The authors gratefully appreciate the ongoing support of our robotic team of nurses Daniela Salber, UIrike Butz, Claudia Hagemann and Beate Gatner-Pytlasinski. Prof. A. Tannapfel and the Institute of Pathology, Ruhr-University, Bochum, Germany provided the histological figures. Furthermore, we thank Mr. Kiril Belyaev for his skillful support on video editing.
The work was not funded.
The research was performed in compliance with institutional guidelines and in accordance to the Declaration of Helsinki.

All steps presented in the surgical method follow the guidelines of the ethics committee of the Ruhr-University Bochum, Germany. The study was approved by the local ethics committee (No.23-7872-BR). Informed consent was obtained from the patient for the presentation of the data and video material.
1. Patient positioning and surgical setting
<ol>
	<li>Patient positioning
	<ol>
		<li>Situate the patient in supine position, anti-Trendelenburg 30&#176; and slightly rolled to the right (10-15&#176;).</li>
		<li>Do not split the legs and position the abdomen at a height of &#62;70 cm above ground by adjusting the operating table.</li>
		<li>Arrange the robotic arms in a &#34;butterfly&#34;-setup with two arm carts on both sides of the patient (Figure 1).</li>
	</ol>
	</li>
	<li>Cutaneous incisions and mini-laparotomy
	<ol>
		<li>Disinfect the skin by using swabs and antiseptics and place self-adhesive sterile covers.</li>
		<li>Incise the skin (1-2 cm) and fascia supraumbilically by using a scalpel and scissors.</li>
		<li>Push the first robotic trocar (11 mm) through the incision. Connect it to a CO2 insufflator.</li>
		<li>Set the insufflator to a pressure of 12 mm Hg. Wait until the favored pressure is reached and control the display.</li>
		<li>Make additional incisions (1 cm) and pierce the abdominal wall with the other trocars by turning and applying constant pressure.</li>
	</ol>
	</li>
	<li>Positioning the trocars 
	NOTE: The optimal positions are shown in Figure 2.
	<ol>
		<li>Insert the surgeon&#39;s left hand-trocar in the right upper abdomen (width 8 mm).</li>
		<li>Position the third trocar (surgeon&#39;s right hand, width 11 mm) in the left upper abdomen and the last robotic trocar for the 4th arm (width 8 mm) laterally in the left upper abdomen.</li>
		<li>Ensure a distance of at least 9 cm between all robotic trocars.</li>
		<li>Place an additional laparoscopic trocar between the endoscope and right-hand port on a more caudal level. For the setup, see Figure 2.</li>
	</ol>
	</li>
	<li>Adjusting of robotic arms
	<ol>
		<li>After a short laparoscopic exploration and the insertion of a gauze swab with a grasping instrument, connect robotic arms to the trocars.</li>
		<li>Adjust arm cart 1 (left side, cranial, surgeon right hand) to a tilt angle of -30&#176; and a docking angle of 40&#176;.</li>
		<li>Set up arm cart 2 (left side, caudal, 4th arm) to a tilt angle of 0&#176; and a docking angle of 110&#176;.</li>
		<li>Align arm cart 3 (right side, caudal, surgeon left hand) to a tilt angle of 0&#176; and a docking angle of 290&#176;.</li>
		<li>Set up arm cart 4 (right side, cranial, endoscope arm) to a tilt angle of -30&#176; and a docking angle of 330&#176;. 
		NOTE: Always control the displays of the arm carts to ensure an optimal setup.</li>
	</ol>
	</li>
	<li>Insertion of the instruments
	<ol>
		<li>Insert the camera into arm cart 4 and use a straight-forward optic (0&#176;), which is indicated by the label.</li>
		<li>Equip the surgeon&#39;s left hand with a bipolar grasper, the surgeon&#39;s right hand with monopolar curved shears, and the 4th arm with a cadiere grasper.</li>
		<li>Insert all instruments strictly under visual control. Set up bipolar energy to 50 watts (standard setup).</li>
		<li>Furthermore, set monopolar energy to 30 watts (blend cut) for cutting and 30 watts (fulguration) for coagulation by adjusting the controls of the electrosurgical generator.</li>
	</ol>
	</li>
</ol>
2. Surgical procedure
<ol>
	<li>Incision of the gastrocolic ligament
	<ol>
		<li>At the beginning of the robotic part of the procedure, grasp and elevate the stomach with the 4th arm and incise the gastrocolic ligament using the bipolar grasper and the monopolar shears in combination with a vessel sealing device.</li>
	</ol>
	</li>
	<li>Dissection of the short gastric vessels
	<ol>
		<li>Insert the sealing device via the additional trocar, which is managed manually by the bedside assistant.</li>
		<li>Cut the gastroepiploic ligament from 3 cm below up to 3 cm above the tumor after coagulation by using the controls of the instrument.</li>
		<li>Use the sealing device to coagulate and dissect all short gastric vessels. For additional coagulation, use the bipolar grasper.</li>
	</ol>
	</li>
	<li>Stapling of the tumor
	<ol>
		<li>Identify the tumor by its shape and superficial appearance compared to normal gastric tissue. Resect the tumor using a laparoscopic stapler (30 mm and 45 mm cartridges).</li>
		<li>Take only small steps and pull the tissue tightly to save as much gastric tissue as possible. The result is a lateral wedge resection of the corpus and fundus of the stomach. After the extirpation, place the specimen on the liver temporarily.</li>
	</ol>
	</li>
	<li>Augmentation of the staple line
	<ol>
		<li>Ask the anesthesiologists to replace the gastric tube below the lesion manually. The tube can be localized visually in the stomach.</li>
		<li>Augment the staple line by single knots. Use absorbable sutures. Cut off surplus sutures laparoscopically and remove the needles fixed to the sutures.</li>
	</ol>
	</li>
	<li>Removal of the specimen and end of surgery.
	<ol>
		<li>Disconnect and remove the robotic arm carts.</li>
		<li>Insert a silicone drain laparoscopically, place it next to the lesion, and fix it to the skin with a suture.</li>
		<li>Remove the tumor using a retrieval bag via a mini laparotomy at the endoscope position.</li>
		<li>Finally, close the fascia with absorbable sutures and the wounds using non-absorbable sutures. Patch up the wounds using plasters.</li>
	</ol>
	</li>
</ol>

