56
laparoscopic Heller myotomy, 63 B
preoperative evaluation Baek, J.H., 221, 223
ambulatory pH monitoring, 56 Bagshahi, H., 17–21, 113–119
barium swallow, 56 Baik, S.H., 221, 223, 239
esophageal manometry, 56 Banerji, N., 33–54
surgery indications, 57 Bariatric surgery
upper endoscopy, 56 BPD/DS operation (see Biliopancreatic diversion
surgical technique with duodenal switch (BPD/DS) operation)
Dor fundoplication, 61–62 Roux-en-Y gastric bypass (see Roux-en-Y gastric
esophagus lower third dissection, 60 bypass (RYGBP))
Heller myotomy (see Robotic-assisted Heller sleeve gastrectomy (see Sleeve gastrectomy (SG))
myotomy) Bartlett, D.L., 161–170
patient position, 58 Bejarano-Pineda, L., 313–323
pearls and pitfalls, 64 Berber, E., 282, 293–302
perioperative considerations, 57 Bianchi, P.P., 221, 223, 239
short gastric vessels division, 60, 61 Biliopancreatic diversion with duodenal switch
trocar placement, 58–60 (BPD/DS) operation
ACROBOT, 5 advantages, 139
Adrenalectomy. See Robotic adrenalectomy (RA) clinical outcomes, 140
Agcaoglu, O., 294 indications, 139
Agile transluminal endoscopic robot, 490 laparoscopic techniques, 133–134
Alasari, S., 249–258 limitation, 139–140
Albert, M., 261–266 patient positioning, 134

K.C. Kim (ed.), Robotics in General Surgery, DOI 10.1007/978-1-4614-8739-5, 499

© Springer Science+Business Media New York 2014
500 Index

Biliopancreatic diversion with duodenal switch robotic-assisted microsurgical vasoepididymostomy

(BPD/DS) operation (cont.) clinical outcomes, 372
robot-assisted technique epididymal adventitia approximation, 370, 375
cholecystectomy, 136 epididymal tubule incision, 370, 374
distal stomach, 136 scrotal incision, 370
endoscopic leak check, 138–139 robotic-assisted targeted microsurgical denervation
greater curvature mobilization, 136, 137 of the spermatic cord
Nathanson liver retractor, 136 clinical outcomes, 380
operating room layout, 137 instrumentation, 378
patient positioning, 134–135 residual nerve fiber hydrodissection, 379–380
proximal alimentary limb anastomosis, 138 robot positioning, 378
side-to-side ileoileostomy, 135 secured axoguard, 380
sleeve gastrectomy, 136, 137 subinguinal incision, 377
trocar placement, 134, 135 testicular artery confirmation, 379
Bowersox, J., 7 robotic-assisted vasovasostomy
Boyle, 6 advantages, 365
Brahmbhatt, J.V., 365–380 anterior luminal anastomosis, 368, 372
Brunaud, L., 282, 294, 299 clinical outcomes, 372
Bryant, A.S., 85–91 midline skin incision, 367, 370
Bucher, P., 249–250 posterior luminal anastomosis, 367, 371
Buchs, N.C., 463 posterior muscular anastomosis, 367, 371
Byrne, 433 skin and vas under towel clip, 367, 370
symptoms, 365
two-hit theory, 365, 366
C Wallerian degeneration, 366
Capek, J., 3 Chung, W., 269–290
Capek, K., 3 Clark, G.W., 113
Caruso, S., 106 Collis gastroplasty procedure
Casciola, L., 307–312 cardia wedge resection, 43, 44
Ceccarelli, G., 307–312 Echelon stapler, 43
Cerfolio, R.J., 85–91 46-50 fr. dilator placement, 43, 44
Choi, G.S., 175–186 fundoplication finishing, 43, 46
Cholangiography neo-esophagus narrowing prevention, 43, 44
indocyanine green (ICG) fluorescence patient BMI, 42
advantages, 463, 465–466 segmental gastric resection, 43, 45
bile duct injury, 462 3 stitch Nissen fundoplication, 43, 46
Calot’s dissection, 463–465 wedge resection, 43, 45
contraindications, 467 Colon and rectum
limitations, 466–467 abdominoperineal resection (see Abdominoperineal
Luschka duct, 463, 465–467 resection (APR))
patient preparation, 462–463 colectomy
SSRC, 462, 463 left (see Robotic left colectomy)
single-site™ cholecystectomy, 444 right (see Robotic right colectomy)
Choledochal cyst low anterior resection (see Low anterior resection
imaging studies, 347 (LAR))
prevelance, 347 robotic transanal surgery (see Robotic transanal
robotic dissection, 348, 349 surgery (RTS))
Rouxen-Y choledochojejunostomy, 349 single-port colorectal surgery (see Robotic single-port
extracorporeal roux limb construction, 347 colorectal surgery)
intracorporeal roux limb construction, 347–348 Colonic tattooing, 474–475
port locations, 348 Compact endoscopic robot ViKY, 490
Chronic orchialgia (CO) Completely portal robotic lobectomy-4 (CPRL-4) method
preoperative preparation, 367 Cadiere grasper, 87–88
prevalence after repair, 365–366 camera port placement, 86
robotic-assisted microsurgical varicocelectomy features, 87, 88
clinical outcomes, 373, 376 metal reusable trocar, 87
dilated vein isolation and ligation, 373, 376 paravertebral block, 87
robot positioning, 372–373 plastic disposable trocar, 87
subinguinal incision, 372 ruler marking, patient skin, 86, 87
vein mapper assistance, 373, 376 treatment outcomes, 90
Index 501

