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This live interactive video demonstrates a robotic total gastrectomy for gastric cancer, including a stepwise lymphadenectomy and precise thorough description of esojejunal anastomosis.
Endocrinologists controlled the absence of abnormal secretion. The size of the lesion increased slightly over a period of 6 months and allowed to establish an indication for surgery. Our team performs adrenalectomies using a transabdominal laparoscopic approach with the patient in a lateral decubitus position. In order to facilitate the intervention, we asked the Visible Patient company to use the CT-scan images to make a 3D model. This reconstruction allowed to better indentify the relationships of the gland, to improve resection, and confirm the operative strategy. During the intervention, the surgeon can use it to better understand the anatomy hidden by peri-adrenal adipose tissue and operate accordingly. We now have a surgical robot (da Vinci Xi™ robotic surgical system, Intuitive Surgical) and we use it for most of the adrenalectomies we perform. It provides great stability of the operative field. The precise dissection is facilitated by the dexterity of the articulated instruments.
In this video, we present the clinical case of 36-year-old man with a seeming early stage antral gastric adenocarcinoma, as preoperatively defined, submitted to a laparoscopic subtotal gastrectomy and D2+ lymphadenectomy.
Before surgery, the patient was submitted to endoscopy with the objective to inject indocyanine green near the tumor (2mL injected into the mucosa 2cm proximally and 2cm distally to the tumor) in order to visualize the lymphatic basin of that tumor during the operation.
Thanks to the ICG’s fluorescence with the light emitted from the photodynamic eye of our laparoscopic system (Stryker 1588® camera), it is possible to clearly visualize both the individual lymph nodes and the lymphatic collectors which drain ICG (and lymph) of the specific mucosal area previously marked with indocyanine green.
This technique could allow for a more precise and radical nodal dissection and a safer work respecting vascular and nerve structures.
The initial approach aims to expose the infundibulum and to successively dissect the anterior and posterior reflection of the peritoneum. It provides a safe view of the cystic duct and the cystic artery which can be dissected in order to secure the “critical view of safety”, exposing the cystic artery clearly away from the common bile duct and the right hepatic artery. This highlights the risky parts of the dissection when rules are not respected.
After complete control of the pedicle, freeing of the gallbladder in the appropriate plane avoids any oozing, keeping the operative field totally clear and safe.
Finally, the video shows the extraction method for the gallbladder, allowing the procedure to be performed with three 5mm ports and one 10-12mm port, thereby limiting the risk of postoperative port-site hernia.
This 20-minute live uncut video is a demonstration of a gold standard procedure.
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