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Z., Ali, T. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Robotic+surgery:+An+evolution+in+practice.">Robotic surgery: An evolution in practice.</a> J Surg Protoc Res Methodol. 2022 (1), snac003 (2022).</li><li>Prata, F., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=State+of+the+art+in+robotic+surgery+with+HUGO+RAS+system:+feasibility,+safety+and+clinical+applications.">State of the art in robotic surgery with HUGO RAS system: feasibility, safety and clinical applications.</a> J Pers Med. 13 (8), 1233 (2023).</li><li>Paciotti, M., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Nerve-sparing+robot-assisted+radical+prostatectomy+with+the+HUGO&#8482;+robot-assisted+surgery+system+using+the+'Aalst+technique.">Nerve-sparing robot-assisted radical prostatectomy with the HUGO&#8482; robot-assisted surgery system using the 'Aalst technique.</a> BJU Intl. 132 (2), 227-230 (2023).</li><li>Bravi, C. A., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Robot-assisted+radical+prostatectomy+with+the+novel+hugo+robotic+system:+initial+experience+and+optimal+surgical+set-up+at+a+tertiary+referral+robotic+center.">Robot-assisted radical prostatectomy with the novel hugo robotic system: initial experience and optimal surgical set-up at a tertiary referral robotic center.</a> Eur Urol. 82 (2), 233-237 (2022).</li><li>Bravi, C. A., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Outcomes+of+robot-assisted+radical+prostatectomy+with+the+hugo+ras+surgical+system:+Initial+experience+at+a+high-volume+robotic+center.">Outcomes of robot-assisted radical prostatectomy with the hugo ras surgical system: Initial experience at a high-volume robotic center.</a> EU Focus. 9 (4), 642-644 (2023).</li><li>Bianchi, P. P., Salaj, A., Rocco, B., Formisano, G. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=First+worldwide+report+on+Hugo+RAS&#8482;+surgical+platform+in+right+and+left+colectomy.">First worldwide report on Hugo RAS&#8482; surgical platform in right and left colectomy.</a> Updates in Surgery. 75 (3), 775-780 (2023).</li><li>Caputo, D., Farolfi, T., Molina, C., Coppola, R. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Full+robotic+cholecystectomy:+first+worldwide+experiences+with+HUGO+RAS+surgical+platform.">Full robotic cholecystectomy: first worldwide experiences with HUGO RAS surgical platform.</a> ANZ J surgery. 94 (3), 387-390 (2023).</li><li>Caruso, R., Vicente, E., Quijano, Y., Ferri, V. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=New+era+of+robotic+surgery:+first+case+in+Spain+of+right+hemicolectomy+on+Hugo+RAS+surgical+platform.">New era of robotic surgery: first case in Spain of right hemicolectomy on Hugo RAS surgical platform.</a> BMJ Case Rep. 16 (12), e256035 (2023).</li><li>Gangemi, A., Bernante, P., Rottoli, M., Pasquali, F., Poggioli, G. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Surgery+of+the+alimentary+tract+for+benign+and+malignant+disease+with+the+novel+robotic+platform+HUGOTM+RAS.+A+first+world+report+of+safety+and+feasibility.">Surgery of the alimentary tract for benign and malignant disease with the novel robotic platform HUGOTM RAS. A first world report of safety and feasibility.</a> Int J Med Robot. 19 (4), e2544 (2023).</li><li>Mintz, Y., Pikarsky, A. J., Brodie, R., Elazary, R., Helou, B., Marom, G. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Robotic+inguinal+hernia+repair+with+the+new+Hugo+RASTM+system:+first+worldwide+case+series+report.">Robotic inguinal hernia repair with the new Hugo RASTM system: first worldwide case series report.</a> MITAT: Official Journal of the Society for Minimally Invasive Therapy. 32 (6), 300-306 (2023).