monthly focus

surgical intervention video

Surrénalectomie droite robotisée pour syndrome de Cushing

Роботическая правосторонняя адреналэктомия

In this educational video, Dr. Vix presents the case of a 77-year-old woman with a large 4.5cm right adrenal gland lesion found on CT-scan during a work-up for Cushing's syndrome. The abdominopelvic CT-scan showed a 4.5cm mass with a density of 32 Hounsfield Units (HU), which increased to 42 HUs after IV contrast administration. The PET CT-scan rules out 18F-FDG uptake. 

During this robotic right adrenalectomy, essential technical steps are highlighted including patient position, trocar placement, entrance to retroperitoneal space, and liver retraction. Extracapsular dissection, and energy use principles, especially at the level of the inferior vena cava are also discussed. 

The video shows a great stability in the operating field, precise dissection, and dexterity provided with the robotic system (da Vinci Xi™ robotic surgical system, Intuitive Surgical). 

Robotic right adrenalectomy for Cushing's syndrome

Gastrectomie robotisée subtotale pour cancer : Localisation de la tumeur avec fluorescence par injection de vert d'indocyanine ICG et cartographie des ganglions lymphatiques

Subtotal or near total gastrectomy for T1b-T2 differentiated cancer of the middle and lower thirds of the stomach is the best therapeutic option with a chance of cure. Eastern experiences have demonstrated the safety of a minimally invasive gastrectomy although this approach remains challenging. The use of the robot has been proven to enhance the precision of each step of this operation. In particular, the possibility of using near-infrared (NIR) vision facilitates the 2 technical key points for a successful resection, i.e. the precise intraoperative determination of tumor distance from the proximal resection margin and the definition of the lymph node basin for an accurate lymphadenectomy. The video outlines relevant surgical steps, i.e. ICG fluorescence-guided tumor identification, definition of surgical margin, and D2 lymph node dissection. Other steps such as subtotal gastrectomy and anastomosis performed as a side-to-side antecolic vertical gastrojejunostomy on the greater gastric curvature according to the Woo Jin Hyung technique are also shown. The peculiarity of our technique lies in ICG fluorescence guidance. In this respect, the robotic NIR vision offers an optimal image modulation necessary to obtain the best image contrast and intraoperative vision. 

Robotic subtotal gastrectomy for cancer: ICG fluorescence-guided tumor location and lymph node mapping

video lecture

Chirurgie robotisée du foie

In this key lecture, Dr. John Martinie outlines robotic liver surgery. 

Robotic liver surgery

 Pancréatectomie entièrement robotisée selon technique de Kimura pour tumeur intracanalaire papillaire mucineuse du pancréas (TIPMP)

This is the case of a 64-year-old male patient presenting with a 35mm cystic lesion diagnosed incidentally after a systematic CT-scan during a preoperative wall hernia repair work-up. His past medical history included heart disease, gonarthrosis, hypertension, amaurosis fugax (right eye), gastric ulcer in 2015, left inguinal hernia repair in 1996, white line hernia repair in 1998, paroxysmal atrial fibrillation, sleeve gastrectomy for morbid obesity in September 2018, and median incisional hernia. A pancreatic MRI confirmed the presence of a distal lesion communicating with the main pancreatic duct associated with a non-enhancing intramural nodule. Initial surveillance was indicated. CEA and CA 19.9 tumor markers were within limits. Control MRI showed an increase in the size of the intramural nodule. After a multidisciplinary discussion, a minimally invasive resection was indicated according to the original Kimura technique. Pathological findings showed a gastric type IPMN with low-grade dysplasia. The postoperative course was uneventful and the patient was discharged on postoperative day (POD) 8.

Full robotic Kimura distal pancreatectomy for intraductal papillary mucinous neoplasm (IPMN)

In this key lecture, Dr. Koh focuses on transitioning from laparoscopy to robotic resections, laying the emphasis on the learning curve.

Transitioning from laparoscopy to robotic resections - Learning curve

De la laparoscopie aux résections robotisées - Courbe d'apprentissage

In this key lecture, Dr. Richard van Hillegersberg focuses on robot-assisted minimally invasive esophagectomy (RAMIE).

Robot-assisted minimally invasive esophagectomy (RAMIE)

Oesophagectomie mini-invasive assistée par robot

In this key lecture, Dr. Chao outlines robotic esophagectomy.

Robotic esophagectomy

Oesophagectomie robotisée

This is the case of a 78-year-old lady presenting with an adenocarcinoma of the pancreatic body. Her past history included a coronary angioplasty, hypercholesterolemia, type 2 diabetes, right shoulder cap rupture, right eye cataract, carpal tunnel syndrome (2018). In June 2020, the patient had a 4 kg weight loss in combination with diabetes imbalance. A pancreatic MRI was then performed and showed a 22 by 17mm corporeal pancreatic mass with dilatation anteriorly to the main pancreatic duct. No liver nor thoracic mestastases were found on CT-scan. An endoscopic ultrasound (EUS) was performed in association with a biopsy of the lesion. Pathological findings showed a moderately to poorly differentiated invasive pancreatic ductal adenocarcinoma. CEA and CA 19-9 tumor markers were within normal range. After a multidisciplinary meeting discussion, a minimally invasive R.A.M.P.S. (Radical Antegrade Modular PancreatoSplenectomy) was indicated. The postoperative course was uneventful and the patient was discharged on POD 9. Pathological findings showed a pT2N2 R0 pancreatic adenocarcinoma.