Congenital diaphragmatic hernia repair da Vinci surgical system, 433

Bochdalek CDH repair adjunctive mediastinotomy, 9
abdominal approach, 353 anthropomorphic principle, 10
defect closure, 354, 356 commercial models, 10
mobilizing tissue, 354, 355 components, 11
posterolateral rim, 353 design, 9
protective barrier, 353, 355 dual-console mode, 10
thoracoscopy, 353 duodenal atresia (see Duodenal atresia (DA))
trocar placement, 353–354 EndoWrist instruments, 10
Morgagni CDH repair, 347, 354, 356 esophageal atresia (see Esophageal atresia with
Ctesibius, 4 tracheoesophageal fistula)
Cubano, M., 481 features, 11
Curet, M.J., 9–15, 431–434 hernia repair (see Ventral and incisional hernia repair)
Curriculum development, residents and fellows mechanical components, 10
da Vinci residency/fellowship training program (see da minimally invasive surgery, 9
Vinci residency/fellowship training program) patient cart, 13–14
evaluation and feedback, 403 set up challenges
flowchart, 412 consistent communication pathways, 418–419
goals and objectives, 386 elements, 415–416
needs assessment, 385–386 instrumentation, 420
outcome measures, 402–403, 409–411 leadership structure, 416–418
Cusatti, D., 145 operating room tasks (see Operating room tasks)
Cyberknife system, 491 personnel, 420
room setup, 420
standardization, 419–420
D superior vision system, 10
D’Annibale, A., 105, 185, 198, 200 surgical console, 11–13
Dapri, G., 26 vision cart, 14–15
da Vinci, L., 4, 10 Delaitre, B., 307
da Vinci residency/fellowship training program Delaney, C.P., 185
components and goals, 388 deSouza, A.L., 185, 200
curriculum templates, 389 Deutsch, G.B., 185
didactic educational methods Devol, G., 5
FRS curriculum, 393 Diamantis, T., 122, 131
Lehigh Valley online modules, 390–393 Diana, M., 479–483
mentored learning time, 393 Dib, M.J., 145–150
model-specific modules, 390 Direct image-guided robots
trainees learn safety measure, 392 Cyberknife system, 491
FRS program, 387 image-guided automated robot (IGAR), 493
skills educational methods innomotion robotic arm, 492
Chamberlain group item, 393–395 MrBot, 492
inanimate models, 393, 394 MRI-compatible robots, 492–493
modified Delphi process, 398–399 RIO (Robotic Arm Interactive Orthopedic System), 492
proficiency score, 395–396 ROBITOM II, 492–493
robotic skills kit, 396, 398 SpineAssist, 491, 492
UTSW data w/prelim construct data, 397–398 Distal pancreatectomy (DP)
(see also University of Texas Southwestern laparoscopic, 151
(UTSW) data) robotic approach
steps involved in, 387 advantages, 151
team training, 402 drawback, 151
technical skills lateral to medial approach, 158–159
deconstructed task list, 390, 392 medial to lateral approach, 157–159
FRS curriculum, 389–390 outcomes, 159–160
Lehigh Valley Health Network curriculum, 390 pancreas and spleen mobilization, 154–155
virtual reality skills training pancreatic and vascular transection, 155–158
da Vinci Si skills simulator backpack, 407 pancreatic neck and body exposure, 153
MIMIC console, 399, 405–407 patient and port positioning, 152
RoSS HOST robotic simulator system, pneumoperitoneum technique, 152
401–402, 407 specimen extraction, 159
SEP robotic simulator system, 401, 405, 408 splenic preservation, 156–157
502 Index

Distal pancreatectomy (DP) (cont.) patient preparation, 462–463

stomach tagging, 153–154 SSRC, 462, 463
trocar placement, 152–153 Foley, C.S., 286
Dulan, G., 390, 403 Four-arm robotic-assisted (RAL-4) lobectomy, 90
Dunkin, B., 385–412 Fundoplication
Dunn, D.H., 31, 33–54 achalasia, 61–62
Duodenal atresia (DA) collis gastroplasty, 43, 46
da Vinci robotics pediatrics
advantages, 349 camera location, 343
duodenal anastomosis, 349, 350 interrupted nonabsorbable sutures, 344
instrument ports, 349–350 learning curve, 343
proximal and distal duodenum, 350 patch defect closure, 344
reverse Trendelenburg position, 349 trocar locations, 343
laparoscopic instrumentation, 348–349 types, 342
Dylewski, M.R., 25–32, 55–64, 69–85, 90