</li><li>Raffaelli, M., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=The+new+robotic+platform+Hugo&#8482;+RAS+for+lateral+transabdominal+adrenalectomy:+a+first+world+report+of+a+series+of+five+cases.">The new robotic platform Hugo&#8482; RAS for lateral transabdominal adrenalectomy: a first world report of a series of five cases.</a> Updates Surg. 75 (1), 217-225 (2023).</li><li>Raffaelli, M., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Feasibility+of+Roux-en-Y+Gastric+Bypass+with+the+novel+robotic+platform+HUGO+RAS.">Feasibility of Roux-en-Y Gastric Bypass with the novel robotic platform HUGO RAS.</a> Front Surg. 10, e1181790 (2023).</li><li>Vicente, E., Quijano, Y., Ferri, V., Caruso, R. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Robot-assisted+cholecystectomy+with+the+new+HUGO&#8482;+robotic-assisted+system:+first+worldwide+report+with+system+description,+docking+settings,+and+video.">Robot-assisted cholecystectomy with the new HUGO&#8482; robotic-assisted system: first worldwide report with system description, docking settings, and video.</a> Updates in Surg. 75 (7), 2039-2042 (2023).</li><li>Belyaev, O., Fahlbusch, T., Slobodkin, I., Uhl, W. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Safety+and+feasibility+of+cholecystectomy+with+the+hugotm+ras:+proof+of+setup+guides+and+first-in-human+German+experience.">Safety and feasibility of cholecystectomy with the hugotm ras: proof of setup guides and first-in-human German experience.</a> Visc Med. 39 (3-4), 76-86 (2023).</li><li>Raffaelli, M., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Robotic-assisted+Roux-en-Y+gastric+bypass+with+the+novel+platform+HugoTM+RAS:+preliminary+experience+in+15+patients.">Robotic-assisted Roux-en-Y gastric bypass with the novel platform HugoTM RAS: preliminary experience in 15 patients.</a> Updates Surg. 76 (1), 179-185 (2024).</li><li>Salem, S. A., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Robotic+Heller's+myotomy+using+the+new+Hugo&#8482;+RAS+system:+first+worldwide+report.">Robotic Heller's myotomy using the new Hugo&#8482; RAS system: first worldwide report.</a> Surg Endosc. 38 (3), 1180-1190 (2024).</li><li>Hoeppner, J. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Robotisch+assistierte+totale+Gastrektomie+mit+D2-Lymphadenektomie+und+intrakorporaler+Rekonstruktion.">Robotisch assistierte totale Gastrektomie mit D2-Lymphadenektomie und intrakorporaler Rekonstruktion.</a> Zentralblatt fur Chirurgie. 147 (5), 427-429 (2022).</li><li>Vicente, E., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Robot-assisted+resection+of+gastrointestinal+stromal+tumors+(GIST):+a+single+center+case+series+and+literature+review.">Robot-assisted resection of gastrointestinal stromal tumors (GIST): a single center case series and literature review.</a> Int J Med Robot. 12 (4), 718-723 (2016).</li><li>Furbetta, N., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Gastrointestinal+stromal+tumours+of+stomach:+Robot-assisted+excision+with+the+da+Vinci+Surgical+System+regardless+of+size+and+location+site.">Gastrointestinal stromal tumours of stomach: Robot-assisted excision with the da Vinci Surgical System regardless of size and location site.</a> J Minim Access Surg. 15 (2), 142-147 (2019).</li><li>Desiderio, J., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Robotic+gastric+resection+of+large+gastrointestinal+stromal+tumors.">Robotic gastric resection of large gastrointestinal stromal tumors.</a> Int J Surg (London, England). 11 (2), 191-196 (2013).</li><li>Al-Thani, H., El-Menyar, A., Mekkodathil, A., Elgohary, H., Tabeb, A. 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Prof. Orlin Belyaev and Dr. Tim Fahlbusch are consultants for Medtronic.
Albert Tafelmeier works for Medtronic.
The other authors declare no conflict of interest.

