Atlas of Minimally Invasive Techniques in Upper Gastrointestinal Surgery 9783030551759, 9783030551766

Table of contents :
Preface
Contents
Contributors
1 Surgical Anatomy of the Esophagus
1.1 Introduction
1.2 Composition
1.3 Fixation
1.4 Topography
1.5 Arteries and Veins
1.6 Lymphatics
1.7 Innervation
References
2 A Concentric-Structured Model for the Understanding of the Surgical Anatomy in the Upper Mediastinum Required for Esophagectomy with Radical Mediastinal Lymph Node Dissection
2.1 Introduction
2.2 Surgical Anatomical Model
2.3 Validation of the Surgical Procedure
References
3 A Surgical Concept for the Subcarinal Anatomy of the Esophagus and Mediastinum
3.1 Introduction
3.2 Surgical Anatomical Observation
References
4 270 Degrees Fundoplication for Gastroesophageal Reflux Esophagitis
4.1 Description of the Surgical Technique
4.1.1 Patient and Trocar Position
4.1.2 Position a Liver Retractor
4.1.3 Opening the Pars Flaccida of the Gastrohepatic Ligament
4.1.4 Incision of the Oesophago-Phrenic Ligament
4.1.5 Blunt Mobilization of the Oesophagus Below the Dorsal Vagal Nerve
4.1.6 Division of the Short Gastric Vessels and Gastrosplenic Ligament
4.1.7 Cut Oesophago-Phrenic Ligament on the Left Side
4.1.8 Dissection of the Left Crus from the patient’s Right Side
4.1.9 Keep Track of the Vagal Nerves
4.1.10 Start of the Suturing of the Crus
4.1.11 Fundus Pull Through
4.1.12 Suturing of the Fundus and Creation of the Fundoplication
4.1.13 Checking and Ending
References
5 Laparoscopic Nissen Fundoplication
5.1 Introduction
5.2 Description of the Surgical Technique
5.2.1 Patient and Trocars’ Position
5.2.2 Exposure of Operative Field
5.2.3 Start the Intervention
5.2.4 Circumferential Exposure of the Distal Esophagus
5.2.5 Taping of the Esophagus for Retraction
5.2.6 Mediastinal Dissection and Esophagus Mobilization
5.2.7 Construction of Floppy Wrap
5.2.8 Crural Opposition
5.2.9 Construction of Fundoplication
5.2.10 Completed Procedure
References
6 Minimally Invasive Surgery of Paraesophageal Hernias
6.1 Introduction
6.2 Description of the Surgical Technique (Video 6.1)
6.2.1 Instruments and Equipment Required
6.2.2 Patient and Trocars’ Position
6.2.3 Reduction of the Sac and Its Contents to the Abdominal Cavity
6.2.4 Division of the First Short Vessels
6.2.5 Dissection of the Sac, from the Left Crus Anti-Clockwise from Left to Right
6.2.6 Dissection Continues to the Dome of the Hiatus and the Right Crus
6.2.7 The Sac (and Lipomas) is Completely Dissected from Mediastinum into the Abdominal Cavity
6.2.8 Mobilization of the Esophagus by Pulling Down the Sac
6.2.9 Creation of a Retroesophageal Window
6.2.10 Approximation of the Pillars Using a Bougie (Foucher) for Calibration
6.2.11 Mesh Placement
6.2.12 Creation of 360 Degrees Fundoplication
References
7 Minimally Invasive Treatment of Esophageal Leiomyoma
7.1 Introduction
7.2 Description of the Surgical Technique (See Videos 7.1 and 7.2)
References
8 Peroral Endoscopic Myotomy (POEM) for Achalasia
8.1 Introduction
8.2 Description of the Peroral Endoscopic Myotomy (POEM) Technique (Video 8.1)
8.3 Description of the Endoscopic Procedure
8.3.1 Post-Procedural Management
References
9 Laparoscopic Heller Myotomy and Dor Fundoplication for Treatment of Esophageal Achalasia: Surgical Technique
9.1 Background
9.2 Surgical Technique. Step by Step
References
10 Endoscopic Treatment of Early Esophageal Cancer
10.1 Introduction
10.2 Description of the Surgical Technique (Video 10.1)
10.2.1 Lift-Suck-Cut Technique
10.2.2 Ligate-And-Cut Technique
10.2.3 Endoscopic Submucosal Dissection
References
11 Transmediastinal Approach for Esophageal Cancer: Upper and Middle Mediastinal Dissection with Single-Port Technique
11.1 Introduction
11.2 Description of the Surgical Technique of Single-Port MATHE (Videos 11.1–11.4)
11.2.1 Surgical Team Members
11.2.2 Left Cervical Procedure
11.2.3 Right Cervical Procedure (Fig. )
11.2.4 Transhiatal procedure (Figs. and )
11.2.5 Esophageal Reconstruction
11.2.6 Postoperative Management
11.3 Conclusions
References
12 Laparoscopic Transhiatal Resection for Distal Esophageal and Gastro-Esophageal Junction Cancer
12.1 Introduction
12.2 Description of the Operative Technique
References
13 Robot-Assisted Minimally Invasive Transhiatal Esophagectomy
13.1 Introduction
13.2 Description of the Surgical Technique
13.2.1 Position of the Robot Xi DaVinci Platform (Intuitive Surgical, Sunnyvale CA)
13.2.2 Patient and Trocar Position
13.2.3 Mobilization of the Stomach and Esophagus
13.2.4 Steps Through Hand Port Supraumbilical—7 cm (Fig. )
13.2.5 Mobilization of the Cervical Esophagus and Resection
13.2.6 Gastric Conduit Creation and Passage Through the Posterior Mediastinum to the Neck
13.2.7 Narrowing the Hiatus
13.2.8 Cervical Esophagogastric Anastomosis According to Orringer
References
14 Minimally Invasive Esophagectomy: Ivor Lewis
14.1 Introduction
14.2 Description of the Surgical Technique (see Video 14.1)
14.2.1 Laparoscopic Phase
14.2.2 Thoracoscopic Phase in Prone Position (Single-Lumen Tube)
15 Thoracoscopic Radical Oesophagectomy for Cancer
15.1 Introduction
15.2 Thoracoscopic Mediastinal Dissection
15.2.1 Surgical Anatomy of Mediastinum with Reference to the Oesophagus
15.2.1.1 Layer Structures and Principle of Dissection in the Mediastinum
15.3 Description of the Surgical Technique (see Video 15.1)
15.3.1 Dissection of the Right Recurrent Nodes
15.3.2 Mobilization of the Dorsal Aspect of the Oesophagus
15.3.3 Mobilization of the Ventral Aspect of the Oesophagus
15.3.4 Dissection of the Left Recurrent Nodes
15.3.5 Dissection of the Tracheobronchial Nodes
References
16 Three-Stage McKeown Minimally Invasive Esophagectomy Procedure in Prone Position
16.1 Introduction
16.2 Step-By-Step Description of the Surgical Procedure (see Videos 16.1 and 16.2)
References
17 Robot-Assisted Minimally Invasive Esophagectomy (RAMIE)
17.1 Introduction
17.2 Description of the Surgical Technique (Robot-Assisted Minimally Invasive Thoraco-Laparoscopic Esophagectomy (RAMIE) at UMC Utrecht)
17.2.1 Thoracoscopic Preparation and Positioning
17.2.2 Thoracoscopic Phase: Operative Procedure
17.2.3 Laparoscopic Phase: Positioning
17.2.4 Laparoscopic Phase: Operative Procedure
17.2.5 Cervical Phase
17.3 Future Directions
17.4 Hand-Sewn Intrathoracic Anastomosis and Upper Esophageal Cancer
17.5 The Steps to Perform an Intrathoracic Gastroesophageal Anastomosis (see Videos 17.1–17.3)
17.6 cT4b Esophageal Cancer
17.7 Conclusion
References
18 Cervical Esophagogastric Anastomosis
18.1 Introduction
18.2 Description of the Operative Technique (see Video 18.1)
18.3 Stapled Anastomosis
18.4 Hand-Sewn Anastomosis
References
19 Intrathoracic Esophago-Gastrostomy After MIE Ivor Lewis Esophageal Resection: End-To-Side Anastomosis by Means of Circular Stapler. The Flap and Wrap Technique
19.1 Introduction
19.2 Description of the Surgical Procedure (see Video 19.1)
19.3 Thoracoscopic Phase in Prone Position
20 Intrathoracic Oesophago-Gastrostomy After MIE Ivor Lewis Resection: Side-To-Side Oesophago-Gastrostomy by Means of a Linear Stapler
20.1 Description of the Operative Procedure (see Video 20.1)
21 Intrathoracic Esophago-Gastrostomy After MIE Ivor Lewis Resection: End-To-Side Anastomosis by Means of a Circular Stapler and Endoloop
21.1 Description of the Operative Procedure (see Video 21.1)
References
22 Intrathoracic Esophago-Gastrostomy After MIE Ivor Lewis Resection: End-to-Side Anastomosis Using a Double Endoloop System
22.1 Description of the Surgical Procedure (See Video 22.1)
Reference
23 Intrathoracic Esophago-Gastrostomy After MIE Ivor Lewis Resection: End-To-Side Hand-Sewn Anastomosis
23.1 Description of the Surgical Technique (see Video 23.1)
Reference
24 Intrathoracic Robot-Assisted Minimally Invasive Esophagectomy (RAMIE) Ivor Lewis End-To-Side Anastomosis
24.1 Description of the Surgical Technique (See Video 24.1)
References (References 2 and 3 could be deleted)
25 Surgical Anatomy of the Stomach and the Omental Bursa
25.1 Introduction
25.2 Anatomical Features
25.3 Structure
25.4 Topographical Relationships
25.5 Vascular Supply
25.6 Lymphatic Drainage
25.7 Innervation
25.8 Omental Bursa
References
26 Minimally Invasive Treatment of Gastric GIST
26.1 Introduction
26.2 Description of the Surgical Technique
26.2.1 Transgastric Resection
26.2.2 Transgastric Resection
References
27 Minimally Invasive Surgery for Treatment of Complications of Gastroduodenal Ulcer
27.1 Introduction
27.2 Description of the Surgical Technique (Videos 27.1 and 27.2)
27.2.1 Ulcer Perforation
27.2.2 Bleeding
27.2.3 Stenosis
References
28 Laparoscopic Adjustable Gastric Band
28.1 Introduction
28.2 Description of the Surgical Technique (Video 28.1)
References
29 Laparoscopic Roux-En-Y Gastric Bypass
29.1 Introduction
29.2 Description of the Surgical Technique (Video 29.1)
References
30 Laparoscopic Sleeve Gastrectomy
30.1 Introduction
30.2 Description of the Surgical Technique (Video 30.1)
References
31 Laparoscopic Duodenal Switch
31.1 Introduction
31.1.1 Description of the Surgical Technique (Video 31.1) [1]
References
32 Single Anastomosis Duodenoileal Bypass with Sleeve Gastrectomy
32.1 Introduction
32.2 Description of the Surgical Technique (Video 32.1)
References
33 Endoscopic and Minimally Invasive Surgical Treatment of Early Gastric Cancer
33.1 Introduction
33.1.1 Laparoscopic Distal Gastrectomy
33.1.2 Description of the Operative Technique (Videos 33.1 and 33.2)
33.1.3 Postoperative Management
33.1.4 Tips, Tricks, and Pitfalls
33.2 Laparoscopy and Endoscopy Cooperative Surgery for Early Gastric Cancer with Sentinel Lymph Node Biopsy
33.2.1 Description of the Operative Technique (See Video 33.1)
References
34 Laparoscopic Partial Gastrectomy for Gastric Cancer
34.1 Introduction
34.2 Clinical Staging and Surgical Plan
34.3 Description of the Surgical Technique (See Video 34.1)
34.4 Description of the Surgical Technique of Roux Y gastrojejunostomy anastomosis
References
35 Modified Billroth-I Delta-Shaped Anastomosis After Distal Gastrectomy
35.1 Introduction
35.2 Description of the Surgical Technique (See Video 35.1)
References
36 Robotic Distal Gastrectomy for Gastric Cancer
36.1 Introduction
36.2 Indication
36.3 Description of the Surgical Steps (See Video 36.1)
References
37 Laparoscopic Total Gastrectomy for Gastric Cancer
37.1 Introduction
37.2 Clinical Staging and Surgical Plan
37.3 Description of the Surgical Technique (See Video 37.1)
37.4 Reconstruction After Total Gastrectomy
References
38 Spleen-Preserving Splenic Hilar Dissection for Proximal Gastric Cancer
38.1 Introduction
References
39 End-To-Side Esophagojejunal Anastomosis Using the Circular Orvil Device
39.1 End-To-Side Esophagojejunal Anastomosis Using the Orvil Device
39.2 Description of the Surgical Technique (See Videos 39.1 and 39.2)
39.3 Linear Side-To-Side Esophagojejunal Anastomosis
39.4 Description of the Surgical Technique (See Video 39.2)
References
40 Hand-Sewn Anastomosis After 95% Gastrectomy, Total Gastrectomy, and Total Gastrectomy Extended to the Distal Esophagus for Gastric Cancer
40.1 Introduction
40.2 Description of the Operative Technique (See Videos 40.1–40.4)
References
41 Robot-Assisted Total Gastrectomy for Gastric Cancer
41.1 Description of the Surgical Procedure (See Video 41.1)
References
42 Laparoscopic Immunofluorescence-Guided Lymphadenectomy in Gastric Cancer Surgery
42.1 Near-Infrared Fluorescent Imaging for Gastric Cancer Surgery
42.2 Description of the Surgical Procedure (See Video 42.1)
42.3 Laparoscopic Total Gastrectomy with D2 Lymph Node Dissection
42.4 Robotic Gastrectomy
References
43 Final Considerations
43.1 Proficiencies
43.2 Permanent Learning
43.3 Progress
Index

Citation preview

M. Asunción Acosta Miguel A. Cuesta Marcos Bruna Editors

Atlas of Minimally Invasive Techniques in Upper Gastrointestinal Surgery

Atlas of Minimally Invasive Techniques in Upper Gastrointestinal Surgery

M. Asunción Acosta · Miguel A. Cuesta · Marcos Bruna Editors

Atlas of Minimally Invasive Techniques in Upper Gastrointestinal Surgery

Editors M. Asunción Acosta Unidad de Cirugia Esofago-gàstrica, Hospital Universitario de Gran Canaria “Dr. Negrìn” Las Palmas, Gran Canaria, Spain

Miguel A. Cuesta Department of Surgery Amsterdam University Medical Centre (UMC) Amsterdam, The Netherlands

Marcos Bruna Department of Surgery Hospital Universitario y Politècnico La Fè Valencia, Spain

ISBN 978-3-030-55175-9 ISBN 978-3-030-55176-6  (eBook) https://doi.org/10.1007/978-3-030-55176-6 © Springer Nature Switzerland AG 2021 This work is subject to copyright. All rights are reserved by the Publisher, whether the whole or part of the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfilms or in any other physical way, and transmission or information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed. The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use. The publisher, the authors and the editors are safe to assume that the advice and information in this book are believed to be true and accurate at the date of publication. Neither the publisher nor the authors or the editors give a warranty, expressed or implied, with respect to the material contained herein or for any errors or omissions that may have been made. The publisher remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. This Springer imprint is published by the registered company Springer Nature Switzerland AG The registered company address is: Gewerbestrasse 11, 6330 Cham, Switzerland

Quiero dedicar este Atlas a mi marido, Rafael. Él es la fuente de mi felicidad, mantiene en pie mi preciosa familia y permite que yo vuele ... I want to dedicate this Atlas to my husband, Rafael. He is the source of my happiness, he holds down my precious family, and he allows me to fly ... M. Asunción Acosta I would like to thank my wife Ineke Radder for her unconditional support and patience, and dedicate this work to all our patients without whom this Atlas would not have happened. Miguel A. Cuesta To my family and masters for being always close to me and giving to me so many wonderful things. Marcos Bruna

Preface

Since the first interventions of laparoscopic antireflux surgery in the early 1990 our interest has been the implementation of minimally invasive procedures in all Upper Gastrointestinal (Upper GI) pathology, benign and malignant. Surgeons continually strive to provide the best care possible for their patients. This focus on enhancing the quality of surgery brings them to employ the Minimally Invasive Surgery (MIS) approach. Doing so, they try to reduce postoperative pain, lower the risk of postoperative complications and increase quality of life. Surgeons have in the past decades demonstrated major progress in improving surgery. We have seen diagnostic invasive procedures replaced by a variety of imaging techniques providing high-resolution insight in the anatomical aspects of the disease, thereby allowing surgical teams to refine their surgical indications and approaches. Based on this better imaging we have seen the development of endoscopic treatments in early cancers, but also image-guided percutaneous placement of stents or drains for relieving obstructions or fluid collections that impede the recovery of patients. And finally, we have seen large abdominal incisions and extensive resections with huge blood losses replaced by minimal incisions and gentle dissection with minimal blood loss, thus allowing patients to ambulate very early after surgery and reassume their activities within days instead of long postoperative stays in the hospital. Moreover the fast track concepts have broken the conservative ideas of perioperative treatments, making the process of every surgical intervention a piece of objectiveness based on evidence. Hence it is no surprise that Minimally Invasive Surgery is currently the standard surgical treatment in almost all areas of Abdominal Surgery, such as gallbladder surgery, the whole benign gastrointestinal surgery, including bariatric surgery, esophageal, gastric and colorectal cancer surgery. Studies do continue to determine the quality of MIS. To be sure, the notion that Minimally Invasive procedures in Upper GI Surgery, especially the oncological processes, are as efficient or even better than their counterpart of Open Surgery, still follows different phases of becoming evident. For some procedures, like esophageal resection and partial gastrectomy for cancer the evidence of the supremacy of MIS is now reasonably certain. High evidence even suggests that MIS may be superior to the counterpart open resections by providing clearer short-term advantages and equal oncologic safety. Other procedures, such as total gastrectomies, hepatic resections and duodenopancreatectomies for pancreatic head cancer are still subject to high-level studies and big data analysis for determining how evidence-based these standard procedures are. In benign diseases, evidence that MIS is better than the conventional is given by high evidence studies and big data analysis with the conclusion that MIS procedures are safe and better in outcomes. Significant is that the introduction of high-definition imaging, 3D technology and robot-assisted surgery demonstrate the advantages of having a better visualization and ergonomy. These techniques involve the capacity to dissect and reconstruct tissues in difficult to locate places and suffice with a relative short learning curve. But the improvements in surgery are constantly moving forward. The concept that collected big data of high digital imaging may facilitate processes of artificial intelligence in the surgical interventions is gaining in acceptance. Using these improvements we should create more efficient and safe surgical vii

viii

Preface

paths for optimal oncological resections in a near future. Despite successes, Upper GI MIS procedures remain difficult to standardize because of the complicated and tortuous surgical anatomy and due to the limited numbers of patients, undergoing these procedures, exception is the bariatric surgery, in comparison with for example the high numbers in colorectal surgery. The objective of an Atlas like this in comparison with a standard book of surgery is to offer after a short introduction to the issue the key steps of operative technique schematic accompanied by clear illustrations, operative photo’s and videos. Despite the body of this ATLAS is formed by bariatric and oncological surgery of esophageal and gastric cancer all other Upper GI diseases are depicted here. The philosophy we follow is that once a good indication is made for surgery, optimal peroperative preparation of the patients is paramount for an optimal outcome. In oncological processes the combination of an optimal use of neoadjuvant therapy, if indicated, with Minimally Invasive Surgery will achieve the best outcome for the patient offering a high quality of life. Our objective in this ATLAS is to depict the current situation of Minimal Upper GI Surgery , benign and oncological. By doing so, we demonstrate how to perform these procedures with the minimum risk for the patients and simultaneously obtaining as many advantages as is feasible. The setup for this book has two sections: the esophageal and the gastric surgery. Each section starts with a chapter dedicated to surgical anatomy followed first of all by different chapters on benign pathology, endoscopic treatment and chapters dedicated to different techniques available for cancer surgery. Other chapters treat the specific operative techniques of MIS, whereby the robot-assisted minimally invasive surgery and near infrared technology is used. Knowledge of surgical anatomy is very important for each surgeon and helps to standardize the use of convenient dissection planes and to perform a standard oncological resection. The call for achieving higher proficiencies in MIS is clear. Mastering the MIS procedures is arduous and may take time. We realize that surgeons and their teams dedicated to Upper GI surgery may have to gain proficiencies involving a lengthy learning curve while under the control and assistance of a master. Moreover, readers of this book will be aided by a well-chosen collection of videos that describe the accomplishment of the surgical procedures in MIS. Our gratitude for the splendid contributions of all authors is great. Their dedication to the design and implementation of the procedures treated in this volume is encouraging. We hope that this book will enrich the knowledge and understanding of surgeons and surgical residents around the world whom are dedicated to Upper Gastrointestinal Surgery and will inspire these professionals to persist in improving on surgery. Las Palmas, Spain Amsterdam, The Netherlands Valencia, Spain

M. Asunción Acosta Miguel A. Cuesta Marcos Bruna

Contents

1

Surgical Anatomy of the Esophagus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 Teus J. Weijs and Ronald L. A. W. Bleys

2

A Concentric-Structured Model for the Understanding of the Surgical Anatomy in the Upper Mediastinum Required for Esophagectomy with Radical Mediastinal Lymph Node Dissection. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 Hiroyuki Daiko

3

A Surgical Concept for the Subcarinal Anatomy of the Esophagus and Mediastinum . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13 Miguel A. Cuesta

4

270 Degrees Fundoplication for Gastroesophageal Reflux Esophagitis. . . . . . . . 19 Ivo A. M. J. Broeders

5

Laparoscopic Nissen Fundoplication. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29 Bernard Dallemagne

6

Minimally Invasive Surgery of Paraesophageal Hernias. . . . . . . . . . . . . . . . . . . . 39 Salvador Morales-Conde, Francisco Lopez Bernal and Isaías Alarcón

7

Minimally Invasive Treatment of Esophageal Leiomyoma. . . . . . . . . . . . . . . . . . 47 Donald. L. van der Peet and Miguel A. Cuesta

8

Peroral Endoscopic Myotomy (POEM) for Achalasia. . . . . . . . . . . . . . . . . . . . . . 51 Barbara A. J. Bastiaansen, André J. P. M. Smout and Paul Fockens

9

Laparoscopic Heller Myotomy and Dor Fundoplication for Treatment of Esophageal Achalasia: Surgical Technique. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55 Eduardo M. Targarona, Sonia Fernandez Ananin and Carmen Balagué Ponz

10 Endoscopic Treatment of Early Esophageal Cancer. . . . . . . . . . . . . . . . . . . . . . . 61 Bas L. A. M. Weusten 11 Transmediastinal Approach for Esophageal Cancer: Upper and Middle Mediastinal Dissection with Single-Port Technique. . . . . . . . . . . . . . . . . . . . . . . . 71 Hitoshi Fujiwara, Atsushi Shiozaki, Hirotaka Konishi and Eigo Otsuji 12 Laparoscopic Transhiatal Resection for Distal Esophageal and GastroEsophageal Junction Cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89 Miguel A. Cuesta and Donald L. van der Peet 13 Robot-Assisted Minimally Invasive Transhiatal Esophagectomy. . . . . . . . . . . . . 99 Rishindra M. Reddy 14 Minimally Invasive Esophagectomy: Ivor Lewis. . . . . . . . . . . . . . . . . . . . . . . . . . 109 Misha Luyer and Grard Nieuwenhuijzen

ix

x

15 Thoracoscopic Radical Oesophagectomy for Cancer . . . . . . . . . . . . . . . . . . . . . . 121 Harushi Osugi, Kousuke Narumiya and Kenji Kudou 16 Three-Stage McKeown Minimally Invasive Esophagectomy Procedure in Prone Position . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 131 Fernando Mingol Navarro, M. Asunción Acosta, Marcos Bruna and Miguel A. Cuesta 17 Robot-Assisted Minimally Invasive Esophagectomy (RAMIE) . . . . . . . . . . . . . . 143 Richard van Hillegersberg, Pieter C. van der Sluis and Jelle P. Ruurda 18 Cervical Esophagogastric Anastomosis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 153 M. Asunción Acosta and Salvador Navarro Soto 19 Intrathoracic Esophago-Gastrostomy After MIE Ivor Lewis Esophageal Resection: End-To-Side Anastomosis by Means of Circular Stapler. The Flap and Wrap Technique. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 159 Suzanne S. Gisbertz and Mark I. van Berge Henegouwen 20 Intrathoracic Oesophago-Gastrostomy After MIE Ivor Lewis Resection: Side-To-Side Oesophago-Gastrostomy by Means of a Linear Stapler. . . . . . . . . 163 Misha Luyer and Grard Nieuwenhuijzen 21 Intrathoracic Esophago-Gastrostomy After MIE Ivor Lewis Resection: End-To-Side Anastomosis by Means of a Circular Stapler and Endoloop . . . . . 171 Fernando Mingol Navarro 22 Intrathoracic Esophago-Gastrostomy After MIE Ivor Lewis Resection: End-to-Side Anastomosis Using a Double Endoloop System . . . . . . . . . . . . . . . . 181 Camiel Rosman and Bastiaan Klarenbeek 23 Intrathoracic Esophago-Gastrostomy After MIE Ivor Lewis Resection: End-To-Side Hand-Sewn Anastomosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 191 Guy-Bernard Cadiere and Benjamin Cadiere 24 Intrathoracic Robot-Assisted Minimally Invasive Esophagectomy (RAMIE) Ivor Lewis End-To-Side Anastomosis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 195 Ismael Diez del Val and Carlos Loureiro González 25 Surgical Anatomy of the Stomach and the Omental Bursa. . . . . . . . . . . . . . . . . . 201 Ronald L. A. W. Bleys and Teus J. Weijs 26 Minimally Invasive Treatment of Gastric GIST. . . . . . . . . . . . . . . . . . . . . . . . . . . 207 Carlos Moreno-Sanz and Miguel A. Cuesta 27 Minimally Invasive Surgery for Treatment of Complications of Gastroduodenal Ulcer. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 215 José A. Ramírez, M. Asunción Acosta and Marcos Bruna 28 Laparoscopic Adjustable Gastric Band. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 221 Jaime Ponce 29 Laparoscopic Roux-En-Y Gastric Bypass. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 229 J. Caetano Marchesini and Natan Zundel 30 Laparoscopic Sleeve Gastrectomy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 237 Michel Gagner 31 Laparoscopic Duodenal Switch. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 243 Jacques Himpens and Roel Bolckmans

Contents

Contents

xi

32 Single Anastomosis Duodenoileal Bypass with Sleeve Gastrectomy. . . . . . . . . . . 249 Andrés Sánchez-Pernaute, María Elia Pérez Aguirre and Aida Pérez Jiménez 33 Endoscopic and Minimally Invasive Surgical Treatment of Early Gastric Cancer. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 257 Noriyuki Inaki 34 Laparoscopic Partial Gastrectomy for Gastric Cancer. . . . . . . . . . . . . . . . . . . . . 271 Antonio Talvane Torres de Oliveira, Croider Franco Lacerda, Paulo A. Bertulucci and Miguel A. Cuesta 35 Modified Billroth-I Delta-Shaped Anastomosis After Distal Gastrectomy . . . . . 279 Takahiro Kinoshita 36 Robotic Distal Gastrectomy for Gastric Cancer. . . . . . . . . . . . . . . . . . . . . . . . . . . 285 Young-Woo Kim and Won Ho Han 37 Laparoscopic Total Gastrectomy for Gastric Cancer . . . . . . . . . . . . . . . . . . . . . . 299 Antonio Talvane Torres de Oliveira, Croider Franco Lacerda, Paulo A. Bertulucci and Miguel A. Cuesta 38 Spleen-Preserving Splenic Hilar Dissection for Proximal Gastric Cancer . . . . . 311 Takahiro Kinoshita 39 End-To-Side Esophagojejunal Anastomosis Using the Circular Orvil Device . . . . . 317 Suzanne S. Gisbertz and Mark I. van Berge Henegouwen 40 Hand-Sewn Anastomosis After 95% Gastrectomy, Total Gastrectomy, and Total Gastrectomy Extended to the Distal Esophagus for Gastric Cancer. . . . . 323 Juan Santiago Azagra, Beniamino Pascotto, Luca Arru, Francisco Javier Ibañez, Silviu T. Makkai-Popa and Martine Goergen 41 Robot-Assisted Total Gastrectomy for Gastric Cancer. . . . . . . . . . . . . . . . . . . . . 333 Felix Berlth and Han-Kwang Yang 42 Laparoscopic Immunofluorescence-Guided Lymphadenectomy in Gastric Cancer Surgery. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 343 Woo Jin Hyung and In Gyu Kwon 43 Final Considerations. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 365 M. Asunción Acosta, Miguel A. Cuesta and Marcos Bruna Index. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 367

Contributors

M. Asunción Acosta  Unidad de Cirugia Esofago-gàstrica, Hospital Universitario de Gran Canaria “Dr. Negrìn”, Las Palmas, Gran Canaria, Spain María Elia Pérez Aguirre Department of Surgery, Hospital Clínico San Carlos, Madrid, Spain Isaías Alarcón  Unit of Innovation in Minimally Invasive Surgery, University Hospital Virgen del Rocío, University of Sevilla, Sevilla, Spain Sonia Fernandez Ananin  Gastrointestinal Surgical Unit, Department of Surgery, Hospital Sant Pau, Autonomous University of Barcelona, Barcelona, Spain Luca Arru  Department of General and Minimally Invasive Surgery, CHL, Luxembourg City, Luxembourg Juan Santiago Azagra  Department of General and Minimally Invasive Surgery(Laparoscopy & Robotic), Centre Hospitalier de Luxembourg (CHL), L-1210 Luxembourg, Luxembourg Barbara A. J. Bastiaansen  Department of Gastroenterology and Hepatology, Amsterdam University Medical Center, University of Amsterdam, Amsterdam, The Netherlands Felix Berlth  Department of Surgery, Division of Gastrointestinal Surgery, Seoul National University Hospital, Seoul, Korea; Department of General, Visceral and Cancer Surgery, University Hospital of Cologne, Cologne, Germany Paulo A. Bertulucci  Department of Upper GI Surgery, Americas Medical City Hospital, Rio de Janeiro, Brazil Ronald L. A. W. Bleys  Department of Anatomy, University Medical Center Utrecht, Utrecht, The Netherlands Roel Bolckmans  Virginia Commonwealth University Hospitals, Richmond, VA, USA Ivo A. M. J. Broeders  Meander Medisch Centrum, Amersfoort and University of Twente, Enschede, The Netherlands Marcos Bruna  Department of Surgery, Hospital Universitario y Politécnico La Fé, Valencia, Spain Benjamin Cadiere  Department of Gastrointestinal Surgery, European School of Laparoscopic Surgery, Saint-Pierre University Hospital, Université Libre de Bruxelles, Brussels, Belgium Guy-Bernard Cadiere Service de Chirurgie Digestive, UMC Saint-Pierre, Bruxelles, Belgium Miguel A. Cuesta  Department of Surgery. Amsterdam UMC, Amsterdam, The Netherlands Hiroyuki Daiko Department of Esophageal Surgery, National Cancer Center Hospital, Tokyo, Japan

xiii

xiv

Bernard Dallemagne  L’Hopital and IRCAD, Strasbourg, France Antonio Talvane Torres de Oliveira  Department of Upper GI Surgery, Americas Medical City Hospital, Rio de Janeiro, Brazil Ismael Diez del Val  Department of Surgery, Hospital Universitario Basurto, Bilbao, Spain Paul Fockens Department of Gastroenterology and Hepatology, Amsterdam University Medical Center, University of Amsterdam, Amsterdam, The Netherlands Hitoshi Fujiwara  Division of Digestive Surgery, Department of Surgery, Kyoto Prefectural University of Medicine (KPUM), Kyoto, Japan Michel Gagner  Department of Surgery, Hopital du Sacre Coeur, Montreal, QC, Canada Suzanne S. Gisbertz Department of Surgery, Amsterdam University Medical Center, Amsterdam, The Netherlands Martine Goergen  Department of General and Minimally Invasive Surgery (Laparoscopy & Robotic), Centre Hospitalier de Luxembourg (CHL), L-1210 Luxembourg, Luxembourg Won Ho Han  Department of Cancer Control and Population Health, National Cancer Center Graduate School of Cancer Science and Policy & Center for Gastric Cancer, National Cancer Center, Ilsandonggu, Goyang, Republic of Korea Jacques Himpens  CHIREC Delta Hospital, Brussels, Belgium Woo Jin Hyung Department of Surgery, Yonsei University College of Medicine, Seoul, Republic of Korea Francisco Javier Ibañez Department of General and Minimally Invasive Surgery (Laparoscopy & Robotic), Centre Hospitalier de Luxembourg (CHL), L-1210 Luxembourg, Luxembourg Noriyuki Inaki  Department of Digestive and General Surgery, Juntendo University Urayasu Hospital, Urayasu, Japan Aida Pérez Jiménez  Department of Surgery, Hospital Universitario Puerta del Sur, Móstoles, Madrid, Spain Young-Woo Kim Department of Cancer Control and Population Health, National Cancer Center Graduate School of Cancer Science and Policy & Center for Gastric Cancer, National Cancer Center, Ilsandonggu, Goyang, Republic of Korea Takahiro Kinoshita Gastric Surgery Division, National Cancer Center Hospital East, Kashiwa, Japan Bastiaan Klarenbeek Department of Surgery, Radboudumc Hospital, Nijmegen, The Netherlands Hirotaka Konishi  Division of Digestive Surgery, Department of Surgery, Kyoto Prefectural University of Medicine (KPUM), Kyoto, Japan Kenji Kudou  Department of Surgery, Institute of Gastroenterology, Tokyo Women’s Medical University, Sinjuku-ku, Japan In Gyu Kwon Department of Surgery, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea Croider Franco Lacerda  Department of Upper GI Surgery, Americas Medical City Hospital, Rio de Janeiro, Brazil Francisco Lopez Bernal Unit of Innovation in Minimally Invasive Surgery, University Hospital Virgen del Rocío, University of Sevilla, Sevilla, Spain Carlos Loureiro González  Department of Surgery, Hospital Universitario Basurto, Bilbao, Spain

Contributors

Contributors

xv

Misha Luyer  Gastro-Intestinal and Oncological Surgery, Catharina Hospital, Eindhoven, The Netherlands Silviu T. Makkai-Popa Department of General and Minimally Invasive Surgery, CHL, Luxembourg City, Luxembourg J. Caetano Marchesini  Department of Endoscopy, Medical School of Mario Covas Hospital and Bariatric Surgery of Sirio Libanés Hospital, Sao Paulo, Brazil Fernando Mingol Navarro Department of Surgery, Esophageal Surgery Unit, Hospital Universitario y Politécnico La Fé, Valencia, Spain Salvador Morales-Conde Unit of Innovation in Minimally Invasive Surgery, University Hospital Virgen del Rocío, University of Sevilla, Sevilla, Spain Carlos Moreno-Sanz  Department of General and Digestive Surgery, Hospital General La Mancha Centro, Alcazar de San Juan, Ciudad Real, Spain Kousuke Narumiya  Department of Surgery, Institute of Gastroenterology, Tokyo Women’s Medical University, Sinjuku-ku, Japan Salvador Navarro Soto  Department of Surgery, Parc Taulí, Sabadell, Barcelona, Spain Grard Nieuwenhuijzen Gastro-Intestinal and Oncological Surgery, Catharina Hospital, Eindhoven, The Netherlands Harushi Osugi Department of Surgery, Institute of Gastroenterology, Tokyo Women’s Medical University, Sinjuku-ku, Japan Eigo Otsuji Division of Digestive Surgery, Department of Surgery, Kyoto Prefectural University of Medicine (KPUM), Kyoto, Japan Beniamino Pascotto  Department of General and Minimally Invasive Surgery(Laparoscopy & Robotic), Centre Hospitalier de Luxembourg (CHL), L-1210 Luxembourg, Luxembourg Jaime Ponce  CHI Memorial Hospital, Chattanooga, TN, USA Carmen Balague Ponz  Gastrointestinal Surgical Unit, Department of Surgery, Hospital Sant Pau, Autonomous University of Barcelona, Barcelona, Spain José A. Ramírez  Clinica San Roque, Las Palmas de Gran Canaria, Gran Canaria, Spain Rishindra M. Reddy Department of Surgery, Section of Thoracic Surgery, University of Michigan, Ann Arbor, MI, USA Camiel Rosman  Department of Surgery, Radboudumc Hospital, Nijmegen, The Netherlands Jelle P. Ruurda Department of Surgical Oncology, University Medical Center Utrecht, Utrecht, The Netherlands Andrés Sánchez-Pernaute Department of Surgery, Hospital Clínico San Carlos, Madrid, Spain Atsushi Shiozaki  Division of Digestive Surgery, Department of Surgery, Kyoto Prefectural University of Medicine (KPUM), Kyoto, Japan André J. P. M. Smout Department of Gastroenterology and Hepatology, Amsterdam University Medical Center, University of Amsterdam, Amsterdam, The Netherlands Eduardo M. Targarona Gastrointestinal Surgical Unit, Department of Surgery, Hospital Sant Pau, Autonomous University of Barcelona, Barcelona, Spain Mark I. van Berge Henegouwen  Department of Surgery, Amsterdam University Medical Center, Amsterdam, The Netherlands

xvi

Donald. L. van der Peet Department of Surgery, Amsterdam UMC, Amsterdam, The Netherlands Pieter C. van der Sluis  Department of Surgical Oncology, University Medical Center Utrecht, Utrecht, The Netherlands Richard van Hillegersberg  Department of Surgical Oncology, University Medical Center Utrecht, Utrecht, The Netherlands Teus J. Weijs Department of Anatomy, University Medical Center Utrecht, Utrecht, The Netherlands Bas L. A. M. Weusten Department of Gastroenterology and Hepatology, St. Antonius Hospital, Nieuwegein, The Netherlands Han-Kwang Yang Department of Surgery, Division of Gastrointestinal Surgery, Seoul National University Hospital, Seoul, Republic of Korea Natan Zundel  Department of Surgery, FIU Herbert Wertheim College of Medicine, Jackson North Medical Center, Miami, FL, USA

Contributors

1

Surgical Anatomy of the Esophagus Teus J. Weijs and Ronald L. A. W. Bleys

1.1 Introduction Many regard the esophagus as merely a “food pipe” through which food traverses the gap between the pharynx and the stomach [1]. However surgeons regard it as an elusive organ; situated central in the body it traverses neck, thorax, and abdomen, surrounded by many vital structures in near proximity. This chapter maps the highlights of the surgical anatomy of the esophagus, from its composition, attachments, topography, blood supply, and lymphatics to relevant structures lying nearby.

