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Hand-assisted robotic surgery in the abdominal phase of robot-assisted oesophagectomy


 Department of Gastroenterological Surgery, Shizuoka General Hospital, Shizuoka, Japan

Date of Submission02-Mar-2020
Date of Decision24-Jun-2020
Date of Acceptance02-Jul-2020
Date of Web Publication10-Sep-2020

Correspondence Address:
Shinsuke Sato,
Department of Gastroenterological Surgery, Shizuoka General Hospital, 4-27-1 Kitaando, Aoi-ku, Shizuoka 420-8527
Japan
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jmas.JMAS_68_20

PMID: 32964879

  Abstract 

Robot-assisted minimally invasive oesophagectomy (RAMIE) has been developed to overcome the technical limitations of conventional thoracoscopic oesophagectomy. Hand-assisted laparoscopic surgery (HALS) is used as a practical and useful technique during the abdominal phase of thoracoscopic oesophagectomy. During RAMIE, a robotic vessel sealer cannot be used with HALS; another vessel sealer or ultrasonic coagulating device for laparoscopic surgery is required. We report an initial experiment using hand-assisted robotic surgery (HARS) for abdominal manipulation during RAMIE as a novel method. Under the pneumoperitoneum induced by insufflating the abdomen to 10 mmHg with carbon dioxide, the assistant surgeon lifted the stomach and greater omentum using the left hand through a 7 cm upper abdominal midline incision at approximately 2 cm below the xiphoid. Subsequently, gastric mobilisation was performed by robot-assisted surgery. Between January 2019 and February 2020, eight patients with thoracic oesophageal cancer underwent RAMIE with HARS at our hospital. The median operative time for extracorporeal manipulation and preparation for the roll-in of the robot was 39.5 min. The median console time was 47.5 min. There were no intraoperative or postoperative complications related to the use of the robot and no in-hospital mortality. In conclusion, HARS seems to be feasible and safe for abdominal manipulation during oesophageal cancer surgery.


Keywords: Hand-assisted laparoscopic surgery, Oesophageal cancer, oesophagectomy, robotic surgery



How to cite this URL:
Sato S, Higashizono K, Nagai E, Taki Y, Nishida M, Watanabe M, Oba N. Hand-assisted robotic surgery in the abdominal phase of robot-assisted oesophagectomy. J Min Access Surg [Epub ahead of print] [cited 2020 Sep 25]. Available from: http://www.journalofmas.com/preprintarticle.asp?id=294810



  Introduction Top


Robot-assisted minimally invasive oesophagectomy (RAMIE) has been developed to overcome the technical limitations of open and thoracoscopic oesophagectomy. Hand-assisted laparoscopic surgery (HALS) is routinely used during the abdominal phase of thoracoscopic oesophagectomy at many institutions.[1] A robotic vessel sealer provides several advantages during RAMIE, such as effective coagulation and effective dissection of tissue during surgery. However, a robotic vessel sealer cannot be used for HALS, because it does not work unless connected to a robot. We present the use of hand-assisted robotic surgery (HARS) for abdominal manipulation during RAMIE as a novel method to effectively and economically use a robotic vessel sealer during hand-assisted surgery.


  Technique Top


During the thoracic phase of RAMIE, the patient was placed in a prone position. After the thoracic phase, the patient was placed in the supine position for the abdominal phase. The procedure commenced with a 7 cm upper abdominal midline incision at approximately 2 cm below the xiphoid. Through the incision, the greater omentum and transverse colon were separated, and the lesser omentum was incised under direct visualisation. We used a wound protector (Smart Retractor M size, TOP Corporation, Tokyo, Japan) as a hand port. Three 8 mm ports were placed for the robotic system. The assistant surgeon inserted a double-gloved left hand into the abdomen, and the outermost glove was placed around the ring of the wound protector [Figure 1].[2] A da Vinci Xi robotic cart (Intuitive Surgical, Mountain View, CA, USA) was introduced on the patient's right lateral side [Figure 2]. Pneumoperitoneum was induced by insufflating the abdomen to 10 mmHg with carbon dioxide. The assistant surgeon lifted the stomach and greater omentum using the left hand. Subsequently, the short gastric vessels and omentum were divided using a robotic sealing device (da Vinci Vessel Sealer Extend, Intuitive Surgical). The left gastric vessels and the left gastroepiploic vessels were divided using the double-bipolar method;[3] then, gastric mobilisation was performed [Figure 3]. After undocking the da Vinci cart, gastric conduit creation through the abdominal incision and reconstruction through the retrosternal route were performed, and anastomosis was performed in the cervical region.
Figure 1: (a) Position of port sites during the procedure. The hand port was located at the upper abdomen, 2 cm below the xiphoid. The manipulative ports were located at the umbilical point (da Vinci Xi No. 2 arm, long bipolar grasper) and the point of intersection between the left vertical axillary line, and the left horizontal line 2 cm below the rib edge (da Vinci Xi No. 4 arm, Maryland bipolar forceps or vessel sealer extend). The observation port was located 6 cm to the left of the flat umbilical point (da Vinci Xi No. 3 arm) (b) Double-glove technique for hand-assisted surgery

