GASTRECTOMY SURGERY

Procedure Guide
Developed with, reviewed and approved by
Woo Jin Hyung, MD, PhD
 GASTRECTOMY SURGERY

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Disclaimer
The following material has been developed with, reviewed and approved by the following independent
surgeon, who is not an Intuitive Surgical employee:

Woo Jin Hyung, MD, PhD

Associate Professor
Department of Surgery
Yonsei University College of Medicine
134 Shinchondong Seodaemunku
Seoul, 120-752
Korea

Labeling Information
Contraindications applicable to the use of conventional endoscopic instruments also apply to the use of all da Vinci
instruments, including Single-Site Instrumentation. General contraindications for endoscopic surgery include
bleeding diathesis, morbid obesity and pregnancy.

All surgeries carry risks of adverse outcomes. While clinical studies support the use of the da Vinci® Surgical
System as an effective tool for minimally invasive surgery for specific indications, individual results may
vary. Temporary pain or nerve injury has been linked to the inverted position often used during abdominal and
pelvic surgery. Risk specific to minimally invasive surgery may include a longer operative time, the need to convert
to an open approach, or for additional or larger incision sites. Converting the procedure could mean a longer
operative time, a long time under anesthesia, and could lead to increased complications. Research suggests that
there may be an increased risk of incision-site hernia with single-incision surgery. We encourage you to discuss
your surgical experience and review these and all risks with your patients, including potential for human error and
for equipment failure. We encourage patients and physicians to review all available information on surgical options
and treatment in order to make an informed decision. Clinical studies are available through the National Library of
Medicine at [Link]/pubmed.

Before performing any da Vinci® procedure, physicians are responsible for receiving sufficient training and
proctoring to ensure that they have the skill and experience necessary to protect the health and safety of their
patients.

da Vinci® users must follow all instructions for use supplied with the system, instruments and accessories. Use of
da Vinci instruments for tasks other than that for which they were designed may result in damage or breakage.
Unless stated in the instructions, do not use EndoWrist Instruments on cartilage, bone or hard objects. Failure to

da Vinci® Gastrectomy Procedure Guide PN 873058 Rev B 8/13 Page 1 of 54

follow instructions may lead to serious injury or surgical complications for the patient, including death. Inadvertent
electrosurgical energy may cause serious injury or surgical complications to the patient, including death. It is
important to ensure a full understanding of the da Vinci System energy user interface and use caution when
working near critical anatomy.

Third-party products shown interacting with the da Vinci System and its instrumentation have been validated by
Intuitive for use with the da Vinci System. Validation is for compatibility only and does not imply endorsement of
the product by Intuitive.

For complete technical information, please refer to the product documentation. Read all instructions carefully.
Failure to properly follow instructions, notes, cautions, warnings and danger messages associated with this
equipment may lead to serious injury or complications for the patient, including death.

In the event that the da Vinci System, instruments, or accessories do not work as expected, if you are aware of a
product deficiency or adverse event, please contact Intuitive Surgical Customer Service immediately. Please refer
to the Customer Service contact information in your user documentation.

Intraoperative video, including video labeled as showing full-length procedures, may have been edited for content,
for length or to meet file-size limitations.

© 2013 Intuitive Surgical, Inc. All rights reserved. Product names are trademarks or registered trademarks of their
respective holders. PN 873058 Rev B 8/13

Page 2 of 54 da Vinci® Gastrectomy Procedure Guide PN 873058 Rev B 8/13

 da Vinci® Gastrectomy Procedure Guide

Table of Contents
1. INSTRUMENTS AND ACCESSORIES
1a. Recommended EndoWrist® Instrumentation
1b. Additional da Vinci Supplies
1c. Recommended Laparoscopic Instrumentation and Accessories
1d. Recommended Sutures/Clips