1.2 Composition The wall of the esophagus is formed by an inner layer of mucosa, surrounded by layers of submucosa, muscularis, and finally adventitia. The esophageal mucosa is composed of squamous cell epithelium. Its transition into the columnar epithelium of the stomach can be visualized as a zig-zag line; the z-line. The muscularis consists of an outer layer of longitudinally oriented muscle fibers and an inner layer of circularly oriented muscle fibers. This is opposite to the pharynx, where the circular muscle fibers form the outer layer. Therefore at the level of the cricoid cartilage, where the pharynx continuous into the esophagus, the orientation of the muscle fibers is rearranged (Fig. 1.1). Here two weak spots emerge posteriorly, which are prone to the development of

T. J. Weijs · R. L. A. W. Bleys (*)  Department of Anatomy, University Medical Center Utrecht, Utrecht, The Netherlands e-mail: [email protected] T. J. Weijs e-mail: [email protected]

diverticula; Killian’s area, above the cricopharyngeus, and Laimer’s area, below the cricopharyngeus. The passage of the esophagus through the thorax, where the pressure is subatmospheric, requires sphincters at both ends to prevent continuous swallowing of air and saliva, and regurgitation of stomach content. The function of upper esophageal sphincter in the neck is exerted by the distal part of the inferior pharyngeal constrictor, which is distinguishable and is called the cricopharyngeus (Fig. 1.1). The lower esophageal sphincter is not a clearly distinct muscle but rather a physiological sphincter. This is composed of the local esophageal circular muscle fibers just below the level of the diaphragm that is able to exert a higher pressure. This action is reinforced by the right crus of the diaphragm which envelopes the esophagus at this location and acts as an external sphincter (Fig. 1.2a and b) [2]. Other factors which contribute to closure of the gastro-esophageal junction are the intra-abdominal course of the last part of the esophagus, the mucosal rosette, and the oblique muscle fibers of the stomach which contribute to the cardiac notch and flap-valve of Hill. Finally the adventitia consists of loose connective tissue, which facilitates movement.

1.3 Fixation The esophagus is attached to the trachea by several connective tissue strands and to the diaphragm by the phrenico-esophageal ligament (Fig.  1.2a) [3]. The phrenico-esophageal ligament stabilizes the esophagus at the level of the diaphragm, which is important to maintain the synergy of the components of gastro-esophageal closure. This ligament wraps the gastro-esophageal junction like a collar and is derived from the endothoracic and transversalis fascias which run above and below the diaphragm, respectively. Furthermore the esophagus is attached to the aorta by a thin layer of connective tissue which is called the aorto-esophageal ligament (Fig. 1.3) [4].

© Springer Nature Switzerland AG 2021 M. Asunción Acosta et al. (eds.), Atlas of Minimally Invasive Techniques in Upper Gastrointestinal Surgery, https://doi.org/10.1007/978-3-030-55176-6_1

1

2

T. J. Weijs and R. L. A. W. Bleys

a

b

Fig. 1.1   Structure of the upper esophagus. Transition zone from the pharynx to the esophagus, where two weak spots emerge above and below the cricopharyngeus (Killian and Laimer) Source: Pearson FG et al. Esophageal surgery. 2nd ed. New York, Churchill Livingstone, 2002

1.4 Topography In the neck, the esophagus courses caudally from the level of the cricoid cartilage. It lies in the visceral compartment which is anteriorly bounded by the strap muscles, laterally by the carotid sheaths and posteriorly by the alar fascia (Fig. 1.4a and b) [5]. This compartment extends to the level of the aortic arch. In the visceral compartment, the esophagus lies between the trachea and alar fascia. A thin layer of connective tissue, the visceral fascia, envelops esophagus and trachea. Of interest are the recurrent laryngeal nerves that course lateral to the trachea and esophagus to the vocal cords. Finally the thyroid gland is found anterior to the trachea. In the thorax, below the aortic arch, the esophagus traverses the posterior mediastinum. This compartment is bounded by the pericardium anteriorly, right pleura on the right lateral side, left pleura and aorta on the left lateral side, and spine posteriorly (Fig. 1.5a–d). The posterior mediastinum is further divided into a peri-esophageal compartment and a para-aortic compartment by the aortoesophageal and aorto-pleural ligaments [6]. In the periesophageal compartment the esophagus, carinal lymph nodes and vagus nerves are located. The para-aortic compartment contains the azygos vein and thoracic duct. The

Fig. 1.2  a. Schematic drawing of the gastro-esophageal junction demonstrating two ways in which the endothoracic and transversalis fascias may contribute to the phrenico-esophageal ligament. On the right side, the endothoracic fascia fuses with the upper leaflet of the transversalis fascia while on the left side they attach separately to the esophagus. b. Mean distances in centimeters between an imaginary horizontal line through the diaphragm and attachment points of the fascial layers of the phrenico-esophageal ligament. It is demonstrated that the upper part of the ligament is the longest part (From Apaydin et al. [3]; with permission.)

para-aortic compartment is an extension of the potential space between the alar fascia and the prevertebral fascia. This space is known as “the danger space”, because retropharyngeal abscesses can quickly spread via this route to the mediastinum[7]. In the abdomen, the esophagus traverses 1.5 cm of the upper abdomen to end in the stomach. The abdominal part of the esophagus is partially covered by peritoneum whereas the other parts do not have a serous lining.

1  Surgical Anatomy of the Esophagus

3

a

b Fig. 1.3  Illustration of the aorto-esophageal ligament, previously named “meso-esophagus”. It is a bilayered connective tissue layer with blood vessels coursing from the descending aorta to the esophagus. Abbreviations: ps: pericardial sac; lu: right lung; vp, right pulmonary vein; ca: carina and right bronchus; meso-oe: meso-oesophagus; az: azygos vein; ao: aorta; oe: oesophagus (From Cuesta et al. [4]; with permission.)

1.5 Arteries and Veins The cervical esophagus is supplied by branches of the inferior thyroid artery (Fig. 1.6a and b). The thoracic esophagus is supplied by 1–2 branches of the bronchial arteries and in 20% by a direct branch of an intercostal artery. Furthermore, between the level of the tracheal bifurcation and the diaphragm 4–5 small arteries branch from the anterior side of the descending aorta to descend obliquely to the esophagus. The abdominal esophagus is supplied by branches of the left gastric artery and often (55%) branches of the left inferior phrenic artery. Occasionally there is an anastomosis between the left gastric artery and left inferior phrenic artery, called Belsey’s artery. The esophageal arteries are connected by a dense uninterrupted network of arterioles located in the esophageal mucosa and submucosa, which secures a good blood supply even when a large part of the esophagus is mobilized [8–10]. The blood leaving the esophagus collects in a subepithelial plexus and a submucosal plexus. These plexus drain through perforating veins into the peri-esophageal plexus surrounding the esophagus. In the neck, these veins drain into the inferior thyroid and vertebral veins. In the thorax, the peri-esophageal plexus generally drains into the azygos

Fig. 1.4  a. The esophagus traversing the visceral compartment in the neck. MR image. Abbreviations: Car: carotid artery; Esophagu: esophagus; Jug: jugular vein; LCM: longus colli; Ln: lymph node; SCM: sternocleidomastoid. b. Schematic drawing. Abbreviations: Car: carotid artery; Eso: esophagus; Jug: jugular vein; LCM: longus colli muscle; Ln: lymph node; Rln: recurrent laryngeal nerve; SCM: sternocleidomastoid; SCA: subclavian artery; V: vagus nerve; VA: vertebral artery

and hemi-azygos veins. In the abdomen, the esophageal plexus drains into the left gastric and inferior phrenic veins; forming a well-known portal-caval anastomosis [11].

4

T. J. Weijs and R. L. A. W. Bleys

a

b

d c

Fig. 1.5  Photograph of a transverse section of the posterior mediastinum between the diaphragm and tracheal bifurcation (a) with a magnetic resonance image of the same section (b), histology (c), and a schematic summary (d). For histology the Verhoef-Von Gieson stain was used (elastin stained black-blue; collagen stained light red-pink). The black arrows indicate the aorto-esophageal ligament, the blue arrows indicate the aorto-pleural ligament, the white arrows indicate the right and left pleural reflections and the red arrows indicate blood vessels. In the schematic drawing the green line represents the pleura, the yellow line represents pericardium and the black line the aorto-esophageal and aortopleural ligaments. Abbreviations: Av: azygos vein; Ln: lymph node; TD: thoracic duct; V: vagus nerve (From Weijs et al. [6]; with permission.)

a

b

Fig. 1.6  a. Arteries of the esophagus. Right view. Abbreviations: a: thyroid inferior artery; b: right bronchial artery; c: esophageal arteries and d: branches from the left gastric artery and inferior phrenic artery. b. Arteries of the esophagus. Left view. a: left superior bronchial artery; b: left inferior bronchial artery; c and d: 7th esophageal arteries from intercostal arteries

1  Surgical Anatomy of the Esophagus

1.6 Lymphatics The lymph drainage of the esophagus is not segmentally organized, in contrast to other parts of the intestines. There is a dense submucosal network of lymphatic channels which are predominantly oriented longitudinally [12]. From here lymph channels traverse the esophageal wall to drain into regional lymph nodes (deep cervical, mediastinal, left gastric, and celiac) or directly into the thoracic duct (43%) [13]. For this reason, lymph node metastasis of esophageal

5

cancer can quickly spread over a long distance from the primary tumor. Mediastinal lymph node stations are categorized following the system of the International Association for the Study of Lung Cancer (Fig. 1.7a and b) or the Japanese Society of Esophageal Cancer and abdominal lymph node stations following the system of the Japanese society for Gastric Cancer [14, 15]. The number of lymph nodes that can be resected is very dependent on the large interindividual variation, for example, the number of mediastinal lymph nodes varies from 11 up to 54 [16].

a

b

Fig. 1.7  a. Lymphatic drainage. The aim of this figure is to show, from a surgical point of view (stations as seen during thoracolaparoscopic esophagectomy in prone position.) the lymph node stations of the supracarinal area, and vagus nerve including recurrent laryngeal nerves and the thoracic duct between the aorta and the azygos vein. Abbreviations: e: esophagus; dth: thoracic duct; rrln: right recurrent laryngeal nerve; lrln: left recurrent laryngeal nerve; ao: aorta; tr: trachea; svc: superior vena cava; lsbra: left superior bronchial artery; libra: left inferior bronchial artery; rbra: right bronchial artery; av: azygos vein; lb: left bronchus; rb: right bronchus; lv: left vagus nerve; rv: right vagus nerve; lpv: left pulmonary vein; rpv: right pulmonary vein; R. Lung: right lung. (From Cuesta et al. [14]; Attribution 4.0 International [CC BY 4.0] https://creativecommons.org/licenses/by/4.0). b. Supracarinal lymph node stations to be resected during esophagectomy. Abbreviations: LN: lymph node; R: right; L: left. c. Gastric lymph node stations according to the system of the Japanese Gastric Cancer Society. APIS: a. phrenica inferior sinistra; AGES: a. gastroepiploica sinistra; AGB: aa. gastricae breves; VGED: v. gastroepiploica dextra; VCDA: v. colica dextra accessoria; VCM: v. colica media; VCD: v. colica dextra

6

The thoracic duct arises from multiple abdominal lymph vessels. These courses cranially to merge in the thorax, 1.8 cm (IQR: − 0.4–2.4 cm) above the esophageal hiatus (Fig. 1.7c) [17]. Caudally in the thorax, the thoracic duct is located between esophagus and spine, just right to the midline. At the level of the azygos vein, it crosses to the left side and eventually drains into the left venous angle. It is important to note that the course of the thoracic duct is typical in only 40–60% of cases. The most important variations are the location of drainage into the venous system and the presence of (partially) duplicated systems.

T. J. Weijs and R. L. A. W. Bleys

a

1.7 Innervation The esophagus is innervated by the vagus nerve and branches of the sympathetic trunk. From the viewpoint of esophageal surgery the vagus nerves are especially important. In their course close to the esophagus they have important branches that course through the previously mentioned lymph node stations. In the neck, the vagus nerves course distally in the carotid sheath between the carotid artery and jugular vein. In the superior mediastinum the right vagus nerve passes anterior to the right subclavian artery. Just below the right subclavian artery the right recurrent laryngeal nerve branches off to curve dorsally and cranially around the right subclavian artery. The left vagus nerve passes anterior to the aortic arch. Just below the aortic arch, the left recurrent laryngeal nerve branches off to curve dorsally and cranially around the aortic arch, through the aorto-pulmonary window (lymph node station #5) and then cranially, lateral to the trachea (lymph node station, #4L). In their ascent to the larynx, the recurrent laryngeal nerves may course next to the esophagus, tracheo-esophageal sulcus, or trachea. Near their entrance into the larynx there is less variation, and both recurrent laryngeal nerves tend to course near the tracheo-esophageal sulcus [18]. In their course to the larynx, the recurrent laryngeal nerves have 8–14 branches which course medially to innervate the trachea and proximal esophagus [19]. The right vagus nerve continues dorso-caudally to pass dorsal to the right main bronchus. In the trajectory between subclavian artery and right main bronchus (lymph node station #4R) a median of 3 vagus nerve branches arise which form the right anterior pulmonary plexus (Fig. 1.8a and b) [20]. This plexus is located just cranial to the right pulmonary artery and contains a small proportion (23%) of the right lung innervation. Dorsally to the right main bronchus a median of 13 vagus nerve branches form the right

b

c

Fig. 1.8  Schematic drawings of the right posterior (a) and left posterior (b) pulmonary vagus nerve plexuses as encountered during transthoracic esophagectomy from a right lateral approach, including a corresponding photograph (c). Abbreviations: A: azygos vein; Ao: aorta; Oeso: esophagus; RLN: left recurrent laryngeal nerve; S, sympathetic trunk; T, trachea; V, vagus nerve. (From Weijs et al. [20]; with permission.)

1  Surgical Anatomy of the Esophagus

posterior pulmonary plexus (77% of right lung innervation). Lymph node station #7 and 10R are located anterior to these branches. The left pulmonary plexus is composed similarly. Below the level of the main bronchi the vagus nerves form the extensive peri-esophageal plexus. In general, the nerve fibers rearrange at the level of the esophageal hiatus in a vagal trunk anterior and posterior to the esophagus, which course caudally to innervate the abdominal organs.

References 1. Esophagus. In Wikipedia. Retrieved April 3, 2018, from https:// en.wikipedia.org/wiki/Esophagus. 2. Boeckxstaens GE. The lower oesophageal sphincter. Neurogastroenterol Motil. 2005 Jun; 17 Suppl 1:13–21. 3. Apaydin N, Uz A, Evirgen O, et al. The phrenico-esophageal ligament: an anatomical study. Surg Radiol Anat. 2008;30:29–36. 4. Cuesta MA, Weijs TJ, Bleys RL, et al. A new concept of the anatomy of the thoracic oesophagus: the meso-oesophagus. Observational study during thoracoscopic esophagectomy. Surg Endosc. 2015; 29:2576–82. 5. Guidera AK, Dawes PJD, Fong A, et al. Head and neck fascia and compartments: no space for spaces. Head Neck. 2014;36:1058–68. 6. Weijs TJ, Goense L, van Rossum PS, et al. The peri-esophageal connective tissue layers and related compartments: visualization by histology and magnetic resonance imaging. J Anat. 2017;230:262–71. 7. Grodinsky M, Holyoke EA. The fascia and fascial spaces of the head, neck and adjacent regions. Am J Anat. 1938;63:367–408. 8. Liebermann-Meffert DM, Luescher U, Neff U, et  al. Esophagectomy without thoracotomy: is there a risk of intramediastinal bleeding? A study on blood supply of the esophagus. Ann Surg 1987; 206:184–92.

7 9. Swigart LL, Siekert RG, et al. The esophageal arteries; an anatomic study of 150 specimens. Surg Gynecol Obstet. 1950;90:234–43. 10. Weijs TJ, Toxopeus EL, Ruurda JP, et al. Leaving a mobilized thoracic esophagus in situ when incurable cancer is discovered intraoperatively. Ann Thorac Surg. 2015;99:490–4. 11. Butler H. The veins of the oesophagus. Thorax. 1951;6:276–96. 12. Sakata K. Uber die Lymphgefasse des Oesophagus und uber seine regionalen. Lymphdrusen mit Berucksichtigung der Verbreitung des Karcinoms. Mitt Grenzbeg Med Chizg 1903; 11:634–56. 13. Murakami G, Sato I, Shimada K, et al. Direct lymphatic drainage from the esophagus into the thoracic duct. Surg Radiol Anat. 1994;16:399–407. 14. Cuesta MA, van der Wielen N, Weijs TJ, et al. Surgical anatomy of the supracarinal esophagus based on a minimally invasive approach: vascular and nervous anatomy and technical steps to resection and lymphadenectomy. Surg Endosc. 2017;31:1863–70. 15. Kajitani T. The general rules for the gastric cancer study in surgery and pathology. Part I Clinical classification. Jpn J Surg. 1981; 11:127–39. 16. Ziyade S, Pinarbasili NB, Ziyade N, et al. A. Determination of standard number, size and weight of mediastinal lymph nodes in postmortem examinations: reflection on lung cancer surgery. J Cardiothorac Surg. 2013; 8:94. 17. Defize IL, Schurink B, Weijs TJ, et al. The anatomy of the thoracic duct at the level of the diaphragm: a cadaver study. Ann Anat. 2018;217:47–53. 18. Liebermann-Meffert DM, Walbrun B, Hiebert CA, Siewert JR. Recurrent and superior laryngeal nerves: a new look with implications for the esophageal surgeon. Ann Thorac Surg. 1999;67:217–23. 19. Yalcin B, Tunali S, Ozan H. Extralaryngeal division of the recurrent laryngeal nerve: a new description for the inferior laryngeal nerve. Surg Radiol Anat. 2008;30:215–20. 20. Weijs TJ, Ruurda JP, Luyer MD, et al. Topography and extent of pulmonary vagus nerve supply with respect to transthoracic oesophagectomy. J Anat. 2015;227:431–9.

2

A Concentric-Structured Model for the Understanding of the Surgical Anatomy in the Upper Mediastinum Required for Esophagectomy with Radical Mediastinal Lymph Node Dissection Hiroyuki Daiko 2.1 Introduction Understanding the surgical anatomy is the key to reducing surgical invasiveness especially in the upper mediastinal dissection for esophageal cancer, which is supposed to have a significant impact on curability and morbidity. However, there is not yet a comprehensive development of the surgical anatomy of the esophagus, although generally speaking the surgical anatomy in abdominal digestive surgery has been developed on the basis of embryological findings of intestinal rotation and fussion fascia [1, 2]. An understandable concept will be of great value for the standardization of a radical esophagectomy and an adequate lymphadenectomy. Therefore, we developed a hypothesis of a “concentric-structured model” of the surgical anatomy in the upper mediastinum based on human embryonic development [3, 4].

2.2 Surgical Anatomical Model This model is characterized by three factors: (1) a concentric and symmetric three-layer structured, (2) bilateral vascular distribution, and (3) an “inter-layer potential space” composed of loose connective tissue. The concentric three-layer structure consists of the visceral layer, the vascular layer, and the parietal layer in transversal and

 lectronic supplementary material  The online version of this E chapter (https://doi.org/10.1007/978-3-030-55176-6_2) contains supplementary material, which is available to authorized users. H. Daiko (*)  Department of Esophageal Surgery, National Cancer Center Hospital, Chuo-ku, Tokyo, Japan e-mail: [email protected]

coronal sectional views (Figs. 2.1 and 2.2): the visceral layer containing the esophagus, trachea and recurrent laryngeal nerves as the central core, the vascular layer of major blood vessels surrounding the visceral core to maintain the circulation, and the parietal layer as the outer frame of the body. The bilateral vascular distribution consists of the inferior thyroid arteries and bronchial arteries originating from the bilateral dorsal aortae in an embryo. This bilateral vascular distribution may be related to the formation of the proper mesentery of the esophagus and frequent lymph node metastasis observed in the visceral layer around recurrent laryngeal nerves (Fig. 2.3). The three concentric layers are bordered by loose connective tissue called the “interlayer potential space”. This inter-layer potential space is the fundamental factor of our concentric-structured model as the appropriate surgical plane of dissection. The peripheral blood vessels, nerves, and lymphatic transition between each layer, thereby penetrating this loose connective tissue forming the inter-layer potential space. Recurrent laryngeal nerves also transition from the vascular layer after branching off from the vagal nerves and then ascend consistently in the visceral layer.

2.3 Validation of the Surgical Procedure We investigated the validity of this concentric-structured model, confirming the intraoperative images and the surgical outcomes of thoracoscopic esophagectomy in a prone position (TSEP) before and after the introduction of this hypothetical anatomy model (Video 2.1). A total of 226 patients with esophageal cancer underwent this procedure from January 2015 to December 2016. After the introduction of this model, the surgical outcomes in 105 patients clearly improved for the operation time of the thoracoscopic procedure (160 min vs 182 min) and the incident or recurrent nerve palsy (19.0 vs. 36.4%). Moreover, we

© Springer Nature Switzerland AG 2021 M. Asunción Acosta et al. (eds.), Atlas of Minimally Invasive Techniques in Upper Gastrointestinal Surgery, https://doi.org/10.1007/978-3-030-55176-6_2

9

10

H. Daiko

Fig. 2.1  The concentric three-layer structure of the upper mediastinum (transverse section). Visceral in yellow, vascular in red, and parietal in blue. Abbreviations: Tra: Trachea; Eso: esophagus; RN: recurrent nerve; SCA: subclavian artery; CCA: common carotid artery; SNT: sympathetic nerve chain; PN: phrenic nerve

Fig. 2.3   Total meso-esophagus excision. Lymph nodes stations (Japanese system of lymph node stations for esophageal cancer). Yellow: esophagus; Green: dissection plane; Blue: carina

Fig. 2.2  A coronal sectional view of the upper mediastinum showing the layer transition of both recurrent laryngeal nerves (RLNs). Both RLNs transition from the vascular layer to the visceral layer immediately after branching off from the vagal nerves (VNs). We believe that both VNs generally belong to the vascular layer in the upper mediastinum, although they follow the esophagus below the tracheal bifurcation. Similar to this neural transition of the RLNs and VNs, other peripheral nerves or blood vessels also transition through the interlayer potential space composed of loose connective tissue as shown in red arrows. Abbreviations: Ao: aortic arch; AzV: azygos vein arch; Eso: esophagus; RLN: recurrent laryngeal nerve; Rt.B.Art: right bronchial artery; Rt.SCA: right subclavian artery; SNc: cardiac branch of the sympathetic nerve; Tra: trachea; VN: vagal nerve; R: right; L: left.

were able to identify the concentric and symmetric layer structure through surgical dissection along the inter-layer potential space between the visceral and vascular layers (viscero-vascular space) in all 105 patients after introduction of the hypothetical model [4]. Previously, different concepts have been given to the model of the meso-esophagus [5–7], adding clarity to the surgical anatomy of the mediastinum. Our model, the concentric-structured model based on embryonic development is clinically beneficial for achieving less-invasive esophagectomy by ensuring a theoretical understanding of the surgical anatomy in the upper mediastinum.

2  A Concentric-Structured Model for the Understanding …

References 1. Sadler TW. Langman’s Medical Embryology. North American: Lippincott Williams & Wilkins; 2014. 2. Mukherji SK, Castillo M. A simplified approach to the spaces of the suprahyoid neck. Radiol Clin North Am. 1998;36:761–80. 3. H. Fujiwara, J. Kanamori, Y. Nakajima, T.et al. An anatomical hypothesis: a “concentric-structured model” for the theoretical understanding of the surgical anatomy in the upper mediastinum required for esophagectomy with radical mediastinal lymph node dissection. Disease of Esophagus. 2018; 32:1–9. 4. Daiko H, Nishimura M. A pilot study of the technical and oncologic feasibility of thoracoscopic esophagectomy with extended lymph

11 node dissection in the prone position for clinical stage I thoracic esophageal carcinoma. Surg Endosc. 2012;26:673–80. 5. Hwang SE, Kim JH, Bae SI, Rodriguez-Vazquez JF, Murakami G, Cho BH. Mesoesophagus and other fascial structures of the abdominal and lower thoracic esophagus: a histological study using human embryos and fetuses. Anat Cell Biol. 2014;47:227–35. 6. Cuesta M A, Weijs T J, Bleys R L, van Hillegersberg R, van Berge Henegouwen MI, Gisbertz SS, et al. A new concept of the anatomy of the thoracic oesophagus: the meso-oesophagus. Observational study during thoracoscopic esophagectomy. Surg Endosc 2015; 29: 2576–82. 7. Matsubara T, Ueda M, Nagao N, Takahashi T, Nakajima T, Nishi M. Cervicothoracic approach for total mesoesophageal dissection in cancer of the thoracic esophagus. J Am Coll Surg. 1998;187:238–45.

3

A Surgical Concept for the Subcarinal Anatomy of the Esophagus and Mediastinum Miguel A. Cuesta

3.1 Introduction There are two important Minimally Invasive Esophagectomy approaches, the three-stage McKeown procedure with cervical anastomosis and the two-stage Ivor Lewis procedure with intrathoracic anastomosis. The second approach is performed increasingly in countries where the predominant esophageal cancer is the adenocarcinoma frequently localized in the distal esophagus and the Gastroesophageal Junction (type 1 and 2 according to Siewert). The three-stage McKeown is performed in proximally localized Adenocarcinomas and in all squamous cell cancers localized in the thoracic esophagus. A comprehensive concept of the live surgical anatomy is necessary for ensuring anatomical accuracy as well as reproducible radical surgical resections for cancer. Heald and Ryall’s definition of the total mesorectal excision (TME) of the mesorectum has been of paramount importance for obtaining a radical resection of rectal cancers by engaging an adequate surgical resection [1]. In the case of the esophagus, having a clear concept regarding the resection margins and the relation with the thoracic aorta is important for standardizing the operative technique and optimizing the radicality of surgery. Essential for realizing these goals is having accurate knowledge of the embryological development of the esophagus, the respiratory tract, and the mediastinum. It seems that the development of proximal esophagus (until the carina level) may be different than the development of the distal one. Yet, in embryology, no complete agreement exists on how the early foregut differentiates into the respiratory  lectronic supplementary material  The online version of this E chapter (https://doi.org/10.1007/978-3-030-55176-6_3) contains supplementary material, which is available to authorized users. M. A. Cuesta (*)  Department of Surgery, Amsterdam UMC, Amsterdam, The Netherlands e-mail: [email protected]

tract and the intestinal tract. In particular, the formation of the early lung buds as well as the process of separation of trachea and esophagus remains still unclear [2, 3]. Metzger et al. studied this development using an electron microscope to scan chicken embryos. They illustrated the steps of the normal foregut development, which ultimately leads to the development of larynx and trachea on the one hand, and pharynx and esophagus on the other hand [4]. In this chapter, we will describe the surgical anatomy of the infracarinal mediastinum in order to resect radically the distal esophageal cancers. This description is based on the findings acquired by (high definition) visualization during esophageal resections by thoracoscopy in prone position.

3.2 Surgical Anatomical Observation Minimally invasive surgical dissection of the esophagus by thoracoscopy in prone position permits us to observe ‘‘live’’ with magnification of the anatomy as it really is (see Video 3.1). During the dissection, by retraction of the esophagus (and the pleura covering it and the thoracic duct) gently from the descending aorta, a thick fascia-like structure is visualized from the aorta arch (carina level) to the lower thoracic aperture in all patients (Fig. 3.1). This fascia is encountered between the whole length of the descending aorta and the left aspect of the infracarinal esophagus. After division of the superficial part of this fascia, both the bronchial arteries, coming from the concavity of the aortic arch and between two and ten esophageal vessels coming from the direction of the thoracic aorta, are visualized between layers of this fascia (Fig. 3.2 a and b), thereby suggesting that the fascia is a bilayered structure. Moreover, lymphatics and left vagal nerves are also present. After division of this fascia (Fig. 3.3 a and b), the left main bronchus, inferior left pulmonary vein, the pericardial sac, and the most distal part of the contralateral pleura covering the left lung can be entirely visualized (Fig. 3.4). On the contrary, on the right side of the esophagus along the right lung, from the hiatus to the right bronchus, no vessels are encountered during the dissection. Between the

© Springer Nature Switzerland AG 2021 M. Asunción Acosta et al. (eds.), Atlas of Minimally Invasive Techniques in Upper Gastrointestinal Surgery, https://doi.org/10.1007/978-3-030-55176-6_3

13

14

M. A. Cuesta

a

b

Fig. 3.1  The meso-esophagus between the descending aorta and the thoracic subcarinal esophagus (a, b)

a

b

Fig. 3.2  The meso-esophagus between aorta and esophagus showing multiple vessels in between. The left pleura is visualized (a, b)

a

b

Fig. 3.3  Division of the meso-esophagus at the proximal level of the descending aorta (a, b). Abbreviations: oe: esophagus; ao: aorta; m-oe: meso-esophagus

3  A Surgical Concept for the Subcarinal Anatomy …

15

a

b

Fig. 3.4  Comprehensive concept of the esophageal anatomy visualized from the prone position of the thorax. Abbreviations: ps: pericard sac; lu: right lung; vp: right pulmonal vein; meso-oe: meso-esophagus; ca: carina and right bronchus; az: azygos vein; ao: aorta; oe: esophagus

level of the carina and the upper thoracic aperture, branches from bronchial arteries (and vagal nerves, recurrent laryngeal nerves, and lymphatics) and from both inferior thyroid arteries are encountered and divided on both sides of the esophagus (Fig. 3.5 a–c). The fascia that encloses vessels from the aorta to the thoracic esophagus, nerves, and lymphatics, we have named the meso-esophagus. This subcarinal meso-esophagus is found in 100% of the patients during ‘‘live’’ dissection. The anatomical concept of the supracarinal mediastinum is depicted in the Chap. 2 Knowledge of these anatomical principles are essential for a correct oncological esophageal resection. Fig. 3.4. offers the comprehensive anatomical picture of the concept. This novel anatomical concept observed in vivo was confirmed by histologic findings in cadavers (Fig. 3.6a). In microscopic sections from the aortic arch level, stained by the Verhoef-von Giessen method, has showed the bilayer structure from the aorta to the left lateral side of the esophagus with esophageal arteries inside (Fig. 3.6b). Moreover MRI of this cadavers mediastinal slices have confirmed the bilayer meso-esophageal fascia (Fig. 3.6c). Prospective “live” study has showed that the neoadjuvant treatment with chemoradiotherapy, here used, has not affected the correct visualization of the meso-esophagus in all patients studied. The pertaining new comprehensive anatomical concept is unmistakeably significant. First, it defines the anatomical

c

Fig. 3.5   Supracarinal dissection showing the right bronchial artery and the vessels between the esophagus and trachea (a, b): Abbreviations: oe: esophagus; tr: trachea; m-oe: meso-esophagus. Schematic supracarinal anastomy (c): Abbreviations: e: esophagus; rrln: right laryngeal nerve; lrln: left laryngeal nerve; ao: aorta; lsbra: left superior bronchial artery; rbra: right bronchial artery; av: azygos vein; rb: right bronchus; lb: left bronchus; rpv: right pulmonary veins; lpv: left pulmonary veins; svc: superior vena cava; tr: trachea; rv: right vagus nerve; lv: left vagus nerve; R. lung: right lung

landmarks of the optimal resection by planes around the esophagus. The clear limit for this meso-esophagus is the carina level. Therefore the left and right bronchial arteries may be also located in this meso-esophagus and only the branches to the esophagus have to be divided, preserving the vascular supply of the trachea and bronchi as much as possible.

16 Fig. 3.6  Cadaver cross section showing the mesoesophagus (a): Abbreviations: TD: thoracic duct; AV: azygos vein. Schematic section (b): Abbreviations: Ln: lymph node; RMB: right brochus; LMB: left bronchus; TD: thoracic duct; AV: azygos vein. MRI at the same level confirming the bilayer meso-esophagus between the descending aorta and the esophagus (c): Abbreviations: TD: thoracic duct; AV: azygos vein

M. A. Cuesta

a

b

c

3  A Surgical Concept for the Subcarinal Anatomy …

17

whereas in the case of esophageal resection it will be a difference of the specimen in the case of adenocarcinoma or squamous cell cancer, being in the last case thinner with less fat tissue. Therefore in all cases, the final appearance of the mediastinum after resection will be important to define the quality of the resection (Fig. 3.7). Differing, yet learning from previous anatomy studies, our definition of meso-esophagus derived from live surgical endoscopic anatomy will improve understanding of the esophageal anatomy, leading to a more adequate and reproducible surgical resection.

Fig. 3.7  How the mediastinal anatomy should be left after esophageal resection

At the level above the carina and on both sides, esophageal vessels coming from bronchial arteries and from inferior thyroid arteries can be identified and divided. After division of this meso-esophagus, the left main bronchus, the inferior left pulmonary vein, pericardial sac, and contralateral left pleura can be visualized (Fig. 3.4). Extension of the meso-esophagus concept supracarinally has to be investigated, probably the different embryological origin of this proximal esophagus will have necessary other surgical anastomical concepts [5]. Other authors have defined the concept of meso-esophagus differently [5–11]. Our definition of meso-esophagus differs from others in that it primarily defines the anatomical structure containing the vessels, nerves, and lymphatics (from or to) the thoracic esophagus. The term ‘‘meso’’ refers to mesentery; however, classical definition of mesentery refers to two sheets of peritoneum with blood vessels, lymph vessels, and nerves in between. In the case of the rectum, as is the case with the esophagus, there is no peritoneal cover at all. Notwithstanding, we stress the importance of a radical resection along the anatomical defined planes in all kinds of oncological resections: high quality oncologic surgery necessitates adequate knowledge of these planes [8]. Difference with the mesorectum concept is that in the case of the rectum, the mesorectal fascia can be studied by the pathologist for integrity,

References 1. Heald RJ, Ryall RDH. Recurrence and survival after total mesorectal excision for rectal cancer. Lancet. 1986;1:1479–82. 2. Kluth D, Fiegel H. The embryology of the foregut. Semin Pediatr Surg. 2003;12:3–9. 3. Brugger PC, Weber M, Prayer D. Magnetic resonance imaging of the normal fetal esophagus. Ultrasound Obstet Gynecol. 2011;38:568–74. 4. Metzger R, Wachowiak R, Kluth D. Embryology of the early foregut. Semin Pediatr Surg. 2011;20:136–44. 5. Cuesta MA, Weijs TJ, Bleys RL et al. A new concept of the anatomy of the thoracic oesophagus: the meso-oesophagus. Observational study during thoracoscopic oesophagectomy. Surg Endosc. 2015;29:2576–82. 6. Cuesta MA, van der Wielen N, Weijs TJ et al. Surgical anatomy of the supracarinal esophagus based on a minimally invasive approach: vascular and nervous anatomy and technical steps to resection and lymphadenectomy. Surg Endosc. 2017;31:1863–1870. 7. Fujiwara H, Kanamori J, Nakajima Y, Kawano T et al. An anatomical hypothesis: a “concentricstructured model” for the theoretical understanding of the surgical anatomy in the upper mediastinum required for esophagectomy with radical mediastinal lymph node dissection. Dis Esophagus. 2019 Aug 1;32(8):doy119. https://doi. org/10.1093/dote/doy119. 8. Matsubara T, et al. Cervicothoracic approach for total mesoesophageal dissection in cancer of the thoracic esophagus. J Am Coll Surg. 1998;187:238–45. 9. Marchand P. The anatomy and applied anatomy of the mediastinal fascia. Thorax. 1951;6:359–68. 10. Riddell AM, et al. High-resolution MRI in evaluation of the surgical anatomy of the esophagus and posterior mediastinum. Am J Roentgenol. 2007;188:37–43. 11. Izon AS, Jose P, Hayden JD, Grabsch HI. Significant variation of resected meso-esophageal tissue volume in two-stage subtotal esophagectomy specimen: a retrospective morphometric study. Ann Surg Oncol. 2013;20:788–97.

