A Robotic Completely Intercorporeal Jejunal Pouch Reconstruction after Gastrectomy

Abstract

Robotic surgery is increasingly gaining importance. While initial results suggest an advantage of the robotic over the minimally invasive approach in patients with gastric cancer, definitive proof of its superiority has yet to be provided. There are numerous approaches to recreate a gastric reservoir after a total gastrectomy. However, a major disadvantage of most conventional reconstructions are long term effects such as dumping syndrome, afferent loop syndrome and poor nutrition intake with severe impact on the patient quality of life. The jejunal pouch reconstruction is a beneficial reconstruction, which provides a larger reservoir capacity after gastrectomy and prevents anastomotic stenosis and dumping syndrome. The completely intercorporeal approach with a Pfannenstiel incision instead of an unfavorable midline incision can potentially decrease delayed complications such as incision hernias. With the increased deployment of robotic surgery, a complete intercorporeal reconstruction is now possible without major increase in operating time or further technical weak points. We provide for the first time a detailed technical explanation of the completely intercorporeal robotic jejunal pouch reconstruction after gastrectomy.

Keywords: Hunt-Lawrence; Pfannenstiel incision; gastrectomy; gastric cancer; pouch; robot.

Figure 1

Setting description of the Da Vinci robotic system in the operating room. After the usual surgical preparations, the surgeon is seated at the da Vinci system console.

Figure 2

Trocar placement. A. Camera port (8 mm). B. 1. Robotic arm (12 mm). C. 2. Robotic arm (12 mm). D. 3. Robotic arm (8 mm). E. Assistant trocar (12 mm). The recommended distance between the port trocars is 8 cm between A and B, as well as B and D, and 12 cm between A and C. The incision for the optic can be done above or under the navel, depending on the patient’s height and torso length. The recommended distance from the camera trocar to the sternum is 20 cm. At least 2 cm distance from the bottom edge of the rib cage is recommended.

Figure 3

Lymphadenectomy. (A) Exposure of the right gastroepiploic vein. (B) Exposure of the celiac trunc, the common hepatic artery, the splenic artery. The left gastric artery has been divided. (C) Exposure of the gastroduodenal artery, the common hepatic artery and the proper hepatic artery. The right gastric artery has been divided. (D) Closure of the duodenal stump.

Figure 4

Jejunal pouch reconstruction. (A) A jejunal pouch is produced using an endoscopic stapler, two to three cartridges are usually required. (B) Closure of the enterotomy at the aboral (distal) end of the pouch. (C) Creation of the posterior wall of the esophagojejunostomy using a linear stapler. (D) The anterior wall of the esophagojejunostomie is created by means of barbed sutures.

Figure 5

Jejunal pouch reconstruction—model; A. Esophagus. B. Jejunal pouch (~15 cm). C. Esophagojejunostomy (modified collard anastomosis). D. Jejunal plication. E. Jejunal stump. F. Intentional incomplete stapling of the jejunal plication. G. Barbed suturing of the stapler insertion area.