The method is tailored for upper gastrointestinal purposes. Low regions of the abdominal cavity are not able to be reached and require different trocar and arm cart positions. A critical step is the placement of the trocars, which are supposed to be placed at a sufficient distance of at least 9 cm from each other. Otherwise, conflicting movements of the robotic arms may occur. Nevertheless, trocars must not be placed too close to osseous structures. Conflicts of the arms can sometimes be circumvented by slight alteration...

Robot-assisted surgery (RAS) is an advanced minimally invasive technique, which is associated with potential advantages such as fastened recovery times, shortened hospitalization and reduced risk of complications. According to Goh et al.1, surgeons benefit from better visualization, ergonomics, and dexterity.
Recently, a much-awaited modular robotic device was approved for in-human use in Europe in the field of visceral surgery2. Extensive experience has already been gathered by urologists earlier on3,4,5. Nevertheless, surgical experience with this new device is scarce but rapidly increasing6,7,8,9,10,11,12,13,14. The system comprises four arm carts for the endoscope and surgical instruments, a system tower, and a surgeon console2. Trocar positions and adjustments of the arm carts are highly important for the success of the surgical approach. False positions may lead to conflicts with robotic arms and technical inoperability. We developed this setup as a standard method for upper gastrointestinal surgery which includes numerous operations and organs such as the stomach, gallbladder, liver, pancreas or spleen. Therefore, the surgical approach needs to cover a wide range of requirements, especially in anatomical regions that are difficult to access. Due to the novelty of the platform, hardly any approaches for upper gastrointestinal surgery were described before. Other authors concentrated on bariatric procedures12. These setups are designed for a minority of obese patients with special anatomical demands12,15. Salem et. al. use alternate localizations of the arm carts for myotomies, which require an intricate positioning of the patient16. The presented method can be utilized for a wide range of purposes and patients and is easy to perform. Setups for other robotic platforms are not transferable17.
We now describe our surgical method and the case of a 69-year-old male patient who presented with an upper gastrointestinal bleeding. The diagnostic measures, including CT scans and endoscopy, revealed a gastric tumor localized at the greater curvature. It was sized 7 cm x 5 cm x 5 cm. Histological examination of a tissue sample suspected a leiomyoma and CT-scans showed no sign of metastatic spread. The patient did not undergo preceding major surgery, was presented with sufficient physical fitness, and, therefore, qualified for minimal-invasive surgery. The surgical resection of the lesion was indicated and performed at St. Josef-Hospital, University Hospital of the Ruhr-University Bochum, Germany, on January 12th, 2024.

<table border="1" fo:keep-together.within-page="1" fo:keep-with-next.within-page="always">
	<tbody>
		<tr>
			<td>Easy Flo&#160;</td>
			<td>P.J. Dahlhausen, K&#246;ln, Germany</td>
			<td></td>
			<td>12 mm</td>
		</tr>
		<tr>
			<td>Endo GIA Ultra&#160;</td>
			<td>Medtronic, Dublin, Ireland</td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>EndoRetrieval Pouch&#160;</td>
			<td>M&#246;lnlycke Health Care GmbH, D&#252;sseldorf, Germany</td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>Ethilon</td>
			<td>Ethicon, Bridgewater, New Jersey, USA</td>
			<td></td>
			<td>3-0</td>
		</tr>
		<tr>
			<td>Hugo RAS</td>
			<td>Medtronic, Dublin, Ireland</td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>Ligasure&#160;</td>
			<td>Medtronic, Dublin, Ireland</td>
			<td></td>
			<td>44 cm, Blunt tip, laparoscopic version</td>
		</tr>
		<tr>
			<td>Stomach Probe</td>
			<td>Medicoplast, Illingen, Germany</td>
			<td></td>
			<td>Probe with plastic guidewire</td>
		</tr>
		<tr>
			<td>UHI CO2 Insufflation Unit</td>
			<td>Olympus, Hamburg Germany</td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>Vicryl Sutures</td>
			<td>Ethicon, Bridgewater, New Jersey, USA</td>
			<td>1 and 3-0</td>
			<td></td>
		</tr>
	</tbody>
</table>

robotics in surgery: a modular robotic platform driven gastric wedge resection

Robotic-assisted surgery has become increasingly popular since the introduction of the first robotic platform. Recently, a modular robotic system was approved for in-human use in Europe. Possible applications for this new robotic system are being explored, and standardized approaches are evolving. In lieu of this, a gastric wedge resection and the standardized setup for upper gastrointestinal procedures using this new system are presented here. This safe and feasible robotic procedure is demonstrated in a 69-year-old patient with a gastric tumor. All steps of the surgery are described in a detailed and reproducible manner. The article also details trocar positioning, arm adjustments, and required surgical instruments. Docking time amounted to 13 min, whereas the console time took 115 min. The patient was discharged after 4 days after ensuring an uneventful course. The presented method is also suitable for other surgical purposes, such as fundoplications or hiatoplasties, and ensures both generalizability and reproducibility.

Docking time amounted to 13 min, whereas console time took 115 min. The tumor was removed, and the wounds were closed after another 15 min. There were no intraoperative complications or robotic malfunctions and hardly any blood loss. The patient was monitored in the recovery room for 3 hours postoperatively. The further course in the hospital was uneventful. There was no sign of postoperative bleeding or insufficiency of the stapling line. Therefore, the drain was removed after 2 days. There were 3 blood tests screening ...