4

270 Degrees Fundoplication for Gastroesophageal Reflux Esophagitis Ivo A. M. J. Broeders

Pathologic reflux disease can be treated by repair of a hiatal hernia and folding of the gastric fundus around the distaloesophagus just below the hiatal opening. The technique of folding the fundus around the oesophagus is called fundoplication. It was originally promoted by Rudolph Nissen and became known as a Nissen fundoplication [1]. In the original Nissen fundoplication, the fundus is folded completely around the distal oesophagus, and sutured to itself, usually with three sutures. This is called a 360 degrees fundoplication. Numerous variations have been developed and published, such as the Toupet fundoplication, Thal, Nissen-Rosetti and valvuloplasty. Most of these fundoplications are partial, leaving a part of the oesophageal surface uncovered [2]. The reason for this is the attempt to diminish the burden of one of the major drawbacks, which is gas bloating [3]. Gas bloating is an expression for annoying postprandial dyspeptic symptoms caused by trapping of air in the fundus. The surgically created valve does not allow air to pass from the proximal stomach back to the mouth resulting in a feel of compression and upper abdominal tension, and resulting in increase of flatulence. There is abundant high level scientific proof that partial fundoplications result in less gas bloating while reflux control at long term is equal [4, 5]. Partial fundoplications should therefore be considered as options of first choice. Nevertheless, the Nissen fundoplication is probably still the most common type of fundoplication because of the traditional transfer of knowledge among surgeons and the ease of the procedure. A 270 degrees fundoplication takes more sutures and more in depth insight in local  lectronic supplementary material  The online version of this E chapter (https://doi.org/10.1007/978-3-030-55176-6_4) contains supplementary material, which is available to authorized users. I. A. M. J. Broeders (*)  Meander Medisch Centrum, Amersfoort and University of Twente, Enschede, The Netherlands e-mail: [email protected]

anatomy and will result in a slightly higher operating room time. Nonetheless a lowering of gas bloating will result in higher patient satisfaction and therefore this procedure may be considered as technique of first choice in patients with pathologic reflux disease and an absent or type 1 hiatal hernia.

4.1 Description of the Surgical Technique The key steps to perform a laparoscopic 270 degrees fundoplication include the following (Video 4.1).

4.1.1 Patient and Trocar Position Patient is placed in supine decubitus position. Five trocars are used to perform this surgery (Fig. 4.1).

4.1.2 Position a Liver Retractor There are many types of liver retractors available. Reusable retractors are preferred from cost perspective. They can be positioned coming from the upper abdomen through a trocar just below the xiphoid bone or through a trocar positioned in the upper and far lateral right abdominal wall. Liver retractors are preferably placed in mechanical arm resulting in a stable lift of the left liver lobe (Fig. 4.2).

4.1.3 Opening the Pars Flaccida of the Gastrohepatic Ligament The procedure starts with opening of the translucent part of the gastrohepatic ligament, the pars flaccida (Fig. 4.3). The hepatic branch of the anterior vagal nerve crosses the pars flaccida in the direction of the left liver lobe (Fig. 4.3). Cutdown of this small branch allows complete opening of

© Springer Nature Switzerland AG 2021 M. Asunción Acosta et al. (eds.), Atlas of Minimally Invasive Techniques in Upper Gastrointestinal Surgery, https://doi.org/10.1007/978-3-030-55176-6_4

19

20

I. A. M. J. Broeders

a

b

Fig. 4.1  Trocar placement

Fig. 4.3  Opening pars flaccida of the gastrohepatic ligament (a), preserving hepatic branch of the vagal nerve (b)

Fig. 4.2  Liver retractor position

the pars flaccida and a better access to the right pillar of the right crus. Cutdown of the hepatic branch may induce slower emptying of the gallbladder. This does not give any symptoms but may result in a higher chance of gallstone formation in the long run. One will often encounter a large arterial branch in the pars flaccida running from the left gastric artery toward the left liver lobe. This aberrant left hepatic artery will be found in up to 30% of patients. The artery should preferably be saved together with the hepatic branch of the vagal nerve. In case it hampers adequate surgical performance due to serious overweight or large hiatal hernia’s, the artery and vagal nerve branch can be sacrificed but adequate hemostatic

techniques are required. One may choose clips or advanced haemostatic surgical equipment. Cutdown of this artery may result in postoperative liver enzyme rise and has incidentally caused liver necrosis in gastrectomy patients. Start the cutdown of the pars flaccida distally, stick to the translucent area, and bent toward the patient’s left in the vicinity of the dome of the oesophageal hiatus. Be aware of the aberrant left hepatic artery in that upper part in case of large hiatal hernia’s because the pars flaccida with its structures may be pulled upward.

4.1.4 Incision of the Oesophago-Phrenic Ligament The next step is to open the oesophago-phrenic ligament. The assistant pulls the curvature minor to the patient’s left, presenting the right pillar of the right crus. The ligament is

4  270 Degrees Fundoplication for Gastroesophageal …

a

21

b

Fig. 4.4  Incision (a) and section (b) of the oesophago-phrenic ligament

incised just medial to the rim of pillar (Fig. 4.4). This gives access to the mediastinum. The incision is started dorsally and continued upward up to the upper rim of the oesophageal hiatus. The left-hand instrument is placed in the mediastinum to push the pillar laterally, and the right-hand instrument pushes the oesophagus with the dorsal vagal nerve medially, resulting in blunt mobilization of the oesophagus. The incision of the oesophago-phrenic ligament is continued just below the upper rim of the hiatus toward the patient’s left side (Fig. 4.4), while the left-hand instrument pulls the gastro-oesophageal fat pad toward the patients left side and assistant pulls the gastric fundus downward. The gastro-phrenic ligament is then exposed and can be cut. Little heat should be applied during dissection at the level of the upper hiatal rim in order to avoid thermal damage to the anterior vagal nerve. The nerve is usually in close vicinity of the oesophageal muscular tube, nevertheless care should be taken not to cut it during mobilization of the oesophagus in the upper area.

a

b

4.1.5 Blunt Mobilization of the Oesophagus Below the Dorsal Vagal Nerve In other surgical textbooks, fundoplications are positioned between the oesophagus and the dorsal vagal nerve. This requires dissection of the nerve, with a fair chance of mechanical or thermal damage. The oesophagus has to be lifted in an upward and medial direction by the assistant, compressing the vagal nerve to the oesophagus. This should be visualized to be certain of the position of the vagal nerve. Subsequently the tissue layer between oesophagus and aorta can be cut with a haemostatic surgical instrument to allow save dorsal mobilization of the oesophagus (Fig. 4.5). The surgeon has to be aware of the margin of the right pleura which is close,

Fig. 4.5  Blunt mobilization of the oesophagus below the dorsal vagal nerve (a) and dissection into the posterior mediastinum (b)

22

certainly in large hiatal hernias. In case of a pleural tear, increase end-respiratory pressure and do not attempt to close. In will very rarely result in a postoperative pneumothorax. A thorax X-ray at the postoperative ward may be advisable to be sure.

I. A. M. J. Broeders

a

4.1.6 Division of the Short Gastric Vessels and Gastrosplenic Ligament The next step is to open the bursa omentalis at the upper greater curvature and cut the short gastric vessels and the spleno-gastric ligament (Fig. 4.6). This step is required to allow a tension-free shift of the fundus behind the oesophagus. It also allows optimal exposition of the left pillar of the right crus. Cutdown of this ligament is debated in literature, but performed by most surgeons in 270–360 degrees fundoplications. The length of the cutdown should be limited to avoid unnecessary devascularisation of the fundus. The ligament is cut at about 0.5–1 cm from the gastric rim. This avoids thermal damage of the gastric wall, but does not leave fatty tissue on the dissected fundus. Also, dissection very close to the splenic hilum is avoided as much as possible. Dissection is performed with advanced bipolar or ultrasonic laparoscopic dissection equipment. Five millimetre instruments perform adequate. Do not pull on the fundus during activation of the instrument because vascular branches may slip from the instrument tip before complete coagulation.

b

c

4.1.7 Cut Oesophago-Phrenic Ligament on the Left Side Once the fundus is completely mobilized, dissection can be continued upward, just medial to the muscular rim of the left pillar of the right crus. The oesophagus can be mobilized on the patients left and left anterolateral side then, merely blunt, with coagulation of small vessels (Fig. 4.7). Care should be taken when mobilizing below the oesophagus, because exposure may lead to torsion of the oesophagus, with migration of the dorsal vagal nerve to the patients left side.

4.1.8 Dissection of the Left Crus from the patient’s Right Side Once mobilization on the patient´s left side is finished, final dissection below the oesophagus from the patient´s right side can be performed (Fig. 4.8). The lower part left pillar

Fig. 4.6  Division the short gastric vessels, starting from caudal (a, b) to cranial (c)

of the right crus is freed and complete circumferential cutdown of the oesopghago-phrenic ligament is verified. A window is thereby created behind the oesophagus, allowing easy passage of the fundus (Fig. 4.8).

4  270 Degrees Fundoplication for Gastroesophageal …

a

23

b

Fig. 4.7  Cut the oesophago-phrenic ligament (a) and blunt mobilization of the oesophagus from the left side (b)

a

4.1.9 Keep Track of the Vagal Nerves The position of the vagal nerves should always be in the mind of the surgeon in order to avoid damage (Fig. 4.9). In case the position is not clear, the nerves should be sought for carefully.

4.1.10 Start of the Suturing of the Crus

b

c

Fig. 4.8  Dissection of the left crus from the patient’s right side (a, b) and creation a window behind the oesophagus (c)

The next step is to narrow the right crus to a size that provides complete covering of the oesophagus by the pillars of the right crus, without oesophageal compressing or narrowing. Suturing is usually started from below (Fig. 4.10). The oesophagus with the adjacent dorsal vagal nerve is lifted upward by the assistant using a blunt instrument. A sling to stretch and position the oesophagus may be applied, broad and atraumatic material should be used. An oesophageal calibration tube may be used when checking the size of the hiatal opening. Various reusable tubes are available for this purpose. They should be positioned with great care under laparoscopic control to avoid oesophageal damage or tears. There is no conclusive evidence that these devices should be used at all times to avoid dysphagia. The crus has to be sutured with strong non-absorbable sutures. 2.0 multifilament polypropylene sutures are used most often. In case the surgeon wants to use running and self-locking sutures, a high-quality clip at the distal end is advised because of the repetitive strain on these sutures. The pillars should be positioned with light compression; gaps are not allowed. Excessive compression is not advised because of the possibility of muscular necrosis or tearing with subsequent widening of the hiatus.

24

a

I. A. M. J. Broeders

b

Fig. 4.9  Preservation of the anterior (a) and posterior (b) vagal nerves after esophageal dissection

The sutures should encompass the complete broad rim of the pillars, with the peritoneum on the outside. Small bites will result in muscular tears. The lower sutures should be positioned with care because the aorta is just behind the lower border of the right crus. In case of puncture of the aorta, carefully remove the needle by pulling back the tread and compress with an instrument on the crus. This gives time to perform suction and position a gauze. Gauze compressing for a few minutes will usually solve the problem. Suturing of the crus requires an adequate laparoscopic suturing technique. The use of sliding knots is advised as tension may be present when bringing the pillars together. Suturing devices such as the Endo Stitch™ can be applied but standard needles will allow optimal tailoring of the stitches. In small hiatal hernia’s one or two stitches behind the oesophagus may be sufficient. In larger hernia’s more stitches are needed and closure above and below the oesophagus is advised. Suturing below the oesophagus only will result in kinking of the oesophagus and may induce unfavourable spread of forces applied on the right crus. When suturing above the oesophagus, start high, just below the diaphragm vein, to alter the shape of the upper dome from oval to triangular, and to avoid excessive force on subsequent upper hiatal sutures (Fig. 4.10). Calibration of the size of the hiatus strongly depends on experience. The hiatal size should be checked without any pulling on oesophagus or stomach. The pillars should completely cover the oesophagus, but tailoring or narrowing is not allowed. When using a bougie, this should be checked again after removal. A laparoscopic instrument has to be passed along the oesophagus into the mediastinum with ease.

4.1.11 Fundus Pull Through After tailoring of the hiatus, the fundus is pulled behind the oesophagus (Fig. 4.11). First, omentum between fundus and spleen is pulled downward, and the fundus is positioned infero-lateral to the oesophagus. Then the oesophagus and dorsal vagal nerves are lifted, exposing the passage behind the oesophagus. The fundus is grabbed with an atraumatic instrument and pulled behind the oesophagus. The pull through should be relatively tension free, and a fair amount of the upper fundus should be passed. The fundus may be grabbed both on the right and left side and moved from side to side, to check for tension and to be sure that the fundus is not rotated.

4.1.12 Suturing of the Fundus and Creation of the Fundoplication The fundus should be fixed to the diaphragm at multiple sites to avoid fundus slippage and recurrence of reflux. Suturing to the oesophagus only induces a fair chance of failure at long term. The muscular fibres of the oesophagus are fragile and the fundus has a tendency to return to its natural position. Suturing of the fundus starts at the patient’s right side (Fig. 4.12). The first suture takes the oesophagus muscular wall, the right pillar close to the upper rim of the hiatus, and the backside of the pulled-through fundus. Subsequently, two sutures are placed along the right side of the abdominal part of the oesophagus. The goal is to cover a stretch as long as possible along the abdominal oesophagus. This implies that the first suture should be placed as high as

4  270 Degrees Fundoplication for Gastroesophageal …

25

a

b

c

d

Fig. 4.10  Posterior (a, b) and anterior (c, d) hiatus closure

a

b

Fig. 4.11  Fundus is pulled behind the oesophagus (a, b)

possible, and the lowest suture as close as possible to the GE junction at the lesser curvature. Be aware not to take branches of the anterior vagal nerve at that point. After finishing the right side of the fundoplication, the fundus is pulled a bit from left to right, and a stitch is positioned from the backside of the fundus to the crus, in between the crural sutures. This stitch releases tension

on the fundoplication and fixes the fundus to the crus once more, in an attempt to provide long-term success (Fig. 4.13). The final part of the procedure is the suturing of the fundoplication on the patient’s left side (Fig. 4.14). The first stitch takes the fundus, close to the diaphragm and close to the oesophagus, then the left pillar of the right

26

a

I. A. M. J. Broeders

a

b

b

c

Fig. 4.12  Suturing the fundus. Schematic (a) and close view (b, c)

c

Fig. 4.13  Suturing of the backside of the fundus to the crus. Schematic (a) and close view (b, c)

4  270 Degrees Fundoplication for Gastroesophageal …

a

27

a

b b

c

Fig. 4.15  Final result of the 270 degrees fundoplication. Schematic (a) and close view (b)

Fig. 4.14  Left side of the fundoplication. Schematic (a) and close view (b, c)

Care should be taken to avoid the anterior vagal nerve when suturing the fundus to the oesophagus. The final two stitches fix the fundus to the left lateral wall of the oesophagus. Again, a stretch as long as possible should be covered. The most distal stitch is positioned in the oesophagus just above the initiation of the gastro-oesophageal fat pad. Take the fundus at its projected rim, close to the oesophagus.

4.1.13 Checking and Ending crus just lateral to the upper rim and then the oesophageal muscular wall as high as possible. The ­gastro-oesophageal fatpad should be pulled downward and slightly to the patient’s right side to expose the structures as mentioned.

The final result is checked (Fig. 4.15). The fundoplication should be tension free and should cover at least a few centimetres of intra-abdominal oesophagus on both sides.

28

The hiatus should cover but not tailor the oesophagus. A blunt instrument may be passed along the upper rim of the oesophagus into the mediastinum, to be sure of a good hiatal size. The area is checked for any bleeding sources, and the liver retractor and trocars are removed under laparoscopic control. As much as possible CO2 is removed by suction before removing the last trocar.

References 1. Nissen R. Eine einfache operation zur beeinflussung der refluxoesophagitis. Schweiz Med Wochenschr. 1956;86:590–2. 2. Broeders JA, Bredenoord AJ, Hazebroek EJ, et al. Reflux and belching after 270 degree versus 360 degree laparoscopic posterior fundoplication. Ann Surg. 2012 Jan; 255(1):59–65.

I. A. M. J. Broeders 3. Kellokumpu I, Voutilainen M, Haglund C, et al. Quality of life following laparoscopic Nissen fundoplication: assessing short-term and long-term outcomes. World J Gastroenterol. 2013;19:3810–8. 4. Xing Du, Zhiwei Hu, Yan C, et al. A meta-analysis of long follow-up outcomes of laparoscopic Nissen (total) versus Toupet (270°) fundoplication for gastro-esophageal reflux disease based on randomized controlled trials in adults. BMC Gastroenterol. 2016;16:88. 5. Broeders JA, Roks DJ, Ahmed Ali U, et al. Laparoscopic anterior 180-degree versus nissen fundoplication for gastroesophageal reflux disease: systematic review and meta-analysis of randomized clinical trials. Ann Surg. 2013;257:850–9.

5

Laparoscopic Nissen Fundoplication Bernard Dallemagne

5.1 Introduction

5.2.2 Exposure of Operative Field

Surgical procedures to treat gastroesophageal reflux are indicated in well-studied patients. Nowadays, different techniques are performed like an antireflux procedure, with no clear differences in functional results. Nissen fundoplication is one of these options. The first laparoscopic Nissen fundoplication was performed in 1991 [1]. Today this procedure is the most common antireflux technique and many variations have been used to improve surgical results. Nissen fundoplication is associated with potential complications: dysphagia, gas bloating, reflux symptoms recidive, etc. [2]. For this reason, this procedure must be indicated in selected patients and it must be performed by an experienced surgeon [3].

A good exposure of the principal structures is required at the beginning of the surgery. To do enough retraction of the left lobe of the liver a Nathason retractor is placed. 30 degrees laparoscope is used at this time to identify pars flaccida of the gastrohepatic ligament and the crura (Fig. 5.2).

5.2 Description of the Surgical Technique The key steps to perform a laparoscopic Nissen fundoplication include the following (Video 5.1) [4].

5.2.1 Patient and Trocars’ Position Patient is placed in french position, the surgeon is located between patient´s legs and five trocars are placed (Fig. 5.1)

 lectronic supplementary material  The online version of this E chapter (https://doi.org/10.1007/978-3-030-55176-6_5) contains supplementary material, which is available to authorized users.

5.2.3 Start the Intervention This step includes: – Division of pars fláccida from inferior to superior (Fig. 5.3). It is important to preserve the nerve branch (from the vagus) and the left hepatic arterial branch from the left gastric artery. – Exposure of the crura. By traction of the stomach the phreno-esophageal membrane is open. After the dissection of the right crus, the esophagus is dissected into the mediastinum (Fig. 5.4). – Dissect the esophagus from the left crus by blunt dissection (Fig. 5.5).

5.2.4 Circumferential Exposure of the Distal Esophagus Abdominal esophagus must be dissected completely, making a posterior window. In this step, it is necessary to take care of and preserve the integrity of the right pleura and vagal nerves (Fig. 5.6).

5.2.5 Taping of the Esophagus for Retraction B. Dallemagne (*)  L’Hopital and IRCAD, 67000 Strasbourg, France e-mail: [email protected]

An umbilical tape is placed around the esophagus to do a correct retraction (Fig. 5.7).

© Springer Nature Switzerland AG 2021 M. Asunción Acosta et al. (eds.), Atlas of Minimally Invasive Techniques in Upper Gastrointestinal Surgery, https://doi.org/10.1007/978-3-030-55176-6_5

29

30

B. Dallemagne

a

Fig. 5.1  Trocars placement

b

Fig. 5.2  Exposure of operative field

5.2.6 Mediastinal Dissection and Esophagus Mobilization By esophageal retraction, a complete mobilization of the esophagus is performed in order to get enough intraabdominal esophagus (at least 3 cm) (Fig. 5.8).

Fig. 5.3  Division of the pars flaccida. Close (a) and schematic view (b)

5.2.7 Construction of Floppy Wrap To make a floppy fundoplication, gastric fundus should be dissected by dividing the short vessels (Fig. 5.9). The

5  Laparoscopic Nissen Fundoplication

a

31

a

b

b

Fig. 5.5  Dissection of the esophagus from the left crus. Close (a) and schematic view (b) Fig. 5.4  Exposure of the crura. Close (a) and schematic view (b)

5.2.8 Crural Opposition division of the short vessels must be performed from down to up. After that, the gastro-phrenic ligament must be divided (Fig. 5.10).

The crura are approximated by non-absorbable stitches. Posterior crura are closed taking the whole muscular thickness (Fig. 5.11). Posteriorly, anterior portion is closed with the same suture (Fig. 5.12).

32

a

B. Dallemagne

b

Fig. 5.6  Circumferential exposure of the esophagus. Anterior (a) and posterior dissection (b)

5.2.9 Construction of Fundoplication This step is divided into the next manoeuvres: – Pulling the fundus: The mobilized fundus is widely pulled through the window created behind the esophagus (Fig. 5.13). – Creating the fundoplication: A floppy 360° fundoplication is created by 3 stitches. Some stitch should be fixed to the esophagus (Fig. 5.14). – Fixation of wrap to the esophagus: The wrap should be fixed to the esophagus in order to avoid any slippage (Fig. 5.15).

Fig. 5.7  Taping of the esophagus for retraction

5  Laparoscopic Nissen Fundoplication

a

33

b

Fig. 5.8  Mediastinal dissection and esophagus mobilization. Anterior (a) and lateral (b) dissection

34

B. Dallemagne

a

b

c

Fig. 5.9  Fundus dissection. Close (a, b) and schematic view (c)

Fig. 5.10  Gastro-phrenic ligament division

5  Laparoscopic Nissen Fundoplication

a

b

c

Fig. 5.11  Posterior crura closure. Close (a, b) and schematic view (c)

35

a

b

c

Fig. 5.12  Anterior crura closure. Close (a, b) and schematic view (c)

36

a

b

c

Fig. 5.13  Pulling the fundus through the window created behind the esophagus. Close (a, b) and schematic view (c)

B. Dallemagne

a

b

c

Fig. 5.14  Creating the fundoplication. Close (a, b) and schematic view (c)

5  Laparoscopic Nissen Fundoplication

37

a

b

Fig. 5.16  Final view of the Nissen fundoplication

Fig. 5.15  Fixation of wrap to the esophagus. Close (a) and schematic view (b)

38

B. Dallemagne

a

b

Fig. 5.17  Laparoscopic (a) and endoscopic (b) view of the fundoplication

5.2.10 Completed Procedure When the fundoplication is completed, it is time to check all the operative field (Fig. 5.16). Then, endoscopy is performed in order to check neither stenosis nor perforation has been done (Fig. 5.17).

References 1. Dallemagne B, Weerts JM, Jehaes C, Markiewicz S, Lombard R. Laparoscopic Nissen fundoplication: preliminary report. Surg Laparosc Endosc. 1991;1:138–43.

2. Du X, Wu JM, Hu ZW, Wang F, Wang ZG, et al. Laparoscopic Nissen (total) versus anterior 180° fundoplication for gastroesophageal reflux disease: a meta-analysis and systematic review. Medicine (Baltimore). 2017;96:e8085. 3. Dallemagne B, Weerts J, Markiewicz S, Dewandre JM, Wahlen C, Monami B, et al. Clinical results of laparoscopic fundoplication at ten years after surgery. Surg Endosc. 2006;20:159–66. 4. Dallemagne B, Perretta S. Twenty years of laparoscopic fundoplication for GERD. World J Surg. 2011;35:1428–35.

6

Minimally Invasive Surgery of Paraesophageal Hernias Salvador Morales-Conde, Francisco Lopez Bernal and Isaías Alarcón

6.1 Introduction Paraesophageal hernia repair and the use of a mesh to avoid any tension during repair is a controversial issue [1]. On one side, due to complications related to those prosthetic materials and, on the other side, about the type of mesh to be used and where they should be placed. The steps of the repair of the paraesophageal hernia are: 1. Dissection of the hiatus and the complete excision of the sac; 2. An adequate mobilization of the esophagus; 3. The repair of the hiatus; 4. To perform an antireflux procedure. The step 3 seems to be the most controversial one, and it concerns when can the crura be approximate with or without a prosthetic mesh. According to the literature, it can be observed that the use of a mesh is associated with excellent short term results with a success rate of 90%, although in the long term, some series report a high recurrence rate even of 100%. The reason of these controversial results may be related to the fact that the use of a mesh is the only factor analyzed without taking in consideration other important factors related to recurrence [2] such as excision of the sac, adequate mobilization of the esophagus, closure of the crura, and the type of suture used. The indication to use a mesh is under debate. In a survey conducted by SAGES [3], there were different reasons that lead surgeons to use a mesh: the size of the defect (some of them when defects were larger than 3 cm, others when  lectronic supplementary material  The online version of this E chapter (https://doi.org/10.1007/978-3-030-55176-6_6) contains supplementary material, which is available to authorized users. S. Morales-Conde (*) · F. Lopez Bernal · I. Alarcón  Unit of Innovation in Minimally Invasive Surgery, University Hospital Virgen del Rocío, University of Sevilla, Sevilla, Spain e-mail: [email protected]

more than 5, cm and other groups of surgeons when the defect is larger than 8 cm), tension detected at the crura, poor crural tissue, obesity, or the age of the patient. Prospective randomized trials comparing the use of a mesh versus non-mesh repair have showed better results when a mesh was used after one year of follow-up [4, 5], but the systematic review published in 2016 [6] shows that even when the results in term of recurrence are lower, the reoperation’s rate is the same in both groups. The reasons for reoperations in the mesh group are due to complications related to the use of the mesh in the hiatus, such as stenosis or extrusion of the mesh through the esophagus [7]. The use of absorbable mesh as an alternative has an unacceptable recurrence rate in the long term [8–10]. Due to previous reasons, our protocol consists in the use of a permanent or absorbable mesh depending on the size of the hernia. The size of the hernia is based on the distance from the gastro-esophageal junction to the cura measured by the endoscopist, and it not based on the intraoperative measurement of the distance between both crura, since this distance could be very narrow even in large hernias. We do not like either to base our decision on the subjective criteria used by some groups of the strength of the crura. If this distance is not measured by endoscopist (for different reasons), we use the obtained, by the barium swallow perform to evaluate the type and size of the hernia. Based on this information different meshes are used in the following situations: Absorbable meshes: • for sliding hernias from 3 to 5 cm or in case the endoscopist does not offer this measurement, if just the fundus is herniated in the image offered by the barium swallow. Permanent meshes: • for sliding hernias larger than 5 cm; and in case the endoscopist does not offer this measurement, if more than the fundus is herniated in the image offered by the barium swallow.

© Springer Nature Switzerland AG 2021 M. Asunción Acosta et al. (eds.), Atlas of Minimally Invasive Techniques in Upper Gastrointestinal Surgery, https://doi.org/10.1007/978-3-030-55176-6_6

39

40

• paraesophageal hernias • “up-side down” stomach Our goals of using a mesh has always been to guarantee that there will be no complications related to the prosthetic materials, avoiding recurrences at the same time. In order to avoid these complications, that might lead to reoperations, we follow the next considerations: – In order to avoid stenosis, we never place the mesh around the esophagus since most of the meshes show some degree of shrinking. For this reason, we place the mesh behind the esophagus with the lateral part covering both crura. – On the other hand, one of the key steps to avoid mesh extruction into the esophagus is to avoid the direct contact of the mesh with it. For this reason, the mesh is fixed to the crura with just one or two stitches and fibrin glue, which will cover the whole mesh, especially in the area where the prosthetic material is in close contact with the esophagus. Fibrin glue will maintain the mesh in place and it will create natural tissue that will cover the mesh avoiding direct contact between the esophagus and the mesh.

S. Morales-Conde et al.

6.2.2 Patient and Trocars’ Position The patient is placed in supine decubitus position, and five trocars are placed (Fig. 6.1).

6.2.3 Reduction of the Sac and Its Contents to the Abdominal Cavity Reduce completely as it can or as much as possible the contents of the hernia to the abdominal cavity (Fig. 6.2): – Make traction of the stomach toward the right leg of the patient. – Start dissection at the left crus, cutting the peritoneum at the rim of the crus (this is the limit of the incision along the hiatus). In large paraesophageal hernias where the reduction of the contents of the hernia is not complete, pull down the sac with the herniated stomach.

6.2 Description of the Surgical Technique (Video 6.1) 6.2.1 Instruments and Equipment Required

• Five trocars are placed to perform this surgical procedure: two 10–11 mm trocars, for the camera and for the right working hand of the surgeon to introduce the energy device and the sutures, and three 5 mm trocars, for the left hand of the surgeon and for the assistant to retract the liver and to pull the stomach • A 10 mm 30º scope • As energy devices, we prefer to use the ultrasonic scalpel • Conventional laparoscopic instruments, including endograspers, endoscissors, and endodissectors • An endograsper to retract the liver • Endostitch® suturing devices • Suture: surgidac® 2/0 • Mesh: Omyra® or BioA® mesh, depending on the size of the hernia as it has been previously mentioned • Fibrin glue and its spray applicator The key steps to perform a laparoscopic correction of a paraesophageal hernia are.

Fig. 6.1  Trocars placement

6  Minimally Invasive Surgery of Paraesophageal Hernias

41

Fig. 6.2  Reduction of the sac and its contents to the abdominal cavity. Schematic (a) and close view (b, c)

6.2.4 Division of the First Short Vessels Transect the first short vessels to reach the bottom of the left crus (Fig. 6.3).

6.2.7 The Sac (and Lipomas) is Completely Dissected from Mediastinum into the Abdominal Cavity

6.2.5 Dissection of the Sac, from the Left Crus Anti-Clockwise from Left to Right

Adhesions of the sac to the pleura are completely released and the sac and lipomas are completely descended to the abdominal cavity (Fig. 6.5). The sac is only excised if it is needed to create the fundoplication later.

Look for the surgical plane between the sac and the pleura and continue anti-clockwise while reducing the sac by pulling down (Fig. 6.4).

6.2.8 Mobilization of the Esophagus by Pulling Down the Sac

6.2.6 Dissection Continues to the Dome of the Hiatus and the Right Crus Maintain the traction of the sac, continue anti-clockwise, cutting the peritoneum at the rim of the hiatus and complete the reduction of the sac until the bottom of the right crus (Fig. 6.5).

Fig. 6.3  Division of the first short vessels. Schematic (a) and close view (b)

If the sac is reduced from mediastinum, the esophagus is dissected free from the sac (Fig. 6.6). The distal esophagus is mobilized from the mediastinum, blunt dissection and ultrasonic scalpel, in order to have enough length to come free in the abdomen.

42

Fig. 6.4  Dissection of the sac from the left crus. Schematic (a) and close view (b, c)

Fig. 6.5  Dissection of the sac and the crura. Schematic (a) and close view (b, c)

Fig. 6.6  Mobilization of the esophagus by pulling down the sac. Schematic (a) and close view (b)

S. Morales-Conde et al.

6  Minimally Invasive Surgery of Paraesophageal Hernias

43

Fig. 6.7  Creation of a retroesophageal window. Schematic (a) and close view (b–d)

6.2.9 Creation of a Retroesophageal Window Creation of a retroesophageal window and to obtain a correct traction of the gastro-esophageal junction to the abdominal cavity with a goldfinger device (Fig. 6.7).

6.2.10 Approximation of the Pillars Using a Bougie (Foucher) for Calibration In this step, a 32 Foucher is placed inside the esophagus as tutor.

From the bottom of the crura where both join together in order to decrease the tension when closing them (Fig. 6.8). Non-absorbable sutures that include the perimysium of the hiatal muscle, preserved during the dissection. First stich must be placed down at the junction of both crura (Fig. 6.8). First two stitches are placed posteriorly to the esophagus and the third one anteriorly before to continue with posterior sutures combined with some anterior sutures when needed. In order to close the hernia hole correctly, anterior suture of the crura is required in many cases (Fig. 6.9).

Fig. 6.8  Approximation of the pillars (posterior side). Schematic (a) and close view (b,c)

44

Fig. 6.9  Approximation of the pillars (anterior side). Schematic (a) and close view (b, c)

Fig. 6.10  Mesh placement. Schematic (a) and close view (b–d)

S. Morales-Conde et al.

6  Minimally Invasive Surgery of Paraesophageal Hernias

45

Fig. 6.11.  360 degrees fundoplication. Schematic (a) and close view (b, c)

6.2.11 Mesh Placement A “U” shaped mesh is placed, and fixed with two stitches to the crura. Biological glue can also be used, as alternative, to fix the mesh (Fig. 6.10).

6.2.12 Creation of 360 Degrees Fundoplication Pull through the fundus behind the esophagus (retroesophageal window), to the right side. Create the fundoplication by two or three fundus-to-fundus stitches, embracing the intra-abdominal portion of the esophagus. In this way, a 360 degree fundoplication is performed (Fig. 6.11).

References 1. Targarona E, Bendahan G, Balagué C, Garriga J, Trias M. Mesh in the hiatus. A Controversial Issue. Arch Surg. 2004;139:1286–96. 2. DeMeester SR. Laparoscopic paraesophageal hernia repair: critical steps and adjunct techniques to minimize recurrence. Surg Laparosc Endosc Percutan Tech. 2013;23:429–35. 3. Pfluke JM, Parker M, Bowers SP, et al. Hiatal hernia repair with mesh: a survey of SAGES members. Surg Endosc. 2012;26:1843–8.

4. Frantzides CT, Madan AK, Carlson MA, Stavropoulos GP. A prospective, randomized trial of laparoscopic polytetrafluoroethylene (PTFE) patch repair vs simple cruroplasty for large hiatal hernia. Arch Surg. 2002;137:649–52. 5. Granderath FA, Schweiger UM, Kamolz T, et al. Laparoscopic Nissen fundoplication with prosthetic hiatal closure reduces postoperative intrathoracic wrap herniation: preliminary results of a prospective randomized functional and clinical study. Arch Surg. 2005;140:40–8. 6. Tam V, Winger DG, Nason KS. A systematic reviw and meta-analysis of mesh vs suture cruroplasty in laparoscopic large hiatal hernia repair. Am J Surg. 2016;211:226–38. 7. Memon MA, Memon B, Yunus RM, Khan S. Suture cruroplasty versus prosthetic hiatal herniorrhaphy for large hiatal hernia. A meta-analysis and systematic review of randomized controlled trial. Ann Surg. 2016; 263:258–66. 8. Oelschlager BK, Pellegrini CA, Hunter J, et al. Biologic prosthesis reduces recurrences after laparoscopic paraesophageal hernia repair. Ann Surg. 2006;244:481–90. 9. Watson DI, Thompson SK, Devitt PG, et al. Laparoscopic repair of very large hiatus hernia with sutures versus absorbable mesh versus non-absorbable mesh. Ann Surg. 2015;261:282–9. 10. Antoniou SA, Pointner R, Granderath FA, Köckerling F. The use of biological meshes in diaphragmatic defects—an evidence-based review of the literature. Front Surg. 2015;2:56.

7

Minimally Invasive Treatment of Esophageal Leiomyoma Donald. L. van der Peet and Miguel A. Cuesta

7.1 Introduction Benign tumors of the esophagus are rare tumors, being around 1% of all esophageal tumors. In children, cysts and duplications cysts are rare congenital disorders of the foregut. In adults, the most frequent benign esophageal tumor is the leiomyoma, submucosal located and formed by smooth muscular fibers. They are most frequently located in the lower and mid esophagus. Asymptomatic tumors are diagnosed during routine endoscopic examination or CT scan performed for other reasons such as gastroesophageal reflux or chest complaints. Symptoms are dysphagia, chest discomfort or pain, regurgitation, and weight loss [1]. Initial diagnosis is the endoscopic examination where the diagnosis of intramural tumor (bulge) with intact mucosa can be diagnosed. Endoscopic ultrasonography can confirm the diagnosis of benign intramural tumor, penetration in the esophageal wall, and size of the tumor. CT scan and barium swallow can help to locate the tumor and visualize its extension. Fine needle aspiration biopsy can confirm the smooth muscular fibers of the tumor, but its value remains controversial because of the difficulty of the diagnosis and the fibrosis that can produce making enucleation difficult. Differential diagnosis with GIST (gastrointestinal stromal tumors) tumors may be difficult. Esophageal GIST are very rare. PET scan can help to differentiate between the two, the leiomyoma showing a negative PET scan image. In some cases, where the tumor is small and the diagnosis is certain, without symptomatology, the patient can be followed conservatively. Symptomatic tumors, tumors  lectronic supplementary material  The online version of this E chapter (https://doi.org/10.1007/978-3-030-55176-6_7) contains supplementary material, which is available to authorized users. D. L. van der Peet · M. A. Cuesta (*)  Department of Surgery, Amsterdam UMC, Amsterdam, The Netherlands e-mail: [email protected]

with uncertain diagnosis, and large size tumors should be resected. In small tumors, endoscopic treatment is possible and POEM (per oral endoscopic myotomy) treatment is one of the treatment modalities. Enucleation via thoracoscopy is the choice approach, lateral or in prone, depending on the side of thoracoscopy, the location of the tumor. Concerning the size of the tumor, it can be classified as small between 2 and 5 cm, and large more than 5 cm. Both can be treated by thoracoscopic enucleation [2], being very large tumors difficult to manipulate during the enucleation. Lesions of the mucosa have to be repaired and covered by muscular layer. Robot-assisted thoracoscopy can help to dissect the large tumors [3]. If enucleation is not technically possible, esophageal resection should be considered. Tumors located in the very distal part of the esophagus should be approached by laparoscopy [4, 5].

