Robotic Approach to Transhiatal Esophagectomy

Fig. 24.1

Positioning patient in steep reverse Trendelenburg on sliding operating table

Robot Positioning

When using the Si system, the table will likely need to be positioned at an oblique angle to the anesthesiologist to allow the robot to dock in a linear fashion over the patient’s head (Fig. 24.2). The surgeon should ensure that the Si robot, which will dock from above the head, will leave enough room for the anesthesiologist to access the airway and face. In addition, there must be enough space for the cervical anastomotic portion of the case. When using the Xi system, the robot can approach from a lateral position with the arms turned 90° to facilitate easier docking (Fig. 24.3). The table is placed in maximal reverse Trendelenburg, then lowered as far down to the ground as possible. Sometimes it is necessary to adjust the sliding position of the table up or down. This is especially important because, unlike the Xi system, the Si boom cannot be raised or lowered. Once the positioning is confirmed , the patient may be prepped and draped.

Fig. 24.2

Room setup for Si system . The robot approaches and docks from above the patient’s head

Fig. 24.3

Room setup for the Xi system . The robot approaches and docks from the patient’s side

Key Points

See Table 24.1.

Table 24.1

Docking key differences

Si	Xi
Dock from above patient’s head	Dock from patient’s left
Turn table	Table position unchanged
Patient in steep reverse Trendelenburg	Patient in steep reverse Trendelenburg

Console Setup/Third Arm Approach

At the authors’ training institution, the use of a dual-console system is advocated in order to facilitate the involvement of trainees. The dual-console setup allows several advantages over a single-console setup. Once the trainee has fulfilled the requisite number of docking and instrument exchanges at the bedside, it is imperative that they participate in the surgery. Taking their place at the console allows involvement and graduated responsibility. Traditionally, using the “3rd arm” has referred to the utilization of the unused arm on the Si system by the assistant on the second console. The arm numbering has been changed on the Xi system and thus the term “assistant arm” will be used in place of the term third arm on the Si and fourth arm on Xi.

The use of the assistant arm allows seamless swapping of instruments between surgeon and assistant. The trainee is able to start with a single arm in order to become more familiar with the mechanics of the robot controls and gradually move to the primary arms with the acquisition of more experience. Placing a trainee bedside with an additional assistant port places emphasis on laparoscopy rather than robotics and does nothing to increase the robotic skillset. The dynamic interchange between robot arms allows the surgeon to take over the main arms during more difficult portions of the case. This technique enhances interplay between surgeon and trainee while facilitating education. It also overcomes the “loneliness” of the robot which can occur when the surgeon is isolated in the console without any other human contact. There may be some surgeons that gravitate towards robotics as a means to be alone and escape human interaction. The authors are not in this group and would encourage the more “social” surgeon to use the assistant arm as a technique of training. It is more convenient to position the two consoles near each other for ease of communication, but is not a requirement and operating room space limitations may preclude this arrangement. The voice communications system within the console may be inadequate for some, and the use of a separate hands-free wireless communication system for improved voice communication has been suggested .

It is important to customize the console settings for the individual surgeon. On both the Si and the Xi, surgeons are able to log in using unique profiles and adjust ergonomics and other settings as needed. In our experience, it is convenient to switch off the Firefly quick switching option to avoid inadvertent camera switching when finger clutching. We also use normal (1:1) motion scaling.

Key Points

Use dual-console setup
Trainee should use assistant arm until proficiency shown
Trainee should then advance to using primary arms (1 and 2 for Si, 1 and 3 for Xi)

Operative Technique

Port Placement

The abdomen can be entered by any manner in which the surgeon is comfortable. The authors prefer to use a 5 mm direct entry optical entry through a supraumbilical stab incision. The abdominal wall is grasped laterally by the surgeon and the assistant and elevated as the trocar and camera are slowly advanced through the layers of the abdominal wall under direct visualization. Once the abdomen is entered, pneumoperitoneum of 15 mmHg is achieved. The underlying bowel and omentum is visualized to rule out inadvertent injury. In the authors’ practice, no documented complications or injuries over hundreds of procedures using this technique have occurred. A thorough exploration of the abdomen with the laparoscope should be undertaken in the patient with malignancy. It is very easy to proceed mechanically without this step and overlook metastatic disease .