G
E Gagner, M., 121, 145, 293
Elli, E.F., 131 Galvani, C.A., 55–64
Ellis, S., 6 Ganz, R., 33–54
Endocrine Gasless transaxillary approach
adrenalectomy (see Robotic adrenalectomy (RA)) radical neck dissection (see Radical neck
thyroidectomy (see Thyroidectomy) dissection)
Engelberger, J., 5 robotic thyroidectomy (see Thyroidectomy)
Eom, B.W., 107 Gastrectomy
Esophageal atresia with tracheoesophageal fistula clinical results, 104
open surgery, 356 complications, 103–104
robotic da Vinci system, 358 indications, 95–96
azygos vein identification, 358 oncologic outcomes, 108
bronchoscopy, 358 operative strategy
fistula dissection, 358–359 gastric decompression, 97
guidelines, 357 instruments insertion, abdominal cavity, 97
instruments, 356–357 liver retraction, 97
NG tube passage, 359, 360 operating room configuration, 96
trocar placement, 35, 358 patient positioning, 96, 97
Esophagectomy. See Robotic assisted minimally invasive pertinent anatomy, 96
esophagectomy port placement, 96–97
Esophagogastroduodenoscopy (EGD), 34 resection extent, intraoperative determination, 97
Esophagus robot docking, 97
achalasia (see Achalasia) operative time and costs, 108
esophagectomy (see Robotic assisted minimally postoperative management, 103
invasive esophagectomy) preoperative work-up, 96
gastroesophageal reflux disease (see robotic distal subtotal gastrectomy and D2 LN
Gastroesophageal reflux disease (GERD)) dissection
Extralevator abdominoperineal resection (EAPR), 247. D2 lymphadenectomy procedure, 101–102
See also Abdominoperineal resection (APR) gastrointestinal reconstruction, 102–103
hepatoduodenal ligament and suprapancreatic
dissection, 99–101
F left gastric artery and splenic vessels retrieval, 101
Fagin, R., 415–429 left side dissection, 98
Fischer, S., 6 lesser curvature dissection, 101
Fleming, C., 365 proximal resection, 101
Fluorescent cholangiography right side dissection and duodenal transection,
advantages, 463, 465–466 98–99
bile duct injury, 462 spleen-preserving total gastrectomy, 102
Calot’s dissection, 463–465 treatment outcomes, 104–108
contraindications, 467 Gastroesophageal reflux disease (GERD)
limitations, 466–467 at Abbott Northwestern Hospital
Luschka duct, 463, 465–467 anti-reflux procedures, 51
Index 503

da Vinci computer-enhanced robotic surgical robotic-assisted technique

system, 47, 49, 50 left hepatectomy (see Left hepatectomy)
intra-operative complications, 51 left lateral sectionectomy, 168, 169
operative time, 50 nonanatomic resection, 169
room time, 50 open surgery, 162
surgical outcomes, 50, 51 patient positioning and room setup, 162, 163
symptomatic relief, 52 right hepatectomy (see Right hepatectomy)
medical management, 33 Hepatobiliary/pancreas
operative management, 33 distal pancreatectomy (see Distal pancreatectomy (DP))
pre-operative diagnostic evaluations hepatic resection (see Hepatic resection)
EGD, 34 Whipple procedure (see Pancreatoduodenectomy (PD))
manometry, 35–37 Hess, D.S., 121, 133
pH-monitoring test, 34–35 Hess, D.W., 133
primary care physicians, 34 History of robotic surgery
self-medication, 34 ACROBOT, 5
robotic assisted operative procedure in ancient history, 4–5
anesthesia team, 36 Arthrobot, 5
anterior vagus nerve dissection, 38, 39 master-slave manipulator, 5
camera port placement, 37 NeuroMate, 5
Collis gastroplasty procedure (see Collis PROBOT, 6
gastroplasty procedure) PUMA, 5, 6
docking time, 36 ROBODOC, 5
Dor (anterior) fundoplication, 40, 42, 43 SARP, 6
fundoplication preparation, 40, 41 SPUD, 6
fundus mobilisation, 40, 41 telemanipulators, 5
gastroesophageal fat pad removal, 38, 39 URobot, 6
harmonic scalpel, 38 visceral surgery, 6–7
hiatus, primary closure, 38, 39 ZEUS robotic system, 7–8
liver retractor port, 38 3-Hole esophagectomy, 25
Nathanson retractor, 38 Horgan, S., 26, 62, 63, 293
360º Nissen fundoplication, 40, 41 Huang, K.H., 108
onlay Gore-Tex graft, 38, 40 Hubens, G., 293
operative time, 36, 37 Hung, A.J., 396, 404
pre-operative time, 36 Hur, H., 105
re-operative robotic procedures, 44, 46–49 Hutteman, M., 471
robotic general surgeon, 37 Hybrid low anterior resection
robotic operation initiation, 38 clinical and pathological outcomes, 231, 238–239
room time, 36 conventional laparoscopic technique, 228
Toupet procedure, 40, 42 laparoscopic-assisted abdominal dissection, 229–231
Genevieve, D., 393 non-pelvic portions, 227
Giulianotti, P.C., 145, 151, 160, 170, 294, 300 patient positioning, 228
Goertz, R., 5 port placement, 229
Goh, A.C., 403 rectal cancer, 227
Gonzalez, A.M., 121–132 robotic-assisted pelvic dissection
Grams, J., 198 anterior rectal dissection, 235, 236
Green, P., 6 avascular presacral plane, 234
Gudeloglu, A., 365–380 bowel continuity, 235, 237
Gutt, C.N., 26 Denonvilliers' fascia, 235, 236
eagle sign, 233, 234
lateral and anterior dissection, 235
H left lateral rectal dissection, 235, 236
Haas, E.M., 227–239 meticulous dissection, 232
Hagen, M.E., 9–15, 431–434 Pfannenstiel incision, 235, 237
Hand-assisted laparoscopy colectomy (HALC), 251 presacral plane dissection, 234
Hellan, M., 198 robotic rectal dissection, 235, 237
Henri-Louis, 4 sacral promontory and retroperitoneal plane,
Hepatic resection 232, 233
history, 161–162 ultralow robotic rectal resection, 235, 238
indications, 162 robotic docking, 231
patient outcomes, 169–170 Hyung, W.J., 95–109, 457–460
504 Index