7.2 Description of the Surgical Technique (See Videos 7.1 and 7.2) If the tumor is located in the thoracic esophagus, two types of enucleation can be considered in relation with the size of the tumor: relative small size (2–5 cm) and giant leiomyoma (between 5 and 10 cm). We approach these tumors by thoracoscopy in prone, depending on the side of the thoracoscopy where the tumor is located, right or left. The key steps to perform a thoracoscopic tumor resection are: 1. Trocar placement. Thoracoscopy in prone position Three or four trocars are placed along the scapula. Single intubation and thoracic insufflation (7–8 mm Hg). Trocars: 10 mm in the tip of the scapula for the 30 degrees laparoscope, two work trocars: 5 mm in the 4th intercostal space and 10 mm in the 7th intercostal space. Another 5 mm may be used for the assistant, placed in the 3rd intercostal space (Fig. 7.1).

© Springer Nature Switzerland AG 2021 M. Asunción Acosta et al. (eds.), Atlas of Minimally Invasive Techniques in Upper Gastrointestinal Surgery, https://doi.org/10.1007/978-3-030-55176-6_7

47

48

D. L. van der Peet and M. A. Cuesta

2. Localization of tumor

6. Mucosa inspection and if needed repair

Localize the leiomyoma by visualization (Fig. 7.2) and if needed by endoscopy.

At the end, it is necessary to check the mucosa by esophagoscopy (Fig. 7.6) and if it is open, then close the defect with running suture with resorbable monofilament 4–0.

3. Opening the pleura along the tumor Open the pleura longitudinally along the tumor (Fig. 7.3). Due to the localization of the tumor, in this case, the azygos vein arch is divided. 4. Dissection of the tumor We recommend to start the dissection around the tumor, splitting muscular fibers (Fig. 7.4). 5. Retraction by stitch Put a stitch through the tumor in order to pull it (Fig. 7.5), helping for the blunt dissection, trying always to preserve the integrity of the mucosa.

Fig. 7.1  Trocars placement

Fig. 7.2  Localization of the tumor. Schematic view (a) and close view (b)

7. Approximation of muscular layer Approximate the muscular layer by running suture (Fig. 7.7). 8. Specimen extraction The specimen is removed into a bag through a small thoracotomy (Fig. 7.8). 9. Thoracic drain It is recommended to leave a drain in the thorax. 10. Endoscopic control To evaluate total resection and to check the aspect of the mucosa, an esophagoscopy is performed after the tumor has been resected.

Fig. 7.3  Opening the pleura along the tumor

7  Minimally Invasive Treatment of Esophageal Leiomyoma

Fig. 7.4  Dissection of the tumor (a), splitting muscular layers (b, c)

Fig. 7.5  Stitch through the tumor (a) to maintain a correct traction (b)

Fig. 7.6  Mucosa inspection and repair. Schematic view (a), intrathoracic view without (b), and with transillumination (c)

49

50

D. L. van der Peet and M. A. Cuesta

Fig. 7.7  Opened muscular layer (a). Approximation of muscular layer (b)

In cases of leiomyomas located in intraabdominal esophagus, we start the procedure as any other upper laparoscopic surgery around the hiatus and we follow these steps: 1. Dissection of the distal esophagus. 2. Localization of the tumor by visualization and palpation and if needed by endoscopy. 3. Put a tape around the esophagus for traction. 4. Start splitting the muscular fibers on the tumor. 5. Stitch in the tumor for traction. 6. Hook and blunt dissection, preserving the mucosa. 7. Endoscopic control suturing the muscular layer.

References

Fig. 7.8  Specimen extraction

By large leiomyomas, the same technique is followed, using for blunt dissection the hook, and sealing devices. Manipulation of the tumor may be difficult because of the size. Finding the mucosa is a good reference mark for dissection. In case of difficult dissection, conversion to thoracotomy should be considered. If enucleation is not possible or mucosa is importantly damaged, an esophageal resection should be done.

1. van der Peet DL, Berends FJ, Klinkemberg-Knol EC, Cuesta MA. Endoscopic treatment of benign esophageal tumors: case report of three patients. Surg Endosc. 2001;15:1489. 2. Coral RP, Madke G, Westphalen A, Tressino D, Carvalho LA, Mastalir E. Thoracoscopic enucleation of a leiomyoma of upper thoracic esophagus. Dis Esophagus. 2003;16:339–41. 3. Boone J, Draaisma WA, Schipper ME, Broeders IA, Rinkes IH, van Hillegersberg R. Robot-assisted thoracoscopic esophagectomy for a giant upper esophageal leiomyoma. Dis Esophagus. 2008;21:90–3. 4. Kent M, d'Amato T, Nordman C, Schuchert M, Landreneau R, Alvelo-Rivera M, et al. Minimally invasive resection of benign esophageal tumors. Thorac Cardiovasc Surg. 2007;134:176–81. 5. Samphire J, Nafteux P, Luketich J. Minimally Invasive techniques for resection of benign esophageal tumors. Semin Thorac Cardiovas Surg. 2003;15:35–43.

8

Peroral Endoscopic Myotomy (POEM) for Achalasia Barbara A. J. Bastiaansen, André J. P. M. Smout and Paul Fockens

8.1 Introduction Achalasia is a relatively rare primary esophageal motor disorder caused by loss of inhibitory postganglionic neurons in the myenteric plexus with a prevalence of 10 per 100.000 individuals. It is characterized by aperistalsis and absent relaxation of the lower esophageal sphincter (LES). Clinically, achalasia manifests as progressive dysphagia, retrosternal pain, regurgitation, and weight loss. However, symptoms of achalasia are nonspecific which often leads to a long delay (up to 5 years) between the onset of symptoms and final diagnosis. Esophageal high-resolution manometry (HRM) is currently considered the test of choice for the diagnosis achalasia. Achalasia is classified into three subtypes, based on characteristics of pressurization measured on HRM: type I (absent pressurization), type II (panesophageal pressurization), and type III (spastic contractions) (Fig. 8.1). Type II achalasia likely represents early-stage achalasia with retained smooth muscle tone generating panesophageal intrabolus pressurization. Type I is generally believed to be a later phase of disease progression with complete loss of contractile activity and a dilated esophagus. Type III achalasia is considered a separate entity, characterized by premature or spastic contractions [1]. Achalasia is considered a chronic disease and cannot be cured, as the pathophysiology of the neural degeneration remains largely unclear. Therapeutic options are therefore directed toward symptom relief by lowering the LES pressure to improve transit of food into the stomach.  lectronic supplementary material  The online version of this E chapter (https://doi.org/10.1007/978-3-030-55176-6_8) contains supplementary material, which is available to authorized users.

B. A. J. Bastiaansen · A. J. P. M. Smout · P. Fockens (*)  Department of Gastroenterology and Hepatology, Amsterdam University Medical Center, University of Amsterdam, Amsterdam, The Netherlands e-mail: [email protected]

The mainstay of achalasia management focuses on LES disruption, classically either by endoscopic pneumatic dilation (PD) or laparoscopic Heller myotomy (LHM) combined with an antireflux procedure. Peroral endoscopic myotomy (POEM) is a relatively new minimally invasive technique and has emerged as a very safe and efficacious therapeutic option for patients with achalasia and other spastic motility disorders. This endoscopic technique allows us to replicate a surgical myotomy by the creation of a submucosal tunnel after mucosal incision followed by myotomy of the circular muscle layer of the esophagus onto the cardia. Complication rate is comparable to surgical Heller myotomy, and POEM carries a mortality risk approaching zero [2]. POEM seems to have promising advantages for treatment of achalasia, being less invasive in nature than the conventional extraluminal surgical approach, avoiding abdominal incisions, offering rapid recovery and the possibility to adapt the length of the desired myotomy. Since the first human study of POEM in 2010, numerous published studies, including thousands of patients worldwide, all report therapeutic success in 82–100% of patients with the longest follow-up in literature now at 5 years [3]. Prospective randomized studies comparing POEM with either LHM or PD are recently completed and results have been published in abstracts showing a higher 1-year therapeutic success rate for POEM (clinical remission 92%) compared to PD (clinical remission 70%) (p 10 years) with a wide range of revisions and removals. Lately, there has been some discouragement with band intolerance, weight regain and other clinical issues requiring band explantation and in some cases, conversion to other procedure.

Electronic supplementary material  The online version of this chapter (https://doi.org/10.1007/978-3-030-55176-6_28) contains supplementary material, which is available to authorized users.

28.2 Description of the Surgical Technique (Video 28.1)

J. Ponce (*)  CHI Memorial Hospital, Chattanooga, TN, USA e-mail: [email protected]

1. Patient and trocar position The correct position to perform this technique is a lithotomy supine position with arms extended, surgeon

© Springer Nature Switzerland AG 2021 M. Asunción Acosta et al. (eds.), Atlas of Minimally Invasive Techniques in Upper Gastrointestinal Surgery, https://doi.org/10.1007/978-3-030-55176-6_28

221

222

J. Ponce

Fig. 28.1  Position of patient and trocar’s placement. Real (a) and schematic view (b)

Fig. 28.2  Dissection of the angle of His. Close (a, b) and schematic view (c)

standing between the patient’s legs, camera holder on the left and assistant on the left of the surgeon (Fig. 28.1). Five ports are used: 4 of 5 mm and 1 of 15 mm. 2. Dissection of the angle of His (Fig. 28.2) After placement of the liver retractor, a small incision is performed on the left side of the gastroesophageal junction within the gastrophrenic ligament. Then a minimal blunt dissection of the angle of His is necessary by means of the articulated dissector type “Goldfinger”, preserving the gastrophrenic ligament. 3. Pars flaccida dissection (Fig. 28.3) In this step, it’s necessary to open the pars flaccida to expose the right crus. 4. Hiatal dissection (Fig. 28.4) A correct dissection from the anterior border of the right crus at its most lower aspect (hiatal “V”: confluence of the right and left pillars of the right crus) must be realized.

5. Hiatal crura repair (Fig. 28.5) If laxity of the right crus posteriorly, this is repaired by approximating both pillars by means of EndoStich (R) or standard stitches. All sliding hiatal hernias are reduced with full mobilization of the distal esophagus, followed by repair. 6. Creation of a retroesophageal window (Fig. 28.6) By blunt dissection by means of an articulated dissector-type Goldfinger, a retroesophageal window is created in direction to the angle of His. 7. Introduction of the band device The band is introduced into the abdomen using the 15 mm trocar (Fig. 28.7). The end of the tube is pulled through the retroesophageal tunnel from the His to the right (Fig. 28.8). The whole tube has to pass in order to place the band properly.

28  Laparoscopic Adjustable Gastric Band

Fig. 28.3  Dissection of the pars flaccida and right crus. Close (a, b) and schematic view (c)

Fig. 28.4  Hiatal dissection. Close (a, b) and schematic view (c)

Fig. 28.5  Hiatal crura repair. Close (a, b) and schematic view (c)

223

224

J. Ponce

Fig. 28.6  Creation of a retroesophageal window. Close (a, b) and schematic view (c)

Fig. 28.7  Introduction of the band device into the abdomen

8. Band locked The locked band should not be tight on the cardias (Fig. 28.9). Once the band is correctly placed around the cardias, the band is locked (Fig. 28.10). The band should rotate freely around the cardias. Otherwise the band needs to be unbuckled and more perigastric fat must be excised. 9. Anterior (superior) gastro-gastric fixation of the band (Fig. 28.11) Anteriorly, a plication of the fundus below the band to the upper gastric pouch is performed (2 stitches). 10. Inferior fixation of the band (Fig. 28.12) With one stich, from the fundus to the high lesser curvature, the band is inferiorly fixed. 11. Placed the port subcutaneously (Fig. 28.13) The distal tube is exteriorized through an abdominal opening to assemble this end with the adjustment access port. With four cardinal stitches the pouch is fixed to the anterior fascia of the anterior rectus muscle. The pouch is placed subcutaneously, not to superficial. The port is fixed to the anterior rectus fascia by four cardinal stitches. 12. Accessing the port and adjustment of the band (Fig. 28.14) Injecting saline through the access port of the band will tight it around the upper stomach. In this way the passage of food from the esophagus to the stomach is reduced.

28  Laparoscopic Adjustable Gastric Band Fig. 28.8  Passing the band tubing. Close (a) and schematic view (b)

Fig. 28.9  Locking the band. Close (a, b) and schematic view (c)

225

226

Fig. 28.10  The band is locked

Fig. 28.11  Anterior-superior gastro-gastric fixation of the band. Close (a, b) and schematic view (c)

J. Ponce

28  Laparoscopic Adjustable Gastric Band

227

Fig. 28.12  Inferior fixation of the band. Close (a) and schematic view (b)

Fig. 28.13  Placed the port subcutaneously. Close (a) and schematic view (b, c)

References

Fig. 28.14   Accessing the port  and adjustment of the band. Schematic view

1. Ponce J. Laparoscopic adjustable gastric banding: technique and outcomes. In: Nguyen NT, Blackstone RP, Morton JM, Ponce J, Rosenthal RJ, editors. The ASMBS Textbook of Bariatric Surgery. New York: Springer; 2015. p. 193–204. 2. Ponce J, Dixon JB. 2004 ASBS consensus conference. Laparoscopic adjustable gastric banding. Surg Obes Relat Dis. 2005;1:310–6. 3. Ren CJ, Horgan S, Ponce J. U.S. experience with the lap-band system. Am J Surg. 2002;184:46S – 50. 4. Phillips E, Ponce J, Cunneen SA, Bhoyrul S, Gomez E, Ikramuddin S, et al. Safety and effectiveness of realize adjustable gastric band: 3-year prospective study in the United States. Surg Obes Relat Dis. 2009;5:588–97. 5. Angrisani L, Lorenzo M, Borelli V. Laparoscopic adjustable gastric banding versus roux-en-y gastric bypass: 5-year results of a prospective randomized trial. Surg Obes Relat Dis. 2007;3:127–33. 6. Nguyen NT, Slone JA, Nguyen XM, Hartman JS, Hoyt DB. A pro-spective randomized trial of laparoscopic gastric bypass versus laparo-scopic adjustable gastric banding for the treatment of morbid obesity. Outcomes, quality of life, and costs. Ann Surg. 2009;250: 631–41. 7. Buchwald H, Avidor Y, Braunwald E, Jensen MD, Pories W, Fahrbach K, et al. Bariatric surgery. A systematic review and meta-analysis. JAMA. 2004;292(14):1724–37.

228 8. O’Brien PE, McPhail T, Chaston TB, Dixon JB. Systematic review of medium-term weight loss after bariatric operations. Obes Surg. 2006;16:1032–40. 9. O’Brien PE, McDonald L, Anderson M, Brown WA. Long term outcomes after bariatric surgery: fifteen year follow up of adjustable

J. Ponce gastric banding and a systematic review of the bariatric surgical literature. Ann Surg. 2013;257(1):87–94.

Laparoscopic Roux-En-Y Gastric Bypass

29

J. Caetano Marchesini and Natan Zundel

29.1 Introduction Laparoscopic gastric bypass is one of the most frequent bariatric procedures performed in the world. Nowadays, only sleeve gastrectomy is more used than this technique. Wittgrove and Clark [1] published their initial results on laparoscopic gastric bypass in 1994 and many centers have chosen this technique like the gold standard procedure for bariatric patients [2], but there is no a uniform way to perform this procedure and each surgical team has its own specific surgical steps. There are different types of gastrojejunal anastomosis [3], different length of the alimentary limb, antecolic or retrocolic route for the Roux limb, and different approaches [4]. All of these techniques have been shown to produce successful outcomes when performed by experienced surgeons. Outcomes are very good, with a % reduction in excess body mass index that significantly improved over time and a highly significant decrease in obesity-related comorbid disease that persisted at 10 years of follow-up [5].

 lectronic supplementary material  The online version of this E chapter (https://doi.org/10.1007/978-3-030-55176-6_29) contains supplementary material, which is available to authorized users.

J. C. Marchesini  Department of Endoscopy, Medical School of Mario Covas Hospitaland Bariatric Surgery of SirioLibanés Hospital, Sao Paulo, Brazil N. Zundel  Department of Surgery, FIU Herbert Wertheim College of Medicine, Jackson North Medical Center, 17038 North Dixie Hwy Beach, Miami, FL 33160, USA e-mail: [email protected]

29.2 Description of the Surgical Technique (Video 29.1) 1. Patient, surgical team and trocar position The patient is taken to the operation table in the supine position with the legs together, monitored, placed under general anesthesia and submitted to skin preparation. Drapes are placed for delimitation of the surgical field. The patient is placed in a semi-sitting position, with the back raised at an approximate angle of 45°. This position decreases the distance between the trocars and the esophagogastric junction, the deeper part of the operative field. This generally avoids the need of long instruments. The patient’s position will be changed to horizontal in the intestinal operating time, back into semi-sitting during the gastrojejunal anastomosis and finally again in horizontal for closure of the Petersen’s space. The surgeon stands on the right side of the patient together with the first assistant, who handles the camera. The second assistant and the scrub nurse stay on the left side (Fig. 29.1). Trocars are placed as follows (Fig. 29.1): – A 10 mm trocar in the umbilicus for the camera – Two 5 mm trocars are then placed in the epigastrium, in a subcostal position, near the xiphoid process 4 cm from midline. The right trocar is used for the surgeon’s left hand and the left trocar is used for liver retraction with a grasper, fixed on the diaphragm near the esophageal hiatus. – Another 10 mm trocar is inserted in the left subcostal margin near the anterior axillary line. This will be used by the second assistant to manipulate instruments to aid the procedure and, if necessary, to place an abdominal drain at the end of the operation. – Two other 13 mm trocars are placed bilaterally in the midclavicular lines. The distance to the costal margin depends on the patient’s abdominal shape.

© Springer Nature Switzerland AG 2021 M. Asunción Acosta et al. (eds.), Atlas of Minimally Invasive Techniques in Upper Gastrointestinal Surgery, https://doi.org/10.1007/978-3-030-55176-6_29

229

230

J. C. Marchesini and N. Zundel

Fig. 29.1  Position of surgical team (a), patient (a) and trocar’s (b) placement

Fig. 29.2  Dissection of the lesser gastric curvature. Close (a) and schematic view (b)

2. Dissection of the lesser gastric curvature (Fig. 29.2) The first surgical step is to place a subhepatic clamp for retraction anchored in right crura. The operation itself begins with dissection of the lesser gastric curvature, next to the third distal vessel of the esophagogastric junction above the “crow’s foot”. 3. Transverse gastric section (Fig. 29.3) A space between the neurovascular bundle and the wall of the stomach is created, along which the first stapler will be inserted.

This first transverse firing is done with a purple or gold 45 mm load, with the stapler inserted by the 13 mm trocar in the right side of the patient. 4. Vertical gastric section The operation continues with vertical firings toward the His angle. To do this step, a 32 Fr Fouchet bougie is introduced into the stomach to be used as a guide for the vertical staples (Fig. 29.4). At this point, we must not apply too much tension of the stomach on the bougie.

29  Laparoscopic Roux-En-Y Gastric Bypass

231

Fig. 29.3  Transverse section of the stomach. Close (a) and schematic view (b) Fig. 29.4  A 32 Fr bougie into the stomach

The stapler is inserted in the 13 mm trocar on the left side of the patient. Purple loads of 45 or 60 mm are used for these staplings. The vertical stapling should finish approximately 2 cm from the esophagus (Fig. 29.5). 5. Reinforcement suture (Fig. 29.6) After reviewing hemostasis, over sewing or not the staple line is done depending on the intensity of local bleeding.

6. Intestinal operating time position For the intestinal operating time, an optional 5 mm trocar can be inserted, between the umbilical and the 13 mm trocar in the right side of the patient, forming a triangular image (Fig. 21.1). This extra trocar gives more ergonomy to the surgeon’s arms, avoiding fatigue in procedures that are longer than usual.

232

J. C. Marchesini and N. Zundel

Fig. 29.5  Vertical gastric section. Close (a, b) and schematic view (c)

7. Transection of the small intestine Using graspers through the 13 and 5 mm right-side trocars for the surgeon’s hands, and the left side 13 mm for one hand of the assistant, the inframesocolic area is exposed to identify the angle of Treitz. At 120 cm of the angle of Treitz, the transection of the small intestine is performed with a white load. The stapler is inserted in the 13 mm right-side trocar (Fig. 29.7). 8. Jejunum-jejunal anastomosis From this point, we count 100 cm from the distal segment of the intestinal transection for the preparation of the alimentary limb and establishing the location of the Roux-en-Y enteroanastomosis.

To avoid confusion, the biliopancreatic limb should be positioned toward the angle of Treitz and the alimentary limb by the patient’s right side with the mesentery exposed open. This facilitates the lifting of the alimentary limb to the gastrojejunal anastomosis at the end of the enteroanastomosis. The mesenteric space is easily exposed in this position. Both the biliopancreatic and the alimentary limbs are positioned side by side in an isoperistaltic manner. Two orifices are made to insert the stapler and the anastomosis is performed with 45 mm white loads (Fig. 29.8). The remaining orifice is closed by means of a continuous suture with 3-0 PDStm thread (Fig. 29.9).

29  Laparoscopic Roux-En-Y Gastric Bypass

233

Fig. 29.6  Reinforcement suture

Fig. 29.7  Transection of the small bowel. Close (a) and schematic view (b)

9. Suture anchoring the alimentary limb to the gastric pouch (Fig. 29.10) To make the gastrojejunal anastomosis, we lift the alimentary limb parallel to the gastric pouch, where it is anchored using a 3-0 Ethibondtm suture in the stapling line, approximately 5 cm above the distal end of the gastric pouch.

10. Gastrojejunal anastomosis Through small orifices, made in the gastric pouch and the alimentary limb with electrocautery or ultrasonic scissors, the stapler with a 45 mm purple or gold load is inserted (Fig. 29.11). The staple firing is made anterior to the section line of the gastric pouch. The hole which results from the

234

J. C. Marchesini and N. Zundel

Fig. 29.8  Jejunum-jejunal anastomosis. Close (a) and schematic view (b)

Fig. 29.9  Close the orifice. Close (a) and schematic view (b)

stapler introduction is closed with double-layer suturing using the same 3-0 PDS™ thread (Fig. 29.11). Despite the controversies, the choice of the anastomotic technique should depend for the most part, based on present evidence, on the surgeon’s preferences and expertise [7, 8]. The choice of the antecolic route for the roux limb is based on the consideration of internal hernias. Two

reviews of internal hernias after laparoscopic gastric bypass found that the retrocolic window was the most common site of symptomatic herniation [9, 10]. Antecolic placement of the Roux limb avoids creation of a retrocolic defect. Only on rare occasion, such as when a Roux limb has poor mobility and would create anastomotic tension at the gastrojejunostomy, do we prefer the retrocolic route for the Roux limb to reach the gastric pouch.

29  Laparoscopic Roux-En-Y Gastric Bypass

235

Fig. 29.10  Suture anchoring the alimentary limb to the gastric pouch. Close (a) and schematic view (b)

Fig. 29.11  Gastrojejunal anastomosis. Close (a) and schematic view (b, c)

11. Close the spaces (Fig. 29.12) The mesenteric defects are closed with 2-0 Ethibond™. The Roux-en-Y enteroanastomosis defect is closed at the end of the procedure, if this was not done earlier. This step can be left to the end to decrease the tension at the time of the gastrojejunal anastomosis. The closing of the Petersen’s space is done with 2-0 Ethibond™.

Upon completion of the procedure, hemostasis and methylene blue test are performed to detect possible leakage through the suture lines. The use of a Penrose drain or similar is optional, and classic criteria are followed. Its use is not a routine.

236

J. C. Marchesini and N. Zundel

Fig. 29.12  Close the spaces. Final view

References 1. Wittgrove AC, Clark GW, Tremblay LJ. Laparoscopic gastric bypass, Roux-en-Y: preliminary report of five cases. Obes Surg. 1994;4(4):353–7. 2. Buchwald H, Oien DM. Metabolic/bariatric surgery worldwide 2011. Obes Surg. 2013;23(4):427–36. 3. Higa KD, Boone KB, Ho T, Davies OG. Laparoscopic Roux-en-Y gastric bypass for morbid obesity: technique and preliminary results of our first 400 patients. Arch Surg 2000;135:1029–33; discussion 1033–1034. 4. Marchesini JC, Marchesini JB, Baretta GA, Castro GR, Sadowski JA, Sobottka WH, Feistler R. Laparoscopic Roux-en-Y gastric bypass with single transumbilical incision–GelPoint®. Arq Bras Cir Dig. 2013;26(1):83–4. 5. Mehaffey JH, LaPar DJ, Clement KC, Turrentine FE, Miller MS, Hallowell PT, Schirmer BD. 10-Year outcomes after Roux-en-Y gastric bypass. Ann Surg. 2016;264(1):121–6.

6. Higa KD, Ho T, Boone KB. LaparoscopicRoux-en-Ygastric bypass: technique and 3-year follow-up. J Laparoendosc Adv Surg Tech A. 2001;11:377–82. 7. Champion JK, Williams MD. Prospective randomized comparison of linear staplers during laparoscopic Roux-en-Y gastric bypass. Obes Surg. 2003;13:855–9; discussion 860. 8. Korenkov M, Goh P, Yucel N, Troidl H. Laparoscopic gastric bypass for morbid obesity with linear gastroenterostomy. Obes Surg. 2003;13:360–3. 9. Higa KD, Ho T, Boone KB. Internal hernias after laparoscopic Roux- en-Y gastric bypass: Incidence, treatment and prevention. Obes Surg. 2003;13:350–4. 10. Champion JK, Williams M. Small bowel obstruction and internal hernias after laparoscopic Roux-en-Y gastric bypass. Obes Surg. 2003;13:596–600.

Laparoscopic Sleeve Gastrectomy Michel Gagner

30.1 Introduction The sleeve gastrectomy is a restrictive  and hormonal procedure, in which stomach is reduced to a vertical tube with a volume less than 2100 mL. A metabolic action has been described in relation to this technique, due to the resection of the greater gastric curvature and the fundus also alters the hormonal milieu of the gut, in particular decreasing ghrelin production [1] with effect in hunger and satiety [2, 3]. This technique was described at the beginning like a first stage of duodenal switch in high-risk patients [4–6]. After evaluating the results of this procedure alone a lot of surgical teams decided to perform this technique like a definitive bariatric procedure. Nowadays, it is the most common bariatric procedure performed around the world. It’s very important to do a correct selection of the patients and make a safe procedure based in expert recommendations [7]. Long-term results are excellent with a correct weight loss and comorbidities curation rates. Complications are infrequent. Stenosis, reflux, bleeding and leaks are the most common complications and an expert multidisciplinary group is necessary to treat them successfully.

 lectronic supplementary material  The online version of this E chapter (https://doi.org/10.1007/978-3-030-55176-6_30) contains supplementary material, which is available to authorized users.

M. Gagner (*)  Department of Surgery, Hopital du Sacre Coeur, 315 Place D’Youville, #191, Montreal, QC H2Y 0A4, Canada e-mail: [email protected]

30

30.2 Description of the Surgical Technique (Video 30.1) 1. Patient, surgical team and trocar position The patient is placed in supine position with legs apart and both arms in abduction. The surgeon stands between patient’s legs, assistant with the camera on the right side of the patient and the first stay on the patient’s left side (French position). Trocars are placed as follows: – A 10 mm trocar in the umbilicus for the camera (30°). – A 5 mm trocar in the epigastrium, near the xiphoid process. It is used for liver retraction. – A 5 mm trocar in the right upper quadrant, for the surgeon’s left hand. – A 12 mm trocar in the left upper quadrant, for the surgeon’s right hand. – A 5 mm trocar laterally in the left abdomen, for the assistant. 2. Exposure of the surgical field First of all, a liver retractor is placed and an evaluation of the stomach and hiatus is performed (Fig. 30.1). 3. Dissection of the greater gastric curvature (Fig. 30.2) In this step, dissection of the greater curvature starts in the antrum and it continues to the angle of His cranially. Distally the dissection ends close to the pylorus. 4. Short gastric vessels section (Fig. 30.3) Carefully short gastric vessels are divided. Sometimes a dilated fundus make this dissection difficult. To obtain a correct view in order to avoid bleeding in this area surgeon and assistant both have to make a careful traction of the fundus to the left. 5. Dissection of the angle of His (Fig. 30.4) Cranially the dissection continues to the angle of His. It’s very important to remove all adherences of the posterior wall of the stomach in order to make a correct dissection of the left crus and the angle of His.

© Springer Nature Switzerland AG 2021 M. Asunción Acosta et al. (eds.), Atlas of Minimally Invasive Techniques in Upper Gastrointestinal Surgery, https://doi.org/10.1007/978-3-030-55176-6_30

237

238

Fig. 30.1  Exposure of the surgical field.

M. Gagner

6. Section of the stomach (Fig. 30.5) After total mobilization of the greater gastric curvature, a Fouche tube (36Fr) is placed into the stomach lumen. The tube is located in the lesser curvature. Then sequential stapler firings along this inserted bougie are used to create a sleeve gastrectomy. The staplers used in this part of the operation are 60 mm/4.8 mm, covered with bioabsorbable material to prevent bleeding and to diminish the rate of leakage. 7. Stitch at the proximal end of the first section (Fig. 30.6) After the first stapler firing, a X stitch is performed at the end of the section, near to the piylorus. 8. Gastric section (Fig. 30.7) The section of the stomach is now performed following the bougie to the angle of His. 9. Stitch at the end of the section near to the angle of His (Fig. 30.8)

Fig. 30.2  Dissection of the greater gastric curvature. Close (a, b) and schematic view (c)

Fig. 30.3  Short gastric vessels section. Close (a) and schematic view (b)

30  Laparoscopic Sleeve Gastrectomy

239

Fig. 30.4  Dissection of the angle of His and the left crus. Close (a) and schematic view (b)

Fig. 30.5  Section of the stomach. Close (a) and schematic view (b)

Fig. 30.6  Stitch at the end of the first stapler line section

After the last stapler firing, a X stitch is performed at the end of the section, near to the angle of His. 10. Pars flaccida is divided (in case of hiatal hernia) (Fig. 30.9) In case of hiatal hernia, when gastrectomy is performed, it’s necessary to repair the hiatus defect. First of all, pars flaccida is divided in order to make a correct dissection of the crura.

Fig. 30.7  Gastric section

240

M. Gagner

Fig. 30.8  Stitch at the end of the gastric section. Close (a) and schematic view (b)

Fig. 30.9  Pars flaccida division Fig. 30.10  Dissection of the right crus

11. Pars flaccida is divided (in case of hiatal hernia) (Fig. 30.10) The next step is to dissect right crus from the posterior to the anterior part of the hiatus. 12. Posterior window behind the esophagus (Fig. 30.11) After a correct identification of the hiatus and dissection of both crura, a posterior window is performed by blunt dissection behind the esophagus. 13. Traction of the esophagus (Fig. 30.12) In order to have a correct view of the hiatus, a traction of the abdominal esophagus is necessary. A Penrose

drain is placed through the posterior window surrounding the esophagus. 14. Closure of the hiatus (Fig. 30.13) The crura are approximated by non-absorbable stitches. Posterior portion of the crura is closed taking the whole muscular thickness One or two stitches are usually necessary to close correctly the hiatus. 1 5. Final view (Fig. 30.14) The procedure finishes with a total revision of the surgical field.

30  Laparoscopic Sleeve Gastrectomy Fig. 30.11  Posterior window behind the esophagus

Fig. 30.12  Traction of the esophagus

Fig. 30.13  Closure of the hiatus. Close (a, b) and schematic view (c)

241

242

M. Gagner

Fig. 30.14  Final view. Close (a) and schematic view (b)

References 1. Camilleri M, Papathanasopoulos A, Odusi ST. Actions and therapeutic pathways of ghrelin for gastrointestinal disorders. Nat Rev Gastroent Hepat. 2009;6:343–52. 2. Neary MT, Batterham RL. Gut hormones: implications for the treatment of obesity. Pharmacol Ther. 2009;124:44–56. 3. Vincent RP, le Roux CW. Changes in gut hormones after bariatric surgery. Clin Endocrinol (Oxf). 2008;69:17317–9. 4. Hess DW, Hess DS. Biliopancreatic diversion with a duodenal switch. Obes Surg. 1998;8:267–82.

5. Marceau P, Biron S, Bourque RA, et al. Biliopancreatic diversion with a new type of gastrectomy. Obes Surg. 1993;3:29–35. 6. Hamoui H, Anthone GJ, Kaufman HS, et al: Sleeve gastrectomy in the high-risk patient, Obes Surg. 2006;16:14451–9. 7. Gagner M, Hutchinson C, Rosenthal R. Fifth International Consensus Conference: current status of sleeve gastrectomy. Surg Obes Relat Dis. 2016;12:750–6. Figure 30.1. Exposure of the surgical field.

Laparoscopic Duodenal Switch Jacques Himpens and Roel Bolckmans

31.1 Introduction Duodenal switch is a malabsorptive procedure that consists of a combination of sleeve gastrectomy and biliopancreatic diversion. The mechanism of weight loss after the duodenal switch is due to restriction caused by sleeve gastrectomy and malabsorption due to reduction of the functional shortening capacity of the small bowel reduces the absorption capacity. The common channel is usually 75–150 cm long. The long-term results of this technique are very good with high percentages of comorbidity reduction and weight loss. In this chapter, the laparoscopic duodenal switch will be described step by step.

31.1.1 Description of the Surgical Technique (Video 31.1) [1] 1. Patient, surgical team, and trocar position The patient is placed in supine position with legs apart and both arms in abduction. The surgeon stands between patient’s legs (French position) (Fig. 31.1). To perform this technique, six trocars are placed as shown in Fig. 31.1.

31

2. Sleeve gastrectomy (Fig. 31.2). In this part of the procedure, dissection of the greater curvature starts in the antrum and it continues to the angle of His cranially. Distally the dissection ends close to the pylorus. After this longitudinal section of the stomach is perfumed with a Fouche tube (36Fr) located in the lesser curvature of the stomach lumen. 3. Cholecystectomy and posterior dissection of the duodenum (Fig. 31.3). After sleeve gastrectomy is finished, a cholecystectomy is performed. In this surgical field, a dissection of the posterior wall of the duodenum is the next step in order to create a passage between the duodenum and the pancreas. This step can be performed using two different approaches: • Anterior approach: the anterior peritoneal sheet at the superior border of the duodenum is dissected and then a passage between above first duodenum and the pancreatic head is created. The duodenum is taken up with a piece of cotton tissue tape. • Posterior approach: the antrum is held up and retrogastric adhesions are divided. Then a passage is created just anteriorly to the pancreatic head. A piece of cotton tissue tape is used to encircle the duodenum and to hold it in order to divide it. 4. Section of the duodenum (Fig. 31.4).

 lectronic supplementary material  The online version of this E chapter (https://doi.org/10.1007/978-3-030-55176-6_31) contains supplementary material, which is available to authorized users.

When a retroduodenal window is created, a stapler is introduced and duodenal section is performed. 5. Change of the surgical team position (Fig. 31.5).

J. Himpens (*)  CHIREC Delta Hospital, Brussels, Belgium e-mail: [email protected] R. Bolckmans  Virginia Commonwealth University Hospitals, Richmond, VA, USA

To do the second part of this procedure, the surgical team has to change this position. At this time, all surgeons are placed on the left side of the patient. The patient is positioned in the Trendelenburg position.

© Springer Nature Switzerland AG 2021 M. Asunción Acosta et al. (eds.), Atlas of Minimally Invasive Techniques in Upper Gastrointestinal Surgery, https://doi.org/10.1007/978-3-030-55176-6_31

243

244

J. Himpens and R. Bolckmans

Fig. 31.1  Position of the surgical team and patient (a) and trocar’s (b) placement

Fig. 31.2  Sleeve gastrectomy. Stapler cutting the stomach (a) and sleeve gastrectomy finished (b)

6. Measurement of the alimentary, biliopancreatic, and common limbs (Fig. 31.6). From the ileocecal valve, the small bowel is measured 75–100 cm (common limb) and marked at this distance with a stitch. From this point, another 175–150 cm is measured (alimentary limb). Proximal to this point, another 175–150 cm in direction to the angle of Treitz is marked (biliopancreatic limb). 7. Small bowel section (Fig. 31.6) After the correct measurement of the common, biliopancreatic, and alimentary limb, the bowel is divided between the biliopancreatic limb and the proximal end of the alimentary limb.

8. Jejunoileostomy This anastomosis is located 75–100 cm from the ileocecal valve is med between this part of the ileum and the distal portion of the biliopancreatic limb after the previous section. This anastomosis can be performed by three different approaches: • Hand sewn side to side (Fig. 31.7) • Semimechanical (Fig. 31.8) • Totally mechanical (Fig. 31.9). After jejunoileostomy is performed, mesenteric defect is closed with a running suture.