Robotically assisted surgery has become highly popular in recent years. Presented here is the standard care for upper gastrointestinal procedures, including a demonstration of a robotic-assisted gastric wedge resection using a modular robotic device.

Robotics in Surgery: A Modular Robotic Platform Driven Gastric Wedge Resection

Robotic-assisted surgery has become increasingly popular since the introduction of the first robotic platform. Recently, a modular robotic system was ...

robotics-surgery-modular-robotic-platform-driven-gastric-wedge

Research

JoVE Journal

Medicine

219 Views.  Ruhr-University Bochum, St. Josef-Hospital. Robotically assisted surgery has become highly popular in recent years. Presented here is the standard care for upper gastrointestinal procedures, including a demonstration of a robotic-assisted gastric wedge resection using a modular robotic device.

Video: Robotics in Surgery: A Modular Robotic Platform Driven Gastric Wedge Resection

Roux-en-Y Gastric Bypass Operation in Rats

Currently, the most effective therapy for the treatment of morbid obesity to induce significant and maintained body weight loss with a proven mortality benefit is bariatric surgery1,2. Consequently, there has been a steady rise in the number of bariatric operations done worldwide in recent years with the Roux-en-Y gastric bypass (gastric bypass) being the most commonly performed operation3. Against this background, it is important to understand the physiological mechanisms by which gastric bypass induces and maintains body weight loss. These mechanisms are yet not fully understood, but may include reduced hunger and increased satiation4,5, increased energy expenditure6,7, altered preference for food high in fat and sugar8,9, altered salt and water handling of the kidney10 as well as alterations in gut microbiota11. Such changes seen after gastric bypass may at least partly stem from how the surgery alters the hormonal milieu because gastric bypass increases the postprandial release of peptide-YY (PYY) and glucagon-like-peptide-1 (GLP-1), hormones that are released by the gut in the presence of nutrients and that reduce eating12.
During the last two decades numerous studies using rats have been carried out to further investigate physiological changes after gastric bypass. The gastric bypass rat model has proven to be a valuable experimental tool not least as it closely mimics the time profile and magnitude of human weight loss, but also allows researchers to control and manipulate critical anatomic and physiologic factors including the use of appropriate controls. Consequently, there is a wide array of rat gastric bypass models available in the literature reviewed elsewhere in more detail 13-15. The description of the exact surgical technique of these models varies widely and differs e.g. in terms of pouch size, limb lengths, and the preservation of the vagal nerve. If reported, mortality rates seem to range from 0 to 35%15. Furthermore, surgery has been carried out almost exclusively in male rats of different strains and ages. Pre- and postoperative diets also varied significantly.
Technical and experimental variations in published gastric bypass rat models complicate the comparison and identification of potential physiological mechanisms involved in gastric bypass. There is no clear evidence that any of these models is superior, but there is an emerging need for standardization of the procedure to achieve consistent and comparable data. This article therefore aims to summarize and discuss technical and experimental details of our previously validated and published gastric bypass rat model.

Numerous studies using gastric bypass rat models have been recently conducted to uncover the underlying physiological mechanisms of Roux-en-Y gastric bypass operations. This article aims to demonstrate and discuss the technical and experimental details of our published gastric bypass rat model to understand advantages and limitations of this experimental tool.

Currently, the most effective therapy for the treatment of morbid obesity to induce significant and maintained body weight loss with a proven mortality ...

Intraoperative Gastroscopy for Tumor Localization in Laparoscopic Surgery for Gastric Adenocarcinoma

Determining resection margins for gastric cancer, which are not exposed to the serosal surface of the stomach, is the most important procedure during totally laparoscopic gastrectomy (TLG). The aim of this protocol is to introduce a procedure for intraoperative gastroscopy, in order to directly mark tumors during TLG for gastric cancer in the middle third of the stomach. Patients who were diagnosed with adenocarcinoma in the middle third of the stomach were enrolled in this case series. Before surgery, additional gastroscopy for tumor localization is not performed. Under general anesthesia, laparoscopic mobilization of the stomach is performed first. After the first portion of the duodenum is mobilized from the pancreas and clamped, the surgeon moves to the other side for the gastroscopic procedure. On the insertion of a gastroscope through the oral cavity into the stomach, 2 - 3 cc of indigo carmine is administered via an endoscopic injector into the gastric muscle layer at the proximal margin of the stomach. The location of stained serosa in the laparoscopic view is used to guide distal subtotal gastrectomy, however, total gastrectomy is performed if the tumor is too close to the esophagogastric junction. A specimen is sampled after distal gastrectomy to confirm sufficient length from resection margin to tumor before reconstruction. In our case series, all patients had tumor-free margins and required no additional resection. There was no morbidity related to the gastroscopic procedure, and the time required for the procedure has gradually decreased to about five minutes. Intraoperative gastroscopy for tumor localization is an accurate and tolerated method for gastric cancer patients undergoing totally laparoscopic distal gastrectomy.

