Shinichi Kadoya

Robotic valvuloplastic esophagogastrostomy using double flap technique following proximal gastrectomy: technical aspects and short-term outcomes

BackgroundValvuloplastic esophagogastrostomy by double flap technique (VEG-DFT) is a promising procedure to prevent reflux after proximal gastrectomy (PG), and is achieved by the burial of the abdominal esophagus into the gastric submucosa; however, laparoscopic VEG-DFT is technically demanding due to complicated suturing and ligation maneuvers. The present study was designed to determine the feasibility and safety of robotic VEG-DFT.MethodsAfter robotic PG, seromuscular flaps were extracorporeally created at the anterior wall of the remnant stomach through a small umbilical incision. Then, using a robot, the posterior wall of the esophagus was fixed to the cranial end of the mucosal window, and layer-to-layer sutures were placed between the anterior aspects of esophagus and the remnant stomach. Finally, the anastomosis was covered by seromuscular flaps. Short-term outcomes of 12 consecutive patients who underwent VEG-DFT between January 2014 and December 2015 were assessed.ResultsOperations were successfully completed using robotic assistance in all patients. Median operative, surgeon console, and anastomosis times were 406 (324–613 min), 267 (214–483), and 104 (76–186) min, respectively, and median estimated blood loss was 31 (5–130) ml. The first six cases were required to reach a learning plateau. Both mortality and morbidity rates within 30 days after surgery were 0%. Postoperative hospital stay was 10 (9–30) days. No postoperative reflux esophagitis was observed, whereas anastomotic stenosis, which required endoscopic balloon dilation, developed in three patients (25%) in postoperative month 2. There was a significant association between the total number of stitches used for VEG-DFT and anastomotic stenosis (p < 0.001).ConclusionsRobotic assistance may be useful for VEG-DFT with a short learning curve. Attention is required to prevent postoperative anastomotic stenosis possibly caused by an excessive number of stitches for esophagogastrostomy.

Robotic surgery for the upper gastrointestinal tract: Current status and future perspectives: Robotic surgery for the upper GI tract

More than 4000 da Vinci Surgical Systems have been installed worldwide. Robotic surgery using the da Vinci Surgical System has been increasingly performed in the last decade, especially in urology and gynecology. The da Vinci Surgical System has not become standard in surgery of the upper gastrointestinal tract because of a lack of clear benefits in comparison with conventional minimally invasive surgery. We initiated robotic gastrectomy and esophagectomy for patients with upper gastrointestinal cancer in 2009, and we have demonstrated the potential advantages of the da Vinci Surgical System in reducing postoperative local complications after gastrectomy and recurrent laryngeal nerve palsy after esophagectomy. However, robotic surgery has the disadvantages of a longer operative time and higher costs than the conventional approach. In this review article, we present the current status of robotic surgery for gastric and esophageal cancer, as well as future perspectives on this approach, based on our experience and a review of the literature.

Outermost layer-oriented medial approach for infrapyloric nodal dissection in laparoscopic distal gastrectomy

BackgroundBased on our experience of suprapancreatic nodal dissection in laparoscopic gastrectomy, we developed an outermost layer-oriented medial approach for infrapyloric nodal dissection. The objective of this single-institution retrospective study was to determine the feasibility, safety, and reproducibility of this novel and unique dissection procedure.MethodsThis approach can be performed in the same manner as suprapancreatic nodal dissection but by replacing the left gastric artery with the right gastroepiploic artery (RGEA), the common hepatic artery with the anterior superior pancreaticoduodenal artery (ASPDA), and the splenic artery with the gastroduodenal artery. It comprises five steps: (1) mobilization of the transverse mesocolon along the prepancreatic membrane, (2) medial dissection along the dissectable layer between the pancreatic head and the dorsal side of the right gastroepiploic vein (RGEV), (3) division of the RGEV and determination of the lateral and cranial borders, (4) dissection along the outermost layer of the RGEA and ASPDA and transection of the infrapyloric artery and RGEA, and (5) transection of the duodenal bulb.ResultsThis novel method was applied in 112 patients who underwent laparoscopic distal gastrectomy from 2014 to 2015. The anatomical landmarks that we determined to appropriately identify the outermost layer were highly reproducible, and our novel procedure based on these landmarks was successfully completed in all cases, without any intraoperative complications. Furthermore, in all cases, no. 6 lymph nodes were fully and adequately dissected within the infrapyloric area anatomically defined in the Japanese Classification of Gastric Carcinoma ver. 14. Pancreatic fistula occurred only in 1.8% cases.ConclusionsThis novel outermost layer-oriented medial approach is a robust procedure that may help laparoscopic surgeons in performing safe and reproducible infrapyloric nodal dissection.

Robot-assisted mediastinoscopic esophagectomy for esophageal cancer: the first clinical series

BackgroundRadical esophagectomy for esophageal cancer is associated with high morbidity, especially with pulmonary complications. Mediastinoscopic esophagectomy via a small left neck incision combined with the esophageal hiatus, without using transthoracic approach, has been reported to reduce pulmonary complication; however, from technical point of view, this approach using non-articulating, straight, long forceps is extremely challenging, especially in the middle mediastinal area. Its technical difficulties may be attenuated using da Vinci Surgical System. The aim of this study was to evaluate the feasibility and safety of robot-assisted mediastinoscopic esophagectomy.MethodsRobot-assisted mediastinoscopic esophagectomy was performed in six patients between October 2016 and May 2017. Robotic esophageal mobilization with upper and middle mediastinal lymphadenectomy was performed via the three da Vinci Xi (Intuitive Surgical, Inc. Sunnyvale, CA) trocars placed on the 5-cm left cervical incision. Thereafter, the remaining part of radical esophagectomy was completed via a transhiatal approach.ResultsUpper and middle mediastinal lymphadenectomy was robotically completed via the transcervical approach in all cases without conversion to transthoracic approach. No postoperative complications (Clavien–Dindo classification grade ≥ III) were observed.ConclusionsRobot-assisted mediastinoscopic esophagectomy was technically feasible and safe. Use of da Vinci Surgical System may help attenuate technical difficulties in transcervical middle mediastinal lymph node dissection.

Robotic technology could contribute to performing precise gastrectomy with D2 lymphadenectomy for gastric cancer while decreasing the risk of local complications

We found the article of Kim et al. —entitled “Multicenter Prospective Comparative Study of Robotic Versus Laparoscopic Gastrectomy for Gastric Adenocarcinoma” published in the January 2016 issue of the journal Annals of Surgery —quite interesting (1).