I Kasai portoenterostomy
Image-guided automated robot (IGAR), 493 biliary drainage, 345
Indocyanine green (ICG) fluorescence camera size, 346
absorption ability, 461 patient positioning, 346
colonic tattooing, 474–475 portal plate dissection, 346, 347
colorectal surgery, 467 portal vein bifurcation, 346, 347
da Vinci 3DHD robotic system, 461 port locations, 346
dosage, 461 Roux-en-Y jejunojejunostomy, 346–347
fluorescent cholangiography Kemp, K., 33–54
advantages, 463, 465–466 Kendrick, M.L., 145
bile duct injury, 462 Kent, T., 145–150
Calot’s dissection, 463–465 Kernstine, K.H., 26, 31
contraindications, 467 Kim, D.J., 26, 31
limitations, 466–467 Kim, J.Y., 224
Luschka duct, 463, 465–467 Kim, M.C., 106, 108
patient preparation, 462–463 Kim, S.H., 213–225
SSRC, 462, 463 Kimura, K., 350
intestinal stump perfusion KiNematics of Endoluminal Surgery (ARAKNES)
advantages, 469–470 program, 258
bowel transection, 468, 469 King Mu, 4
contraindications, 470 King-shu Tse, 4
imaging techniques, 467 Kiriakopoulos, A., 284, 287
limitation, 470 Kuang, W., 365
rectal transection, 468, 470 Kuchenbecker, K.J., 486
side-to-side anastomosis, 468–470 Kudszus, S., 469
subjective impression of surgeon, 467 Kuppersmith, R.B., 283
transection line assessment, 468 Kwak, J.M., 213–225
lymph node mapping, 470
advantages, 473–474
colorectal resection, 471 L
contraindications, 474 Ladd, W., 344
endoscopic injection, 471 Ladd’s procedure, malrotation
limitations, 474 appendectomy, 345
periaortic lymph nodes, 471–473 bowel cleaning, 344–345
subserosal ICG injection, 472–474 Ladd's bands, 344, 345
surgical oncology, 471 mesentery widening, 345
near-infrared (NIR) fluorescence explanation, 462 port locations, 345
Insertable Robotic Effectors Platform (IREP), 494 Landary, R.B., 286
Ishikawa, N., 283 Landry, C.S., 282
Ishizawa, T., 463 Lang, B.H., 283, 286
Isogaki, J., 105 Langenbuch, D., 161
Ito, C., 113 Lanier, J., 6
Ivor Lewis trans-thoracic esophagectomy (TTE) Laparo-endoscopic single-site surgery (LESS),
procedure, 25 489–490, 495
Laparoscopic splenectomy (LS), 307–308
Lateral transabdominal (LT) adrenalectomy
J hybrid vs. totally robotic approach, 296
Jacobs, M., 187 operation steps, 294, 296, 297
Jacquard, J., 4 positioning, 293, 294
Jafari, M.D., 241–247 robot positioning and docking, 294, 295
Jaquet-Droz, P., 4 trocar placement, 294, 295
Johnson, E.M., 33–54 Lazzaro, R., 69–84
Joseph, R.A., 253 Lee, H.H., 105
Julien, J., 301 Lee, J., 269–290
Lee, K.H., 241–247
Lee, S., 133–140
K Left hepatectomy
Kandil, E.H., 283 docking, 168
Kang, S.W., 282–284, 287 gastrohepatic ligament, 168
Kaouk, J.H., 250, 252 laparoscopic ultrasound, 168
Karabulut, K., 294 parenchyma, 168–169
Index 505

portal dissection, 168 compact endoscopic robot ViKY, 490

port placement, 167, 168 da Vinci surgical system, 485, 486
round and falciform ligaments, 168 DLR MIRO system, 488
Left lateral sectionectomy, 168, 169 Laparo-Endoscopic Single-Site Surgery, 489–490
Left thoracotomy/left thoracoabdominal approach, 25 NeuroArm, 488
Leon, S., 33–54 Raven II, 488, 489
Lewis, C.M., 282 Robin Heart 2 robot, 488–489
Lim, M.S., 252, 253 sofie, 488
Liu, F.L., 105 Titan Medical, 486, 487
Liver surgery. See Hepatic resection McGreevy, M., 6
Longmire, Jr.W.P., 145 McKenna, R.J., 79, 81
Low anterior resection (LAR) McKeown esophagectomy (MKE), 25
clinical outcomes, 220–222 Mediastinal mass
da Vincir robotic system, 213 da Vinci system
functional outcomes, 223–224 ganglioneuroma resection, 350, 351
hybrid (see Hybrid low anterior resection) germ cell tumor, 352
hybrid technique, 213 neuroblastoma, 351
IMA, 219 serum markers, 351
indications and contraindications, 222 teratoma, 351, 352
oncological outcomes, 223, 224 trocar locations and robot cart positioning,
patient positioning 352, 353
initial exposure, 215 location, 350
modified lithotomy position, 213 Meehan, J.J., 339–361
pelvic TME, 217–219 Melfi, F., 89, 90
rectal division and anastomosis, 218–220 Melvin, W.S., 62, 63, 145
RLQ and RUQ ports, 215 Memnon, 4
robot positioning and docking, 215, 216 Mercan, S., 293
splenic flexure mobilization, 216–217 Mimic technology
Trendelenburg position, 214 advanced arm manipulation, 399, 406
trocar placement, 214–215 console, 399, 405
two right trocars, 215 MScore display, 407
surgical procedure for, 213 needle driving, 399, 406
total mesorectal excision, 213 Min, B.S., 249–258
Luca, F., 185 Miniature robots
Lujan, H.J., 187–200 Center for Advanced Surgical Technology
Lymph node mapping, 470 (CAST), 494
advantages, 473–474 Insertable Robotic Effectors Platform (IREP), 494
colorectal resection, 471 Magnetic anchoring and guidance systems
contraindications, 474 (MAGS), 494
endoscopic injection, 471 micro-electro-mechanical systems (MEMS), 494–495
limitations, 474 nano-robots, 495
periaortic lymph nodes, 471–473 SPRINT, 494
subserosal ICG injection, 472–474 video capsule endoscopy, 493–494
surgical oncology, 471 Wire-driven HeartLander model, 494
Lyons, C., 390 Minimally invasive endoscopic surgery (MIES)
technique, 497–498
Minnich, D.J., 90
M Modified radical neck dissection (MRND). See Radical
Mack, M.J., 69 neck dissection
Magnetic anchoring and guidance systems (MAGS), 494 Morino, M., 298
Makino, T., 251 Moser, A.J., 145–150
Marceau, P., 133 Myasthenia gravis (MG)
Marescaux, J., 7, 479–483 clinical features, 354–355
Martino, M., 389 diagnosis, 355
Mason, E.E., 113 robotic thymectomy
Massasati, S., 283 dual lumen endotracheal tube, 355
Master–Slave robots innominate vein dissection, 356, 358
agile transluminal endoscopic robot, 490 patient position, 355–357
ALF-X Telelap robot, 486, 487 phrenic nerve identification, 356, 358
Amadeus by Titan Medical Inc., 486 trocar placement, 356, 357
body-global positioning system, 490–491 steroids, 355
506 Index

