Robot-assisted surgery is an advanced, minimally invasive technique, which is associated with potential advantages, such as test and recovery times, short hospitalization, and reduced risk of complications. Recently, a much-awaited, modular robotic device was approved for inhuman use in Europe in the field of visceral surgery. Extensive experience has already been gathered by urologists earlier on.
Nevertheless, surgical experience with this new device is scarce, but rapidly increasing. The system consists of forearm casts for the endoscope and surgical instruments, a system tower, and a surgeon console. We now describe our surgical method in the case of a 69-year-old male patient who presented with an upper gastrointestinal bleeding.
The diagnostic measures including CT scans and an endoscopy revealed the gastric tumor localized at the greater curvature. The surgical resection of the lesion was indicated and performed at St.Josef-Hospital University Hospital of Ruhr University Bochum Germany on January 12th in 2024. Situate the patient in supine position.
Do not split the legs and arrange the robotic arms in the butterfly setup with two arm cards on both sides of the patient. Incise the skin and fascia supraumbilically by using a scalpel and scissors. Make additional incisions and pierce the abdominal wall with the other trocars.
The optimal positions are shown in figure two. Insert the surgeon's left hand trocar in the right upper abdom. Position the third trocar, surgeon's right hand in the left upper abdom, and the last robotic trocar for the fourth arm laterally in the left upper abdom.
Ensure a distance of at least nine centimeters between all robotic trocars. Place an additional laparoscopic trocar between the endoscope and right hand port on a more coral level. For the setup, see figure two.
Adjust arm card one to a tilt angle of minus 30 degrees and the docking angle of 40 degrees. Set up arm card two to a tilt angle of zero degrees and the docking angle of 110 degrees Always control the displays of the arm cards to ensure an optimal setup. Equip surgeon left hand with a bipolar grasper, surgeon right hand with monopolar curved shears and the fourth arm with a grasper.
At the beginning of the robotic part of the procedure. Grasp and elevate the stomach with a fourth arm and incise the gastrocolic ligament using the bipolar grasper and the monopolar shears in combination with a vessel sealing device. Cut the gastro epicoloric ligament from three centimeters below up to three centimeters above the tumor after coagulation by using the controls of the instrument.
The tumor can be identified by its shape and superficial appearance in comparison to normal gastric tissue. Resect the tumor using a laparoscopic stapler. Take only small steps and pull the tissue tightly to save as much gastric tissue as possible.
The result is a lateral wide resection of the corpus and fundus of the stomach. Augment the staple line by using single knots. Use absorbable sutures, cut off surplus sutures laparoscopically, and remove the needles that were fixed to the sutures.
Remove the tumor using the retrieval bag via a mini laparotomy at the endoscope position. Docking time amounted to 13 minutes, whereas console time took 115 minutes. There were no intraoperative complications or robotic malfunctions and hardly any blood loss.
The patient was monitored in the recovery room for three hours postoperatively and discharged after four days. The endoscopic findings revealing a central necrosis in the tumor prior to surgery are shown in figure three. The histological examination was performed after resection of the tumor.
It revealed a schwannoma which was resected entirely. No additional treatment or readmission was necessary. A follow-up examination after three months showed no sign of recurrence.
In figure five to pre and post-surgical CT scans of the upper abdom highlight successful resection of the tumor. Table two compares similar cases of partial gastric resections, which were performed using different robotic systems. Similar values for duration of surgery, tumor size and length of stay in hospital were presented.
In conclusion, for a gastric wide resection, the new modular robotic platform was safe and feasible. Furthermore, the developed method is also suitable for other surgical purposes, such as fun applications or heteroplastys, and ensures both generalizability and reproducibility.