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Figure 2: (a) Operating room setup. (b) Assistant surgeon and robotic system positioning

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Figure 3: Intraoperative photograph of hand-assisted robotic surgery. (a) Right gastroepiploic artery was clipped. (b) Short gastric arteries were transected. (c) No. 7, 8a and 9 lymph nodes were dissected, and the left gastric artery was revealed. (d) Gastric mobilisation was performed towards the oesophageal hiatus

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  Discussion Top


Between January 2019 and February 2020, eight patients with thoracic oesophageal cancer underwent RAMIE with HARS at our hospital. Ethics approval was obtained from the ethics committee of our hospital, and all patients provided their informed consent. Robotic surgery is expected to overcome the limitations of conventional laparoscopic surgery. Suda et al. reported that RAMIE results in fewer instances of recurrent laryngeal nerve paralysis compared to thoracoscopic oesophagectomy.[4] It has also been reported that, regarding lymphadenectomy, RAMIE has significant advantages over thoracoscopic oesophagectomy.[5] However, one of the disadvantages of robotic surgery is the high medical cost. When performing abdominal manipulation with HALS, another vessel sealer or ultrasonic coagulating device for laparoscopic surgery is required. This makes the cost of RAMIE even higher.

One of the advantages of HARS is that the robotic vessel sealer used for the thoracic phase can be used in the same way that it is used during the abdominal phase. Compared with using another vessel sealer or ultrasonic coagulating device for laparoscopic surgery, using a robotic vessel sealer can reduce costs by US$600 to US$900 per procedure. During HALS, the operator can use only one pair of laparoscopic forceps at one time. However, surgery can be performed more precisely during HARS because the surgeon can use two pairs of forceps simultaneously. In addition, during HARS, the risk of damaging the stomach for the reconstruction is as low as it is during HALS, because the stomach and omentum can be gently held by the assistant's hand. HARS may reduce the number of injuries of the stomach and the gastroepiploic arcade used for reconstruction compared to performing abdominal manipulations by a robot, because there is no sense of touch or force during pure robotic surgery.

The number of robotic arms is reduced from four to three during HARS. However, the operative cavity is not narrowed compared to when four-arm robotic surgery is performed because the assistant surgeon can create a large field of view by hand.

Regarding the safety of HARS, it is important to maintain close communication during surgery so that the intention of the operator is understood by the assistant surgeon. Moreover, the operator must manipulate the robot slowly in a position where the assistant's fingers are always visible on the monitor; if this is not performed, then the assistant surgeon's hand may be injured by the robotic arms or instruments. The lack of tactile feedback to the operator is an important drawback of HARS. It is important always to keep the robotic forceps and the assistant's hands apart as much as possible to avoid hand injury. When operating on the omental side, the assistant's hand should be placed on the right side of the patient; however, when operating on the superior margin of the pancreas, the hand should be placed on the ventral side. In the case of bleeding, the assistant can insert a suction tube or other device in the number 2 port by removing the number 2 arm from the robot. This port arrangement involves exactly the same position as during HALS, and it is easy to change to a normal HALS procedure instantly.

In our series, the median number of dissected abdominal lymph nodes was 19.5 (range, 14–40). The median operative time for extracorporeal manipulation and preparation for the roll-in of the robot was 39.5 (range, 26–46) min. The median console time was 45.5 (range, 25–60) min. In all cases, blood loss was minimal. There were no intraoperative or postoperative complications related to the use of the robot.


  Conclusion Top


HARS seems to be feasible for abdominal manipulation during oesophageal cancer surgery.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Oshikiri T, Yasuda T, Kawasaki K, Harada H, Oyama M, Hasegawa H, et al. Hand-assisted laparoscopic surgery (HALS) is associated with less-restrictive ventilatory impairment and less risk for pulmonary complication than open laparotomy in thoracoscopic esophagectomy. Surgery 2016;159:459-66.  Back to cited text no. 1
    
2.
Johnston CR, Lawther RE. Cost-effective port for hand-assisted laparoscopic surgery (HALS). Tech Coloproctol 2014;18:199-200.  Back to cited text no. 2
    
3.
Suda K, Nakauchi M, Inaba K, Ishida Y, Uyama I. Robotic surgery for upper gastrointestinal cancer: Current status and future perspectives. Dig Endosc 2016;28:701-13.  Back to cited text no. 3
    
4.
Suda K, Ishida Y, Kawamura Y, Inaba K, Kanaya S, Teramukai S, et al. Robot-assisted thoracoscopic lymphadenectomy along the left recurrent laryngeal nerve for esophageal squamous cell carcinoma in the prone position: Technical report and short-term outcomes. World J Surg 2012;36:1608-16.  Back to cited text no. 4
    
5.
Deng HY, Huang WX, Li G, Li SX, Luo J, Alai G, et al. Comparison of short-term outcomes between robot-assisted minimally invasive esophagectomy and video-assisted minimally invasive esophagectomy in treating middle thoracic esophageal cancer. Dis Esophagus 2018;31.doi: 10.1093/dote/doy012.  Back to cited text no. 5
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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2004 Journal of Minimal Access Surgery
Published by Wolters Kluwer - Medknow
Online since 15th August '04