N Patriti, A., 105, 221, 223, 224, 307–312

Natural orifice transluminal endoscopic surgery Pediatric robotic surgery
(NOTES), 249, 437, 489–490, 494, 495 CHD repair (see Congenital diaphragmatic hernia
Navarra, G., 437 repair)
NeuroArm, 488 choledochal cyst (see Choledochal cyst)
Ninan, M., 90 2D system, 341, 342
Nordenstrom, E., 294 3D system, 341
fundoplication (see Fundoplication)
future aspects, 359–361
O instruments, 342
Oberholzer, J., 313–323 Kasai portoenterostomy, 345–347
Obias, V., 252 Ladd’s procedure, 344–345
Onaitis, M.W., 79 mediastinal mass (see Mediastinal mass)
Operating room tasks myasthenia gravis (see Myasthenia gravis (MG))
back table setup, 422, 423 robot positioning, 339–340
continuous improvement cycle 4th arm, 342
gauge measurements, 428 trocar depth, 340–341
improved operations, 429 trocar location, 340
operation and activity standardization, 426 Pedraza, R., 227–239
requirements and productivity innovation, 428 Pelosi, M.A., 249
standardized operation measurement, 427 Pernazza, G., 106
docking procedure, 423, 426 Perrisat, J., 7
patient considerations, 422, 424 Pfleiderer, S.O., 492
room cleanup, 424–425, 428 Piazza, L., 293
surgeon needs, 422–423, 425 Pigazzi, A., 223, 224, 227, 241–247
surgeon off console, 424, 427 Plasencia, G., 187–200
Ortiz-Ortiz, C.M., 203–212 Podolsky, E.R., 302
Ostrowitz, M.B., 250, 252, 253 Pomp, A., 145
Posterior retroperitoneal (PR) adrenalectomy
ergonomic manipulation, 298
P hybrid vs. totally robotic approach, 297
Palanivelu, C., 145 operation steps, 297, 299, 300
Pancreatoduodenectomy (PD) patient positioning, 297, 298
laparoscopic, 145 robot positioning and docking, 297, 299
robotic-assisted trocar placement, 297, 298
antecolic, two-layer duodenojejunostomy, 148, 149 PROBOT, 6
bile duct division, 147 Pugliese, R., 107
clinical outcomes, 149 Puntambekar, S.P., 26
docking, 147
duct-to-mucosa pancreaticojejunostomy, 147–148
duodenum division, 147 R
gastrocolic omentum division, 146 RA. See Robotic adrenalectomy (RA)
operating room setup, 147 Rabaza, J., 121–132
pancreatic neck division, 147 Radical neck dissection
portal dissection, 147 anatomical neck LN dissection, 277
portal vein mobilization, 147 console stage, 280–281
ports position, 146 patient positioning, 278–280
retroperitoneal margin division, 147 postoperative outcomes, 289
right colon and pancreatic head mobilization, 146 PTC, 277
single-layer end-to-side hepaticojejunostomy, 148 robot positioning and docking, 280
surgical drain placement, 149 Raman, S.R., 294
selection criteria, 145–146 RAVE. See Robotic-assisted microsurgical
technical aspects, 145 vasoepididymostomy (RAVE)
Papillary thyroid cancer (PTC), 277 Raven II, 488, 489
Parekattil, S.J., 365–380 RAVV. See Robotic-assisted vasovasostomy (RAVV)
Park, J.S., 185, 221, 223, 239 RAVx. See Robotic-assisted microsurgical
Parker, A., 432 varicocelectomy (RAVx)
Parks, B.J., 89, 90 Rawlings, A.L., 185, 188, 200
Parra-Davila, E., 203–212 Remote surgery and robotics
Patel, V., 3–8 augmented reality (AR) guidance, 482–483
Index 507