31  Laparoscopic Duodenal Switch Fig. 31.3  Posterior dissection of the duodenum. Close (a, b, c) and schematic view (d)

Fig. 31.4  Duodenal section. Close (a, b) and schematic view (c)

245

246

Fig. 31.5  Second surgical team position

Fig. 31.6  Common (a) and alimentary limb measurement where the bowel is divided (b)

J. Himpens and R. Bolckmans

31  Laparoscopic Duodenal Switch

Fig. 31.7  Hand sewn side to side jejunoileostomy (a, b, c)

Fig. 31.8  Semimechanical jejunoileostomy (a, b, c)

Fig. 31.9  Totally mechanical jejunoileostomy (a, b, c)

Fig. 31.10  Duodenoileal anastomosis. Close (a, b) and schematic view (c)

247

248

J. Himpens and R. Bolckmans

Fig. 31.11  Hand sewn duodenoileal anastomosis (a, b, c, d)

9. Duodenoileal anastomosis To perform this anastomosis, the surgeon can be at the left side of the patient or between patient’s leg. This anastomosis can be performed by these approaches: • Semimechanical (Fig. 31.10) • Hand sewn (Fig. 31.11). 10. Leak test, closure of Petersen space, drain, and trocar extraction. At the end of this procedure, blue methylene test is performed to check duodenoileal anastomosis leak. Petersen’s space is closed with a 2/running suture. A drain is placed when the surgeon considers it is necessary.

References 1. Dapri G, Cadière GB, Himpens J. 32 laparoscopic malabsorptive procedures: technique of duodenal switch. In: Brethauer S, Schauer P, Schirmer B, editors. Minimally invasive bariatric surgery. Springer, New York, NY; 2015. 2. Hess DS, Hess DW. Biliopancreatic diversion with a duodenal switch. Obes Surg. 1998;8:267–82. 3. Marceau P, Hould FS, Simard S, et al. Biliopancreatic diversion with duodenal switch. World J Surg. 1998;22:947–54. 4. Ren CJ, Patterson E, Gagner M. Early results of laparoscopic biliopancreatic diversion with duodenal switch: a case series of 40 consecutive patients. Obes Surg. 2000;10:514–23. 5. Skogar ML, Sundbom M. Weight loss and effect on co-morbidities in the long-term after duodenal switch and gastric bypass: a population-based cohort study. Surg Obes Relat Dis. 2020;16:17–23.

Single Anastomosis Duodenoileal Bypass with Sleeve Gastrectomy

32

Andrés Sánchez-Pernaute, María Elia Pérez Aguirre and Aida Pérez Jiménez

32.1 Introduction Single anastomosis duodenoileal bypass with sleeve gastrectomy (SADI-S) was introduced in Spain in May 2007 as a modification and simplification of the traditional biliopancreatic diversion with duodenal switch (DS) [1]. SADI-S is a one-loop duodenal switch in which the sleeve gastrectomy is performed over a wide bougie (54 French), the antrum of the stomach is partially preserved (section 5–6 cm from the pylorus) and the duodenum is anastomosed to the proximal ileum, with a variable length of the common alimentary limb from 250 to 300 cm. Duodenal dissection is ideally performed with preservation of the right gastric artery, to improve vascularization and avoid anastomotic problems. The duodeno-ileostomy can be hand sewn or mechanically performed, with an usual width of 2–3 cm. Advantages of the technique over Roux en Y gastric bypass are the preservation of the pylorus—which warrants a better antidiabetic response and avoids dumping syndrome—and a better weight loss, usually 15% better than the standard gastric bypass [2, 3]. The main advantage over the Roux en Y duodenal switch is that reduction to one anastomosis saves time in surgery, reduces anastomotic postoperative complications, and eliminates the probability of internal hernia in the follow-up. The increase in the length of the common

 lectronic supplementary material  The online version of this E chapter (https://doi.org/10.1007/978-3-030-55176-6_32) contains supplementary material, which is available to authorized users.

A. Sánchez-Pernaute (*) · M. E. P. Aguirre  Department of Surgery, Hospital Clínico San Carlos, Madrid, Spain e-mail: [email protected] A. P. Jiménez  Department of Surgery, Hospital Universitario Puerta del Sur, Móstoles, Madrid, Spain

channel decreases bowel movements and improves the quality of life [4]. The key points of the operation are: (1) To perform a wide sleeve gastrectomy with complete resection of the gastric fundus. This is achieved through the introduction of a wide bougie that minimizes the probability of stricture at the incisura angularis; also, the partial preservation of the antrum helps with the gastric emptying and reduces gastroesophageal reflux. (2) To dissect as much duodenum as possible. A complete “under-vision” dissection is preferred, separating the proximal duodenum from the head of the pancreas as far as possible. A great help is to identify the gastroduodenal artery from the origin of the right gastroepiploic artery to the origin of the right gastric artery. (3)  To perform the duodeno-ileostomy at the proximal ileum, leaving at least 250 cm of common channel but not more than 300 cm. (4) To avoid tension at the anastomosis. For a successful result of SADI-S, a strict selection of patients and a close follow-up with an adequate supplementation are mandatory.

32.2 Description of the Surgical Technique (Video 32.1) 1. Patient, surgical team, and trocar position The patient is placed in supine position with legs apart and right arm in abduction. The surgeon stands between patient’s legs. Trocars are placed as follows (Fig. 32.1): – A 10-mm trocar in the left upper quadrant for the camera (30°). – A 5-mm trocar in the epigastrium, near the xiphoid process. It is used for the left hand of the surgeon and for the liver retraction.

© Springer Nature Switzerland AG 2021 M. Asunción Acosta et al. (eds.), Atlas of Minimally Invasive Techniques in Upper Gastrointestinal Surgery, https://doi.org/10.1007/978-3-030-55176-6_32

249

250

A. Sánchez-Pernaute et al.

3. Dissection of the posterior wall of the pylorus and duodenum (Fig. 32.4). The dissection of the duodenum starts at its posterior wall, trying to find a retroduodenal window. 4. Suprapyloric duodenal dissection (Fig. 32.5). After that, a suprapyloric dissection of the duodenum is performed in order to find the communication with the posterior window. 5. Duodenal dissection (Fig. 32.6). At this step, a complete dissection of the duodenum is performed and a vessel-loop is used to reference it. 6. Sleeve gastrectomy (Fig. 32.7). The sleeve gastrectomy is now performed following a bougie introduced into the stomach. The section starts 4 cm proximally from the pylorus and continues to the angle of His. Fig. 32.1  Trocar placement

7. Duodenal section and reference stitch.

– A 10-mm trocar in the right upper quadrant, for the liver retraction and for the left hand of the surgeon to the introduction of the stapler. – A 10-mm trocar in the left upper quadrant, just above in a subcostal position for the surgeon´s right hand. 2. Dissection (Fig. 32.2)

of

the

greater

gastric

curvature

This first step includes a complete dissection of the greater curvature. It starts in the fundus and continues to the angle of His cranially. Distally the dissection ends close to the pylorus (Fig. 32.3). It is necessary to divide gastric short vessels and has a correct view of the left crura.

Section of the duodenum is performed with a stapler (Fig. 32.8). After the section, a reference stitch is located in the proximal portion of the sectioned duodenum (Fig. 32.9). This stitch will be used to fix the ileum in the duodenoileal anastomosis. 8. Measurement of the small bowel (Fig. 32.10). The next step is to measure small bowel to select the area of the anastomosis. At this point in the procedure, the surgeon is positioned on the left side of the patient. Then 300 cm is measured from the ileocecal valve. 9. Hand sewn end to side duodenoileal anastomosis First of all to perform the duodenoileal anastomosis is to complete a previous fixation stitch (Fig. 32.11) between

Fig. 32.2  Dissection of the greater gastric curvature. Close (a, b) and schematic view (c)

32  Single Anastomosis Duodenoileal Bypass with Sleeve Gastrectomy

251

Fig. 32.3  Dissection of the greater gastric curvature and duodenum. Close (a, b) and schematic view (c)

duodenum and antimesenteric side of the ileum selected to the anastomosis. A posterior running suture is performed as the first step of the duodenoileal anastomosis. After this, the duodenum and the ileus are opened (Fig. 32.12). A running suture is now performed to complete the posterior wall of the anastomosis. Then the anterior wall of the end to side duodenoileal anastomosis is now performed with a running suture. Some stitches are placed over this suture in order to reinforce the anastomosis (Fig. 32.13). 10. Final view (Fig. 32.14). Fig. 32.4  Dissection of the posterior wall of the pylorus duodenum

Fig. 32.5  Suprapyloric duodenal dissection. Close (a) and schematic view (b)

The procedure finishes with a total revision of the surgical field.

252 Fig. 32.6  Duodenal dissection. Close (a, b, c) and schematic view (d)

Fig. 32.7  Sleeve gastrectomy. Close (a, b) and schematic view (d)

A. Sánchez-Pernaute et al.

32  Single Anastomosis Duodenoileal Bypass with Sleeve Gastrectomy Fig. 32.8  Duodenal section. Close (a) and schematic view (b)

Fig. 32.9  Reference stitch at the duodenum. Close (a) and schematic view (b)

253

254 Fig. 32.10  Measurement of the small bowel

Fig. 32.11  Fixation stitch between duodenum and ileum. Close (a) and schematic view (b)

A. Sánchez-Pernaute et al.

32  Single Anastomosis Duodenoileal Bypass with Sleeve Gastrectomy Fig. 32.12  Hand sewn end to side duodenoileal anastomosis (posterior wall). Close (a, b, c) and schematic view (d)

Fig. 32.13  Hand sewn duodenoileal anastomosis (anterior wall). Close (a, b) and schematic view (c)

255

256

A. Sánchez-Pernaute et al.

Fig. 32.14  Final view

References 1. Sánchez-Pernaute A, Rubio Herrera MA, Pérez-Aguirre E, García Pérez JC, Cabrerizo L, Díez Valladares L, Fernández C, Talavera P, Torres A. Proximal duodenal-ileal end-to-side bypass with sleeve gastrectomy: proposed technique. Obes Surg. 2007;17(12):1614–8. Epub 2007 Nov 27. PubMed PMID: 18040751. 2. Sánchez-Pernaute A, Herrera MA, Pérez-Aguirre ME, Talavera P, Cabrerizo L, Matía P, Díez-Valladares L, Barabash A, MartínAntona E, García-Botella A, Garcia-Almenta EM, Torres A. Single anastomosis duodeno-ileal bypass with sleeve gastrectomy (SADI-S). One to three-year follow-up. Obes Surg. 2010;20(12):1720–6. https://doi.org/10.1007/s11695-010-0247-3. PubMed PMID: 20798995. 3. Sánchez-Pernaute A, Rubio MÁ, Pérez Aguirre E, Barabash A, Cabrerizo L, Torres A. Single-anastomosis duodenoileal bypass

with sleeve gastrectomy: metabolic improvement and weight loss in first 100 patients. Surg Obes Relat Dis. 2013;9(5):731–5. https:// doi.org/10.1016/j.soard.2012.07.018. Epub 2012 Aug 7. PubMed PMID: 22963820. 4. Surve A, Cottam D, Sanchez-Pernaute A, Torres A, Roller J, Kwon Y, Mourot J, Schniederjan B, Neichoy B, Enochs P, Tyner M, Bruce J, Bovard S, Roslin M, Jawad M, Teixeira A, Srikanth M, Free J, Zaveri H, Pilati D, Bull J, Belnap L, Richards C, Medlin W, Moon R, Cottam A, Sabrudin S, Cottam S, Dhorepatil A. The incidence of complications associated with loop duodeno-­ileostomy after single-anastomosis duodenal switch procedures among 1328 patients: a multicenter experience. Surg Obes Relat Dis. 2018;14(5):594–601. https://doi.org/10.1016/j.soard.2018.01.020. Epub 2018 Feb 2. PubMed PMID: 29530597.

Endoscopic and Minimally Invasive Surgical Treatment of Early Gastric Cancer

33

Noriyuki Inaki

33.1 Introduction Early gastric cancer (EGC) is defined as invasive gastric cancer that invades no more deeply than the submucosa, irrespective of lymph node metastasis (T1, any N). Treatment modalities for early gastric cancer (EGC) according to stage include endoscopic resection, laparoscopic gastrectomy, antibiotic treatment for eradication of Helicobacter pylori, and adjuvant therapies. In this chapter, the two most important modalities of treatment will be discussed, the laparoscopic distal gastrectomy (LDG) and the laparoscopy and endoscopy cooperative surgery for early gastric cancer with sentinel lymph node biopsy (LECS).

33.1.1 Laparoscopic Distal Gastrectomy Laparoscopic distal gastrectomy has become common, and gastrectomy has gained consensus as a suitable treatment for early-stage gastric cancer [1]. The efficacy of laparoscopic gastrectomy for advanced cancer and total laparoscopic gastrectomy and proximal gastrectomy for upper gastric cancer is currently being studied [2]. This chapter will illustrate and provide a summary of laparoscopic gastrectomy with D1+ dissection performed for early gastric cancer.

 lectronic supplementary material  The online version of this E chapter (https://doi.org/10.1007/978-3-030-55176-6_33) contains supplementary material, which is available to authorized users.

N. Inaki (*)  Department of Digestive and General Surgery, Juntendo University Urayasu Hospital, 2-1-1 Tomioka, Urayasu 279-0021, Japan e-mail: [email protected]

33.1.2 Description of the Operative Technique (Videos 33.1 and 33.2) The key steps to perform a laparoscopic distal gastrectomy by an early gastric cancer are: 1. Indications, setup, and port settings Laparoscopic distal gastrectomy with D1+ dissection is generally prescribed for clinical stage I cancer that was diagnosed prior to surgery. Before surgery, the patient’s body was placed in the supine position with the legs spread apart. The monitor is commonly a single monitor and it was placed at the head of the patient (Fig. 33.1). There were five ports for the trocar: a 12-mm camera port at the navel, a 12-mm port below the left hypochondriac region, a 5-mm port on the left side of the abdomen, a 5-mm port on the right upper side of the abdomen, and a 12-mm port on the right side of the abdomen (Fig. 33.2). 2. Lifting the left hepatic lobe At the beginning of surgery, a Silicon Disc ™ (Hakko Co. ltd., Nagano) was used and the left hepatic lobe was lifted with a straight needle and 2–0 nylon thread (Fig. 33.3). 3. Distal gastrectomy and lymph node dissection D1+ (1) Dissection of the left greater omentum: The assistant grasped the greater curvature of the stomach with the right hand and the greater omentum with the left hand. The greater omentum was separated while ensuring at least 3 cm distance from the veins and arteries at the margin (Fig. 33.4). (2) Handling of the veins and arteries of the greater omentum on the left side of the stomach (No. 4sb dissection): Clip separation was performed at the point where the gastroepiploic branch branches off from the veins and arteries of the greater omentum on the left side of the stomach (Fig. 33.5).

© Springer Nature Switzerland AG 2021 M. Asunción Acosta et al. (eds.), Atlas of Minimally Invasive Techniques in Upper Gastrointestinal Surgery, https://doi.org/10.1007/978-3-030-55176-6_33

257

258

N. Inaki

Fig. 33.3  Lifting the left hepatic lobe: left hepatic lobe is lifted up using Silicon Disk™ with suturing

Fig. 33.1  Setup

Fig. 33.4  Dissection of left greater omentum: the greater omentum was separated while ensuring a 4-cm distance from the veins and arteries at the margin

Fig. 33.2  Port positions. Camera port, navel, 12 mm. Right abdomen, 5 mm, ×  1 and 12 mm,  ×  1. Left abdomen, 5 mm,  × 1 and 12 mm, × 1 Fig. 33.5  No.4sb LN dissection: left gastroepiploic artery was cut preserving the vessel branch for the left side of the omentum

33  Endoscopic and Minimally Invasive Surgical …

(3) Trimming: The greater omentum was trimmed up to the point where the gastric corpus would be resected (Fig. 33.6). (4) Separation of the right side of the greater omentum: The surgeon changed position to stand on the left side of the patient. The assistant makes “matador-like” traction and the surgeon used his left hand to create a separated surface of the greater omentum and then proceeded to separate it progressively (Fig. 33.7). (5) Pancreatic head lymph node dissection (No. 6 dissection): After the colon was moved aside, the anterosuperior pancreatoduodenal veins were exposed. (Foot-side boundary of the No. 6 lymph node) (Fig. 33.8). The assistant used his left hand to lift the veins and arteries of the greater omentum on the right side of the stomach, and his right hand to grasp and lift the posterior wall of the gastric antrum and he expanded the backside of the pyloric ring (Fig. 33.9). The layer outside the nerve (Outer-most layer) of around the right gastroepiploic artery was secured, while expanding the detachable layer between the veins of the right gastroepiploic artery (Fig. 33.10). The right gastroepiploic artery was clipped and separated. Later, the adipose tissue, including the No. 6 lymph node that was at the time easily detachable, was dissected while retaining the detachable layer of the front surface of the pancreatic head, which had been ensured (Fig. 33.11). (6) Separation of the duodenum: Gauze was inserted into the backside of the lesser curvature side of the duodenum; the gauze protruding from the abdomen side was released as a guide, and the veins and arteries of the upper duodenum were separated up to the point where the gastroduodenal artery could be confirmed (Fig. 33.12). The duodenum was transected with a linear stapler (Fig. 33.13). (7) Release of the lesser omentum: The surgeon returned to stand on the right side of the patient. The lesser omentum was released near the root of the right gastric artery and separated up to the lesser curvature of the stomach (Fig. 33.14). The serous membrane on the anterior surface of the crura of the diaphragm was incised with an electric scalpel (Fig. 33.15), and the surface with which the myofascial layer would not be damaged was determined and this layer was expanded. Gauze for laparoscopic use was used to fill this fusion fascia layer to create a dorsal and temporal side receptacle for the dissected superior margin of the pancreas (Fig. 33.16).

259

Fig. 33.6  Trimming: the greater omentum was trimmed up

Fig. 33.7  Separation of the right side of the greater omentum. The assistant makes “matador-like” traction

Fig. 33.8  Station 6 lymph node dissection. The anterosuperior pancreatoduodenal veins were exposed

260

Fig. 33.9  Dissection at backside of the stomach. The assistant used his left hand to lift the veins and arteries of the greater omentum on the right side of the stomach

Fig. 33.10  Outermost layer around the right gastroepiploic artery. The layer outside the nerve (outermost layer) of around the right gastroepiploic artery was secured

Fig. 33.11  Separation of the right gastroepiploic artery. The right gastroepiploic artery was clipped and separated

N. Inaki

Fig. 33.12  The lesser curvature side of the duodenum. The gauze protruding from the abdomen side was released as a guide, and the veins and arteries of the upper duodenum were separated up to the point where the gastroduodenal artery could be confirmed

Fig. 33.13  Transection of the duodenum. The duodenum was transected with a linear stapler

Fig. 33.14  Release of the lesser omentum. The lesser omentum was released near the root of the right gastric artery

33  Endoscopic and Minimally Invasive Surgical …

Fig. 33.15  Incision of the serous membrane on the anterior surface of the crura. The serous membrane on the anterior surface of the crura of the diaphragm was incised with an electric scalpel

Fig. 33.16  Detection of the fusion fascia. Gauze for laparoscopic use was inserted to the layer at the fusion fascia

(8) Handling of the right gastric artery: The assistant used his right hand to grasp and lift the pedicle of the right gastric artery and his left hand to grasp the surgical sponge, Securea™ (Hogy Medical, Tokyo, Japan), and he compressed the lower rim of the pancreas to turn the pancreas over (Fig. 33.17). The root of the right gastric artery was peeled back while enlarging the surface; the root part was clip-separated (Fig. 33.18). (9) Dissection of the suprapancreatic lymph node: The assistant used his right hand to firmly grasp (activate the ratchet) and lift the gastropancreatic fold (pedicle of the left gastric artery), and with his left hand, turned the pancreas over by compressing the lower margin of the pancreas with a surgical sponge, Securea™ ((Hogy Medical, Tokyo, Japan) (Fig. 33.19). Detachment was performed in one continuous motion from the anterior surface of the common hepatic artery to the anterior

261

Fig. 33.17  Handling of the right gastric artery. The assistant grasped and lifted the pedicle of the right gastric artery and compressed the lower rim of the pancreas to turn the pancreas over

Fig. 33.18  Separation of right gastric artery. The root of right gastric artery was clip separated

Fig. 33.19  Suprapancreatic lymph node dissection. The assistant lifted the gastropancreatic fold (pedicle of the left gastric artery) and turned the pancreas over by compressing the lower margin of the pancreas with a surgical sponge

262

Fig. 33.20  Outermost layer of the left gastric artery. The outermost layer of the left gastric artery was separated

Fig. 33.21  The left side of the lymph nodes around celiac artery. The left side of the lymph nodes on the superior margin of the pancreas was cut out

Fig. 33.22  Separation of the left gastric artery. The periphery of the left gastric artery was clipped and separated

N. Inaki

surface of the splenic artery. The so-called “ω-line” was ensured. The detachable layer outside the nerve on the left side of the left gastric artery was separated (Fig. 33.20). Both lateral sides of the left gastric artery were detached as much as possible to the backside. To prevent damage to the pancreatic parenchyma and pancreatic artery, the positions where they were ascertained (Fig. 33.21). The periphery of the left gastric artery was clipped and separated (Fig. 33.22). The base on the right side of the lymph nodes on the superior margin of the pancreas (near the boundary between No. 8a, 9, and 8p) was adequately sealed using the laparoscopic coagulating shears and separated (Fig. 33.23). The posterior wall of the lesser curvature of the stomach was separated. At this point, if the vagus nerve was intact, it would have been cut out (Fig. 33.24).

Fig. 33.23  The right side of the lymph nodes around celiac artery. The right side of the lymph nodes around celiac artery was adequately sealed and separated

Fig. 33.24  Dissection at the posterior wall of the lesser curvature. The posterior wall of the lesser curvature of the stomach was separated

33  Endoscopic and Minimally Invasive Surgical …

(10) Trimming of the lesser curvature of the stomach (No. 1 and No. 3 lymph node dissection): The assistant lifted the lesser omentum with two hands in the manner of a matador and separated the lesser omentum from the gastric corpus from the backside of the lesser curvature of the stomach (Fig. 33.25). Next, the stomach was returned to its normal position, and the lesser omentum was separated from the gastric corpus on the abdominal side (Fig. 33.26). (11) Separation of the gastric corpus: The gastric corpus is separated into two rounds (Fig. 33.27). (12) Extraction of the extracted stomach and reinsufflation: The extracted stomach was stored in a plastic bag (to prevent tumor dispersion and wound contamination) and extracted from the navel opening. The wound was extracted only large enough to perform the extraction. After extraction, a wound protector was inserted, a silicone cap was used as a cover, the camera port previously mentioned was inserted, and the stomach was

263

Fig. 33.27  Separation of the gastric corpus. The gastric corpus is separated by linear stapler in two rounds

reinsufflated (Fig. 33.28). When all procedure of lymphadenectomy is finished, dissection area was checked (Fig. 33.29). 4. Roux-en-Y reconstruction

Fig. 33.25  Trimming of the lesser curvature. The lesser omentum was separated from the gastric corpus from the backside of the lesser curvature of the stomach

Fig. 33.26  Trimming of the lesser curvature (anterior). The lesser omentum was separated from the gastric corpus on the abdominal side

A small hole was made in the jejunal mesentery, at a part that was approximately 25 cm from the ligament of Treitz, and the jejunum was separated with the linear stapler. The mesentery was only slightly separated (separation of the arteries and veins at the margin) (Fig. 33.30). A small hole was made at the site approximately 25 cm from the tip of the lifted jejunum and at the tip of the afferent loop jejunum (Fig. 33.31), and the linear stapler was used to perform side-to-side anastomosis (Fig. 33.32). The insertion holes of the stapler were suture closed in a continuous single layer using 3–0 absorbent thread. The needle was handled from the far end of the visual field toward the near end of the visual field. As a trick for handling the needle, try to firmly stitch at the seromuscular layer and only slightly at the membrane surface (Fig. 33.33). A small hole was made at the jejunum of Roux limb (Fig. 33.34). Anastomosis of the residual stomach and jejunum: The residual stomach and jejunum were anastomosed in an isoperistaltic manner. A small hole was made in the anal side approximately 60 mm from the tip of the lifted jejunum and in the tip of the lesser curvature side of the staple line of the residual stomach and anastomosis was performed using the linear stapler (Fig. 33.35). The insertion holes of the stapler were suture closed using almost the same procedure as for the Y limb (Fig. 33.36). Closure of Petersen’s space: A 3-0 nonabsorbent thread was used to continuously suture close Petersen’s space. When doing this, the needle was handled from the front of the visual field to the back (from the leg side to the head

264

N. Inaki

Fig. 33.28  Retrieval of the specimen and reinsufflation. The resected specimen was stored in a plastic bag and extracted from umbilicus (a). Wound protector and silicone cap were attached and the stomach was reinsufflated (b)

Fig. 33.29  Completion of lymph node dissection: suprapancreatic region (a) and pancreatic head (b)

Fig. 33.30  Transection of jejunum. A small hole was made in the jejunal mesentery, at a part that was approximately 25 cm from the ligament of Treitz

Fig. 33.31  Preparation of Y limb. A small hole was made at the site approximately 25 cm from the tip of the lifted jejunum and at the tip of the afferent loop jejunum

33  Endoscopic and Minimally Invasive Surgical …

Fig. 33.32  Side-to-side anastomosis. The linear stapler was used to perform side-to-side anastomosis

Fig. 33.33  Closure of entry hole of stapler. The insertion holes of the stapler were suture closed in a continuous single layer using 3-0 absorbent thread

265

Fig. 33.35  Gastrojejunostomy. Gastrojejunostomy was performed using the linear stapler

Fig. 33.36  Closure of entry hole of stapler. The insertion holes of the stapler were suture closed

Fig. 33.37  Completion of reconstruction. The rout of reconstruction was inspected Fig. 33.34  Preparation of Roux limb. A small hole was made on the anal side approximately 60 mm from the tip of the lifted jejunum

266

side), and the space was suture closed up to near the colon. In patients in whom the greater omentum was conserved, the greater omentum would be gathered into the hands to perform stitching and the bottom rim would then be cut. Closure of the Y limb mesentery: The gap of the mesentery of the Y limb was continuously suture closed using nonabsorbent thread. During this, the needle was handled so that the staple line of the resection stump of the jejunum was immersed under the mesentery as much as possible. This can be expected to prevent adhesion to the surface where the staples were exposed. After the completion of reconstruction, the rout of reconstruction was inspected (Fig. 33.37). Depending on the circumstances, a 19 Fr closure-type drain should be placed from the right-upper 5-mm port to the lower surface of the liver, but at our facility, drain placement is not performed for D1 + dissection gastrectomies.

33.1.3 Postoperative Management The patient may begin drinking water 2 days after the operation. From day 3, soup is allowed; whole porridge and soft foods can be added, each at 2-day intervals. The patient can be discharged 8 days after the operation.

Fig. 33.38  Setup and port placement. In addition to the preparation for the laparoscopic distal gastrectomy, endoscope scope set is prepared and placed. Port setup corresponds to the laparoscopic distal gastrectomy

N. Inaki

33.1.4 Tips, Tricks, and Pitfalls When performing a dissection, close attention should be paid to keeping the visual field expansion and operative field dry. In addition to standardizing expansion, the electronic devices normally used to perform surgery are laparoscopic coagulating shears, Bipolar Maryland dissectors, and suction and water delivery devices with a button electrode. With regard to reconstruction, the Y limb can usually be created from the small laparotomy surface in the navel. Depending on the capabilities of the surgeon, the abilities of the team, and the level of familiarity, when it is possible to do from the small laparotomy, it is recommended to be performed under direct visual guidance.

33.2 Laparoscopy and Endoscopy Cooperative Surgery for Early Gastric Cancer with Sentinel Lymph Node Biopsy Laparoscopic gastric resection for gastric submucosal tumors (SMTs) is a minimally invasive procedure developed to resect these early gastric cancers. But its

33  Endoscopic and Minimally Invasive Surgical …

problem is to determine the exact extent of the tumor borders, and this is essential to perform an adequate radical resection. In order to accomplish this, a combination of laparoscopic and luminal endoscopic intervention, the so-called laparoscopic and endoscopic cooperative surgery (LECS) technique has been developed to perform a proper resection. The procedure entails a laparoscopic gastric resection assisted by an endoscopic submucosal dissection. Intervention can be used for SMTs in all gastric locations including the esophagogastric junction. In the case of technical problems, intervention should be converted to open surgery. The procedure is safe and feasible for resection of gastric SMTs tumors.

Fig. 33.39  Dot marking and a local injection of the indocyanine green: dot marking is performed around the tumor and a local injection of the indocyanine green in subserosal area is performed. Close (a) and schematic view (b)

Fig. 33.40  Normal vision. a Lymph flow by the indocyanine green b Lymph flow is observed by the indocyanine green, and the lymphatic basin, including the sentinel node, is dissected

267

33.2.1 Description of the Operative Technique (See Video 33.1) The key steps to perform a LECS procedure are: 1. Setup and port placement: In addition to the preparation for the laparoscopic distal gastrectomy, endoscope scope set is prepared and placed. Port setup corresponds to the laparoscopic distal gastrectomy (five trocars placed in the upper abdomen). Surgeon operates between the legs of the patient (Fig. 33.38). 2. Dot marking and a local injection of the indocyanine green: Dot marking is performed around the tumor and a local injection of the indocyanine green in subserosal area is performed (Fig. 33.39). 3. Lymph flow by the indocyanine green: Lymph flow is observed by the indocyanine green, and the lymphatic basin, including the sentinel node, is dissected (Fig. 33.40).

268

N. Inaki

Fig. 33.41  Circumferential dissection of mucosal and submucosal layer: mucous membrane and submucosal layer are circumferentially dissected during endoscopy. Close (a) and schematic view (b)

Fig. 33.42  Marking at serosal surface: marking with pyocyanine is performed from the serosal surface during laparoscopy. Close (a) and schematic view (b)

Fig. 33.43  Suture of serosal layer using SECREA: serosal surfaces are sutured so that the SECUREA is buried in the serosal surface of the tumor. Close (a) and schematic view (b)

4. Circumferential dissection of mucosal and submucosal layer: Mucous membrane and submucosal layer are circumferentially dissected during endoscopy (Fig. 33.41). 5. Marking at serosal surface: Marking with pyocyanine is performed from the serosal surface during laparoscopy (Fig. 33.42). 6. Suture of serosal layer using SECUREA: Serosal surfaces are sutured so that the SECUREA is buried in the serosal surface of the tumor (Fig. 33.43). 7. Completion of the seromuscular suture: After completion of the serous membrane suture (Fig. 33.44).

8. Cutting of all layers: The incision surface is tensed due to the SECUREA, and it is possible to incise all layers with the endoscope (Fig. 33.45). 9. Removal of the specimen and SECUREA: The resected specimen and the SECUREA are collected using the oral endoscopy (Fig. 33.46). 10. Endoscopic examination (after 3  months): During endoscopic examination at 3 months after the surgery, scar deformity after partial resection of the vestibular area is observed while food debris and residual gastritis are not present (Fig. 33.47).

33  Endoscopic and Minimally Invasive Surgical … Fig. 33.44  Completion of the seromuscular suture: after completion of the serous membrane suture. Close (a) and schematic view (b)

Fig. 33.45  Cutting of all layers: the incision surface is tensed due to the SECUREA, and it is possible to incise all layers with the endoscope. Close (a) and schematic view (b)

Fig. 33.46  Removal of the specimen and SECUREA: the resected specimen and the SECUREA are collected using the oral endoscopy. Close (a) and schematic view (b)

Fig. 33.47  Endoscopic examination (after 3 months): during endoscopic examination at 3 months after the surgery, scar deformity (a) after partial resection of the vestibular area is observed while food debris and residual gastritis are not present (b)

269

270

N. Inaki

References

Suggested Reading

1. Katai H, Sasako M, Fukuda H, et al., JCOG Gastric Cancer Surgical Study Group. Safety and feasibility of laparoscopy-assisted distal gastrectomy with suprapancreatic nodal dissection for clinical stage I gastric cancer: a multicenter phase II trial (JCOG 0703). Gastric Cancer. 2010;13(4):238–44. 2. Inaki N, Etoh T, Ohyama T, et al. A Multi-institutional, prospective, phase II feasibility study of laparoscopy-assisted distal gastrectomy with D2 lymph node dissection for locally advanced gastric cancer (JLSSG0901). World J Surg. 2015;39(11):2734–41.

3. Matsuda T, Hiki N, Nunobe S, et al. Feasibility of laparoscopic and endoscopic cooperative surgery for gastric submucosal tumors (with video). Gastrointest Endosc. 2016;84:47–52. 4. Matsuda T, Nunobe S, Kosuga T, et al., Society for the Study of Laparoscopy and Endoscopy Cooperative Surgery. Laparoscopic and luminal endoscopic cooperative surgery can be a standard treatment for submucosal tumors of the stomach: a retrospective multicenter study. Endoscopy. 2017;49:476–83.

Laparoscopic Partial Gastrectomy for Gastric Cancer

34

Antonio Talvane Torres de Oliveira, Croider Franco Lacerda, Paulo A. Bertulucci and Miguel A. Cuesta

34.1 Introduction

34.2 Clinical Staging and Surgical Plan

Gastrectomy, total or subtotal, with a proper lymphadenectomy after neoadjuvant therapy, if indicated, is the main treatment for resectable gastric cancer. Many studies have shown that Minimally Invasive Surgery (MIS) for other gastrointestinal malignancies [1, 2], such as colorectal and esophageal cancer, is oncologically safe and has several important short-term advantages in comparison with the conventional open surgical techniques. These studies showed favorable outcomes for MIS such as a less blood loss, faster patient recovery, and fewer complications with similar oncological outcomes. Concerning MI gastrectomy for cancer, important advances include the use of neoadjuvant (and adjuvant) therapy [3] in advanced gastric cancer and universal implementation of the principles of oncological resection including a proper lymphadenectomy based on the Japanese guidelines [4]. Minimally invasive gastrectomy may have the same advantages as its use in other digestive cancers. Evidence for this MIS for gastric cancer is based on European (Hulscher’s study, STOMACH, and LOGICA trials) and South Korean (KLASS studies) and some metaanalysis [5–11]. They have shown that there are some shortterm advantages for partial gastrectomy whereas, for total gastrectomy, they have shown similar short-term outcomes while preserving oncological outcomes.

If gastric cancer is diagnosed by gastroscopy and biopsies, clinical staging should be done by means of endoscopic ultrasound, CT, and PET–CT scans (cTNM). If the tumor seems resectable, depending on the clinical staging and location of the tumor, a surgical plan is designed, concerning: • Use of neoadjuvant therapy (stage II or higher) • Type of resection: local, proximal, distal, or total gastrectomy. In advanced gastric cancer, the margin of resection will be at least 5 cm. • The type of lymphadenectomy, D1, D1 + , or D2.

We follow the Japanese Gastric Cancer treatment guidelines 2014 [4] and classified the lymph node stations in the surgical field according to it (Fig. 34.1).

34.3 Description of the Surgical Technique (See Video 34.1) The key steps to perform a laparoscopic partial or subtotal gastrectomy are: 1. Positioning of patient and placement of trocars.

 lectronic supplementary material  The online version of this E chapter (https://doi.org/10.1007/978-3-030-55176-6_34) contains supplementary material, which is available to authorized users.

A. T. T. de Oliveira · C. F. Lacerda · P. A. Bertulucci  Department of Upper GI Surgery, Americas Medical City Hospital, Rio de Janeiro, Brazil e-mail: [email protected] M. A. Cuesta (*)  Department of Surgery. Amsterdam UMC, Amsterdam, The Netherlands e-mail: [email protected]

Patient is placed in lithotomy position. Surgeon stands between the legs of the patient (Fig. 34.2). 5 trocars of 5/12 mm are placed in the upper abdomen. Assistance incision is placed on the left side (trocar site) or Pfannenstiel incision (Fig. 34.3). 2. Omentectomy. Omentectomy will be started from the middle to the left. Omental bursa is opened (Fig. 34.4a– c). In partial gastrectomy omentectomy will end at the level of the gastric resection.

© Springer Nature Switzerland AG 2021 M. Asunción Acosta et al. (eds.), Atlas of Minimally Invasive Techniques in Upper Gastrointestinal Surgery, https://doi.org/10.1007/978-3-030-55176-6_34

271

272

Fig. 34.1  Operative field with lymph node stations

A. T. T. de Oliveira et al.

3. Lymphadenectomy of station 6 (right gastroepiploic vessels), followed bydivision of the right gastroepiploic vessels with clips at the level of the head of the pancreas (Fig. 34.5a, b). 4. The supraduodenal window is created (Fig.  34.6a, b). Opening hepatoduodenal ligament with division of pars flaccida along the liver edge, up to the right crus (Fig. 34.7a–c). Division of the right gastric artery (Fig. 34.7d). Lymphadenectomy of stations 8a and 12a, (Fig. 34.7e–g). 5. Dissection of the superior part of the duodenum (supraduodenal window) and division of the proximal duodenum by stapler (Fig. 34.8a, b). 6. Dissection and lymphadenectomy of the celiac trunk (stations 9, 7, and 11p) (Fig. 34.9a–c). Division of the left gastric vessels between clips (Fig. 34.9d). After partial gastrectomy, reconstruction can be made by a Roux Y gastrojejunostomy anastomosis or a Billroth I Delta anastomosis. In this chapter, we present the first type of anastomosis. Dr. Kinoshita’s Delta anastomosis will be presented in the next chapter (see Chap. 35).

