Robotics in Surgery: A Modular Robotic Platform Driven Gastric Wedge Resection

Summary

Robotically assisted surgery has become highly popular in recent years. Presented here is the standard care for upper gastrointestinal procedures, including a demonstration of a robotic-assisted gastric wedge resection using a modular robotic device.

Abstract

Robotic-assisted surgery has become increasingly popular since the introduction of the first robotic platform. Recently, a modular robotic system was approved for in-human use in Europe. Possible applications for this new robotic system are being explored, and standardized approaches are evolving. In lieu of this, a gastric wedge resection and the standardized setup for upper gastrointestinal procedures using this new system are presented here. This safe and feasible robotic procedure is demonstrated in a 69-year-old patient with a gastric tumor. All steps of the surgery are described in a detailed and reproducible manner. The article also details trocar positioning, arm adjustments, and required surgical instruments. Docking time amounted to 13 min, whereas the console time took 115 min. The patient was discharged after 4 days after ensuring an uneventful course. The presented method is also suitable for other surgical purposes, such as fundoplications or hiatoplasties, and ensures both generalizability and reproducibility.

Introduction

Robot-assisted surgery (RAS) is an advanced minimally invasive technique, which is associated with potential advantages such as fastened recovery times, shortened hospitalization and reduced risk of complications. According to Goh et al.¹, surgeons benefit from better visualization, ergonomics, and dexterity.

Recently, a much-awaited modular robotic device was approved for in-human use in Europe in the field of visceral surgery². Extensive experience has already been gathered by urologists earlier on^3,4,5. Nevertheless, surgical experience with this new device is scarce but rapidly increasing^{6,7,8,9,10,11,12,13,14}. The system comprises four arm carts for the endoscope and surgical instruments, a system tower, and a surgeon console². Trocar positions and adjustments of the arm carts are highly important for the success of the surgical approach. False positions may lead to conflicts with robotic arms and technical inoperability. We developed this setup as a standard method for upper gastrointestinal surgery which includes numerous operations and organs such as the stomach, gallbladder, liver, pancreas or spleen. Therefore, the surgical approach needs to cover a wide range of requirements, especially in anatomical regions that are difficult to access. Due to the novelty of the platform, hardly any approaches for upper gastrointestinal surgery were described before. Other authors concentrated on bariatric procedures¹². These setups are designed for a minority of obese patients with special anatomical demands^12,15. Salem et. al. use alternate localizations of the arm carts for myotomies, which require an intricate positioning of the patient¹⁶. The presented method can be utilized for a wide range of purposes and patients and is easy to perform. Setups for other robotic platforms are not transferable¹⁷.

We now describe our surgical method and the case of a 69-year-old male patient who presented with an upper gastrointestinal bleeding. The diagnostic measures, including CT scans and endoscopy, revealed a gastric tumor localized at the greater curvature. It was sized 7 cm x 5 cm x 5 cm. Histological examination of a tissue sample suspected a leiomyoma and CT-scans showed no sign of metastatic spread. The patient did not undergo preceding major surgery, was presented with sufficient physical fitness, and, therefore, qualified for minimal-invasive surgery. The surgical resection of the lesion was indicated and performed at St. Josef-Hospital, University Hospital of the Ruhr-University Bochum, Germany, on January 12th, 2024.

Protocol

All steps presented in the surgical method follow the guidelines of the ethics committee of the Ruhr-University Bochum, Germany. The study was approved by the local ethics committee (No.23-7872-BR). Informed consent was obtained from the patient for the presentation of the data and video material.

