monthly focus

surgical intervention video

This video aims to highlight the most important steps of a robot-assisted subtotal gastrectomy with a D2 lymphadenectomy and Roux-en-Y reconstruction, as an aid to others considering such a surgery. 

This is the case of a 77-year-old woman who presented with melena and anemia. 

An upper GI endoscopy identified a prepyloric ulcer which was found to be a poorly differentiated adenocarcinoma on biopsies. 

The patient underwent further work-up with CT, EUS, and staging laparoscopy. The gastric carcinoma appeared limited to the mucosa and submucosa (cT1 N0 M0). A synchronous primary lung carcinoma was also identified on CT, which was potentially manageable using stereotactic ablative radiotherapy (SABR), for which she also had a PET-CT scan.

The case was discussed in the multidisciplinary team (MDT) meeting and due to poor tumor differentiation, suspected submucosal invasion and the lesion abutting the pylorus, it was not thought to be suitable for endoscopic resection. In conjunction with the MDT opinion, the patient opted to proceed directly to gastric surgery, with a plan to undergo treatment for her lung carcinoma following this. 

The procedure was performed without incident using the da Vinci Xi™ platform. There were no intraoperative or postoperative complications. The patient was discharged home on postoperative day 7. 

Histological findings demonstrated a moderate to poorly differentiated mixed-type adenocarcinoma (pT1a L0 V0 N0). None of the 50 retrieved lymph nodes contained any tumor deposits.

Disclosures: The surgery was performed by a specialist esophagogastric surgeon. At the time of submission, the video was not presented at any meeting and was not recorded during a live broadcast. Informed consent has been granted by the patient to use the recorded surgery to produce an educational video. The authors do not have any conflict of interest to report. Of note, the video is assumedly played x2 speed for demonstration purposes. 

Robotic subtotal gastrectomy with D2 lymphadenectomy and Roux-en-Y reconstruction for prepyloric gastric adenocarcinoma

Gastrectomie subtotale robotisée avec lymphadénectomie D2 et reconstruction de Roux-en-Y pour adénocarcinome gastrique prépylorique

Gastrectomie D2 élargie avec pancréatectomie gauche, splénectomie et colectomie pour cancer gastrique

According to global estimates, gastric cancer is the fourth most common cancer, and the second most common cause of cancer-related deaths in the world. Adenocarcinoma is the most common malignant gastric tumor, constituting 95% of malignant neoplasms of the stomach. As gastric tumors are associated with high morbidity and mortality, conventional resection is considered a procedure with favorable oncological results. Videolaparoscopic resection is currently under discussion due to its technical difficulty in preserving free margins and its steeper learning curve compared to its counterpart. 

Extended D2 gastrectomy with left pancreatectomy, splenectomy, and colectomy in gastric cancer

Lateral hernias are a complex and challenging pathology. There are numerous reconstructive techniques but most of them are unable to achieve a sufficient mesh overlapping to cover the defect. 

The posterior component separation with transversus abdominis release (TAR) is a novel surgical technique that offers a reliable solution for lateral hernias by closing the defect and achieving wide mesh reinforcement of the abdominal wall. The TAR is becoming the gold standard procedure for treating complex ventral and lateral hernias. 

Using robotic approaches brings us an ergonomic way to perform this technique in a minimally invasive manner, is associated with several postoperative benefits, and has comparable outcomes to the open approach. 

This is the case of a 73-year-old male patient with a surgical history of low anterior resection and loop ileostomy due to a colorectal cancer. He was then operated on for bowel reconstruction and open right groin hernioplasty. 

The patient consulted for a lateral hernia at the level of the previous ileostomy and a recurrence of his groin hernia. On the CT-scan, an L2W2 incisional hernia (according to the European Hernia Society Classification) and a right groin hernia were observed. 

Authors decided to perform a robotic right transversus abdominis release (TAR) to solve the incisional hernia, as well as the groin hernia.

Robotic transversus abdominis release

Libération robotisée du muscle transverse de l'abdomen

Laparoscopic extended right hemicolectomy with complete mesocolic excision (CME) is one of the most challenging colon procedures. This surgery involves an extensive scope and a number of key organs, where a clear understanding of the superior mesenteric vein (SMV) anatomy, and ligation of the middle colic artery at its origin, are needed. This educational video presents the anatomy and the technique of a laparoscopic extended right hemicolectomy with central ligation of the middle colic vessels. 

Laparoscopic extended right hemicolectomy with D3 lymphadenectomy: a stepwise approach

Clinical case presentation

This is the case of a 39-year-old male patient with a BMI of 37. He presented with bleeding per rectum, gradual progressive constipation, tenesmus, and persistent pelvic pain. There was no relevant medical or surgical history. MRI of the pelvis revealed a T4 N2 M0 rectosigmoid mass. Colonoscopy showed a rectosigmoid mass (multiple biopsies) and 2 sessile polyps at the ascending colon (hot snaring). The histopathological examination showed a gastrointestinal adenocarcinoma on top of a villous adenoma. The polyps also showed tubulovillous adenomas with low-grade dysplasia. The patient was subjected to a neoadjuvant chemotherapy, and the PET-CT showed a very minimal response. Consequently, the patient was subjected to an extended course of chemoradiotherapy resulting in incomplete response and downstaging to T2 N0 M0. The carcinoembryonic antigen was high, namely 57ng/mL. The metastatic work-up showed no evidence of metastatic disease. 

Preoperative preparation

Preoperative routine laboratory investigations were performed. The patient was prepared for surgery with mechanical and chemical bowel preparation. 

Surgical procedure

The patient underwent a laparoscopic low anterior resection with total mesorectal excision in combination with a D3 lymphadenectomy and a high ligation of inferior mesenteric vessels. Bowel continuity was restored through a colorectal anastomosis using a double stapling technique with a covering ileostomy. 

Outcomes

The postoperative course was uneventful. The patient started oral intake on postoperative day 1 and was discharged on postoperative day 4. The specimen showed a gastrointestinal adenocarcinoma infiltrating down to the subserosa, with positive lymphovascular tumor emboli, free cut margins, and 16 harvested lymph nodes free. 

Focus on highly advanced minimally invasive GI surgery

Extended D2 gastrectomy with left pancreatectomy, splenectomy, and colectomy in gastric cancer

Robotic transversus abdominis release

Laparoscopic low anterior resection for locally advanced rectosigmoid carcinoma

Laparoscopic extended right hemicolectomy with D3 lymphadenectomy: a stepwise approach

Robotic subtotal gastrectomy with D2 lymphadenectomy and Roux-en-Y reconstruction for prepyloric gastric adenocarcinoma