34.4 Description of the Surgical Technique of  Roux Y gastrojejunostomy anastomosis The key steps to perform a reconstruction after partial gastrectomy [] by a Roux Y gastrojejunostomy anastomosis are:

Fig. 34.2  Position of patient and surgeons during laparoscopic gastrectomy

Fig. 34.3  Placement of trocars (a) and help incision (b)

7. Before division of the stomach, resection of stations 1 and 3 along the small curvature is done (between the esophagogastric junction and the level of resection on the small curvature. These tissues should be included with the specimen (Fig. 34.10a, b).

34  Laparoscopic Partial Gastrectomy for Gastric Cancer

273

Fig. 34.4  Start with omentectomy until the place of the gastrectomy. Close (a, b) and schematic view (c)

Fig. 34.5  Dissection and division of the gastroepiploic vessels and lymphadenectomy (station 6). Close (a, b) and schematic view (c)

Fig. 34.6  Dissect the supraduodenal window. Close (a) and schematic view (b)

8. Division of proximal stomach is performed at the chosen level by means of linear stapler including the lymph node stations 1 and 3 (Fig. 34.11a–c). 9. A hole is made in the transverse mesocolon and the jejunal loop able for the anastomosis is prepared and divided by staplers (Fig. 34.12). 10. The distal jejunal loop is ascended through the opening of the mesocolon, to the stump of the stomach in the supramesocolic space (Fig. 34.13a–c). 11. A side-to-side gastrojejunal anastomosis is performed with the linear stapler. The anastomosis is located in

the posterior wall of the gastric remnant a couple of cm from the stapled line (Fig. 34.14a, b). The gastrojejunal defect (used to introduce the stapler) is closed by running suture (Fig. 34.14c, d). 12. A side-to-side jejunojejunostomy is performed by means of linear stapler (Fig. 34.15a, b), follow by closure of mesenteric defects. Final view of the anastomosis (Fig. 34.16). 13. Specimen is retrieved through a well-protected incision using the Alexis device®. 14. Trocars are retrieved, closing the defects in the abdominal wall.

274

A. T. T. de Oliveira et al.

Fig. 34.7  Open the hepatoduodenal and hepatogastric ligament: close (a, b, c) and schematic view (d). Ligation of right gastric artery: close (e) and schematic view (f). Lymphadenectomy of the hepatoduodenal (stations 8a and 12a) along the portal vein (g, h, i) Fig. 34.8  Duodenum division by staplers. Close (a, b) and schematic view (c, d)

34  Laparoscopic Partial Gastrectomy for Gastric Cancer

275

Fig. 34.9  Lymphadenectomy of stations 9, 7, and 11p. Close (a, b, c) and schematic view (d). Ligation of the left gastric artery by clips (e). General view of the lymphadenectomy (8a, 12a, 7, 9, and 11p) (f)

Fig. 34.10  Lymphadenectomy stations 1 and 3. Close (a, b) and schematic view (c)

276

A. T. T. de Oliveira et al.

Fig. 34.11  Division of the proximal stomach by linear stapler: close (a, b) and schematic view (c). View of the proximal gastric stump (d)

Fig. 34.12  Opening the transverse mesocolon. Close (a) and schematic view (b)

Fig. 34.13  Division of the jejunal loop (a) and ascending the loop through the mesocolon (b). Gastric stump and jejunal loop alongside (c)

34  Laparoscopic Partial Gastrectomy for Gastric Cancer Fig. 34.14  Gastrojejunal side-to-side anastomosis: close (a) and schematic view (b). Closure of the defect: close (c) and schematic view (d)

Fig. 34.15  Side-to-side gastrojejunal anastomosis. Close (a) and schematic view (b)

277

278

Fig. 34.16  Final view of the reconstruction

References 1. Bonjer HJ, Deijen CL, Haglind E, et al. A randomized trial of laparoscopic versus open surgery for rectal cancer. N Engl J Med. 2015;373(2):194. 2. Straatman J, van der Wielen N, Cuesta MA, et al. Minimally invasive versus open esophageal resection: three-year follow-up of the previously reported randomized controlled trial: the TIME trial. Ann Surg. 2017;266(2):232–6. 3. Al Batran SE, Homann N, Pauligk C et al. Perioperative chemotherapy with fluouracil plus leucovorin, oxaliplatin, and docetaxel versus fluouracil or capecitabine plus cisplatin and epirubicin for locally advanced, resectable gastric cancer or gastro-oesophageal junction adenocarcinoma (FLOT 4): a randomized, phase 2/3 trial. Lancet 2019; 393: 1948–1957.

A. T. T. de Oliveira et al. 4. Japanese Gastric Cancer Association. Japanese gastric cancer treatment guidelines 2014 (ver. 4). Gastric Cancer 2017;20(1):1–19. 5. Beyer K, Baukloh AK, Kamphues C, et al. Laparoscopic versus open gastrectomy for locally advanced gastric cancer: a systematic review and meta-analysis of randomized controlled studies. World J Surg Oncol. 2019;17(1):68. 6. van der Wielen N, Straatman J, Cuesta MA, et al. Short-term outcomes in minimally invasive versus open gastrectomy: the differences between East and West. A systematic review of the literature. Gastric Cancer 2018;21(1):19–30. 7. Haverkamp L, Weijs TJ, van der Sluis PC, et al. Laparoscopic total gastrectomy versus open total gastrectomy for cancer: a systematic review and meta-analysis. Surg Endosc. 2013;27:1509–20. 8. Kim W, Kim HH, Han SU, et al. Decreased morbidity of laparoscopic distal gastrectomy compared with open distal gastrectomy for stage I gastric cancer: short-term outcomes from a multicenter randomized controlled trial (KLASS-01). Ann Surg. 2016;263(1):28–35. 9. Lee HJ, Hyung WJ, Yang HK, et al. Short-term outcomes of a multicenter randomized controlled trial comparing laparoscopic distal gastrectomy with D2 lymphadenectomy to open distal gastrectomy for locally advanced gastric cancer (KLASS-02-RCT). Ann Surg. 2019;270(6):983–91. 10. Straatman J, van der Wielen N, Cuesta MA, et al. Surgical techniques, open versus minimally invasive total gastrectomy after chemotherapy (STOMACH trial): study protocol for a randomized controlled trial. Trials. 2015;16:123. 11. Haverkamp L, Brenkman HJF, Seesing MFJ, et al. Laparoscopic versus open gastrectomy for gastric cancer, a multicenter prospectively randomized controlled trial (LOGICA-trial). BMC Cancer. 2015;15:556.

Modified Billroth-I DeltaShaped Anastomosis After Distal Gastrectomy

35

Takahiro Kinoshita

35.1 Introduction Laparoscopic distal gastrectomy is increasingly implemented worldwide according to the positive outcomes of some randomized studies. In terms of reconstruction, several methods have been attempted such as Billroth-I, Billroth-II, or Roux-en-Y. Each method has pros and cons, and probably decisions are made according to the individual patient’s conditions, surgeon’s preference, or regional trends. Advantages of Billroth-I are simplicity, save of time, and physiological passage of foods. In our center, we choose Billroth-I when meeting the following criteria; (i) large enough size of a remnant stomach, (ii) no d­ uodenal invasion, and (iii) no reflux esophagitis or hiatus hernia. Therefore, in general, localized tumors at the antrum or lower stomach body seem to be suitable candidates. As an intracorporeal Billroth-I reconstruction, delta-shaped anastomosis only using a linear stapler is broadly accepted [1], which was originated from the concept of functional e­ ndto-end anastomosis.

1. Port placement and patient’s position The patient is positioned in supine and legs apart with head-up tilt. Five ports are used and the operator stands at the right side of the patient (Fig. 35.1). The first assistant stands at the left side of the patient and the camera assistant between the legs (Fig. 35.2). Lateral segment of the liver should be retracted in either method to attain sufficient operative space (Fig. 35.3). Technical steps 2. Transection of the duodenum After infrapyloric lymphadenectomy, dissection of the station No. 6 according to the Japanese Classification [2], the duodenal bulb is skeletonized for consequent transection. Therefore, the duodenum should be normally divided just beneath the pyloric ring in anterior–posterior direction as much as possible using a 60-mm linear stapler advanced from a left lower port. 3. Resection of the stomach

35.2 Description of the Surgical Technique (See Video 35.1) The key steps to perform a Billroth I Delta-shaped anastomosis are:

 lectronic supplementary material  The online version of this E chapter (https://doi.org/10.1007/978-3-030-55176-6_35) contains supplementary material, which is available to authorized users.

T. Kinoshita (*)  Gastric Surgery Division, National Cancer Center Hospital East, 6-5-1 Kashiwanoha, Kashiwa 277-8577, Japan e-mail: [email protected]

After suprapancreatic and lesser curvature site lymphadenectomy (No. 1 and No. 3), the stomach is resected. If the tumor is invisible from the serosal surface, intraoperative peroral endoscopy is employed to confirm the tumor location. Recently, indocyanine green (ICG) injection is also conducted for this purpose. Resection line should be dyed on the stomach wall (Fig. 35.4), and usually requiring twice firing of a 60-mm stapler (Fig. 35.5). The resected specimen is placed in an extraction bag. 4. Testing the tension After resection of the stomach, simulation should be done to test whether the tension is adequate between the remnant stomach and the duodenum. Both the remnant stomach and the duodenum stump are moved medially to be overlapped (Fig. 35.6). If the tension seems too tight, relevant adhesion

© Springer Nature Switzerland AG 2021 M. Asunción Acosta et al. (eds.), Atlas of Minimally Invasive Techniques in Upper Gastrointestinal Surgery, https://doi.org/10.1007/978-3-030-55176-6_35

279

280

T. Kinoshita

Fig. 35.1  Placement of ports. Close (a) and schematic view (b)

Fig. 35.2  Position of patient and surgical team (a, b)

should be lysed or switch to another method should be considered. 5. Creating entry holes for stapler insertion First, the edge at the greater curvature site of the stomach stump is hold by forceps to be cut in 1 cm in length, being adjusted for stapler’s caliber (Fig. 35.7). A suction device is put into the remnant stomach through this hole to withdraw contents. Then, the edge of the posterior side of the duodenal stump is held to be cut in a similar way (Fig. 35.8). 6. Gastroduodenostomy using a linear stapler

Fig. 35.3  Liver retraction

A 45-mm stapler is introduced from the left lower port and a cartridge site is inserted into the stomach (Fig. 35.9). The stapler is temporarily clamped at the posterior wall site and moved toward the duodenal stump. The duodenal stump is

35  Modified Billroth-I Delta-Shaped Anastomosis …

281

Fig. 35.4  Gastric resection line dyed. Close (a) and schematic view (b)

Fig. 35.5  Stomach is divided by linear stapler. Close (a, b) and schematic view (c)

grasped by forceps to be lifted up and moved a little medially. Temporary clamp is released and an anvil fork of the stapler is gently inserted into the duodenum (Fig. 35.10). The remnant stomach is a slightly twisted to keep a certain distance between the stomach stump and the anastomotic line aiming no ischemic area. Regarding the duodenum, such a twisting is not required because the stump will be resected together when closing the common entry hole by stapler. After verifying that both intestinal walls are fastened in 40–45 mm in length with no gap, the stapler can be fired (Fig. 35.11). After removal of the stapler, hemostasis on the staple line should be proved using the suction device. 7. Closure of the common entry hole

Fig. 35.6  After resection of the stomach, simulation should be done to test whether the tension is adequate between the remnant stomach and the duodenum

Using a 3-0 suture material, three or four stay sutures are placed in advance. These sutures should be stitched at the stomach and duodenal walls to expand a V-shape of the anastomotic stapling line (Fig. 35.12). Closure of the entry hole is made by twice firing of linear staplers. As a first

282 Fig. 35.7  Opening in the gastric stump. Close (a) and schematic view (b)

Fig. 35.8  Opening in the duodenal stump. Close (a) and schematic view (b)

Fig. 35.9  A 45-mm stapler is introduced from the left lower port and a cartridge site is inserted into the stomach. Close (a) and schematic view (b)

Fig. 35.10  The other cartridge site is introduced into the duodenum. Close (a) and schematic view (b)

T. Kinoshita

35  Modified Billroth-I Delta-Shaped Anastomosis …

283

stapling, the 45-mm stapler is used. Only 30-mm length is utilized very close to the edge of the hole to avoid anastomotic stricture. Stretching the entry hole in straight line by retracting the stay sutures is mandatory. As a second stapling, the 60-mm stapler is used. In this stapling, the duodenal stump is resected at the same time so that the operator should control the position of it. The stapler must be clamped and released several times to find the best stapling position (Fig. 35.13). 8. After finishing the anastomosis, a nasogastric tube is introduced into the stomach and air-tight test is employed to confirm the integrity (Fig. 35.14). Fig. 35.11  The stapler can be fired

Fig. 35.12  Using a 3-0 suture material, three or four stay sutures are placed in advance. These sutures should be stitched at the stomach and duodenal walls to expand a V-shape of the anastomotic stapling line. Close (a, b) and schematic view (c)

Fig. 35.13  Closure of the entry hole is made by twice firing of linear staplers. As the first stapling, the 45-mm stapler is used. Only 30-mm length is utilized very close to the edge of the hole to avoid anastomotic stricture. Close (a) and schematic view (b)

284

T. Kinoshita

References 1. Kanaya S, Gomi T, Momoi H, et al. Delta-shaped anastomosis in totally laparoscopic Billroth I gastrectomy: new technique of intraabdominal gastroduodenostomy. J Am Coll Surg. 2002;195:284–7. 2. Japanese Gastric Cancer Association. Japanese classification of gastric carcinoma: 3rd English edition. Gastric Cancer. 2011;14(2):101–12.

Fig. 35.14  Final aspect of the anastomosis

Robotic Distal Gastrectomy for Gastric Cancer

36

Young-Woo Kim and Won Ho Han

36.1 Introduction Gastrectomy with extended lymph node dissection is the only standard curative treatment for locally advanced gastric cancer. The development of laparoscopic surgery has changed much in gastric cancer surgery over recent decades, and robotic technology tried to overcome the limitations of laparoscopic surgery [1, 2]. However, basic principle of robotic gastrectomy is same as open gastrectomy. Then, what is standard gastrectomy? The answer for this question is not simple because the standard D2 gastrectomy has evolved over 60 years. Currently, it is believed important to keep “surgical plane based on embryological origin” to perform an en bloc dissection of mesogastrium. The difficulty comes from the fact that pancreas is in the middle of the mesogastrium and should be saved with major vessels like common hepatic artery, splenic artery, and splenic vein. Suprapancreatic nodal dissection must be the most challenging part of the surgery with laparoscopic approach due to the technological limitation. Robotic surgery could have a role in this technological challenge of laparoscopic gastric surgery [3]. Robotic gastrectomy has several advantages over laparoscopic gastrectomy including flexibility of instruments, a three-dimensional view, correction of hand tremors, and improved ergonomics. These advantages are favorable for lymph node dissection while avoiding vessel injury and minimizing damage to adjacent organs [4–6] However, robotic  lectronic supplementary material  The online version of this E chapter (https://doi.org/10.1007/978-3-030-55176-6_36) contains supplementary material, which is available to authorized users.

Y.-W. Kim (*) · W. H. Han  Department of Cancer Control and Population Health, National Cancer Center Graduate School of Cancer Science and Policy & Center for Gastric Cancer, National Cancer Center, 323 Ilsan-ro, Ilsandonggu, Goyang 10408, Republic of Korea e-mail: [email protected]

gastrectomy has limitations in lack of tactile sense, longer duration of operating time due to the additional time for the robotic arms comparing with laparoscopic gastrectomy.

36.2 Indication Robotic subtotal gastrectomy is indicated in the presence of malignancy. Although it has been widely accepted as an appropriate treatment in early gastric cancer, performing the operation in advanced gastric cancer is still controversial similar to laparoscopic subtotal gastrectomy.

36.3 Description of the Surgical Steps (See Video 36.1) The key steps to perform a robotic distal gastrectomy are: 1. General preparation of the patient, surgical team, and placement of trocars After induction of general anesthesia, the patient is placed in supine position. The skin of the lower chest and upper abdomen is prepared in a routine manner. A 12-mm port is placed by open technique above the umbilicus, and a pneumoperitoneum to 12 mmHg is established. Under direct vision, three 8-mm robotic trocars are placed, two ports in the upper abdomen at the midclavicular line on the left (robotic arm No. 1) and on the right (robotic arm no. 2) and one port at the right anterior axillary line (robotic arm No. 3). In addition, a 12-mm port for the assistant is placed between the left robotic port and the camera port. Each trocar requires a distance of at least 7–8 cm for the motion (Fig. 36.1). 2. Liver retraction Straight needle 2-0 monofilament thread is inserted through the left side of subcostal margin. Then the needle punctured

© Springer Nature Switzerland AG 2021 M. Asunción Acosta et al. (eds.), Atlas of Minimally Invasive Techniques in Upper Gastrointestinal Surgery, https://doi.org/10.1007/978-3-030-55176-6_36

285

286

Y.-W. Kim and W. H. Han

mesocolon should be dissected to avoid damage to the transverse mesocolon (Fig. 36.3). 4. Left gastroepiploic vessel ligation and No. 4sb Lymph node dissection

Fig. 36.1  Position of the trocars

out at the inferior of the right subcostal margin. After cutting the needle, phrenoesophageal ligament is clipped with thread together (Fig. 36.2). Then the thread is pulled and tied. 3. Left partial omentectomy Left partial omentectomy is performed at a distance of 3–4 cm from the gastroepiploic vessel arcade. Operator holds the stomach anterior wall and lifts it up, it is easy to observe the vessel going to the greater omentum. The physiologic plane between greater omentum and transverse

Fig. 36.2  Phrenoesophageal ligament is clipped with thread together

The partial omentectomy is performed in the direction of the spleen lower pole, the spleen lower pole and distal pancreas are identified. When the dissected omentum is lifted up, the contour of the left gastroepiploic vessel branching from the splenic artery and vein appears. After branching the left gastroepiploic vessel from the splenic vessels, there are vessels to the greater omentum. Vessel ligature should be made at its proximal part, so that it is preserved (Fig. 36.4). When operator lifts the greater omentum including No. 4sb and No. 4d lymph node, the boundary between greater curvature of stomach and omentum appears, which is easier to separate by ultrasonic device. Unlike conventional laparoscopic gastrectomy, articulated movement can easily dissect it without adjusting the angle of the surgical plane (Fig. 36.5). 5. Right partial omentectomy and Right gastroepiploic vessel ligation and No. 6 and No. 14v Lymph node dissection Partial omentectomy is performed toward right side on starting site of the left partial omentectomy. After dissection along the physiology plane between greater omentum and transvers mesocolon, the head of pancreas is identified. By lifting the right gastroepiploic vessel, operator can occasionally vertically erect or tilt it to identify and expose the surrounding major structures. First, physiologic adhesion of posterior wall of stomach and pancreas body should be divided to identify gastroduodenal artery (Fig. 36.6). Then,

36  Robotic Distal Gastrectomy for Gastric Cancer Fig. 36.3  The physiological plane between greater omentum and transverse mesocolon should be dissected to avoid damage to the transverse mesocolon

Fig. 36.4  After branching the left gastroepiploic vessel from the splenic vessels, there are vessels to the greater omentum. Vessel ligature should be made at its proximal part, so that it is preserved

Fig. 36.5  Unlike conventional laparoscopic gastrectomy, articulated movement can easily dissect it without adjusting the angle of the surgical plane

287

288

Y.-W. Kim and W. H. Han

Fig. 36.6  First, physiologic adhesion of posterior wall of stomach and pancreas body should be divided to identify gastroduodenal artery

Fig. 36.7  To identify the duodenum and pancreas head, the transverse mesocolon can be easily separated by following the physiologic plane

to identify the duodenum and pancreas head, the transvers mesocolon can be easily separated by following the physiologic plane (Fig. 36.7). The border of the No. 6 lymph node is separated from the upper margin of the anterior superior pancreaticoduodenal vein (ASPDV) (Fig. 36.8). After identifying and ligating the right gastroepiploic vein branching from proximal of ASPDV and right accessory colic vein, ligate the right gastroepiploic artery from the posterior right gastroepiploic vein (Figs. 36.9 and 36.10). Infrapyloric vessels should be ligated because hemostasis is not easy by ultrasonic device (Fig. 36.11).

6. Rt. Gastric vessels ligation, No. 5 Lymph node dissection, and duodenal resection After No. 6 lymph node dissection, Put the gauze between the duodenum and the pancreas and Let the assistant pull the duodenum downward. Then supraduodenal vessels are exposed (Fig. 36.12). Common hepatic artery, proper hepatic artery, and right gastric artery should be identified and then ligated the origin of right gastric artery with No. 5 lymph node dissection simultaneously (Fig. 36.13). Duodenal resection is performed by stapler through assistant port (Fig. 36.14).

36  Robotic Distal Gastrectomy for Gastric Cancer Fig. 36.8  No. 6 lymph node is separated from the upper margin of the anterior superior pancreaticoduodenal vein (ASPDV)

Fig. 36.9  After identifying and ligating the right gastroepiploic vein branching from proximal of ASPDV and right accessory colic vein

Fig. 36.10  Ligate the right gastroepiploic artery from the posterior right gastroepiploic vein

289

290 Fig. 36.11  Infrapyloric vessels should be ligated because hemostasis is not easy by ultrasonic device

Fig. 36.12  Then supraduodenal vessels are exposed

Fig. 36.13  Common hepatic artery, proper hepatic artery, and right gastric artery should be identified and then ligated the origin of right gastric artery with No. 5 lymph node dissection simultaneously

Y.-W. Kim and W. H. Han

36  Robotic Distal Gastrectomy for Gastric Cancer

291

Fig. 36.14  Duodenal resection is performed by stapler through assistant port

7. Suprapancreatic lymph node dissection To expose surgical plane between pancreatic upper border and suprapancreatic lymph node, operator lifts the left gastric vessel vertically. Articulated movement of robotic arm can prevent the assistant from compressing the pancreas to damage it (Fig. 36.15). After dissection along the common hepatic artery (Fig. 36.16), left gastric vein is ligated (Fig. 36.17). Around celiac trunk, the origin of the common hepatic artery on the left side and the origin of the splenic artery on the right side should be identified, then left gastric artery is divided and ligated (Fig. 36.18). No. 12a lymph node dissection requires exposure of the anterior side of the proper hepatic artery and portal vein. It is easy to expose portal vein by retracing the adjacent tissue of common hepatic artery (Fig. 36.19). In No. 11p lymph node dissection, operator lifts No. 11p lymph node vertically and tilts left side slightly. Assistant retracts the pancreas to the caudal side to expose splenic vein (Fig. 36.20). 8. Abdominal esophagus and No. 1, 3 lymph node dissection. The anterior and posterior sides of the abdominal esophagus are dissected to divide the surrounding tissue. After

Left and right vagus nerve ligation, stomach is freed to dissect No. 1, 3 lymph node dissection (Fig. 36.21). Assistant retracts soft tissues including No. 1, 3 lymph nodes to straighten the lesser curvature (Fig. 36.22). 9. Billroth I anastomosis The two ends of the duodenal and gastric stump are placed facing each other (Fig. 36.23). Opening of the duodenal stump (Fig. 36.24). Opening of the gastric stump (Fig. 36.25). Traction stitch from the gastric opening to outside (Fig. 36.26). Linear stapler in the gastric side (far from the staple line) (Fig. 36.27). The other part is placed on the duodenal side (Fig. 36.28). GastroduodenalBillroth I anastomosis is performed (Fig. 36.29). Closure of the opening by linear stapler (Fig. 36.30). Aspect of the anastomosis (Fig. 36.31).

292 Fig. 36.15  Articulated movement of robotic arm can prevent the assistant from compressing the pancreas to damage it

Fig. 36.16  After dissection along the common hepatic artery

Fig. 36.17  Left gastric vein is ligated

Y.-W. Kim and W. H. Han

36  Robotic Distal Gastrectomy for Gastric Cancer Fig. 36.18  Left gastric artery is divided and ligated

Fig. 36.19  It is easy to expose portal vein by retracing the adjacent tissue of common hepatic artery

Fig. 36.20  Assistant retracts the pancreas to the caudal side to expose splenic vein

293

294 Fig. 36.21  After Left and right vagus nerve ligation, stomach is freed to dissect No. 1, 3 lymph node dissection

Fig. 36.22  Assistant retracts soft tissues including No. 1, 3 lymph nodes to straighten the lesser curvature

Fig. 36.23  After resection, the two ends (duodenal and gastric stump) are placed in front of each other. Close (a) and schematic view (b)

Y.-W. Kim and W. H. Han

36  Robotic Distal Gastrectomy for Gastric Cancer Fig. 36.24  Duodenal stump is open. Close (a) and schematic view (b)

Fig. 36.25  Gastric stump is open. Close (a, b) and schematic view (c)

Fig. 36.26  Traction stitch at the gastric opening and put through trocar outside. Close (a–c) and schematic view (d)

295

296 Fig. 36.27  Linear stapler (anvil side) is placed in the gastric side. Close (a) and schematic view (b)

Fig. 36.28  Linear stapler (cartridge side) is placed in duodenal side (a, b)

Fig. 36.29  GastroduodenalBillroth I anastomosis. Close (a–d) and schematic view (e, f)

Y.-W. Kim and W. H. Han

36  Robotic Distal Gastrectomy for Gastric Cancer

297

Fig. 36.30  Closure of the opening by linear stapler

References

Fig. 36.31  Final aspect of the Billroth I anastomosis

1. Kim HI, Han SU, Yang HK, et al. Multicenter prospective comparative study of robotic versus laparoscopic gastrectomy for gastric adenocarcinoma. Ann Surg. 2016;263(1):103–9. 2. Kim MC, Heo GU, Jung GJ. Robotic gastrectomy for gastric cancer: surgical techniques and clinical merits. Surg Endosc. 2010;24(3):610–5. 3. D’Annibale A, Pende V, Pernazza G, et al. Full robotic gastrectomy with extended (D2) lymphadenectomy for gastric cancer: surgical technique and preliminary results. J Surg Res. 2011;166(2):e113–20. 4. Eom BW, Yoon HM, Ryu KW, et al. Comparison of surgical performance and short-term clinical outcomes between laparoscopic and robotic surgery in distal gastric cancer. Eur J Surg Oncol: J Eur Soc Surg Oncol Br Assoc Surg Oncol. 2012;38(1):57–63. 5. Park JY, Jo MJ, Nam BH, et al. Surgical stress after robot-assisted distal gastrectomy and its economic implications. Br J Surg. 2012;99(11):1554–61. 6. Yoon HM, Kim YW, Lee JH, et al. Robot-assisted total gastrectomy is comparable with laparoscopically assisted total gastrectomy for early gastric cancer. Surg Endosc. 2012;26(5):1377–81.

Laparoscopic Total Gastrectomy for Gastric Cancer

37

Antonio Talvane Torres de Oliveira, Croider Franco Lacerda, Paulo A. Bertulucci and Miguel A. Cuesta

37.1 Introduction

37.2 Clinical Staging and Surgical Plan

Gastrectomy, total or subtotal, with a proper lymphadenectomy after neoadjuvant therapy, if indicated, is the main treatment for resectable gastric cancer. Many studies have shown that Minimally Invasive Surgery (MIS) for other gastrointestinal malignancies [1, 2], such as colorectal and esophageal cancer, is oncologically safe and has several important short-term advantages in comparison with the conventional open surgical techniques. These studies showed favorable outcomes for MIS such as a less blood loss, faster patient recovery, and fewer complications with similar oncological outcomes. Concerning MI gastrectomy for cancer, important requirement includes the use of neoadjuvant (and adjuvant) therapy [3] in advanced gastric cancer and to adopt the principles of oncological resection including a proper lymphadenectomy based on the Japanese guidelines [4]. Evidence for this MIS for gastric cancer is based on European (Hulscher, STOMACH, and LOGICA) and South Korean (KLASS studies) and some meta-analysis [5–11]. They have shown that there are some short-term advantages for partial gastrectomy whereas for total gastrectomy, it seems they shown similar short-term and oncological outcomes.

If gastric cancer is diagnosed, clinical staging should be done (cTNM) by means of endoscopic ultrasound, CT and PET-CT scans. If the tumor seems resectable, depending on the clinical staging and location of the tumor, a surgical plan is designed, concerning: – Use of neoadjuvant therapy (stage II or higher). – Type of resection: local, distal, or total gastrectomy. In advanced gastric cancer, the margin of resection will be at least 5 cm. – The type of lymphadenectomy, D1, D1+ , or D2. We follow the Japanese Gastric Cancer treatment guidelines 2014 [4] and classify the lymph node stations in the surgical field according to it. Figure 37.1 shows the operative field with lymph node stations.

37.3 Description of the Surgical Technique (See Video 37.1) The key steps for a laparoscopic total gastrectomy are:

 lectronic supplementary material  The online version of this E chapter (https://doi.org/10.1007/978-3-030-55176-6_37) contains supplementary material, which is available to authorized users. A. T. T. de Oliveira · C. F. Lacerda · P. A. Bertulucci  Department of Upper GI Surgery, Americas Medical City Hospital, Rio de Janeiro, Brazil e-mail: [email protected] C. F. Lacerda e-mail: [email protected] M. A. Cuesta (*)  Department of Surgery, Amsterdam UMC, Amsterdam, The Netherlands e-mail: [email protected]

1. Positioning of patient and placement of trocars. Patient is placed in lithotomy position. Surgeon stands between the legs of the patient (Fig. 37.2) 5 trocars of 5/12 mm are placed in the upper abdomen. Assistance incision used is placed on the left side (trocar site) or Pfannenstiel incision (Fig. 37.3). 2. Omentectomy. Omentectomy will be started from the middle to the left. Omental bursa is opened. After this, greater curvature is dissected after division of the left gastroepiploic vessels and short vessels up to left crus (Fig. 37.4), after this we will proceed the omentectomy to the right side, up to hepatic flexure and duodenum (Fig. 37.5).

© Springer Nature Switzerland AG 2021 M. Asunción Acosta et al. (eds.), Atlas of Minimally Invasive Techniques in Upper Gastrointestinal Surgery, https://doi.org/10.1007/978-3-030-55176-6_37

299

300

A. T. T. de Oliveira et al.

Fig. 37.1  Operative field with lymph node stations

Fig. 37.3  Placement of trocars and help incision

11p). Division of the left gastric vessels between clips (Fig. 37.10). General view of lymphadenectomy of the stations 12, 8, 9, 7 and 11p, along the hepatic artery, and celiac trunk. Left gastric vessels have been divided (Fig. 37.11). 7. Continue the dissection from here to the hiatus. Dissect the distal esophagus free and divide the distal esophagus by staplers, and prepare it depending on the type of esophagojejunostomy anastomosis that you will perform (Fig. 37.12). 8. Complete the lymphadenectomy of distal splenic artery and hilum of the spleen (stations 11d and 10) (Fig. 37.13). General view of the D2 lymphadenectomy in total gastrectomy (Fig. 37.14).

37.4 Reconstruction After Total Gastrectomy Fig. 37.2  Position of patient and surgeons during laparoscopic gastrectomy

3. Lymphadenectomy of station 6 (right gastroepiploic vessels). Division of the right gastroepiploic vessels with clips at the level of the head of the pancreas (Fig. 37.6). 4. Opening hepatoduodenal ligament in the length with division of pars flaccida along the liver edge, up to the right crus (Fig. 37.7). Division of the right gastric artery and lymphadenectomy of stations 8 and 12, along the common and hepatic artery proper. (Fig. 37.8). 5. Dissection of the superior part of the duodenum (supraduodenal window) and posterior division of the proximal duodenum by stapler (Fig. 37.9). 6. Retraction of stomach to the left. Dissection and lymphadenectomy of the celiac trunk (stations 9, 7, and

There are four ways to perform the esophagojejunostomy anastomosis: 1. Conventional circular stapler. 2. Circular Orvil® stapler device (21 or 25 mm) (Chap. 39). 3. Linear stapler side to side anastomosis (Chap. 39). 4. Hand-sewn (Chap. 40). 1. Conventional circular stapler • Introduction of the anvil and preparation for circular anastomosis. • Loop around the esophagogastric junction for traction of the esophagus (Fig. 37.15a) and open the anterior wall of the esophagus.

37  Laparoscopic Total Gastrectomy for Gastric Cancer Fig. 37.4  Omentectomy to the left crus (ligation of the left gastroepiploic and short vessels). Close (a, b) and schematic view (c, d)

Fig. 37.5  Omentectomy to the hepatic flexure. Close (a) and schematic view (b)

301

302

A. T. T. de Oliveira et al.

Fig. 37.6  Dissection and lymphadenectomy (station 6) of the right gastroepiploic vessels. Close (a, b) and schematic view (c)

Fig. 37.7  Open the hepatoduodenal ligament and division of the hepatogastric ligament. Close (a, b, c) and schematic view (d)

37  Laparoscopic Total Gastrectomy for Gastric Cancer

303

Fig. 37.8  Dissection and ligation of right gastric artery. Close (a, b, c) and schematic view (d). Lymphadenectomy of the hepatoduodenal ligament (8a, 12) Lymphadenectomy station 12 along portal vein (e, f, g)

Fig. 37.9  Dissection of the supraduodenal space (a). Duodenum division by staplers. Close (b) and schematic view (c)

304

A. T. T. de Oliveira et al.

Fig. 37.10  Lymphadenectomy (stations 9, 7, and 11p). Dissection and ligation of the left gastric vessels by clips. Close (a, b, c) and schematic view (d) Fig. 37.11  General view of the lymphadenectomy (8a, 12, 7, 9, and 11p) (a, b)

Fig. 37.12  Dissection (a) and division (b) of the distal esophagus

37  Laparoscopic Total Gastrectomy for Gastric Cancer

Fig. 37.13  Lymphadenectomy distal splenic artery (station 11p and 10). Close (a, b, c) and schematic view (d)

Fig. 37.14  General view of the lymphadenectomy

305

306

• Introduce the anvil (25 mm) through the widened opening of the trocar of the left flank (Fig. 37.15b). • To the end of the anvil is a thread with circular needle attached. • Introduce the anvil through the opening in the anterior wall of the distal esophagus; push the anvil

A. T. T. de Oliveira et al.

proximally in the esophagus (Fig. 37.15c, d, e) and use the needle to put the thread (and the needle) out the wall of the esophagus (Fig. 37.15f). • Division of the esophagus by linear stapler, distal of the thread. The opening of the distal esophagus is included in the specimen with the whole stomach (Fig. 37.15g, h).

Fig. 37.15  A sling is placed around the esophagus (a). An anvil (25 mm) attached to a thread and a needle is introduced through the widened opening of the trocar of the left flank: close (b, c) and schematic view (d). The anvil is push in the esophagus and the thread (and the needle) is put through the anterior wall of the esophagus (e, f). Division of the esophagus by linear stapler, distal of the thread: close (g) and schematic view (h). Preparation of the anvil by traction of the thread attached to the anvil: close (i, j) and schematic view (k)

37  Laparoscopic Total Gastrectomy for Gastric Cancer

307

Fig. 37.16  A opening is made in the transverse mesocolon. Close (a) and schematic view (b)

• Preparation of the anvil by traction of the thread attached to the anvil, the prick perforates the anterior wall of the distal esophagus near the stapled line (Fig. 37.15e). • The specimen is placed in a bag. • Preparation of the jejunal loop: – Opening the transverse mesocolon (Fig. 37.16) – Divide the proximal jejunum by means of the stapler – The distal loop is introduced through the open transverse mesocolon in direction to the distal esophagus (Fig. 37.16b and 37.17). • Esophagojejunal anastomosis: – Introduce the EEA device® through the widened trocar opening in the abdominal wall. – Perform an end-to-side esophagojejunal anastomosis with 25 mm circular stapler (Fig. 37.18).

Fig. 37.17  Jejunal loop is divided by staplers. The distal jejunal loop is introduced through the open transverse mesocolon in direction to the distal esophagus

308

A. T. T. de Oliveira et al.

Fig. 37.18  Perform an end-to-side esophagojejunal anastomosis with 25-mm circular stapler. Close (a, b, c) and schematic view (d)

– A side-to-side jejunojejunal anastomosis by means of linear stapler is performed. The anastomosis is located inframesocolic (Fig. 37.19). – Closure the mesenteric spaces. The mesenteric defects and the Petersen space are closed by means of a running suture. – Retrieval of the specimen is performed through a small assistance incision at the level of the trocar of the left flank (Fig. 37.20). Protect the extraction site with Alexis type device®. Protected Pfannenstiel incision is other option. – Drain the anastomosis using a Jackson Pratt drain. – General view of the reconstruction (Fig. 37.21).

Fig. 37.19  A side-to-side jejunojejunal anastomosis by means of linear stapler is performed follow by closure of the opening

37  Laparoscopic Total Gastrectomy for Gastric Cancer

309

Fig. 37.20  Retrieval of the specimen in a bag is performed through a small assistance incision. Close (a) and schematic view (b)

Fig. 37.21  General view of the reconstruction

References 1. Bonjer HJ, Deijen CL, Haglind E, et al. A randomized trial of laparoscopic versus open surgery for rectal cancer. N Engl J Med. 2015;373(2):194. 2. Straatman J, van der Wielen N, Cuesta MA, et al. Minimally invasive versus open esophageal resection: three-year follow-up of the previously reported randomized controlled trial: the TIME trial. Ann Surg. 2017;266(2):232–6. 3. Ilson DH. Perioperative Chemotherapy for Resectable Gastric Cancer, reviewing Al-Batran SE et al. Lancet 2019; April 10. NEJM J Watch. April 19, 2019. 4. Japanese Gastric Cancer A. Japanese gastric cancer treatment guidelines 2014 (ver. 4). Gastric Cancer. 2017;20(1):1–19.