2. PATIENT SELECTION AND PREPARATION

2a. Patient Selection

2b. Patient Preparation
2c. Operating Room Configuration

3. POSITIONING, PORT PLACEMENT AND DOCKING

3a. Patient Positioning
3b. Port Placement
3c. Patient Cart Docking

4. PROCEDURE STEPS – Right Hemicolectomy

4a. Anatomy & Procedure Overview: A Word on Lymph Nodes
4b. Step 1: Retract Liver
4c. Step 2: Preoperative Clip Placement
4d. Step 3: Left Dissection & Greater Curvature Mobilization
4e. Step 4: Right Dissection & Infrapyloric Dissection
4f. Step 5: Suprapyloric Dissection & Duodenum Division
4g. Step 6: Suprapancreatic Division & Lesser Curvature Mobilization
4h. Step 7: Gastric Resection
4i. Step 8: Reconstruction & Closure
4ii. Billroth II (Distal)
4iii. Roux-en-Y (Total)
4j. Step 9: Closing

5. POST-OPERATIVE CARE

APPENDIX A – Cannula Remote Center Set-Up

da Vinci® Gastrectomy Procedure Guide PN 873058 Rev B 8/13 Page 3 of 54

Page 4 of 54 da Vinci® Gastrectomy Procedure Guide PN 873058 Rev B 8/13
1. INSTRUMENTS AND ACCESSORIES

1a. Recommended EndoWrist Instrumentation

 Harmonic ACE® Curved Shears: 400275/420275
 Maryland Bipolar Forceps: 400172/420172
 Large Clip Applier: 400230/420230
 Cadiere Forceps: 400049/420049

Alternative EndoWrist Instrumentation

 Permanent Cautery Hook: 400183/420183
 Hot Shears™ (Monopolar Curved Scissors): 400179/420179 (Requires Tip Cover: 400180)
 Fenestrated Bipolar Forceps: 400205/420205
 ProGrasp™ Forceps: 400093/420093
 Large Needle Driver: 400006/420006
 SutureCut™ Needle Driver: 400209/420209
 Graptor™ (Grasping Retractor): 400278/420278
 Double Fenestrated Grasper: 400189/420189

1b. Additional da Vinci Supplies

 Basic accessory kit and drapes
 Intuitive Surgical camera head
 Intuitive Surgical 0º and 30º endoscopes
 da Vinci stapling cannula kit (420295)

1c. Recommended Laparoscopic Instrumentation and Accessories Per Surgeon Preference

 Graspers/Forceps/Scissors
 Olympus® ([Link]
 Long Johann Forceps, 330 mm with Ergo handle (WA63130A)
 Maryland Forceps, 330 mm with Ergo handle (A63320A)
 Short Maryland Forceps, 330 mm with Ergo handle (A63340A)
 Metzenbaum Scissors, 330 mm with Ergo handle (A63810A)
 Grasping Forceps with Lumen, 330 mm with Ergo handle (A63040A)
 Atraumatic Grasping Forceps, 330 mm with Ergo handle (A63010A)
 HiQ+™ Needle Holder
or
 Karl Storz® ([Link]
o CLICKLINE® Kelly Dissecting and Grasping Forceps 5 mm (33322ML)
o CLICKLINE Scissors 5 mm (34321MA)
o CLICKLINE Bowel Grasper fenestrated 5 mm (33300)
o CLICKLINE Forceps atraumatic 5 mm (33431WTD)
o CLICKLINE Grasping Forceps 10 mm (33532 SG)

 Sealing/Division
o LigaSure™ V ([Link]
o LigaSure Atlas™ ([Link]
o EnSeal™ 5 mm ([Link]

da Vinci® Gastrectomy Procedure Guide PN 873058 Rev B 8/13 Page 5 of 54

  Staplers
 Endo GIA™ Universal Roticulator with single use loading units (sizes 30, 45 and 60 mm
lines, [Link]
 Echelon™ 60 Endopath® Stapler DST Series™ EEA™ Stapler (blue and white loads)
 Endopath ETS-Flex Endoscopic Linear Cutter ([Link]
 Proximate® Intraluminal CDH Stapler ([Link]
 Other
 544965 Endo5 ML Hem-o-lok Clip Applier, 32.5 cm, 5 mm
([Link]
 5 mm suction/irrigation device
 Alexis® Wound Retractor Ref. #C8301 2.5-6 cm) (Applied Medical®)
 Gentian violet or vital dye used for marking stomach
 LapBag® L, 160 mm x 160 mm by Sejong
 Aesculap® bulldog applier
 Aesculap anvil holder
 Bulldogs