Robotic radical antegrade modular pancreatosplenectomy (R.A.M.P.S.) for resectable adenocarcinoma of the pancreatic body

Technique RAMPS (radical antegrade modular pancreatosplenectomy) robotisée pour adénocarcinome résécable du corps du pancréas 

In this educational video, Dr. Emanuele Felli demonstrates a robotic cholecystectomy for gallbladder stones in a 54-year-old female patient. The procedure is clearly outlined in a series of operative key steps including exposure of Calot's triangle, critical view of safety, and retrograde cholecystectomy (from infundibulum upward).

This is the case of a 54-year-old lady presenting with symptomatic gallbladder microlithiasis associated with altered liver blood tests, all accountable for right upper quadrant tenderness. Her past medical history includes psoriatic rheumatism diagnosed in 2012 and Hashimoto's thyroiditis. Magnetic resonance cholangiography did not show any common bile duct stones. A robotic cholecystectomy was then indicated. The postoperative course was uneventful, and the patient was discharged on the day of the operation as an outpatient procedure. Pathological findings showed the presence of chronic cholecystitis with microlithiasis.

Robotic cholecystectomy for gallbladder stones

Cholécystectomie robotisée pour calculs de la vésicule biliaire

Bypass gastrique avec anse de Roux en Y entièrement robotisé

In this educational video, Dr. Vix presents the case of a 36-year-old morbidly obese woman (BMI of 46). A robotic Roux-en-Y gastric bypass (RYGB) was proposed due to the presence of hiatal hernia and GERD during the preoperative work-up. 

During the video, the surgical technical steps are highlighted using the da Vinci Xi™ robotic surgical system (Intuitive Surgical), namely trocar placement, liver retraction, sequential steps for gastric pouch creation, and limb measurement with robotic instruments. The use of robotic staplers and barbed sutures during anastomotic creation is also discussed.

Fully robotic Roux-en-Y gastric bypass

We present the case of a 25-year-old woman with a goiter, mainly on the left side. On the ultrasound, the right lobe is 3.82cm3 and the left lobe 18.96cm3. The left lobe has a large nodule 48 by 32 by 20mm (16.31cm3), classified EU-TIRADS 3. The nodule was punctured and the pathology was benign (Bethesda II). A robot-assisted transaxillary left lobectomy was put forward to the patient who was managed with neuromonitoring. The da Vinci Si™ robotic surgical system was used, with four robotic arms (30-degree camera, Maryland forceps, ProGrasp™ forceps, and ultrasonic scalpel), without complications, with identification and preservation of the recurrent nerve and both parathyroid glands. In this procedure, in a first phase, the recurrent nerve was not identified due to a variation of the inferior thyroid artery coursing on the nerve instead of crossing it. After a careful dissection and positive response to neurostimulation behind the vessel, the nerve was identified. The time of the procedure was 50 minutes (docking time: 5 min; console time: 20 min). 

The patient was discharged on postoperative day one. She was asymptomatic, without calcium reposition or levothyroxine. Pathological findings confirmed a left lobe (49 by 37 by 19mm – 16 grams) with a large adenoma (with a maximum diameter of 48mm), without malignant features or parathyroid glands. 

We concluded that a robotic transaxillary thyroid lobectomy is a feasible and safe approach. We are convinced that neuromonitoring is a useful tool in this surgery, but should not replace the surgeon’s view. 

Transaxillary left robotic lobectomy: anatomical recurrent and inferior thyroid artery variation

Lobectomie robotique transaxillaire gauche : variante anatomique (artère thyroïdienne inférieure)

Bypass gastrique avec anse de Roux en Y entièrement robotisé : anastomose gastrojéjunale entièrement manuelle et anastomose jéjunojéjunale par agrafage

In this educational video, Dr. Vix presents the case of a morbidly obese 35-year-old woman with a BMI of 49 who underwent a fully robotic Roux-en-Y gastric bypass (da Vinci Xi™ robotic surgical system, Intuitive Surgical). The video is focused on the critical steps to create the gastric pouch along with sequential technical steps for the handsewn gastrojejunostomy. These steps include information about suture materials and instructions for the posterior and anterior layers, the importance of a landmark suture for traction, the use of scissors to open the stomach and jejunal limb, and the role of the calibrating tube during the gastrojejunostomy. The technical steps used for the stapled jejunojejunostomy are also described. During the video, the stability and wide range of motion provided by the robotic surgery platform is clearly demonstrated.

Focus on robotic surgery