A 12 mm robotic trocar is placed in the left upper abdomen which will be used for the energy device and stapler (Fig. 24.4). The location will vary depending on the energy device used. A more cephalad position along the mid-clavicular line (MCL) towards the costal margin is required for the ultrasonic dissector in order to maximize the extent of its reach. It is the authors’ preference to use the Harmonic ACE™ ultrasonic dissector device in this position. If using the robotic vessel sealer, the port can be placed in a more caudal position just superior to the horizontal level of the midline camera port. The ultrasonic dissector is shorter than the vessel sealer and so the left mid-clavicular port must be placed more cephalad if the former device is being used. An 8 mm robotic port will be used to “piggyback” through the 12 mm port. The 8 mm robotic port is placed inside the 12 mm port and the arm is docked to the robotic port in the normal fashion. In order to gain more reach when using the ultrasonic shears, the 12 mm port may be “burped” by the assistant which involves retracting the shears and clutching the arm and advancing the port in order to gain more distance for the instrument. Regardless of the robotic system used, this trocar should be spaced at least 10 cm away from the camera port.

Fig. 24.4

Port placement for the Si and Xi system . If using the Harmonic device, the 12 mm port will be placed more cephalad than if using the Vessel Sealer. The camera port will be a bariatric length 11 mm trocar for the Si, or an 8 mm robotic trocar if using the Xi

An 8 mm trocar is then placed in the far left abdomen, below the costal margin at least 10 cm from the energy device port. This port should be placed far laterally while safely avoiding bowel. If the trocar is placed too far laterally, however, docking of this port can be challenging and there can be external collisions with the patient’s left arm. A ProGrasp™ instrument will be used through this port and will be controlled by the assistant if using a dual-console setup. This port will be placed at the same location on the abdomen regardless of whether the Si or Xi system is used.

An 8 mm port is placed in the right abdomen on the right MCL at the level of the camera port. This will be the surgeon’s right hand and a fenestrated bipolar grasper will be used. In order to maximize the effectiveness of the bipolar instrument, the tips must be slightly open when coagulating tissue; otherwise the electrocautery will not be as effective. This port will be placed in a more caudal position resulting in a more linear angle if using the Xi system.

A liver retractor system is set up by securing the clamp to the rails of the table in cooperation with the anesthesiologist to avoid clamping any of the patient lines. A flexible triangular liver retractor (Snowden-Pencer^®) is placed in the abdomen and, under direct visualization, is positioned under the left lobe of the liver to expose the hiatus. This is secured in place by the assistant using the Fast Clamp system .

The 5 mm camera port is then upsized to a robotic port under direct visualization. In the Si system, a bariatric length 12 mm trocar is placed and a 12 mm camera is used. In the Xi system, an 8 mm trocar is placed and an 8 mm scope is used with the advantage of being able to use any of the 8 mm ports as the camera port. A disposable 5 mm port is placed in the far right abdomen in a subcostal position. A 5 mm AirSeal^® port can be placed for improved insufflation and evacuation. If using the AirSeal^® system , the surgeon should place this port last. Once AirSeal^® is initiated, placement of ports becomes very difficult as the system will maintain the pressure of 15 mmHg and not allow for elevated pressures associated with trocar placement. The authors prefer this system as this is very efficient at steam evacuation without affecting pneumoperitoneum.

Docking

Once the liver retractor is placed, the patient is placed in reverse Trendelenburg. It may be necessary for the table to be lowered and slid down towards the floor in order to achieve the correct height to accommodate the robot.

Si System

For the Si system , the patient is approached in a linear manner from the head of the bed, i.e., dock from above the head. The robot should be advanced with the bed in the flat position. Once the camera arm appears to be in good position, the table is then placed in steep reverse Trendelenburg position and, with the surgeon watching carefully, ensures that the camera arm is still dockable. The robot will likely need to be advanced once the table position is achieved. The robot should be centered in line with the center camera port. Once the robot is positioned, the brake is applied and the camera arm is docked to the midline port, with the arm indicator in the blue “sweet spot”. With a very tall patient, the surgeon may have to dock with the camera arm in the straight position. This is not a major concern, but the robot must be advanced as close to the head of the bed as possible. Use of a bariatric 12 mm trocar at the midline position helps achieve greater mobility and decreases the likelihood of port slippage. Once the camera arm is docked, the remaining arms are docked. Arm three should be positioned to the patient’s left side. If there are external collisions, the arms may need to be adjusted. A 12 mm camera is placed through the camera port and the remaining instruments are placed under direct visualization. All four arms are used .

Xi System

For the Xi system , the patient is approached from either the right or left side (see Fig. 24.3), depending on the room setup. The driver will input the location of the surgery (upper abdomen) and the direction of the approach (right or left). The green laser guides are then aligned with the midline camera port and arm 2 is docked to the 8 mm robotic port. The 8 mm camera is inserted and the targeting sequence is initiated by aiming the camera towards the hiatus and pressing the target button on the camera while holding the trocar firmly in place. The remaining free arms will move as the boom rotates. Once the targeting sequence is completed, the remaining arms are docked. Arm 3 will be docked to a free 8 mm port and “piggybacked” into a 12 mm left mid-clavicular line port.

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