In early gastric cancer, the aim of surgery is to precisely remove the distal stomach including the primary tumor. To do this, accurate localization of the tumor is crucial, especially in totally laparoscopic surgery. This protocol describes a procedure for intraoperative gastroscopy in totally laparoscopic subtotal gastrectomy.

Determining resection margins for gastric cancer, which are not exposed to the serosal surface of the stomach, is the most important procedure during ...

Emergency Undocking in Robotic Surgery: A Simulation Curriculum

The following is a training platform to allow robotic surgeons to develop the skills necessary to lead an interprofessional team in emergency undocking of a robotic system. In traditional robotic training for surgeons, a brief web based overview of performing an emergency undocking is provided during initial introductory training to the robotics system. During such a process, there is no training in delineation of interdisciplinary roles for operating room (OR) personnel. The training presented here uses formative simulation and debriefing followed by a lecture. For the simulation, a modified gynecologic simulator is draped in a steep trendelenburg position consistent with most gynecologic laparoscopic surgery. The training torso is modified using tubing hooked to pressure bags of red food colored IV fluid used to simulate a catastrophic vessel injury on demand. Positioned throughout the operating room setting is an interprofessional team consisting of embedded standardized persons (ESPs) to fulfill the roles of a circulating nurse, scrub nurse, anesthesiologist, and bedside assist surgeon. Robotic surgeons are presented a case scenario necessitating emergency undocking, and given control of the robotic instruments. The scenario is terminated following either successful completion of an emergency undock, or at five minutes due to the emergent nature of the case. A debriefing session with hands on training of the steps to emergency undocking, necessary equipment, troubleshooting techniques, and operating room personnel roles follows the simulation. The learners are presented with a short lecture reemphasizing the material presented in the debriefing for their own self-study. This training results in improved time accessing the patient, improved knowledge, confidence, and completion of critical actions, and can be replicated in most institutions. All robotic surgeons should be able to demonstrate competence in this crucial intervention. A limitation of the curriculum is ability to access the in-situ environment for training purposes.

This training platform is designed to allow robotic surgeons to develop the skills necessary to lead an interprofessional team in emergency undocking of the robotic system. Training includes the utilization of the technology and equipment to perform an emergency undocking, as well as delineation of roles for such a scenario.

The following is a training platform to allow robotic surgeons to develop the skills necessary to lead an interprofessional team in emergency undocking of ...

Endoscopic Septoplasty with Limited Two-line Resection: Minimally Invasive Surgery for Septal Deviation

Endoscopic septoplasty is a surgical procedure in otolaryngology that is commonly performed to treat nasal airway obstruction caused by nasal septal deviation. It has a long history with multiple variations. In this article, a modified endoscopic septoplasty procedure using the limited two-line resection (2LoRs) technique at the posterior and inferior junction of the cartilaginous and bony septum is presented based on embryologic and anatomic knowledge of the nasal septum and the biomechanics of cartilaginous behavior. With this procedure, the quadrangular cartilage can be preserved as much as possible, which is helpful in retaining the supporting framework and rigidness of the septum. 2LoRs has been proven effective and sound for the correction of nasal septal deviation with rare complications. This modified procedure can be applied to correct the deviated nasal septum in the absence of any external nasal deformity to improve nasal patency or to improve access to the middle meatus or to the axillary region of the middle turbinate. It may also be used to expand the indications of septoplasty to children and adolescents because of its minimally invasive approach.

Endoscopic septoplasty is a time-honored surgical procedure with multiple variations. This paper focuses on a step-by-step surgical approach to perform a modified septoplasty procedure known as limited two-line resection. This surgical technique can be applied to correct a deviated nasal septum in the absence of an external nasal deformity.

Endoscopic septoplasty is a surgical procedure in otolaryngology that is commonly performed to treat nasal airway obstruction caused by nasal septal ...

One-anastomosis Gastric Bypass (OAGB) in Rats

The goal of this protocol is to set up a preclinical model of bariatric surgery and, more specifically, OAGB in obese rats. Based on this preclinical model, longitudinal studies can be carried out to provide an improved understanding of the mechanisms underlying the outcomes seen after bariatric surgery in humans. For this purpose, rats are operated on through a laparotomy under general anesthesia with isoflurane. First, the surgeon creates a long and tubular gastric pouch: after greater curve and hiatal dissection, the nonglandular stomach is stapled and removed. Then, the remaining stomach is also stapled in order to create a gastric tube and exclude the antrum of the stomach. After that, the surgeon performs a single end-to-side gastrojejunostomy 35 cm from the duodenojejunal angle. This limb length has been chosen in order to reproduce the same ratio between the biliopancreatic limb (BPL) and common limb (CL) length as in human bariatric surgery. The operation ends by aponeurotic and cutaneous closure. The early postoperative management consists of subcutaneous hydration, an intramuscular prophylactic antibiotic injection, a parietal injection of xylocaine, the administration of painkillers, and a progressive reintroduction of diet.

