Novel application of simultaneous multi-image display during complex robotic abdominal procedures

Three robotic operations, left hepatectomy with intraoperative common bile duct exploration, low anterior resection, and radical distal subtotal gastrectomy with intracorporeal gastrojejunostomy, were performed by three different surgeons at a tertiary academic medical center. The patients’ perioperative factors and clinicopathologic characteristics are shown in Table 1.

A 66-year-old female patient with hypertension was diagnosed on routine screening colonoscopy with rectal cancer and subsequently underwent robotic low anterior resection with intraoperative colonoscopy. The preoperative colonoscopy revealed an ulcerofungating tumor located in the proximal rectum (Figure 2A). A computed tomography (CT) scan demonstrated no distant metastases.

Robotic low anterior resection was performed using the 6-port method as previously described[17]. In brief, after placement of the ports (one 12-mm and five 8-mm ports) and docking of the robot, a monopolar device, Cadiere forceps, and ultrasonic shears were used to mobilize the splenic flexure. The robotic arms were repositioned for the remainder of the operation. The surgeon mobilized the colon from the lateral peritoneal attachments by division of the left paracolic gutter with careful preservation of the ureteral and gonadal vessels. Under direct 3-dimensional (3D) magnified vision, pelvic autonomic nerves and visceral fascia were preserved. The mesocolon was divided with ligation of the embedded feeding vessels, and the pericolic fat removed for preparation of resection of the sigmoid colon.

At this time, the assistant performed a colonoscopy (Olympus, Optical Co. Ltd, Tokyo, Japan) to localize the rectal lesion. The images from the colonoscopy were displayed on the surgeon’s console along with the intraoperative extraluminal view of the rectum (Figure 2B). The tumor was found on the right side of the mid-rectum, and the distal margin was delineated. Aftern colonoscopic identification of the tumor was confirmed, simultaneous images on the screen of the previously cleared rectum permitted easy identification of the resection margin from the surgeon’s console (Additional file1). After confirmation of the rectal lesion colonoscope was removed since the patient did not required full colonoscopy.

The operation continued immediately after the colonoscope was removed. The distal margin was resected with an endolinear stapler, and the proximal colon exteriorized. A double stapling method using the CDH 33 mm (Ethicon Endo-surgery, Johnson & Johnson, Cincinnati, OH, USA) was used for the colorectal anastomosis. The total operation time was 396 minutes. The patient was discharged 7 days after surgery without postoperative complications. Final pathological examination revealed a 2.2 × 1.7-cm moderately differentiated adenocarcinoma of the rectum that invaded the proper muscle and one of 24 lymph nodes was positive, staged as pT2N1M0, stage IIIA. The proximal and distal margins from the tumor were 12 cm and 3.3 cm, respectively.

A 41-year-old male patient with no significant past medical history underwent robotic radical gastrectomy with gastrojejunal reconstruction for early gastric cancer. He was diagnosed with gastric cancer on screening esophagogastroduodenscopy, which was confirmed by biopsy as signet ring carcinoma. The lesion was identified at the angle of the lesser curvature (Figure 3A). A CT scan revealed neither enlarged intraabdominal lymph nodes nor distant metastatic disease.

Robotic radical gastrectomy was performed as previously described[13, 18]. In brief, the patient was positioned in the supine position with the operating table placed in reverse Trendelenburg, and the trocars were inserted. After docking of the robotic arms and retraction of the liver, the proximal jejunum was identified and clamped to prevent small bowel distension during endoscopic air insufflation. Endoscopy was performed using a gastroscope (Olympus, Tokyo, Japan) to localize the tumor and determine the proximal resection margin. The endoscopic view was seen simultaneously with the intraoperative view of the stomach (Figure 3B). After endoscopic localization of the tumor, compression of the area of the tumor and the endoscopic light was used to define the proximal margin of resection. This view was facilitated by reducing the light from the robotic camera. The resection line was drawn on the external, anterior wall of the stomach (Additional file2).

Robotic gastrectomy proceeded with partial omentectomy, ligation and division of the left gastroepiploic vessels, clearance of the greater curvature, and right-side dissection of the head of the pancreas with ligation and division of the right gastroepiploic vessels. After transecting the duodenum, dissection of the soft tissues surrounding the common hepatic artery and the celiac axis continued with identification, ligation, and division of the left gastric artery. The opening of the lesser sac and dissection along the retroperitoneal attachments to the stomach were completed with clearance of the lesser curvature. The previously determined proximal resection line was used as a guide to divide the stomach using an endolinear stapler. Since the intraluminal gastric lesion could not be palpated during robotic surgery, the use of an endoscope to identify the cancer assured an oncologically safe margin of proximal resection for proper intracorporeal anastomosis. Intracorporeal gastrojejunal reconstruction was performed with robotic assistance and stapler manipulation by the bedside assistant.

The total operation time was 200 minutes. The patient had an uneventful postoperative recovery and was discharged 5 days after surgery. Final pathological examination revealed a 3.2-cm × 2.5-cm signet ring cell carcinoma invading the mucosa with no positive lymph nodes, staged as pT1aN0M0, stage IA. Proximal and distal margins from the lesion were 5.5 cm and 4.5 cm, respectively.

A 56-year-old woman with an 8-year history of hypothyroidism treated with methimazole underwent robotic left hepatectomy with intraoperative common bile duct exploration for multiple left intrahepatic duct stones associated with chronic cholangiohepatitis. A preoperative CT scan demonstrated multiple radioopaque stones in the left hepatic duct with ductal dilatation and parenchymal atrophy of the left lobe of the liver (Figure 4A).

Robotic left hepatectomy was performed as previously described[19]. In brief, the left lobe of the liver was freed from its attachments and adhesions due to chronic inflammation. The left hepatic artery was identified during hilar dissection and ligated. After identifying and preserving the venous branches to the caudate and Spiegel lobes, the left portal vein was ligated and divided. During parenchymal dissection, the left hepatic duct was identified and ligated. At this point, an incision was made proximal to the ligation of the left hepatic duct, and common bile duct exploration was performed.

The patient-side assistant introduced a 5-mm flexible choledochoscope (Olympus, Tokyo, Japan) into the abdominal cavity via the 12-mm assist port. The surgeon sitting at the master console directed the choledochoscope using the first and third arms of the robot. The Cadiere forceps controlled by the third robotic arm held open the left hepatic duct, while the bipolar Maryland dissector was used to direct the choledochoscope into the open stump of the left hepatic duct and into the common bile duct. The view obtained from the choledochoscope was made available to the surgeon sitting at the console via the Tilepro multi-input system simultaneously with an intraoperative 3D view obtained by the da Vinci System’s camera (Figure 4B). Robot-assisted intraoperative common bile duct exploration completely visualized the common bile duct and identification of the ampula of Vater but found no stones. Once the exploration was complete, the choledochoscope was removed, and the left hepatic duct was sutured closed using 5-0 prolene suture with robotic assistance (Additional file3). Left hepatectomy was completed by identification and ligation of the left hepatic vein using a vascular endolinear stapler. The operation time was 465 minutes. The patient’s postoperative course was complicated by fluid collection at the hepatic resection bed, which did not require invasive intervention. The patient was discharged 12 days after surgery. Final pathological examination revealed hepatolithiasis with pigment stones and chronic proliferative cholangitis. A follow-up CT scan obtained 1 month after surgery confirmed that no radioopaque stones were left in the common bile duct.