5. Beyer K, Baukloh AK, Kamphues C, et al. Laparoscopic versus open gastrectomy for locally advanced gastric cancer: a systematic review and meta-analysis of randomized controlled studies. World J Surg Oncol. 2019;17(1):68. 6. van der Wielen N, Straatman J, Cuesta MA, et al. Short-term outcomes in minimally invasive versus open gastrectomy: the differences between East and West. A systematic review of the literature. Gastric Cancer. 2018;21(1):19–30. 7. Haverkamp L, Weijs TJ, van der Sluis PC, et al. Laparoscopic total gastrectomy versus open total gastrectomy for cancer: a systematic review and meta-analysis. Surg Endosc. 2013;27:1509–20. 8. Kim W, Kim HH, Han SU, et al. Decreased morbidity of laparoscopic distal gastrectomy compared with open distal gastrectomy for stage i gastric cancer: short-term outcomes from a multicenter randomized controlled trial (KLASS-01). Ann Surg. 2016;263(1):28–35. 9. Lee HJ, Hyung WJ, Yang HK, et al. Short-term outcomes of a multicenter randomized controlled trial comparing laparoscopic distal gastrectomy with D2 lymphadenectomy to open distal gastrectomy for locally advanced gastric cancer (KLASS-02-RCT). Ann Surg. 2019;270(6):983–91. 10. Straatman J, van der Wielen N, Cuesta MA, et al. Surgical techniques, open versus minimally invasive gastrectomy after chemotherapy (STOMACH trial): study protocol for a randomized controlled trial. Trials. 2015;16:123. 11. Haverkamp L, Brenkman HJF, Seesing MFJ, et al. Laparoscopic versus open gastrectomy for gastric cancer, a multicenter prospectively randomized controlled trial (LOGICA-trial). BMC Cancer. 2015;15:556.

Spleen-Preserving Splenic Hilar Dissection for Proximal Gastric Cancer

38

Takahiro Kinoshita

38.1 Introduction Lymph nodes around the splenic hilum is numbered as station No. 10 in the Japanese Gastric Cancer Classification [1]. Nodal metastasis to No. 10 is sometimes seen in proximal advanced stomach cancer. For complete removal of No. 10, splenectomy had been performed in Japan. However, a randomized clinical trial (JCOG0110) which compared between splenectomy versus non-splenectomy clearly demonstrated unnecessity of splenectomy or intensive dissection of the No. 10 if the tumor does not invade the greater curvature [2]. Meanwhile, if the tumor invades the greater curvature, metastasis to No. 10 is recognized in around 15% of the patients [3]. Necessity of splenectomy or efficacy of spleenpreserving dissection is still unclear, but the potential benefits gained by preserving the spleen seems unquestionable. In this context, the indication of the spleen-preserving splenic hilar dissection in our center is advanced gastric cancer involving the proximal greater curvature site without direct invasion to the splenogastric ligament nor obvious nodal metastasis to No. 10. Remarkable anatomical variation of the splenic vessels is well acknowledged. Preoperative anatomical reconstruction using three-dimensional CT images is effective to understand individual anatomy in advance [4]. Description of the surgical rechnique (see Video 38.1). The key steps to perform a Spleen-preserving splenic hilar dissection for proximal gastric cancer are.

 lectronic supplementary material  The online version of this E chapter (https://doi.org/10.1007/978-3-030-55176-6_38) contains supplementary material, which is available to authorized users.

T. Kinoshita (*)  National Cancer Center Hospital East, 6-5-1 Kashiwanoha, Kashiwa 277-8577, Japan e-mail: [email protected]

1. Port placement and patient’s position The patient is positioned in supine legs apart with head-up and left-up tilted rotation to obtain optimal exposure around the splenic hilar region. Five ports are used, and the operator stands at the right side of the patient. The first assistant stands at the left side of the patient and the camera assistant between the legs. 2. Technical steps Timing of the splenic hilar dissection Splenic hilar dissection is usually employed in combination with total gastrectomy. After exploration of the abdominal cavity (and lavage cytology if required), the lateral segment of the liver is retracted (Fig. 38.1). Then, splenic hilar dissection should be immediately initiated. Performing splenic hilar dissection at the late phase of the surgery is challenging because of the excessive fluid (lymphatic or bloody) at the left subphrenic fossa. Splenic hilar dissection is certainly a complex procedure; therefore, it should be finished at the early phase of surgery in the finest circumstances. 1. Dissection of the greater omentum. The greater omentum is dissected at their attachment to the transverse colon toward the lower pole of the spleen (Fig. 38.2); however, splenopancreatic mobilization from the retroperitoneal bed is not required. When the omental disection reaches the splenic lower pole, adipose tissue including the gastroepiploic vessels arcade at the greater curvature of the stomach body is ligated to be lifted up using a pre-tied loop which is pulled out through the abdominal wall (Fig. 38.3). By performing this retraction, the splenogastric ligament is stretched and a favorable view around the splenic hilum can be provided. 2. Exposure of the left gastroepiploic vessels originated from the inferior branch (Fig. 38.4). Then, the splenic hilum is identified from the caudal view to be dissected exposing the inferior branch of the splenic vessel (Fig. 38.5). The left gastroepiploic vessel can be identified which is usually originated from the inferior branch.

© Springer Nature Switzerland AG 2021 M. Asunción Acosta et al. (eds.), Atlas of Minimally Invasive Techniques in Upper Gastrointestinal Surgery, https://doi.org/10.1007/978-3-030-55176-6_38

311

312

T. Kinoshita

Fig. 38.1  The liver is retracted with a special constructed retractor. Close (a, b, c, d) and schematic view (e, f)

Fig. 38.2  Omentectomy in direction to the spleen. Close (a) and schematic view (b)

After cutting the left gastroepiploic vessels, in most of the cases, a short gastric vessel tends to be identified close to its stump, which can be also divided at this timing (Fig. 38.6).

3. Dissection along the main trunks of splenic vessels. Next, dissection is resumed from the main trunk of the splenic vessels which are likely to be visualized at the upper rim of the distal pancreas. This dissection is

38  Spleen-Preserving Splenic Hilar Dissection …

313

Fig. 38.3  Stomach is retracted by means of an endoloop. Close (a, b) and schematic view (c)

Fig. 38.4  Proximal stomach is further retracted by means of a rolled gauze. Close (a) and schematic view (b)

carried out toward the splenic hilum and ordinally the bifurcation is identified at the level of the pancreas tail (Fig. 38.7). During these procedures, preoperative anatomical reconstruction using three-dimensional CT images is indeed helpful. A separated small branch running into the upper pole of the spleen is recognized in about 35% of the patients. This branch can be preserved if possible, but its division is even considered to be basically non-problematic in clinical sense (Fig. 38.8).

4. Dissection around the upper branch. Finally, the adipose tissue along the superior branch is dissected. In this region, the stomach wall tends to be located adjacently near the spleen, and the short gastric vessels have very short segment. Therefore, careful attention should be paid when dividing these vessels not to cause hemorrhage. If the plane in front of the Gerota fascia is dissected in advance, the splenogastric ligament at the upper pole can be extended, which facilitates the consequent division of the short gastric vessels (Fig. 38.9).

314 Fig. 38.5  The splenic hilum is identified from the caudal view to be dissected exposing the inferior branch of the splenic vessel (a, b)

Fig. 38.6  After cutting the left gastroepiploic vessels, in most of the cases, a short gastric vessel tends to be identified close to its stump, which can be also divided at this time (a, b)

Fig. 38.7  Dissection is carried out toward the splenic hilum, and ordinally the bifurcation is identified at the level of the pancreas tail (a, b)

T. Kinoshita

38  Spleen-Preserving Splenic Hilar Dissection … Fig. 38.8  A separated small branch running into the upper pole of the spleen is recognized in about 35% of the patients. Close (a, b) and schematic view (c)

Fig. 38.9  Final view of the lymphadenectomy. Close (a) and schematic view (b)

315

316

References 1. Japanese Gastric Cancer Association. Japanese classification of gastric carcinoma: 3rd English edition. Gastric Cancer. 2011;14(2):101–12. 2. Sano T, Sasako M, Mizusawa J, et al. Randomized controlled trial to evaluate splenectomy in total gastrectomy for proximal gastric carcinoma. Ann Surg. 2017;265(2):277–83.

T. Kinoshita 3. Watanabe M, Kinoshita T, Enomoto N, et al. Clinical significance of splenic hilar dissection with splenectomy in advanced proximal gastric cancer: an analysis at a single institution in Japan. World J Surg. 2016;40(5):1165–71. 4. Kinoshita T, Shibasaki H, Enomoto N, et al. Laparoscopic splenic hilar lymph node dissection for proximal gastric cancer using integrated three-dimensional anatomic simulation software. Surg Endosc. 2016;30(6):2613–9.

End-To-Side Esophagojejunal Anastomosis Using the Circular Orvil Device

39

Suzanne S. Gisbertz and Mark I. van Berge Henegouwen

39.1 End-To-Side Esophagojejunal Anastomosis Using the Orvil Device There are four ways to perform the esophagojejunal anastomosis after a total gastrectomy: the conventional circular stapler (described in Chap. 36), the circular Orvil® device anastomosis, the linear stapler side-to-side, and the handsewn anastomosis (reported in Chap. 39). In this chapter, first of all a description is made of the end-to-side anastomosis by means of circular Orvil® device, followed by a description of the linear side-to-side anastomosis. This anastomosis is ideal for a situation where the distal part of the esophagus has been resected with the stomach (e.g., Siewert 2), and there is no space for a sideto-side anastomosis by means of linear stapler (Fig. 39.1).

39.2 Description of the Surgical Technique (See Videos 39.1 and 39.2) The key steps to perform an end-to-side esophagojejunal anastomosis using the Orvil® device are: 1. The stapled esophagus is brought in view, and the anaesthesiologist introduced the 25 mm Orvil device (R) through the mouth (tube first)

 lectronic supplementary material  The online version of this E chapter (https://doi.org/10.1007/978-3-030-55176-6_39) contains supplementary material, which is available to authorized users. S. S. Gisbertz (*) · M. I. van Berge Henegouwen  Department of Surgery, Amsterdam UMC, Amsterdam, The Netherlands e-mail: [email protected]

2. The tube is felt in the distal esophagus, and the middle of the stapled line is open by diathermy in order to retrieve the tube (Fig. 39.2) 3. The tube is pulled until the anvil is correctly placed in the distal esophagus 4. The thread is cut, and the tube and the anvil are disconnected (Fig. 39.2) 5. The previously prepared jejunal loop (with the circular stapler inside) is advanced and assembled with the anvil) 6. An end-to-side esophagojejunostomy anastomosis is performed (Fig. 39.3) 7. Lateral jejunal loop is stapled (Fig. 39.4).

39.3 Linear Side-To-Side Esophagojejunal Anastomosis This side-to-side anastomosis has been developed by the bariatric surgeons, and it seems to be the ideal anastomosis after total gastrectomy with enough length of distal esophagus [1, 2].

39.4 Description of the Surgical Technique (See Video 39.2) The key steps to perform a laparoscopic linear side-to-side esophagojejunal anastomosis are. 1. Both parts, the distal esophagus and the jejunal loop are prepared for the anastomosis 2. An opening is made with diathermia at the level of the stapled distal esophagus and the jejunal loop (Fig. 39.5) 3. Linear stapler is introduced in the jejunal loop (5–6 cm from the staple line), and in the esophagus (Fig. 39.6) 4. Linear endostapler (medium thick reload) is closed and fired being the side-to-side anastomosis performed  (Fig. 39.7)

M. I. van Berge Henegouwen e-mail: [email protected] © Springer Nature Switzerland AG 2021 M. Asunción Acosta et al. (eds.), Atlas of Minimally Invasive Techniques in Upper Gastrointestinal Surgery, https://doi.org/10.1007/978-3-030-55176-6_39

317

318 Fig. 39.1  The stapled esophagus is brought in view (a, b)

Fig. 39.2  The 25 mm Orvil® device is introduced through the mouth by anaesthesiologist. The tube is exteriorized through a small opening in the stapled line. The tube is pulled out and the anvil is placed in the distal esophagus. The thread is cut, and the tube and the stapler are disconnected. Close (a) and schematic view (b)

Fig. 39.3  The prepared jejunal loop (with the stapler inside) is advanced and connected with the anvil, and a circular end-to-side esophagojejunostomy is performed. Close (a, b, c) and schematic view (d)

S. S. Gisbertz and M. I. van Berge Henegouwen

39  End-To-Side Esophagojejunal Anastomosis Using … Fig. 39.4  Jejunal loop is shortened and stapled. Anastomosis is placed in the mediastinum. Close (a, b) and schematic view (c)

Fig. 39.5  Stump of the esophagus and of the jejunual loop are open. Close (a) and schematic view (b, c)

319

320

S. S. Gisbertz and M. I. van Berge Henegouwen

Fig. 39.6  Linear stapler is introduced in the jejunum and esophagus. Close (a, b, c) and schematic view (d)

5. After the Side-to-side anastomosis is performed, the opening is closed by suture (Fig. 39.8) 6. Nasogastric tube is passed through the anastomosis to distal before the closure 7. After closure, anastomosis is tested for watertight.

Fig. 39.7  Linear side-to-side anastomosis is performed

39  End-To-Side Esophagojejunal Anastomosis Using … Fig. 39.8  Common opening is closed by V-Lock suture®. Close (a, b, c) and schematic view (d)

References 1. Chang KK, Patel MS, Yoon SS. Linear-stapled side-to-side esophagojejunostomy with hand-sewn closure of the common enterotomy after prophylactic and therapeutic total gastrectomy. J Gastrointest Surg. 2017;21:712–22. 2. Kim JJ, Song KY, Chin HM, et al. Totally laparoscopic gastrectomy with various types of intracorporeal anastomosis using laparoscopic linear staplers: preliminary experience. Surg Endosc. 2008;22:436–42.

321

Hand-Sewn Anastomosis After 95% Gastrectomy, Total Gastrectomy, and Total Gastrectomy Extended to the Distal Esophagus for Gastric Cancer

40

Juan Santiago Azagra, Beniamino Pascotto, Luca Arru, Francisco Javier Ibañez, Silviu T. M ­ akkai-Popa and Martine Goergen

40.1 Introduction Total gastrectomy is a surgery with significant perioperative morbidity and mortality, being considered the treatment of choice in proximal gastric cancer. First described in 1980, our group reported and standardized totally laparoscopic 95% gastrectomy in 2014 [1, 2]. This technique aims to reduce the complications of total gastrectomy while maintaining oncological radicality. In these patients, a standard hand-sewn anastomosis was performed. A prospective observational study was carried out in 67 patients with laparoscopic 95% gastrectomy between 2014 and 2017. The main objective has been to detect complications (Clavien Dindo > IIIa), focusing on anastomotic leaks. The secondary objective was to assess the quality of oncological surgery. Sixty-seven consecutive patients were included, in whom 95% totally laparoscopic gastrectomy was performed. There was no case of anastomotic leak. Two patients

(2.98%) had one or more Clavien Dindo complications equal to or greater than IIIa. The total hospital stay was six (3–13) days. R0 radical resection was performed in all patients. 95% gastrectomy allows selected patients to meet the oncological standards of resection in proximal gastric cancer in a reproducible and safe manner, reducing perioperative risks such as anastomotic leakage. Sometimes, in high localized cancers, a standard total gastrectomy should be performed with proximal resection at the distal esophagus. Moreover, in patients with Siewert II, a distal esophagectomy should be added to be radical, and this implies to perform an esophagojejunal anastomosis, transhiatal or by thoracoscopy in prone using a long jejunal loop. Furthermore, Robot-assisted gastrectomy is being used increasingly in daily practice [3, 4]. After a near total, and total gastrectomy, anastomosis can be performed as described above.

 lectronic supplementary materialThe online version of this E chapter (https://doi.org/10.1007/978-3-030-55176-6_40) contains supplementary material, which is available to authorized users.

40.2 Description of the Operative Technique (See Videos 40.1–40.4)

J. S. Azagra (*) · B. Pascotto · F. Ibañez · M. Goergen  Department of General and Minimally Invasive Surgery(Laparoscopy & Robotic), Centre Hospitalier de Luxembourg (CHL), L-1210 Luxembourg, Luxembourg e-mail: [email protected] B. Pascotto e-mail: [email protected] L. Arru  Department of General and Minimally Invasive Surgery, CHL, Luxembourg City, Luxembourg e-mail: [email protected] S. T. Makkai-Popa  Department of General and Minimally Invasive Surgery, CHL, Luxembourg City, Luxembourg e-mail: [email protected]

We described the same type of anastomosis in four different types of interventions: 1. Laparoscopic end-to-side Roux-en-Y Gastrojejunostomy after 95% Gastrectomy 2. Laparoscopic side-to-side Roux-en-Y Esophagojejunostomy after Total Gastrectomy 3. Laparoscopic or Robotic end-to-side Roux-en-Y Esophagojejunostomyafter Total Gastrectomy 4. Right Thoracoscopic end-to-sideesophagojejunostomy in Prone Position The key steps to perform a hand-sewn end-to-side Rouxen-Y gastrojejunostomy reconstruction after laparoscopic 95% gastrectomy are

© Springer Nature Switzerland AG 2021 M. Asunción Acosta et al. (eds.), Atlas of Minimally Invasive Techniques in Upper Gastrointestinal Surgery, https://doi.org/10.1007/978-3-030-55176-6_40

323

324

J. S. Azagra et al.

3. With enough radical margin (at least 5 cm), the proximal stomach is divided by means of staplers, leaving a small pouch of 5% (Fig. 40.2a–c) 4. After resection, retrocolic jejunal loop is ascended into the rest stomach (Fig. 40.3a) 5. A V-Loc™ 3.0 wound closure device is used to aproximate the seromuscular layer of the jejunum to the rest stomach through and through the stapler line (outer posterior layer) (Fig. 40.3b–d) 6. Another V-Loc is passed through the corner and placed there for traction. 7. The stomach and the jejunal loop are opened by diathermia (Fig. 40.4a, b) 8. With the last V-Loc™ placed in the corner, the inner posterior layer is sutured in a continuos fashion (Fig. 40.5a, b) 9. The anterior layer is now sutured in a continuous fashion by means of a V-Loc™ (Fig. 40.6a–e) 10. The jejunal loop is divided by means of staplers (Fig. 40.7a, b) 11. Jejunojejunal side-to-side anastomosis is now per formed by linear stapler (Fig. 40.8a, b)

Fig. 40.1  Patient, surgical team, and trocar placement (1–10 mm: 0° telescope, 2–10 mm: stapler, 5 mm: sealer, clips, etc.). Abbreviations: S1: First surgeon, S2: Second surgeon, S3: nurse

1. Patient position, surgical team, and trocars have been placed in the upper abdomen (Fig. 40.1) 2. After inspection of the abdominal cavity and local inspection, dissection of the stomach is performed according to the oncological rules (dissection and extension of the lymphadenectomy according to Japanese Gastric Cancer Society)

In the rest of the four procedures mentioned above, the procedures are different but the hand-sewn anastomosis is performed in the same way as previously described. Some details about the different procedures are given below: 1. In total gastrectomy, position of patient, surgical team, and trocar placement are done in the same way as in the 95% gastrectomy. Laparoscopic end-to-side Roux en Y esophago-jejunostomy (Figs. 40.1, 40.9a–c, 40.10 and 40.11a–c). 2. In a Robotic-assisted 95% or total gastrectomy, position of the patient, surgical team, and trocar placement are given in Fig. 40.12. Anastomosis is performed in the same hand-sewn fashion as described above.

40  Hand-Sewn Anastomosis After 95% Gastrectomy, Total Gastrectomy … Fig. 40.2  95% gastrectomy by staplers (a, b). Schematic view of the resection (c)

325

326 Fig. 40.3  Posterior outer layer by continuous suturing with V-Loc™ (a, b, c, d)

Fig. 40.4  Stomach and jejunum are open by diathermia and a stitch od V Loc® set in the far corner (a, b)

Fig. 40.5  The inner posterior layer is done (a, b)

J. S. Azagra et al.

40  Hand-Sewn Anastomosis After 95% Gastrectomy, Total Gastrectomy … Fig. 40.6  The anterior layer is sutured (a, b, c, d). Schematic view of the anastomosis (e)

Fig. 40.7  The jejunal loop is divided by stapler (a, b)

327

328

J. S. Azagra et al.

Fig. 40.8  Jejunojejunal anastomosis and closure of the defect (a, b)

Fig. 40.9  After total gastrectomy. Esophagojejunostomy anastomosis. Outer post layer (a, b, c)

3. In the specific patients with a Siewert II, the total gastrectomy should be extended to the distal esophagus in order to get an R0resection. There are two possibilities to perform the anastomosis: 1. Transhiatal anastomosis using the linearstapler followed by closure of the defect with barbed V-Loc™ suture, (Fig. 40.13a–i)

2. After completion of the resection, if the anastomosis can not be performedtechnicallytranshiatally, esophagus is stapled and jejunal loop is introduced through the hiatus into mediastinum and there fixed. Patient is placed in prone position for thoracoscopy. Placement of trocars are given in Fig. 40.14. The jejunal loop is anastomosed to the esophagus in the same fashion as described above (Figs. 40.15, 40.16a, b, 40.17a, b, 40.18 and 40.19).

40  Hand-Sewn Anastomosis After 95% Gastrectomy, Total Gastrectomy …

329

Fig. 40.10  Esophagus and jejunum are open

Fig. 40.12  Position of the patient, surgical team, and trocar placement for Robotic-Assisted Gastrectomy (A: bipolar robotic grasper and robotic 4 or 6 cm stapler, B: 30° robotic optique, C: monopolar scissors and robotic 4 or 6 cm stapler, and D: Cadiere grasper). Distance between robotic trocars: 8 cm, and between optique and target: 20 cm. Abbreviations: RAS: robotic assistant surgeon

Fig. 40.11  Anterior layer with continuous suturing is performed (a, b, c)

330 Fig. 40.13  Mediastinal esophagojejunal anastomosis by means of linear stapler (a, b, c, d, e, f, g, h, i)

J. S. Azagra et al.

40  Hand-Sewn Anastomosis After 95% Gastrectomy, Total Gastrectomy …

331

Fig. 40.14   Thoracoscopy in prone position. Trocar placement. Abbreviations: S1: First surgeon, S2: assistant, A: sealer, clips, needle holder, B: 30° telescope, C: grasper Fig. 40.15  By thoracoscopy, the first stitch is done to approximate the two ends

Fig. 40.16  The first outer layer is sutured by V-Loc™ suturing device (a, b)

Fig. 40.17  Jejunum and esophagus are open. First stitches of the inner posterior layer (a, b)

332

J. S. Azagra et al.

Fig. 40.18  Anterior layer is sutured (a). Schematic view of esophagojejunostomy anastomosis (b)

References 1. Arru L, Azagra JS, Facy O, et al. Totally laparoscopic 95% gastrectomy for cancer: technical considerations. Langenbecks Arch Surg. 2015;400(3):387–93. 2. Sarriugarte A, Arru L, Makai-Popa S, et al. Short-term results of near-total (95%) laparoscopic gastrectomy. Cir Esp. 2018;96(10):634–9. 3. Parisi A, Nguyen NT, Reim D, et al. Current status of minimally invasive surgery for gastric cancer: A literature review to highlight studies limits. Int J Surg. 2015;17:34–40. 4. Desiderio J, Jiang ZW, Nguyen NT, et al. Robotic, laparoscopic and open surgery for gastric cancer compared on surgical, clinical and oncological outcomes: a multi-institutional chart review. A study protocol of the International study group on Minimally Invasive surgery for GASTRIc Cancer-IMIGASTRIC. BMJ Open. 2015;19;5(10):e008198. Fig. 40.19  Final aspect of the intrathoracic anastomosis

Robot-Assisted Total Gastrectomy for Gastric Cancer

41

Felix Berlth and Han-Kwang Yang

41.1 Description of the Surgical Procedure (See Video 41.1) The key steps to perform a Robot-assisted Total Gastrectomy are 1. Preparation. Position of patient. Trocar placement. Start with laparoscopy Patient is put into straight supine position. The trocar positioning is similar for all different extend of gastric cancer resection. Camera trocar is placed in supraumbilical position. Overall, four other trocars are placed, one assistant 12 mm trocar on the patient’s right side and one 8 mm robotic trocar at least 8 cm away from the camera trocar and some centimeters above. Two 8 mm trocars are placed most laterally and above and are placed under careful vision in order to provide the highest range of motion for the instruments [1]. In contrary to the laparoscopic gastrectomy setting (sharp V-angle), the trocars in robot-assisted gastrectomy are more placed in a round (smiling) shape position with more caudal location of the lateral trocars in order to avoid external robotic arm collision. The right 12 mm trocar is used for the assistant to bring in and out gauze, use suction or retrieve small pieces of tissue, and to insert stapler, if desired (Fig. 41.1) [2]. The liver can be retracted by the use of two sutures that are pierced through the middle upper abdomen and tied on

 lectronic supplementary material  The online version of this E chapter (https://doi.org/10.1007/978-3-030-55176-6_41) contains supplementary material, which is available to authorized users.

F. Berlth · H.-K. Yang (*)  Department of Surgery, Division of Gastrointestinal Surgery, Seoul National University Hospital, Seoul, Republic of Korea e-mail: [email protected] F. Berlth  Department of General, Visceral and Cancer Surgery, University Hospital of Cologne, Cologne, Germany

a gauze. The first suture is catching the ligamentum teres hepatis and exposes the area of pylorus and hepatoduodenal ligament. The second suture is clipped on the hiatal arch in order to lift up the left liver and expose the esophagogastric junction and lesser curvature (Fig. 41.2a, b). Robotic system is docked, and instruments are to be brought in (Figs. 41.3a, b and 41.4). One good option is to use an energy device in the left 8 mm trocar as right hand of the surgeon. Fenestrated bipolar forceps are used as the operator’s left hand through the right lateral 8 mm trocars. Third instrument (fenestrated, e.g., Cadiere forceps) is inserted through the left patient’s side to provide traction. As haptic feedback is lacking in robotic surgery so far, it has to be mentioned that these instruments are feasible to use under visual control to provide gentle tissue handling (Fig. 41.5a, b). 2. Omentectomy and greater curvature The resection begins with the omentectomy. In case of cT3 or cT4, total omentectomy is performed; in case of cT1 and cT2, partial omentectomy including 3 cm distance from the arcade represents an appropriate extend. Before finding the correct plane, the stomach can be lifted up to invite air into the lesser sac in order to separate the omentum from the underlying structures. Omentectomy starts along the stomach’s lower body and is proceeded in direction to the spleen and the left gastroepiploic vessels which are clipped and cut (Fig. 41.6a, b, c). The short gastric vessels can be safely clipped as well. If bleeding occurs or the exposure is difficult, further mobilization and dissection of the stomach can be carried out first. The greater curvature is mobilized up to the left crus of diaphragm, where the esophagus is mobilized from left side. If the exposure is good, the suprapancreatic lymph node dissection can be started from the left pancreas upper border along the splenic vessels (Fig. 41.7). Then, the omentectomy is completed to the right side and finished by dividing the plane toward the gallbladder. Then, the infrapyloric region is exposed.

© Springer Nature Switzerland AG 2021 M. Asunción Acosta et al. (eds.), Atlas of Minimally Invasive Techniques in Upper Gastrointestinal Surgery, https://doi.org/10.1007/978-3-030-55176-6_41

333

334

F. Berlth and H.-K. Yang

Fig. 41.1  Patient’s position in supine and trocar’s placement. Real (a) and schematic view (b)

Fig. 41.2.  Liver retraction by a stitch (right needle) (a) around the falciform ligament (b)

Fig. 41.3  Robot system is docked (a, b)

3. Infrapyloric node dissection For the infrapyloric dissection, the stomach is gently grasped at the posterior side of antrum by the third arm and lifted above and to the left side of the patient. The right gastroepiploic vessels should be in orthogonal position with good exposure of the avascular fusion plane of infrapyloric tissue and mesocolon (Fig. 41.8). For better mobilization, the pylorus and duodenum first portion (posterior) is dissected from the pancreas. The

desired extend of duodenal resection can be decided; the gastroduodenal artery can be exposed usually (Fig. 41.9). The fusion plane of infrapyloric tissue and mesocolon is then carefully divided first anterior, then in direction of gallbladder, and finally the anterior side of the duodenum is exposed (Fig. 41.10). The infrapyloric tissue is dissected along the pancreas, and the gastroepiploic vein, artery, and infrapyloric artery are clipped and cut. Now, the stomach is prepared on the

41  Robot-Assisted Total Gastrectomy for Gastric Cancer

335

Now, a retroduodenal window is dissected between right gastric artery and first portion of duodenum (Fig. 41.12a–d). Then, the dissection is continued toward the hepatoduodenal ligament, dissecting lymph node station #12a over the proper hepatic artery. The right gastric vessels are exposed at its roots, clipped, and cut (Fig. 41.13a–c). Now, the duodenum is transected with the linear stapler (Fig.  41.14a, b). Duodenal stump is resutured (Fig. 41.15a, b). After transection of the duodenum, lymph node dissection completion in the suprapancreatic area can be easier. 5. Suprapancreatic lymph node dissection Fig. 41.4  Robot port placement. Ⓐ: assistant port, Ⓒ: camera port

greater curvature and posterior side for transection of the duodenum (Fig. 41.11a–c). 4. Right gastric vessels and hepatoduodenal ligament One gauze is put behind right gastric artery under the stomach in the lesser sac. This gauze will act as a cushion to protect injury of underlying structures such as common hepatic artery, and it also lifts up the right gastric artery for better dissection.

The suprapancreatic lymph node dissection can be started when the antrum is lifted for infrapyloric dissection. But after transection of the duodenum, the exposure might be easier. Lymph node station #8a is carefully dissected on the upper pancreatic border along the common hepatic artery up to the roots of left gastric artery. Normally, the left gastric vein appears on the way and is cut after clipping. A good way of retraction is to hold up the left gastric artery toward the ventral side with the third arm. Putting a gauze between the third arm’s joint and the liver can provide additional liver retraction if necessary (Fig. 41.16a, b).

Fig. 41.5  Instrument setting. Triangulation for retraction of the tissue. Assistant’s instrument (Ⓐ) counter-tracts against the main retracting device, Cadiere forceps at the third robot arm (a, b)

Fig. 41.6  Omentectomy to the left (a), short gastric and left gastroepiploic vessels are clipped and divided (b, c)

336

F. Berlth and H.-K. Yang

Fig. 41.9  Duodenum is dissected from the pancreas Fig. 41.7  Omentectomy to the right

Fig. 41.8  Exposure of the right gastroepiploic lymph nodes

Fig. 41.10  Fusion plane between the mesocolon and infrapyloric tissue is divided

41  Robot-Assisted Total Gastrectomy for Gastric Cancer Fig. 41.11  Right gastroepiploic vessels are clipped and divided. Close (a, b) and schematic view (c)

Fig. 41.12  A gauze is place in the retroduodenal area and retrieved in front (a, b, c). A retroduodenal window is done (d)

Fig. 41.13  Hepatoduodenal ligament is opened (a). Right gastric artery is dissected (b) clipped and cut (c)

Fig. 41.14  Duodenum is divided by stapler (a, b)

337

338

F. Berlth and H.-K. Yang

Fig. 41.15  Duodenum stump is resutured (a, b)

Fig. 41.16  Lymphadenectomy of Lymph nodes 8a (a, b)

Fig. 41.17  Retraction of the tissue by the second and third arm. The Cadiere forceps at the third arm hold up the pedicle of the left gastric artery, and lift up the left liver by articulating wrist at the same time. Instrument setting for traction and counter traction

Most important maneuver for a good exposure of the suprapancreatic area is gentle retraction of the pancreas. Therefore, a gauze should be placed on the pancreas, and with an opened assistant’s grasper, the pancreas can be gently rolled downwards to expose the vessels on the upper border. This maneuver is believed to be safer when performed by the assistant rather than by robotic arm. The ventral traction of the third arm and the countertraction of the assistant provide best exposure of the suprapancreatic area (Fig. 41.17). When clearing the root of left gastric artery, the suprapancreatic dissection goes over to lymph node station #11p. For a radical dissection, the splenic vein has to be exposed as well as the artery. Along the splenic vessel dissection, a posterior gastric vessel might occur. The lymph node station #11d can be dissected by either following the splenic vessels further or starting from the splenic hilum going direction towards left gastric artery (Fig. 41.18a, b).

41  Robot-Assisted Total Gastrectomy for Gastric Cancer

339

Fig. 41.18  Lymphadenectomy of stations 11p and 11d (a, b)

Fig. 41.19  Dissection of left gastric artery, cleared to all sides and  dissect at other level if a important left hepatic artery is observed. Close (a, b, c) and schematic view (d)

Fig. 41.20  Remnant tissue around the hiatus is resected. Close (a) and schematic view (b)

6. Left gastric artery, celiac trunk, and right diaphragmatic crus Root of the left gastric artery is cleared to all sides, and the artery is clipped and cut. Now, the exposure of the area behind, representing lymph node station #9, might be better, so the dissection of this particular station can be completed (Fig. 41.19a–d).

Following the remnant connecting tissue to the right crus represents lymph node dissection of station #1. The esophagus should be cleared from all sides to have good conditions for transection and reconstruction (Fig. 41.20).

340

F. Berlth and H.-K. Yang

Fig. 41.21  Esophagus is dissected free (a) and a tape is placed around it (b)

Fig. 41.22  Small assistance supraumbilical laparotomy is performed and protected by Alexis system® (a). By means of a glove, the insufflation can be maintained. Anvil with a stitch is put in the operative field (b)

Fig. 41.23  Esophagus is open on the anterior side and a 25 anvil (with a stitch) is put inside. The needle is put through the posterior wall

7. Reconstruction: Roux-en-Y (laparoscopic) The esophagus is ligated with a U-tape so that the assistant can easily retract downwards. It also prevents spillage of lumen content. Before transection, the esophagus is opened longitudinal with monopolar device on the anterior side just below the desired transection line. The circular stapler anvil (25 mm) is prepared with a 2 cm needle suture connected

to the anvil trocar. The anvil is pushed through the opening into the esophagus completely, but the connected needle is still in reach. The needle is now stitched through the esophagus on the posterior side above the level of intended transection. The anvil is pulled through, but not completely. Now the transection of the esophagus can be performed with linear stapler. Transection should be performed above the anterior opening to assure whole circumference is included. For that, the edges of the opening can be grasped by the assistant if necessary. The anvil can be pulled through completely now, and anvil trocar is removed (Figs. 41.21a, b, 41.22a, b, 41.23a, and 41.24a, b). The specimen is put into a specimen bag and retrieved (Fig. 41.25a, b). Ligament of Treitz is visualized, and the jejunum is followed 20 cm aboral direction for transection. Orientation can be given by marking the small bowel with color for right direction and distance. If the patient’s constitution allows, the jejunojejunostomy can be performed extracorporeally. Therefore, the supraumbilical port incision can be extended up to 5 cm. The specimen is retrieved though this minilaparotomy. Then, the jejunum can be transected and re-anastomosed 35 cm distal from desired location for esophagojejunostomy by side-to-side linear stapling. The stapler opening is closed by 3-0 polyfilament absorbable continuous suture (Fig. 41.26a, b).

41  Robot-Assisted Total Gastrectomy for Gastric Cancer Fig. 41.24  Esophagus is transected distal of the stitch (a). View of the prik through the posterior wall of the esophagus (b)

Fig. 41.25  Specimen is introduced in a bag (a) and retrieved through the small laparotomy (b)

Fig. 41.26  Jejunum loop is exteriorized and prepared for the anastomosis (a). Jejunojejunostomy is done (b)

Fig. 41.27  Circular stapler is introduced into the jejunum, fixed, and introduced into the abdomen through the glove (a, b, c)

341

342

F. Berlth and H.-K. Yang

location, the jejunum is tighted to the stapler with the help of a rubber band. This provides prevention of slipping jejunum off the stapler and also from accidental closure of the loop when firing the stapler (Fig. 41.27a–c). The stapler goes into the umbilical incision; camera now comes in from the right 12 mm trocar. The stapler is connected to the anvil, and the esophagojejunostomy is performed. The jejunum’s opening is closed with linear stapler (Fig. 41.28).

References

Fig. 41.28  Esophagojejunostomy (end-to-side) anastomosis

The exact location for esophagojejunostomy is now marked on the jejunum; the circular stapler is introduced with the help of lubricant. After insertion and correct

1. Park JM, Kim HI, Han SU, et al. Who may benefit from robotic gastrectomy?: A subgroup analysis of multicenter prospective comparative study data on robotic versus laparoscopic gastrectomy. Eur J Surg Oncol. 2016. https://doi.org/10.1016/j.ejso.2016.07.012. 2. Han D-S, Suh Y-S, Ahn HS, et al. Comparison of surgical outcomes of robot-assisted and laparoscopy-assisted pylorus-preserving gastrectomy for gastric cancer: a propensity score matching analysis. Ann Surg Oncol. 2015. https://doi.org/10.1245/s10434-014-4204-6.