1. Patient positioning and surgical setting

1. Patient positioning
   1. Situate the patient in supine position, anti-Trendelenburg 30° and slightly rolled to the right (10-15°).
   2. Do not split the legs and position the abdomen at a height of >70 cm above ground by adjusting the operating table.
   3. Arrange the robotic arms in a "butterfly"-setup with two arm carts on both sides of the patient (Figure 1).
2. Cutaneous incisions and mini-laparotomy
   1. Disinfect the skin by using swabs and antiseptics and place self-adhesive sterile covers.
   2. Incise the skin (1-2 cm) and fascia supraumbilically by using a scalpel and scissors.
   3. Push the first robotic trocar (11 mm) through the incision. Connect it to a CO₂ insufflator.
   4. Set the insufflator to a pressure of 12 mm Hg. Wait until the favored pressure is reached and control the display.
   5. Make additional incisions (1 cm) and pierce the abdominal wall with the other trocars by turning and applying constant pressure.
3. Positioning the trocars
   NOTE: The optimal positions are shown in Figure 2.
   1. Insert the surgeon's left hand-trocar in the right upper abdomen (width 8 mm).
   2. Position the third trocar (surgeon's right hand, width 11 mm) in the left upper abdomen and the last robotic trocar for the 4^th arm (width 8 mm) laterally in the left upper abdomen.
   3. Ensure a distance of at least 9 cm between all robotic trocars.
   4. Place an additional laparoscopic trocar between the endoscope and right-hand port on a more caudal level. For the setup, see Figure 2.
4. Adjusting of robotic arms
   1. After a short laparoscopic exploration and the insertion of a gauze swab with a grasping instrument, connect robotic arms to the trocars.
   2. Adjust arm cart 1 (left side, cranial, surgeon right hand) to a tilt angle of -30° and a docking angle of 40°.
   3. Set up arm cart 2 (left side, caudal, 4^th arm) to a tilt angle of 0° and a docking angle of 110°.
   4. Align arm cart 3 (right side, caudal, surgeon left hand) to a tilt angle of 0° and a docking angle of 290°.
   5. Set up arm cart 4 (right side, cranial, endoscope arm) to a tilt angle of -30° and a docking angle of 330°.
      NOTE: Always control the displays of the arm carts to ensure an optimal setup.
5. Insertion of the instruments
   1. Insert the camera into arm cart 4 and use a straight-forward optic (0°), which is indicated by the label.
   2. Equip the surgeon's left hand with a bipolar grasper, the surgeon's right hand with monopolar curved shears, and the 4^th arm with a cadiere grasper.
   3. Insert all instruments strictly under visual control. Set up bipolar energy to 50 watts (standard setup).
   4. Furthermore, set monopolar energy to 30 watts (blend cut) for cutting and 30 watts (fulguration) for coagulation by adjusting the controls of the electrosurgical generator.

2. Surgical procedure

1. Incision of the gastrocolic ligament
   1. At the beginning of the robotic part of the procedure, grasp and elevate the stomach with the 4^th arm and incise the gastrocolic ligament using the bipolar grasper and the monopolar shears in combination with a vessel sealing device.
2. Dissection of the short gastric vessels
   1. Insert the sealing device via the additional trocar, which is managed manually by the bedside assistant.
   2. Cut the gastroepiploic ligament from 3 cm below up to 3 cm above the tumor after coagulation by using the controls of the instrument.
   3. Use the sealing device to coagulate and dissect all short gastric vessels. For additional coagulation, use the bipolar grasper.
3. Stapling of the tumor
   1. Identify the tumor by its shape and superficial appearance compared to normal gastric tissue. Resect the tumor using a laparoscopic stapler (30 mm and 45 mm cartridges).
   2. Take only small steps and pull the tissue tightly to save as much gastric tissue as possible. The result is a lateral wedge resection of the corpus and fundus of the stomach. After the extirpation, place the specimen on the liver temporarily.
4. Augmentation of the staple line
   1. Ask the anesthesiologists to replace the gastric tube below the lesion manually. The tube can be localized visually in the stomach.
   2. Augment the staple line by single knots. Use absorbable sutures. Cut off surplus sutures laparoscopically and remove the needles fixed to the sutures.
5. Removal of the specimen and end of surgery.
   1. Disconnect and remove the robotic arm carts.
   2. Insert a silicone drain laparoscopically, place it next to the lesion, and fix it to the skin with a suture.
   3. Remove the tumor using a retrieval bag via a mini laparotomy at the endoscope position.
   4. Finally, close the fascia with absorbable sutures and the wounds using non-absorbable sutures. Patch up the wounds using plasters.

Results

Docking time amounted to 13 min, whereas console time took 115 min. The tumor was removed, and the wounds were closed after another 15 min. There were no intraoperative complications or robotic malfunctions and hardly any blood loss. The patient was monitored in the recovery room for 3 hours postoperatively. The further course in the hospital was uneventful. There was no sign of postoperative bleeding or insufficiency of the stapling line. Therefore, the drain was removed after 2 days. There were 3 blood tests screening ...

Discussion

The method is tailored for upper gastrointestinal purposes. Low regions of the abdominal cavity are not able to be reached and require different trocar and arm cart positions. A critical step is the placement of the trocars, which are supposed to be placed at a sufficient distance of at least 9 cm from each other. Otherwise, conflicting movements of the robotic arms may occur. Nevertheless, trocars must not be placed too close to osseous structures. Conflicts of the arms can sometimes be circumvented by slight alteration...

Materials

List of materials used in this article

Name	Company	Catalog Number	Comments
Easy Flo	P.J. Dahlhausen, Köln, Germany		12 mm
Endo GIA Ultra	Medtronic, Dublin, Ireland
EndoRetrieval Pouch	Mölnlycke Health Care GmbH, Düsseldorf, Germany
Ethilon	Ethicon, Bridgewater, New Jersey, USA		3-0
Hugo RAS	Medtronic, Dublin, Ireland
Ligasure	Medtronic, Dublin, Ireland		44 cm, Blunt tip, laparoscopic version
Stomach Probe	Medicoplast, Illingen, Germany		Probe with plastic guidewire
UHI CO2 Insufflation Unit	Olympus, Hamburg Germany
Vicryl Sutures	Ethicon, Bridgewater, New Jersey, USA	1 and 3-0