One-anastomosis Gastric Bypass OAGB in Rats

This protocol is for the performance of one-anastomosis gastric bypass (OAGB) on rat. The operator performs a long and tubular-stapled gastric pouch followed by hand-sewn anastomosis. For this model, the operator reproduces the same ratio between biliopancreatic and common limb in humans; therefore, the biliopancreatic limb measures 35 cm.

The goal of this protocol is to set up a preclinical model of bariatric surgery and, more specifically, OAGB in obese rats. Based on this preclinical ...

Robotic Lateral Pancreaticojejunostomy for Chronic Pancreatitis

Lateral pancreaticojejunostomy (LPJ) has shown good postoperative outcomes in patients with painful, morphine dependent, chronic pancreatitis (CP). The recent rise of robotic and laparoscopic pancreatic surgery has found benefits such as reduced time to functional recovery. Few studies have reported on the feasibility, technique and outcome of robotic LPJ, especially including transection of the gastroduodenal artery. The present study describes the main steps for robotic LPJ in a patient with painful chronic pancreatitis with a dilated main pancreatic duct. The patient underwent robotic LPJ. The LPJ anastomosis is performed using a running suture technique in a longitudinal side-to-side manner. Routinely, the gastroduodenal artery is transected to drain the entire length of the main pancreatic duct. The patient is in French position; 7 trocars are placed (4 robotic, 2 laparoscopic assistants, 1 liver-retractor). After docking of the robot system, the omental bursa is opened, and the right gastroepiploic artery and vein are ligated at their base at the lower border of the pancreas. Intraoperative ultrasonography is performed in order to determine trajectory of the dilated main pancreatic duct which is opened for its entire length after the gastroduodenal artery has been suture ligated both cranially and caudally from the main pancreatic duct. A Roux limb is created, and a latero-lateral PJ is fashioned using several 3-0 barbed sutures. A stapled jejuno-jejunostomy is created at sufficient distance from the pancreatic anastomosis, aided by a 50 cm suture. The described technique for robotic LPJ is a complex but feasible operation for patients with treatment refractory CP and a dilated main pancreatic duct. Due to its complexity, implementation in high volume centers with extensive experience with CP surgery may improve outcomes.

Robotic lateral pancreaticojejunostomy (RLPJ) may be used in patients with painful, morphine dependent, chronic pancreatitis and a dilated main pancreatic duct. We describe a standardized and reproducible technique for RLPJ, which includes transection of the gastroduodenal artery.

Lateral pancreaticojejunostomy (LPJ) has shown good postoperative outcomes in patients with painful, morphine dependent, chronic pancreatitis (CP). The ...

Robot-Assisted Radical Antegrade Modular Pancreatosplenectomy Including Resection and Reconstruction of the Spleno-Mesenteric Junction

This article shows the technique of robot-assisted radical antegrade modular pancreatosplenectomy, including resection and reconstruction of the spleno-mesenteric junction, for cancer of the body-tail of the pancreas. The patient is placed supine with the legs parted and a pneumoperitoneum is established and maintained at 10 mmHg. To use the surgical system, four 8 mm ports and one 12 mm port are required. The optic port is placed at the umbilicus. The other ports are placed, on either side, along the pararectal line and the anterior axillary line at the level of the umbilical line. The assistant port (12 mm) is placed along the right pararectal line. Dissection begins by detaching the gastrocolic ligament, thus opening the lesser sac, and by a wide mobilization of the splenic flexure of the colon. The superior mesenteric vein is identified along the inferior border of the pancreas. Lymph node number 8a is removed to permit clear visualization of the common hepatic artery. A tunnel is then created behind the neck of the pancreas. To permit safe resection and reconstruction of the spleno-mesenteric junction, further preemptive dissection is required before dividing the pancreatic neck to bring in clear view all relevant vascular pedicles. Next, the splenic artery is ligated and divided, and the pancreatic neck is divided, with selective ligature of the pancreatic duct. After vein resection and reconstruction, dissection proceeds to complete the clearance of peripancreatic arteries that are peeled off from all lympho-neural tissues. Both celiac ganglia are removed en-bloc with the specimen. The Gerota fascia covering the upper pole of the left kidney is also removed en-bloc with the specimen. Division of short gastric vessels and splenectomy complete the procedure. A drain is left near the pancreatic stump. The round ligament of the liver is mobilized to protect the vessels.

The robotic technique shown herein aims at faithfully reproducing the open procedure for radical treatment of cancer of the body-tail of the pancreas. The protocol also demonstrates the ability to master involvement of major peripancreatic vessels without conversion to open surgery.

This article shows the technique of robot-assisted radical antegrade modular pancreatosplenectomy, including resection and reconstruction of the ...