Laparoscopic Immunofluorescence-Guided Lymphadenectomy in Gastric Cancer Surgery

42

Woo Jin Hyung and In Gyu Kwon

Near-infrared (NIR) is an electromagnetic wave with a range of 700–900 nm close to visible light in the infrared light. Because NIR has a longer wavelength than visible light, it can penetrate tissue several millimeters or centimeters. Therefore, we can see a deep target behind the normal tissue. Moreover, NIR light does not interfere with the surgical field since it is invisible by the human eye. Contrast agents are essential for NIR fluorescent imaging. Methylene blue, indocyanine green (ICG), 5-aminolevulinic acid, etc., is used for NIR fluorescent imaging. Among them, ICG is most commonly used. NIR fluorescent imaging has recently emerged in various clinical conditions. It is applied for sentinel lymph node mapping, direct tumor imaging, imaging of vital structures, vascular perfusion, etc. [1–3].

42.1 Near-Infrared Fluorescent Imaging for Gastric Cancer Surgery In gastric cancer field, near-infrared fluorescent imaging has been used mainly to identify the sentinel lymph nodes [4–6]. Intraoperative injection of ICG to a submucosal or subserosal layer can visualize the draining lymph nodes by near-infrared fluorescent images. Although previous studies showed a high detection rate of sentinel lymph nodes by using nearinfrared fluorescent imaging, there is a limitation for clinical Electronic supplementary material  The online version of this chapter (https://doi.org/10.1007/978-3-030-55176-6_42) contains supplementary material, which is available to authorized users.

W. J. Hyung (*)  Department of Surgery, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul 120-752, Republic of Korea e-mail: [email protected] I. G. Kwon  Department of Surgery, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea

application of sentinel lymph node sampling as a routine procedure due to the complex lymphatic drainage system around the stomach. So far, gastrectomy with D2 lymphadenectomy is the standard for gastric cancer surgery [7, 8]. If the ICG is injected enough time before lymph node dissection, it might visualize every draining lymph node from the area of the primary tumor. ICG solution is prepared as a concentration of 1.25 mg/mL. One day before surgery, ICG is injected 0.6 mL of the prepared solution along with the submucosal layer at four points around the primary tumor (Figs. 42.1a, b and 42.2). The total amount of injected ICG solution was 2.4 ml (3 mg). NIR fluorescent image before lymph node dissection could distinguish between lymphatics and normal tissue. This allows anatomical dissection to avoid normal tissue injury. NIR image after lymphadenectomy could help to evaluate the completeness of lymph node dissection in real time. This allows the improvement of surgical quality. Moreover, retrieval of a lymph node from the resected specimen under the NIR image could facilitate find tiny lymph nodes. This allows more accurate diagnosis [9]. In case of NIR fluorescent image-guided gastrectomy, there is no difference with default laparoscopic gastrectomy with D2 lymphadenectomy. The steps for lymphadenectomy during minimally invasive gastrectomy are standardized (Fig. 42.3a–h).

42.2 Description of the Surgical Procedure (See Video 42.1) Laparoscopic surgery has been expanded and applied for gastric cancer. Laparoscopic gastrectomy with lymph node dissection has already established as a standard for early gastric cancer or stage I disease [7]. Several clinical studies about laparoscopic surgery for advanced gastric cancer is currently ongoing and the results are being published one by one [10–12].

© Springer Nature Switzerland AG 2021 M. Asunción Acosta et al. (eds.), Atlas of Minimally Invasive Techniques in Upper Gastrointestinal Surgery, https://doi.org/10.1007/978-3-030-55176-6_42

343

344

W. J. Hyung and I. G. Kwon

Here, the following procedure note will describe laparoscopic distal gastrectomy with D2 lymphadenectomy, which is the standard extent of lymph node dissection. And, the different points for total gastrectomy and robotic gastrectomy also will be described subsequently. The key steps to perform a laparoscopic distal gastrectomy with D2 lymph node dissection under infrared fluorescent imaging guidance are: 1. Trocar insertion and position Five trocars are used usually. A 12 mm trocar is placed at the midline just below the umbilicus. After CO2 pneumoperitoneum of 12 mmHg is achieved, the operation table is placed in 15–30° of reverse-Trendelenburg position to fall down the transverse colon and small intestine by gravity. Four additional trocars are inserted under direct visualization: two 12-mm and two 5-mm trocars. Specifically, a 5-mm diameter trocar is placed just below the costal margin and right side of the falciform ligament, as cephalic as possible on the patient’s right side. Then, a 12-mm trocar is inserted on the mid-clavicular line of the mid-abdomen. This trocar is mainly used with advanced energy devices for the core procedure of lymphadenectomy by coagulation and dissection. Therefore, the upper position of the trocar is advantageous for dissection of the suprapancreatic area. Other 5- and 12-mm trocars for an assistant are inserted on the left side. The port placement for minimally invasive gastrectomy and robot-assisted gastrectomy are in our department standardized (Fig. 42.4a–c). 2. Liver retraction Pars flaccida is divided after the exposure of the hepatogastric ligament by pushing the liver upward. Puncture of the abdominal wall on both sides of the falciform ligament and subcostal margin by a straight needle with thread. The mid-portion of the thread is anchored to pars condensa. The thread of V shape is effectively retracted liver upward [13] (Fig. 42.5). 3. Partial omentectomy (total omentectomy)

Fig. 42.1  a, b Primary tumor

Fig. 42.2  Peritumoral injection of ICG by gastroscopy a day before surgery

If there is no evidence of serosa invasion by the tumor on laparoscopic exploration (Fig. 42.6a, b), partial omentectomy could be performed. Pushing stomach superiorly and anteriorly from the assistant will make it easy to find the thin layer by tenting the omentum. Left-side dissection and greater curvature mobilization begin by dividing the omentum more than 3 cm far from gastroepiploic vessels of the greater curvature side. Left-side dissection of omentum proceeds toward the lower pole of the spleen (Fig. 42.7). 4. Ligation of left gastroepiploic vessels The root of the left gastroepiploic vessel is identified and ligated using clips. When the partial omentectomy is performed, the omental branch of the left gastroepiploic vessel should be preserved for the prevention of remnant omentum ischemia (Fig. 42.8). 5. Clearance of soft tissue along the greater curvature

42  Laparoscopic Immunofluorescence-Guided Lymphadenectomy …

345

Fig. 42.3  a–h Steps for lymphadenectomy during minimally invasive gastrectomy. Left-side dissection for #4sb around LGEV (a). Right-side dissection for #6 lymph nodes above the páncreas (b). For #5 and #8a, RGA is exposed and soft tissues around the CHA are dissected (c). Soft tissues medial to the PV and PHA are dissected for proper #12a dissection in D2 lymphadenectomy (d). LGA is exposed above the celiac trunk (e). For #11p dissection, SV and SA are exposed and all soft tissues are cleaned along these vessels (f). Lesser curvature is cleaned to remove #1 lymph nodes (g). Final view of lymph node dissection (h). Abbreviations: LGEV: left gastroepiploic vessels, ASPDV: anterior superior pancreaticoduodenal vein, RCV: right colic vein, MCV: middle colic vein, MCA: middle colic artery, RGA: right gastric artery, PHA: proper hepatic artery, CHA: common hepatic artery, PV: portal vein, LGA: left gastric artery, LGV: left gastric vein, SV: splenic vein, SA: splenic artery, LC: lesser curvature, AHA: accessory hepatic artery arising from LGA

The short gastric vessels are usually preserved for a distal gastrectomy; however, if the tumor is located in a high body, one or two short gastric arteries can be sacrificed to obtain proper resection margins and to create enough space for the anastomosis. All of the soft tissue along the greater curvature area should be removed from the stomach by dissecting the pylorus to complete the #4sb and #4d lymph node harvest (Fig. 42.9a, b). 6. Ligation of right gastroepiploic vein Right side and infra-pyloric dissection are performed by incising the soft tissue from the colonic vessels to the root of the superior mesenteric vessels while

exposing the head of the pancreas (Fig. 42.10a, b). The gastrocolic trunk is identified as it drains into the superior mesenteric vein and station #6 lymph nodes are dissected. The right gastroepiploic vein is isolated and divided while preserving the venous drainage from the head of the pancreas (anterior superior pancreaticoduodenal vein) and colon. 7. Ligation of right gastroepiploic artery Further dissection along the surface of the pancreas head exposes the right gastroepiploic artery and it is divided at its origin (Fig. 42.11a, b). 8. Creation of a window for duodenal transection

346

Fig. 42.3  undefined

Fig. 42.4  a, b, c Port placement for minimally invasive gastrectomy. 6-port (a) or 5-port (b) surgery can be used for laparoscopic gastrectomy. Place for ports in robotic gastrectomy (c). Abbreviations: C: Camera, S: Surgeon, A: Assistant, R: Retractor

W. J. Hyung and I. G. Kwon

42  Laparoscopic Immunofluorescence-Guided Lymphadenectomy …

Fig. 42.5  Liver retraction

Fig. 42.6  a, b Laparoscopic view of the adenocarcinoma with serosal involvement (lower body, anterior wall) (a) and infrared imaging (b)

347

The duodenum is mobilized from the pancreas along the gastroduodenal artery, and dissection continues to the bifurcation of the proper hepatic artery. In preparation for the duodenal transaction, the area above the pancreas and the duodenum are dissected. Placing a gauze on top of the pancreas and underneath the duodenum helps create the supraduodenal dissection plane and prevent injury to the pancreas. Next, the supraduodenal vessels are divided and dissection continues along the gastroduodenal artery until the right gastric vessels are exposed (Fig. 42.12a, b). 9. Duodenal transection An endo-linear stapler is introduced through the right lower port or the assistant port (left lower), and the duodenum is transected (Fig. 42.13a, b).

348

W. J. Hyung and I. G. Kwon

Fig. 42.7  Omentectomy to the left

Fig. 42.8  Ligation of the left gastroepiploic vessels

10. Ligation of the right gastric artery Retraction of the liver upward by the assistant allows for easier dissection of the anterior portion of the hepatoduodenal ligament. Then, the right gastric artery is identified and ligated at its origin (Fig. 42.14a–c). 11. Division of the lesser omentum up to the right side of the esophageal hiatus Soft tissue and posterior attachments are dissected along the gastrohepatic ligament toward the left side of the esophageal hiatus. 12. Dissection of lymph node station 12a The soft tissues around the common hepatic artery and proper hepatic artery are dissected to remove lymph nodes #8a and #12a. To expose of the portal vein,

grasp the tissues around the common hepatic artery the retraction laterally (Fig. 42.15a, b). 13. Dissection of lymph node station 8 and 9 Dissection is then continued along the common hepatic artery to harvest station #9 lymph nodes. Since the location and draining vein of the left gastric vein is various, precise dissection is required (Figs. 42.16a–c and 42.17a, b). 1 4. Dissection of lymph node station 7 and ligation of left gastric artery The left gastric artery is then identified and skeletonized; the camera angle can be rotated to reveal the posterior side of the left gastric artery in the oblique view (Fig. 42.18a–c). The artery is then clipped and

42  Laparoscopic Immunofluorescence-Guided Lymphadenectomy …

349

Fig. 42.9  a, b General view after omentectomy (a) and infrared imaging (b)

ligated, which facilitates exposure for #11p lymph nodes. Dissection of lymph node station 11p. The pancreas should be pulled toward the caudal direction to exposure splenic artery or vein (Fig. 42.19a–c). 15. Clearance of soft tissues along the lesser curvature Dissection of soft tissue is performed along the lesser curvature from the esophageal hiatus down to the transaction line of the stomach (Fig. 42.20a-c). 1 6. Gastric transection and different types of anastomosis (Figs. 42.21a, b and 42.22a–f). 1 7. Pathology outcome of the presented case (Fig. 42.23a–c)

Adenocarcinoma, poorly differenced, type diffuse (Lauren) that invades proper muscle (pT2). Lymph nodes metastasis in 5 out of 53 lymph nodes (Fluorescent nodes: 5/33 and Non-Fluorescent nodes: 0/20).

42.3 Laparoscopic Total Gastrectomy with D2 Lymph Node Dissection After left gastroepiploic vessel ligation, lymph node dissection continues to the direction of upward for ligating short gastric artery (station 4sa) and separation of gastrosplenic ligament up to the left side of the esophageal hiatus. After

350 Fig. 42.10  a, b Fusion of the mesocolon and the right gastroepiploic vessels is dissected (a). Infrared imaging (b)

W. J. Hyung and I. G. Kwon

42  Laparoscopic Immunofluorescence-Guided Lymphadenectomy … Fig. 42.11  a, b After lymphadenectomy of station 6, right gastroepiploic vessels are divided (a, b)

351

352 Fig. 42.12  a, b Dissection of the retropyloric area (a) and infrared imaging (b) showing the gastroduodenal artery

W. J. Hyung and I. G. Kwon

42  Laparoscopic Immunofluorescence-Guided Lymphadenectomy … Fig. 42.13  a, b Duodenal transection by staplers (a, b)

353

354 Fig. 42.14  a, b, c After opening the hepatoduodenal ligament, hepatic artery, right gastric artery with lymph nodes is showed (a). Division of the right gastric artery by clips (b). Infrared imaging (c)

W. J. Hyung and I. G. Kwon

42  Laparoscopic Immunofluorescence-Guided Lymphadenectomy …

355

Fig. 42.15  a, b Lymphadenectomy along portal vein (Stations 8 and 12) (a). Infrared imaging (b)

exposing the splenic hilar area, the tail of pancreas was retracted to the caudal direction and the dissection of stations 11d and 10 starts from the distal portion of the splenic vessels to the splenic hilum.

42.4 Robotic Gastrectomy The trocar placements are somewhat different from laparoscopic gastrectomy except for camera port. Robotic gastrectomy also requires total five trocars; one 12-mm and three 8-mm ports. Specifically, an 8-mm diameter port for

the third arm of the robot is placed 1 cm below the costal angle of the right abdomen, as far lateral as possible. Another 8-mm port for the second robotic arm should be inserted 2–4 cm above along an imaginary line that intersects the middle of the camera port and the right ­subcostal port; this step allows easier access to the pancreatic head and duodenum and achieves a proper angle with the ultrasonic shears, which are not wristed. Another 8-mm port for the first arm should be inserted 1 cm below the costal angle of the left abdomen as far lateral as possible. An assistant port is placed on the left side of the camera port at the midpoint between the camera and the port for the first arm; the

356 Fig. 42.16  a, b, c Lymphadenectomy of stations 8 and 9 (a, b). Infrared imaging (c)

W. J. Hyung and I. G. Kwon

42  Laparoscopic Immunofluorescence-Guided Lymphadenectomy …

357

Fig. 42.17  a, b Dissection and lymphadenectomy along left gastric vein (a). Infrared imaging (b)

assistant port should be placed 2 cm below an imaginary line drawn from the insertion site of the first robotic arm to the umbilical camera port (Fig. 42.24). The Cadiere grasper is inserted through the third arm and its main function is traction. Maryland forceps and ultrasonic devices are inserted through the first and second arms, respectively [14, 15].

Sometimes traction through the assistant port by the assistant could make a better surgical view. The overall order of procedure and extent of lymphadenectomy with the robotic system is mostly similar to laparoscopic gastrectomy with lymph node dissection.

358 Fig. 42.18  a, b, c Lymphadenectomy along left gastric artery (station 7) and division of the artery by clips (a, b, c)

W. J. Hyung and I. G. Kwon

42  Laparoscopic Immunofluorescence-Guided Lymphadenectomy … Fig. 42.19  a, b, c Lymphadenectomy along the splenic artery (station 11p) (a, c). Infrared imaging (b)

359

360 Fig. 42.20  a, b, c Lymphadenectomy station stations 1 and 3 along the small curvature (a, b). Infrared imaging (c)

W. J. Hyung and I. G. Kwon

42  Laparoscopic Immunofluorescence-Guided Lymphadenectomy … Fig. 42.21  a, b Division of the proximal stomach (a) guided by infrared (b)

361

362

Fig. 42.22  a-f Types of anastomosis after minimally invasive gastrectomy (subtotal and total) (a, b, c, d, e, f)

W. J. Hyung and I. G. Kwon

42  Laparoscopic Immunofluorescence-Guided Lymphadenectomy …

363

Fig. 42.24  Placement of trocars for surgeon and assistants for robotic-assisted gastrectomy

References

Fig. 42.23  a, b, c Pathology of the case (a, b, c)

1. Vahrmeijer AL, Hutteman M, van der Vorst JR, van de Velde CJ, Frangioni JV. Image-guided cancer surgery using near-infrared fluorescence. Nat Rev Clin Oncol. 2013;10(9):507–18. 2. Marano A, Priora F, Lenti LM, Ravazzoni F, Quarati R, Spinoglio G. Application of fluorescence in robotic general surgery: review of the literature and state of the art. World J Surg. 2013;37(12):2800–11. 3. Schaafsma BE, Mieog JS, Hutteman M, et al. The clinical use of indocyanine green as a near-infrared fluorescent contrast agent for image-guided oncologic surgery. J Surg Oncol. 2011;104(3):323–32. 4. Miyashiro I, Kishi K, Yano M, et al. Laparoscopic detection of sentinel node in gastric cancer surgery by indocyanine green fluorescence imaging. Surg Endosc. 2011;25(5):1672–6. 5. Tajima Y, Yamazaki K, Masuda Y, et al. Sentinel node mapping guided by indocyanine green fluorescence imaging in gastric cancer. Ann Surg. 2009;249(1):58–62. 6. Miyashiro I, Miyoshi N, Hiratsuka M, et al. Detection of sentinel node in gastric cancer surgery by indocyanine green fluorescence imaging: comparison with infrared imaging. Ann Surg Oncol. 2008;15(6):1640–3. 7. Japanese gastric cancer treatment guidelines 2014 (ver. 4). Gastric Cancer. 2017;20(1):1–19. 8. Ajani JA, D’Amico TA, Almhanna K, et al. Gastric Cancer, Version 3.2016, NCCN clinical practice guidelines in oncology. J Natl Compr Cancer Netw. 2016;14(10):1286–312. 9. Kwon IG, Son T, Kim HI, Hyung WJ. Fluorescent lymphographyguided lymphadenectomy during robotic radical gastrectomy for gastric cancer. JAMA Surg. 2018. 10. Hu Y, Huang C, Sun Y, et al. Morbidity and mortality of laparoscopic versus open D2 distal gastrectomy for advanced

364 gastric cancer: a randomized controlled trial. J Clin Oncol. 2016;34(12):1350–7. 11. Hur H, Lee HY, Lee HJ, et al. Efficacy of laparoscopic subtotal gastrectomy with D2 lymphadenectomy for locally advanced gastric cancer: the protocol of the KLASS-02 multicenter randomized controlled clinical trial. BMC Cancer. 2015;15:355. 12. Park YK, Yoon HM, Kim Y, et al. Laparoscopy-assisted versus open D2 distal gastrectomy for advanced gastric cancer: results from a randomized phase II multicenter clinical trial (COACT 1001). Ann Surg. 2018;267(4):638–45. 13. Woo Y, Hyung WJ, Kim H, Obama K, Son T, Noh SH. Minimizing hepatic trauma with a novel liver retraction method:

W. J. Hyung and I. G. Kwon a simple liver suspension using gauze suture. Surg Endosc. 2011;25(12):3939–45. 14. Kim YM, Son T, Kim H, Noh SH, Hyung WJ. Robotic D2 lymph node dissection during distal subtotal gastrectomy for gastric cancer: toward procedural standardization. Ann Surg Oncol. 2016;23(8):2409–10. 15. Song J, Oh SJ, Kang WH, Hyung WJ, Choi SH, Noh SH. Robotassisted gastrectomy with lymph node dissection for gastric cancer: lessons learned from an initial 100 consecutive procedures. Ann Surg. 2009;249(6):927–32.

Final Considerations M. Asunción Acosta, Miguel A. Cuesta and Marcos Bruna

The objective of this ATLAS was to depict the current situation of the Minimal Upper GI Surgery. Our philosophy has been, that once a good indication exists for surgery, a perfect preoperative preparation of the patient and the approach by Minimally Invasive Surgery will achieve the best outcome for the patient offering a high quality of life. We explained how achieving an optimal operative technique by changing the functioning of an organ or by an oncological resection; a perfect knowledge of the surgical anatomy leads to performing the necessary steps for an adequate surgical technique. We have made clear that an extensive knowledge of the surgical anatomy requires information gathered on the practice of minimally invasive surgery. This knowledge gives the surgeon the best prospect for doing perfect surgery by being able to dissect through surgical planes. We take into regard that MIS Upper GI procedures—benign including the endoscopic but also the extensive bariatric techniques and the oncological including esophageal and gastric resections, but also the endoscopic techniques for early cancers—are implemented less frequently than the more frequent cholecystectomies and colorectal procedures and are far more complex. We delineated that decisions to implement these procedures can be based on the shortterm advantages obtained after a successfully conducted minimally invasive procedure. The long-term advantages including optimal functional results and survival and other M. A. Acosta  Unidad de Cirugia Esofago-gàstrica, Hospital Universitario de Gran Canaria “Dr. Negrìn”, Las Palmas, Gran Canaria, Spain e-mail: [email protected] M. A. Cuesta (*)  Department of Surgery, Amsterdam UMC, Amsterdam, The Netherlands e-mail: [email protected] M. Bruna  Department of Surgery, Hospital Universitario y Politécnico La Fé, Valencia, Spain e-mail: [email protected]

43

oncological outcomes are already based on studies that confirm the efficacies of these MIS procedures. Consequently, to operate correctly in the particular MIS way as we have depicted, a surgeon’s gaining adequate training is paramount. Young surgeons and residents need to learn and continue to relearn MIS proficiencies. Accompanying implementation of Upper Abdominal MIS, surgeons and their teams need to engender dedication to these procedures as carried out in high-volume centers and through continual training. This entails the need for initial training in the laboratory using models and cadavers and then advancing in skills through adequate programs in which the role of a mentor is crucial. Moreover, the surgical robot has been implemented in many fields of complex MIS and provides important advantages when performing difficult dissections in difficult places and in difficult anastomoses. All authors and contributors to this ATLAS demonstrated success with MIS, thereby prompting some considerations regarding proficiencies, permanent learning, and progress, which I would like to share.

43.1 Proficiencies The model adopted in this ATLAS encompasses what we think are the most appropriate proficiencies to perform complex surgery once a good indication comes about. Foremost is the aptitude of wanting to know and being passionate about surgical anatomy of a specific area, in this case, the upper abdomen. We encourage this propensity strongly for without adequate knowledge it is impossible to do a good surgical intervention through adequate planes, thus preventing avoidable risks. Such good practice is based on a description of surgical anatomy as portrayed in this book and which was carried out mainly in the Department of Anatomy in Utrecht Medical Center (UMC), by Dr. R. Bleys. Moreover, the recent surgical insight into the anatomy of the esophagus has been depicted by Dr. Daiko and

© Springer Nature Switzerland AG 2021 M. Asunción Acosta et al. (eds.), Atlas of Minimally Invasive Techniques in Upper Gastrointestinal Surgery, https://doi.org/10.1007/978-3-030-55176-6_43

365

366

Dr. Cuesta. An adequate MIS technique for a correct antireflux surgery is treated by Dr. Broeders, Dr. Dallemagne, and Dr. Morales. Other esophageal benign diseases, such as benign tumors and achalasia have been treated by Dr. van der Peet and Dr. Fockens. Description of specific minimally invasive procedures have been treated by surgeons and their teams with a long-time dedication to these procedures, such as Dr. B. Weusten, describing endoscopic treatments for early esophageal cancers, being the rest of the chapters about benign and malignant diseases treated by Drs. Osugi, Fujiwara, Reddy, Mingol, Gisbertz, van Berge Henegouwen, Cadiere, Ramirez, Luyer, Diez del Val, Rosman, Moreno Sanz, Ramirez, Ponce, Gagner, Sanchez Pernaute, Himpens, van Hillegersberg, Talvane, Inaki, Kinoshita, Azagra, Kim, Yang, and Hyung.

43.2 Permanent Learning An ATLAS on surgical practice will be dedicated extensively to the operative technique. This will be given by explanatory text, including the key steps, illustrations, pictures, and videos. Remarkably, all authors expressed their willingness to engage in permanent learning regarding all aspects of surgery. Our shared philosophy is that continual changes in surgery require an augmented search for

M. A. Acosta et al.

minimizing the operative trauma, increasing its oncological efficiency, and decreasing the complication rate. All the while, a (re)learning of MIS continuously seeks high evidence. Fitting this aim, the inclusion of videos per chapter of all procedures has added important information regarding MIS. The paramount quality of the videos is magnificent and is conducive for continual learning.

43.3 Progress Reflecting on this development, we consider this ATLAS as a good summary of the progress of surgery; yet we are aware that in the coming years the contents of this ATLAS will undergo changes. Our advice for residents and young surgeons is to learn the techniques we covered in this ATLAS and to do so deeply by drawing on the motivation to improve the life expectations of our patients and to reduce their suffering. Finally, we must recognize with distinction the essential role of the anesthesia and intensive-care personnel on whom all of us rely day in and day out for performing the challenges of major surgery. Our communal effort, made manifest by authors and contributors to this ATLAS, continues to inspire us to persevere in gaining the best outcome for the patient offering a high quality of life.

Index

A Achalasia, 51, 52, 55, 366 Anastomosis, 3, 13, 94, 96, 99, 104, 106, 107, 109, 111, 112, 117–119, 137, 141, 143, 148–150, 153–156, 158–161, 163, 166, 168, 169, 171, 180, 181, 187, 189, 191, 194–196, 198, 199, 203, 214, 217, 219, 220, 229, 232–235, 244, 247–251, 255, 263, 265, 272, 273, 277, 279, 283, 284, 291, 296, 297, 300, 307, 308, 317, 319, 320, 323, 324, 327, 328, 330, 332, 341, 342, 345, 349, 362 B Benign tumor, 47, 366 Biliopancreatic diversion, 243, 249 Billroth I, 272, 279, 291, 296, 297 C Cancer, 5, 9, 10, 13, 17, 53, 61, 68, 71, 88, 89, 99, 109, 143, 150, 151, 195, 257, 271, 299, 311, 323, 343, 365, 366 Cervical anastomosis, 13, 94, 96, 143 Cervical approach, 71, 74, 84, 153 Circular stapler, 109, 159, 161, 175, 300, 307, 308, 317, 340–342 Circular stapler anastomosis, 109, 159, 300, 307, 308, 317 Complications, 29, 39, 40, 51, 63, 65, 71, 89, 121, 143, 151, 153, 215, 216, 221, 237, 249, 271, 299, 323, 366 Concentric model, 9, 10 Cooperative surgery, 257, 266, 267 D Delta-shaped, 279 Distal, 1, 13, 19, 23, 27, 41, 47, 50, 52–54, 62, 82, 83, 89, 93, 100, 103, 104, 106, 110–112, 119, 132, 133, 147, 148, 150, 163, 171, 196, 201, 204, 207, 208, 212–214, 216, 217, 219, 222, 224, 230, 232, 233, 238, 244, 257, 266, 267, 271, 273, 279, 285, 286, 300, 304–307, 312, 317, 318, 320, 323, 328, 340, 341, 344, 345, 355 Distal esophageal cancer, 13, 89 Duodenal switch, 237, 243, 249 Duodenoileal bypass, 249 E Early cancer, 365 Early gastric cancer, 61, 257, 266, 285, 343 Endoloop, 132–134, 171, 176, 181, 184, 185, 313 Endoscopic submucosal dissection, 64, 65, 267 Endoscopic therapy, 61 Endoscopic treatment, 47, 61, 366 End-to-side anastomosis, 109, 150, 181, 317 Enucleation, 47, 50

Esophageal adventitia, 1 Esophageal anastomosis, 3, 13, 99, 106, 109, 112, 143, 147, 150, 153, 195, 197, 203 Esophageal cancer, 5, 9, 10, 13, 53, 61, 71, 88, 89, 99, 109, 143, 150, 151, 271, 299, 366 Esophageal myotomy, 51 Esophagectomy, 5, 6, 9, 10, 13, 71, 73, 88, 99, 109, 121, 143, 144, 149–151, 195, 323 Esophagojejunal anastomosis, 307, 308, 323, 330 Esophago-jejunostomy, 323, 324 Esophagus, 1–7, 9, 10, 13–17, 29–33, 36, 37, 39–43, 45, 47, 50, 51, 53, 55–57, 59, 61, 62, 71, 77–86, 88, 89, 91–94, 100, 101, 103, 104, 106, 107, 110–112, 115–117, 119, 127, 132, 134–137, 141, 144–151, 153–156, 159–161, 163, 171, 173, 175, 181–185, 191, 192, 196, 197, 201, 203, 204, 206, 219, 222, 224, 231, 240, 241, 291, 300, 304, 306, 307, 317–320, 323, 328, 329, 333, 339–341, 365 G Gastrectomy, 20, 207, 229, 237–239, 243, 244, 249, 250, 252, 257, 266, 267, 271–273, 279, 285, 299, 300, 317, 323, 324, 328, 329, 333, 343–345, 349, 355 Gastric, 3–5, 19–22, 29, 30, 53, 55, 56, 58, 59, 85, 92–96, 99–101, 104–106, 109–112, 117, 119, 136–138, 148, 150, 159–163, 165, 166, 171, 175, 177, 179–181, 188, 191, 192, 195–197, 199, 201, 203–209, 214–216, 221, 224, 226, 230, 232–235, 237–240, 249–251, 257, 259–263, 266, 267, 271–276, 281, 282, 285, 288, 290–296, 299, 300, 303, 304, 312–314, 333, 335, 337–339, 343, 345, 347–349, 365 Gastric band, 221 Gastric bypass, 109, 221, 229, 234, 249 Gastric cancer, 5, 61, 73, 204, 205, 257, 266, 271, 285, 299, 311, 323, 324, 333, 343 Gastric conduit, 95, 96, 99, 102, 104–106, 110, 111, 113, 119, 137, 139–141, 143, 144, 147–150, 153–157, 160, 163, 171, 175, 177, 179–181, 186, 191, 194, 196, 197 Gastroduodenal ulcer, 215 Gastro-esophageal cancer, 89 Gastroesophageal reflux, 29, 47, 51, 249 Gastroesophageal reflux disease, 19 Gastrojejunostomy, 234, 265, 272, 323 GE Junction cancer, 25 GERD, 51, 52, 54 GIST, 47, 207, 208, 210, 212 H Hand sewn, 150, 154, 191, 244, 247, 248, 250, 255, 323, 324 Hand sewn anastomosis, 154, 323, 324 Hiatus hernia, 279 Hilar dissection, 311

© Springer Nature Switzerland AG 2021 M. Asunción Acosta et al. (eds.), Atlas of Minimally Invasive Techniques in Upper Gastrointestinal Surgery, https://doi.org/10.1007/978-3-030-55176-6

367

368

Index

I Immunofluorescence-guided surgery, 343 Indocyanine green, 105, 267, 279, 343 Innervation lymph nodes, 6, 204 In prone, 5, 13, 47, 109, 111, 114, 143, 159, 171, 181, 191, 192, 323, 328, 331 Intrathoracic anastomosis, 13, 109, 143, 150, 191, 196, 332 Ivor Lewis, 13, 109, 143

O Obesity, 39, 229 Oesophageal cancer, 13 Oesophagectomy, 129 Oesophagus, 3, 19, 21–25, 27, 28, 121–128, 132, 134, 163, 164, 166, 195 Omentum wrap, 162, 171, 181, 189 Orvil device®, 317

J Japanese classification, 279

P Paraesophageal hernia, 39, 40 Parietal layer, 9 Partial, 19, 54, 131, 249, 268, 269, 271, 272, 286, 299, 333, 344 Peroral endoscopic myotomy (POEM), 47, 51–55 Peroral treatment, 51 Pleura flap, 160, 162 Prone position, 9, 15, 47, 111, 121, 131, 144, 159, 171, 195 Proximal gastric cancer, 311, 323

L Laparoscopic, 19, 22–24, 28, 38, 40, 51, 55, 71, 84, 88, 109, 137, 140, 143, 145, 148–151, 207, 215, 216, 221, 229, 234, 243, 257, 259, 261, 262, 266, 267, 271, 272, 279, 285–287, 299, 300, 317, 323, 324, 333, 340, 343, 344, 349, 355, 357 Laparoscopic correction, 40 Laparoscopic fundoplication, 27, 29, 38 Laparoscopic gastrectomy, 257, 272, 285–287, 300, 323, 333, 343, 346, 355, 357 Laparoscopic Nissen, 29 Laparoscopy, 47, 72, 109, 135, 137, 143, 148, 159, 195, 215, 257, 266, 268, 333 Lateral thoracoscopy, 47, 121 LECS, 257, 267 Left recurrent laryngeal nerve, 6, 77, 127, 128, 135, 137 Leiomyoma, 47, 48, 50, 207 Lift-suck-cut technique, 62, 63 Ligate-and-cut technique, 62, 63 Linear esophagojejunal anastomosis, 308, 330 Linear stapler, 116, 137, 149, 150, 153–156, 159, 163, 164, 196, 198, 208, 213, 214, 259, 260, 263, 265, 273, 276, 279–281, 283, 291, 296, 297, 300, 306, 308, 317, 320, 324, 328, 335, 340, 342, 347 Lymphadenectomy, 9, 61, 71, 77, 80, 88, 89, 91, 92, 94, 109, 111, 112, 116, 121, 131, 132, 134–138, 143, 145, 146, 148, 149, 151, 159, 195, 263, 271–275, 279, 299, 300, 302–305, 315, 324, 338, 339, 343–345, 351, 355–360 Lymphatic stations, 5 Lymph nodes stations, 10 M Manual, 109, 220 MATHE dissection, 71, 74 Mediastinum, 2, 4, 6, 9, 10, 13, 17, 21, 24, 28, 29, 41, 53, 55, 71, 72, 78, 84, 88, 89, 103–106, 121, 122, 124, 126, 131, 133, 149, 150, 319, 328 Mesh, 39, 40, 44, 45 Meso-esophagus, 3, 10, 14–17 Minimally invasive, 13, 51, 61, 71, 88, 99, 109, 131, 143, 151, 207, 266, 271, 299, 343, 344, 365, 366 Minimally invasive anastomosis, 13, 99, 109, 143, 195 Minimally invasive esophagectomy, 71, 109, 143, 195 Minimally Invasive Surgery (MIS), 88, 129, 271, 299, 365, 366 Muscular layer, 47–50, 116, 164, 191, 263, 324 N 95% gastrectomy, 323–325 Nissen, 19, 29, 37

R RAMIE, 143, 144, 150, 151, 195, 196 RAMIE assisted, 150, 195 Recurrent laryngeal nerve lymphadenectomy, 137 Recurrent laryngeal nerves, 2, 3, 5, 6, 9, 10, 15, 71, 103, 121, 128, 153 Reflux disease, 19 Resection, 13, 15, 17, 47, 48, 50, 61–65, 67–70, 91, 99, 101, 103, 109, 111, 126, 128, 131, 137, 143, 149–151, 153, 171, 179, 195, 198, 204, 207, 208, 210, 237, 249, 257, 266–269, 271, 272, 279, 281, 288, 291, 294, 299, 323–325, 328, 333, 334, 345, 365 Robot assisted, 47, 148, 151, 195, 323, 344 Robotic surgery, 285, 333 S Sentinel lymph node, 257, 266, 343 Single anastomosis, 249 Single port, 78, 79 Sleeve gastrectomy, 229, 237, 238, 243, 244, 249, 250, 252 Splenic preserving, 311 Stapled anastomosis, 153 Stomach, 1, 2, 19, 24, 29, 40, 51–54, 58, 59, 84, 85, 88, 89, 91–95, 99, 100, 102–104, 106, 107, 126, 135–138, 149, 159, 201–204, 206–208, 210, 213, 224, 230, 231, 237–239, 243, 244, 249, 250, 257, 259, 260, 262–264, 271–273, 276, 279–283, 286, 288, 291, 294, 299, 306, 311, 313, 317, 324, 326, 333–335, 343–345, 349, 361 Subcarinal esophagus, 14, 134 Supracarinal lymphadenectomy, 121, 134 Surgery, 6, 9, 13, 17, 19, 29, 50, 52, 55, 59, 61, 72, 73, 75, 99, 109, 129, 143, 150, 151, 215, 221, 249, 257, 266–269, 285, 311, 323, 343, 344, 346, 365, 366 Surgical anatomy, 1, 9, 10, 13, 71, 121, 365 T 360 degrees, 19, 22, 32, 45 Thoracoscopic esophagojejunostomy, 323 Thoracoscopy, 13, 47, 109, 121, 129, 143, 150, 181, 191, 195, 323, 328, 331 Total gastrectomy, 271, 299, 300, 311, 317, 323, 324, 328, 333, 344, 349

Index Toupet fundoplication, 19, 55, 59 Transhiatal approach, 71, 88, 89, 99 Transhiatal esophagectomy, 71, 99, 109 Transhiatal resection, 99, 207, 323, 328 270 degrees, 19, 27, 59

369 V Vascularization, 249 Vascular layer, 9, 10 Visceral layer, 9, 10