data transmission speed, 481 positioning, 293, 294

FDA-approved surgical robots, 480–481 robot positioning and docking, 294, 295
PUMA 200 industrial robot, 480 trocar placement, 294, 295
ROBODOC, 480 perioperative outcomes, 300–301
telementoring posterior retroperitoneal (PR)
benefits and efficacy, 481 ergonomic manipulation, 298
infancy, 483 hybrid vs. totally robotic approach, 297
internet-based communication speed operation steps, 297, 299, 300
and quality, 482 patient positioning, 297, 298
intravascular robot-guided catheter, 483 robot positioning and docking, 297, 299
network latency, 481 trocar placement, 297, 298
zero-gravity surgery, 481 pregnancy, 302
ultrasound-guided PROBOT, 480 randomized prospective trial, 298
virtual reality (VR) patient models, 482 robot vs. standard laparoscopy, 301
Ren, C.J., 133 underwent laparoscopic adrenalectomy, 301
Right donor nephrectomy, 318–319 ZEUS AESOP system, 293
Right hepatectomy Robotic-assisted Heller myotomy
abdominal cavity, 162 gastroesophageal junction (GEJ), 12 o'clock position,
cholecystectomy, 164 61
dock, 164 minimally invasive treatment option, 63
falciform ligament, 162, 163 outcome evaluation, 62, 63
hepatic duct division, 164, 166 proximal extension of myotomy, 61
hepatic flexure, 163 three-dimensional vision support, 63
IVC dissection., 164, 167 vagus nerve, anterior branch identification,
laparoscopic ultrasound, 164 60, 61
ligamentous attachments, 162 Robotic-assisted hepatectomy. See Hepatic resection
portal dissection, 164 Robotic assisted laparoscopic surgery (RALS),
portal vein ligation, 164, 165 28–30
port placement, 162, 163 Robotic-assisted microsurgical varicocelectomy
right hepatic artery dissection and ligation, 164, 165 (RAVx)
triangular ligament., 163–164 clinical outcomes, 373, 376
Right robotic assisted thoracoscopic surgery (RRATS), dilated vein isolation and ligation, 373, 376
27–28 robot positioning, 372–373
RMDSC. See Robotic-assisted targeted microsurgical subinguinal incision, 372
denervation of the spermatic cord (RMDSC) vein mapper assistance, 373, 376
Robin Heart 2 robot, 488–489 Robotic-assisted microsurgical vasoepididymostomy
ROBODOC, 5 (RAVE)
Robot-assisted splenectomy clinical outcomes, 372
Jackson-Pratt drain, 312 epididymal adventitia approximation, 370, 375
laparoscopic operating room, 308 epididymal tubule incision, 370, 374
laparoscopic splenectomy (LS), 307–308 scrotal incision, 370
necessary laparoscopic and robotic instruments, 308 Robotic assisted minimally invasive esophagectomy
procedure anesthesia, 26–27
anterior approach, 308–309 early complications
patient positioning and robot docking, 308, 309 anastomotic leaks, 30
pedicle dissection, 309–311 chylothorax, 30
peritoneal cavity inspection, 308 delayed gastric emptying, 30–31
port placement, 308, 309 gastric tip necrosis, 30
short gastric vessels, 309, 310 vocal cord paralysis, 30
specimen extraction, 311–312 Ivor Lewis TTE procedure, 25
spleen mobilization, 311, 312 late complications, 31
Robotic adrenalectomy (RA) left cervicotomy, 28
AESOP, 293 left thoracotomy/thoracoabdominal approach, 25
BMI, 300 McKeown esophagectomy, 25
cortical-sparing partial, 301 postoperative management, 30
indications, 293 published reports, 26
laparoscopic techniques, 293, 299 RALS, 28–30
lateral transabdominal (LT) RRATS, 27–28
hybrid vs. totally robotic approach, 296 transhiatal esophagectomy, 25
operation steps, 294, 296, 297 treatment outcomes, 31–32
508 Index

Robotic-assisted targeted microsurgical denervation Robotic pulmonary resection

of the spermatic cord (RMDSC) four-arm technique
clinical outcomes, 380 CPRL-4 (see Completely portal robotic
instrumentation, 378 lobectomy-4 (CPRL-4))
residual nerve fiber hydrodissection, 379–380 disadvantage, 74
robot positioning, 378 patient positioning, 86
secured axoguard, 380 RAL-4, 90
subinguinal incision, 377 robotic positioning and docking, 86, 87
testicular artery confirmation, 379 robotic right upper lobectomy, 88–89
Robotic-assisted vasovasostomy (RAVV) utility incision, 85–86
advantages, 365 three-arm technique
anterior luminal anastomosis, 368, 372 camera selection, 81–82
clinical outcomes, 372 camera trocar positioning, 72
midline skin incision, 367, 370 clinical results, 76, 78
posterior luminal anastomosis, 367, 371 complications, 79–81
posterior muscular anastomosis, 367, 371 fiberoptic bronchoscopy, 70
skin and vas under towel clip, 367, 370 general anesthesia, 70
Robotic kidney transplantation haptics feedback and retraction, 82
conventional laparoscopy, 320 hemodynamic side effects, 72–73
donor selection and preoperative evaluation, 313–314 hilar structures dissection and division, 74–75
ESRD, 320 learning curve, 76, 78, 79
living donor nephrectomy, 313 lymph node dissection, 82
procedures, 320 mediastinal lymph node dissection, 74–75
recipient operation, 319 morbidity and mortality, 70
surgical procedure patient characteristics, 76, 77
adrenal gland, 316 patient positioning, lateral decubitus position, 70
field inspection and closure, 317–318 port placement, 70–73
graft backbench preparation, 318 specimen extraction, 76–78
hilar vessels and kidney graft extraction, 317, 318 vascular isolation, 81
incision and port placement, 314–315 Robotic right colectomy
mobilization, left colon, 315 benign conditions, 188
patient preparation and positioning, 314 da Vincir surgical robot, 187
renal artery identification, 317 four-arm technique
renal vein identification, 316 colon and terminal ileum, 178, 179
ureter and posterior mobilization, 316 colon mobilization, 179
ureter identification, 315–316 exploration and wound closure, 183–184
surgical technique ileocolic anastomosis and specimen extraction, 179
backbench preparation, graft, 320 indications and contraindications, 175
graft implantation and reperfusion, 321, 322 intracorporeal anastomosis, 180–183
patient positioning and port placement, 320 minimally invasive techniques, 175
ureteroneocystostomy, 322, 323 NOSE procedure, 183, 184
vascular exposure, 321 patient cart docking, 177
Robotic left colectomy patient position, 176
clinical outcomes, 211–212 port placement, 176–177
da Vinci system, 203 postoperative treatment, 184
operation room configuration, 204, 205 preoperative assessment, 176
patient positioning, 204 surgical outcomes, 184–186
patient preparation, 204 vascular control and lymphadenectomy, 178–181
patient selection, 203–204 laparoscopic colectomy, 187
robotic arms malignant diseases, 188
da Vinci vessel sealer, 208 oncologic outcome
double-docking technique, 208, 210, 211 conversion rate, 191, 200
IMA, 205 dissection and anastomosis, 191, 200
lateral dissection, 208 extracorporeal technique, 198
medial dissection, 205 extraction site excision, 198
periaortic hypogastric nerve plexus, 205 fourth robotic arm, 192
splenic flexure, 205, 208 intracorporeal and extracorporeal anastomosis,
trocar placement 198–199
double-docking technique, 204, 208–209 intraoperative complications, 191
hybrid technique, 204, 207 laparoscopy, 197–198
single-docking technique, 204, 206 operative times, 191, 192, 200, 201
Index 509

