Trans-Umbilical Lymphadenectomy Using an Articulating Bipolar Vessel-Sealing Device (TULAB) during Robotic Surgery for Gastric Cancer: Enhancing the Surgeon's Eye for Reduced-Port Robotic Gastrectomy

Abstract

Background: Docking the scope and instruments through a multi-channel trocar has enabled reduced-port robotic distal gastrectomy (RRDG) for gastric cancer. To facilitate lymphadenectomy over the anatomical hindrances during RRDG, we recently introduced the Vessel Sealer Extend^® (VSE) (Intuitive Surgical, Sunnyvale, CA, USA), a bipolar vessel-sealing device (BVSD) with an articulating jaw.

Methods: From May 2020 to August 2023, we performed RRDG to treat T1 gastric cancer. One endoscope arm and three instrument arms of the da Vinci^® Xi Surgical System (Intuitive Surgical) were used. During the lymphadenectomy, the endoscope and VSE (Intuitive Surgical) were docked through a multi-channel trocar established on a trans-umbilical incision. Two Cardiere forceps were docked through cannulas established on each flank. A trans-umbilical lymphadenectomy using an articulating BVSD (TULAB) was then performed.

Results: A total of 42 patients underwent planned RRDG with the TULAB technique. The number of retrieved lymph nodes did not differ between the patients who underwent RRDG and those who underwent conventional laparoscopic distal gastrectomies (CLDG) (p = 0.362). There was no statistically significant difference in postoperative complications between the RRDG and CLDG group (p = 0.189). The mean time to first semi-fluid diet was shorter in the patients who underwent RRDG than CLDG (p = 0.030), and the incidence of postoperative ileus was lower in the RRDG group than the CLDG group (0% and 9.9%, respectively, p = 0.034).

Conclusions: Despite use of fewer ports, RRDG with TULAB had similar outcomes to CLDG in terms of the incidence of postoperative morbidity and the number of harvested lymph nodes. Furthermore, by reducing the number of incisions, the incidence of the intra-abdominal adhesions can potentially be lowered when RRDG is used.

Keywords: Vessel Sealer Extend® (VSE); gastric cancer; reduced-port robotic distal gastrectomy (RRDG); trans-umbilical lymphadenectomy using an articulating BVSD (TULAB).

Figure 1

Port locations on the abdomen. (a) Location of the ports in a reduced-port robotic distal gastrectomy (the robot arm docked to each port is indicated in parentheses). (b) Location of the ports in a conventional laparoscopic distal gastrectomy.

Figure 2

Images of a lymphadenectomy using the Vessel Sealer Extend^® (Intuitive Surgical, Sunnyvale, CA, USA). (a) Lymphadenectomy in lymph node 4sb (GEA, gastro-epiploic arcade; LN, lymph node); the greater curvature side of the gastric fundus was cleared using VSE (second arm), with the stomach pulled using Cadiere forceps (first arm). (b) Lymphadenectomy in lymph node 6 (RGEA, right gastro–epiploic artery; RGEV, right gastro-epiploic vein); the right gastro–epiploic artery was divided using VSE (second arm), with the duodenum pulled cranially using Cardiere forceps (first arm). (c) Lymphadenectomy in lymph node 5 (CHA, common hepatic artery; RGA, right gastric artery); the right gastric artery was divided using VSE (second arm), with the duodenum pulled caudally using Cardiere forceps (first arm). (d) Lymphadenectomy in lymph node 8 (LN, lymph node; RGA, right gastric artery); the supra-pancreatic lymph node was dissected using VSE (second arm), with the left gastric pedicle pulled cranially using Cardiere forceps (first arm). (e) Lymphadenectomy in lymph node 7 (CHA, common hepatic artery; LGA, left gastric artery; RGA, right gastric artery; SA, splenic artery); the left gastric artery was divided using VSE (second arm), with the left gastric pedicle pulled cranially using Cardiere forceps (first arm). (f) Lymphadenectomy in lymph node 1 (LGA, left gastric artery); the lesser curvature side of the esophago–gastric junction was cleared using VSE (second arm), with the left lateral section of the liver pushed cranially using Cadiere forceps (first arm).

Figure 3

Images of robot-controlled surgical stapling. (a) The duodenum was divided using the robot-controlled surgical stapler (second arm) (GB, gall bladder). (b) The stomach was divided using the robot-controlled surgical stapler (second arm). (c) A gastro–jejunal anastomosis was performed using the robot-controlled surgical stapler (second arm).

Figure 4

Port wounds on the abdomen. (a) Location of port wounds in a reduced-port robotic distal gastrectomy (red line indicates the costal margin). (b) Location of port wounds in a conventional laparoscopic distal gastrectomy (red line indicates the costal margin).

Figure 5

Exposure of the portal vein and the splenic vein during a lymphadenectomy. (a) The articulating bipolar vessel-sealing device (BVSD) was advantageous during the lymphadenectomy in lymph nodes 8 and 12a. (b) Due to the absence of a cavitation effect, it was difficult to perform a trans-umbilical lymphadenectomy using the articulating BVSD in lymph node 11p.