Intraoperative Assessment of Resection Margins in Oral Cavity Cancer: This is the Way

The goal of head and neck oncological surgery is complete tumor resection with adequate resection margins while preserving acceptable function and appearance. For oral cavity squamous cell carcinoma (OCSCC), different studies showed that only 15%-26% of all resections are adequate. A major reason for the low number of adequate resections is the lack of information during surgery; the margin status is only available after the final histopathologic assessment, days after surgery.
The surgeons and pathologists at the Erasmus MC University Medical Center in Rotterdam started the implementation of specimen-driven intraoperative assessment of resection margins (IOARM) in 2013, which became the standard of care in 2015. This method enables the surgeon to turn an inadequate resection into an adequate resection by performing an additional resection during the initial surgery. Intraoperative assessment is supported by a relocation method procedure that allows accurate identification of inadequate margins (found on the specimen) in the wound bed.
The implementation of this protocol resulted in an improvement of adequate resections from 15%-40%. However, the specimen-driven IOARM is not widely adopted because grossing fresh tissue is counter-intuitive for pathologists. The fear exists that grossing fresh tissue will deteriorate the anatomical orientation, shape, and size of the specimen and therefore will affect the final histopathologic assessment. These possible negative effects are countered by the described protocol. Here, the protocol for specimen-driven IOARM is presented in detail, as performed at the institute.

The goal of this protocol is to provide a clear overview of specimen-driven intraoperative assessment of resection margins. It is encouraged to implement this protocol to improve patient care at other institutes.

The goal of head and neck oncological surgery is complete tumor resection with adequate resection margins while preserving acceptable function and ...

A Protocol for Roux-en-Y Gastric Bypass in Rats using Linear Staplers

Roux-en-Y gastric bypass (RYGB) is commonly performed for the treatment of severe obesity and type 2 diabetes. However, the mechanism of weight loss and metabolic changes are not well understood. Multiple factors are thought to play a role, including reduced caloric intake, decreased nutrient absorption, increased satiety, the release of satiety-promoting hormones, shifts in bile acid metabolism, and alterations in the gut microbiota.
The rat RYGB model presents an ideal framework to study these mechanisms. Prior work on mouse models have had high mortality rates, ranging from 17 to 52%, limiting their adoption. Rat models demonstrate more physiologic reserve to surgical stimulus and are technically easier to adopt as they allow for the use of surgical staplers. One challenge with surgical staplers, however, is that they often leave a large gastric pouch which is not representative of RYGB in humans. 
In this protocol, we present a RYGB protocol in rats that result in a small gastric pouch using surgical staplers. Utilizing two stapler fires which remove the forestomach of the rat, we obtain a smaller gastric pouch similar to that following a typical human RYGB. Surgical stapling also results in better hemostasis than sharp division. Additionally, the forestomach of the rat does not contain any glands and its removal should not alter the physiology of RYGB.
Weight loss and metabolic changes in the RYGB cohort were significant compared to the sham cohort, with significantly lower glucose tolerance at 14 weeks. Furthermore, this protocol has an excellent survival of 88.9% after RYGB. The skills described in this protocol can be acquired without previous microsurgical experience. Once mastered, this procedure will provide a reproducible tool for studying the mechanisms and effects of RYGB.

Roux-en-Y gastric bypass (RYGB) is performed to treat obesity and diabetes. However, the mechanisms underlying RYGB's efficacy are not fully understood, and studies are limited by technical difficulty leading to high mortality in animal models. This article provides instructions on how to perform RYGB in rats with high success rates.

Roux-en-Y gastric bypass (RYGB) is commonly performed for the treatment of severe obesity and type 2 diabetes. However, the mechanism of weight loss and ...

Use of 3D Robotic Ultrasound for In Vivo Analysis of Mouse Kidneys

Common modalities for in vivo imaging of rodents include positron emission tomography (PET), computed tomography (CT), magnetic resonance imaging (MRI), and ultrasound (US). Each method has limitations and advantages, including availability, ease of use, cost, size, and the use of ionizing radiation or magnetic fields. This protocol describes the use of 3D robotic US for in vivo imaging of rodent kidneys and heart, subsequent data analysis, and possible research applications. Practical applications of robotic US are the quantification of total kidney volume (TKV), as well as the measurement of cysts, tumors, and vasculature. Although the resolution is not as high as other modalities, robotic US allows for more practical high throughput data collection. Furthermore, using US M-mode imaging, cardiac function may be quantified. Since the kidneys receive 20%-25% of the cardiac output, assessing cardiac function is critical to the understanding of kidney physiology and pathophysiology.

Use of 3D Robotic Ultrasound for In Vivo Analysis of Mouse Kidneys

This protocol demonstrates robotic ultrasound (US) as a practical, cost-effective, and quick alternative to traditional non-invasive image modalities.

Common modalities for in vivo imaging of rodents include positron emission tomography (PET), computed tomography (CT), magnetic resonance imaging (MRI), ...

Methods Article

Robotics in Surgery: A Modular Robotic Platform Driven Gastric Wedge Resection