skin-to-skin, 197 Alexis wound retractor, 255

total operating room times, 192, 201 anastomosis, 257
three-arm technique articulating endostapler, 257
bipolar fenestrated grasper, 188 homemade glove port, 255
cecum and ileocecal junction, 188 IMA, 256
colotomy and ileotomy, 189, 192 IMV, 256
endoscopic linear stapler, 189, 193 medial-to-lateral dissection, 256
extracorporeal anastomosis, 190 operating theater setting, 255
extraction incision site, 191, 194 patient position, 255
hot shears (R1), 188 patient selection, 254
ileal mesentery, 188 patient-side assistant., 257
intracorporeal anastomosis, 188, 190, 191, 194, peritoneum, 256
195, 199 pneumoperitoneum, 256
Keith needle, 189, 192 robotic arms, 256
lithotomy position, 190 splenic flexure, 256
medial-to-lateral dissection technique, 188, 190, trocars, 255–256
195, 196 terminology, 250
mesocolic mobilization, 188 Robotic Single-Site™ right colectomy
middle colic, 190, 194 advantages, 453–454
12 mm left lateral port, 195 clinical outcome, 451–452
pneumoperitoneum, 188, 189 future aspects, 455
right lower quadrant, 190, 195 limitation, 454–455
robotic-sewn anastomosis, 191 Pfannenstiel incision, 449
robotic suturing techniques, 190, 193 procedure
room setup, 188, 189 bowel perfusion, 450–451, 453, 454
specimen extraction, 190, 198 ileocolic vessels clipped and cut, 449, 452
subcuticular fashion, 191, 194 last ileocolic loop, 449, 450
terminal ileum and transverse colon stump, middle colic vessel dissection, 449, 453
189, 191 patient preparation, 449, 450
transect terminal ileum, 190, 196 peritoneum dissection, 449, 451
transect transverse colon, 190, 197 side-to-side anastomosis, 450–451, 454, 455
trocar placement, 188–190 specimen extraction, 449
vascular pedicle, 188 Robotic surgery
Robotic right upper lobectomy, 88–89 clinical advantages, 19
Robotic single-port colorectal surgery clinical limitations, 20
access ports for, 250–251 mechanical advantage, 17–18
advantages of, 251 robotic simulation system, 19
arm collision, 253 technical limitations, 19
benign and malignant procedures, 252 telementoring, 18
chopstick arrangement, 253 telerobotic procedure, 18
coaxial arrangement, 253 Robotic transanal surgery (RTS)
conventional laparoscopy, 253 operating room
da Vinci S robot, 253 Allen stirrups, 262
da Vinci S system, 252 diaphragmatic excursion, 262
future innovation for, 258 downward-angled lens, 262
GelPort, 252, 253 GelPOINT path cannulas, 262–263
history, 249–250 hook cautery and Maryland grasper, 263–265
human wrist-like motion, 251, 252 laparoscopic equipment, 262
laparoscopy, 251 parenteral antibiotics, 262
learning curve, 258 rectal lumen, 264
operative outcome, 252 robotic cart, 263
patient outcomes, 257 robotic intraluminal suturing, 265
pyeloplasty and nephrectomy, 252 smoke evacuation, 263, 264
radical prostatectomy, 252 thermal energy, 263
randomized controlled trials, 251 V-Loc stitch, 265
robotic single-site platform, 254 patient selection, 261–262
short-term outcome, 252, 253 preoperative workup, 262
SILS port, 252, 253 Rosen, J., 6
skin incision, 252 Rosser, J.C., 433
surgical technique RoSS HOST robotic simulator system, 401–402, 407
510 Index

Roux-en-Y gastric bypass (RYGBP) limitation, 448

advantages, 117 liver bed detachment, 443–444, 447
future aspects, 118–119 patient chart set-up, 441
gastric pouch creation, 115 peritoneum insertion, 443, 445
gastrojejunal anastomosis creation, 116 port, clamping and marking, 442, 444
jejunojejunostomy creation, 116 scope, retracted and repositioned, 442, 445
limitations, 117–118 specimen extraction, 444, 447
patient positioning, 114 unfolded clamp technique, 442, 443
trocar placement Skylizard, L., 90
internal liver retractor, 115, 116 Sleeve gastrectomy (SG)
Nathanson liver retractor, 115 advantages, 121–122
port placement, 114–115 ASMBS, 121
Ryu, H.R., 282 bougie placement, 127, 128
complete gastric mobilization, 126, 128
complications, 122–123
S fascial site closure, 129
Sabbaghian, M.S., 161–170 fundus and left crus, 124, 127
Saklani, A., 249–258 harmonic scalpel, 124–126
Samamé, J., 55–64 history, 121
Sanchez, B.R., 117 intraoperative endoscopy, 128–129
Sanchez, L.A., 258 limitations, 122
Sarela, A.I., 122 mechanism, 122
Satava, R., 7 neofundus, 124, 127
Sawyer, M., 433 operating room layout, 123
Scheinman, V., 5 outcomes, 130–131
Sebajang, H., 433 patient positioning, 123
Shi, Y., 4 posterior dissection, 126, 128
Singh, J., 252, 253 pylorus location, 124, 125
Single-incision laparoscopic surgery (SILS) short gastric vessels, 124, 126
azimuth angle, 437–438 staple line reinforce, 128, 131
elevation and manipulation angle, 438 trocar placement
fulcrum placement, 437 Nathanson retractor position, 124
instruments and accessories port placement, 123, 124
robotic flexible instruments, 440–441 robot docked overhead, 124, 125
Single-Site™ accessories, 440 Smith, 6
Single-Site™ port, 440, 441 Smith, C., 403
multi single-port access devices, 437 Snyder, B., 117, 327–334
NOTES, 437 Sofie, 488
robotic platform Song, J., 104, 105
GelPort/GelPOINT™, 438–439 Spinoglio, G., 185, 200, 437–455, 461–475
Single-Site™ Platform, 439–440 Splenectomy. See Robot-assisted splenectomy
technological advantages, 438 SPRINT. See Single-Port lapaRoscopy blmaNual robot
triangulation, 437, 438 (SPRINT)
Single-port colorectal surgery. See Robotic single-port SSRC. See Single-Site™ cholecystectomy (SSRC)
colorectal surgery Stein, H., 9–15
Single-Port lapaRoscopy blmaNual robot (SPRINT), Strasberg, S.M., 445
258, 494 Sudan, R., 133–140
Single-site™ cholecystectomy (SSRC) Sutherland, J., 26
advantages
Cadiere forceps, 447
Calot’s triangle, 445–446 T
near-infrared fluorescent vision system, 448 Tae, K., 283, 286, 287
cholangiography, 444 Taskin, H.E., 293–302
clinical outcomes, 448–449 Telemanipulators, 5
contraindications, 448 Telementoring
curved cannulae insertion, 442, 444 dual console da Vinci surgery, 433
cystic duct and artery, 443, 446 future perspective, 434
folded clamp technique, 442, 443 general surgery procedures, 432–433
Hem-o-Lok ML clips, 443, 446 goal of, 431
Index 511

systems and technical requirements, 432 V

telementors, 431 Vaucanson, J., 4
value and limitations, 432 Ventral and incisional hernia repair
Teleproctoring, 433 da Vinci Robotic approach
Thyroidectomy absorbable suture, 331
console stage, 277–279 advantages, 328
docking stage fascial defect closure, 330
single-incision technique, 274–276 hybrid vs. totally robotic approach, 331
two-incision technique, 272–275 intracorporeal suturing, 333
history and development of, 269–270 intracorporeal suturing technique, 332
indications and contraindications, 270–271 vs. laparoscopy, 331–332
limitations and future directions of, limitations, 333
289–290 mesh position, 330, 331
oncologic efficacy and outcome, 285–287 patient positioning, 328, 329
operation time and surgical learning curve, 285 robot positioning and docking, 328–330
patient perception and satisfaction, suirigal outcomes, 333–334
285–289 transabdominal sutures and tackers, 332
patient positioning, 271–274 trocar placement, 328
perioperative outcome, 281–285 incidence, 327
procedure, 271, 272 laparoscopic approach
robot positioning and cannula placement, 272 complications, 327
Tieu, K., 118 postoperative pain, 328
TilePro™ recurrence, 327
application surgical outcomes, 333
cardiac surgery, 458 open technique, 327
general surgery, 458–460 Veronesi, G., 90
urology, 458 Video-assisted thoracoscopic surgery (VATS) lobectomy
data integration tool, 457 technique, 69–70, 80–83, 85
limitation Video capsule endoscopy (VCE), 493–495
data transmission, 458–459 Vilallonga, R., 131
radiologic images manipulation,
459–460
setup and use of, 457–459 W
Titan Medical, 486, 487 Wang, Y., 7
Torriano, G., 4 Waters, J., 160
Total mesorectal excision (TME), 213, 217–219 Weber, P.A., 187, 213, 251
Transhiatal esophagectomy (THE), 25 Weksler, B., 26, 31
Trastulli, S., 185 Whipple procedure. See Pancreatoduodenectomy (PD)
Trauma pod surgical robot, 21 Whitson, B.A., 79
Traverso, L.W., 145 Wilson, E.B., 17–21, 113–119
Tsung, A., 161–170 Winter, J.M., 294
Tzvetanov, I.G., 313–323 Wittgrove, A.C., 113
Woo, Y., 95–109, 457–460
Woodruff, V.D., 17–21, 113–119
U
University of Texas Southwestern (UTSW) data
clutch and camera movement, 399 Y
clutch and camera peg transfer, 401 Yiengpruksawan, A., 151–160
pattern cut, 402 Yoon, H.M., 107
peg transfer, 399 Yu, P.W., 105
rubber band transfer, 400 Yu, S., 117
run and cut rubber band, 402
running suture, 402
simple suture, 400 Z
stair rubber band transfer, 399, 401 Zeh, H.J., 145
URobot, 6 ZEUS robotic system, 7–8