1d. Recommended Sutures/Clips

 Hem-o-lok Large Clips #544240 (violet)
 2-0 Prolene™, with straight needle for liver sling
 2-0 Prolene on SH needle for esophageal purse-string suture (total gastrectomy only)
 Autosuture® Endo Clip™ 10 mm L (15 titanium clips) for marking transection line on
greater/lesser curvature
 2-0 Polydioxanone sutures for closing trocar sites
 3-0 Silk sutures for closing subcutis and cutis
 Skin staples

Page 6 of 54 da Vinci® Gastrectomy Procedure Guide PN 873058 Rev B 8/13

2. PATIENT SELECTION AND PREPARATION

2a. Patient Selection

Ideal Patient Selection Criteria for Early Cases

 Good performance status
 Non-obese patients (BMI < 30)
 Healthy: age < 70, few comorbidities
 No previous intra-abdominal or pelvic surgery
 No prior chemotherapy or abdominal radiotherapy
 Avoid patients with moderate to severe cardiopulmonary compromise. Prolonged operative
times may be poorly tolerated by patients with cardiopulmonary disease

Recommended for patients with the following conditions:

 Early stage cancer (adenocarcinoma confined to mucosa or to submucosa)
 T1 or T2 stage tumors massively invasive to the submucosa

Not recommended for patients with the following conditions:

 Lesions where endoscopic mucosal resection can be performed
 Patients with:
o Intestinal obstruction requiring urgent decompression
o Contraindication to general anesthesia under pneumoperitoneum
 Otherwise, the same considerations for open surgery apply to the robotic approach.

2b. Patient Preparation

Pre-Operative Patient Preparation

 Bowel preparation is dependent on surgeon‟s preference and is identical to that of open or
laparoscopic gastrectomy.

Intra-Operative Patient Preparation

 Intra-operative preparation includes shaving the patient from the costal margin to the
pubic bone. The abdomen is prepped and draped in the usual sterile fashion. A Foley
catheter is inserted.
 If a nasogastric tube is not placed, then percutaneous aspiration with a 9 cm 19-gauge
spinal needle should be used to eliminate air from the stomach. 1

1
Hyung WJ, Song C, Cheong JH, Choi SH, Noh SH. Percutaneous needle decompression during laparoscopic gastric surgery: a
simple alternative to nasogastric decompression. Yonsei Med J. 2005 Oct 31;46(5):648-51.

da Vinci® Gastrectomy Procedure Guide PN 873058 Rev B 8/13 Page 7 of 54

 2c. Operating Room (OR) Configuration

Figure 1 shows an overhead view of the recommended OR configuration for

da Vinci Gastrectomy.

Figure 1: Operating room setup

 Patient-side assistant is on patient‟s left side.

 Scrub nurse is at the lower right side of the table.
 Main assistant monitor is located on the patient‟s right side.
 Vision cart is located at the patient‟s feet.
 It is useful to have a second monitor on the right side of the table across from the assistant.
 Sterile back tables (instruments) are located at the patient‟s right knee and at the foot of the
bed.

NOTE: Configuration of the operating suite is dependent on the room dimensions as well as the
preferences and experience of the surgeon.

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3. POSITIONING, PORT PLACEMENT AND DOCKING

3a. Patient Positioning

 Patient's arms are alongside the body to lessen possibility of shoulder injury.
 Pad pressure points and bony prominences.
 Carefully secure body position with gel pad or bean bag and apply a strap across the patient‟s
thighs to avoid any shifting of the reverse Trendelenburg position.
 A urinary catheter is placed.
 A body warmer to prevent patient hypothermia can be applied.
 After positioning, padding, securing and preparing the patient in the supine position, the table
is then placed in a reverse Trendelenburg position (15).

3b. Port Placement

Preparing for Port Placement

 Insufflation of 12 mmHg is achieved through a Veress needle at the level of the anticipated da
Vinci Camera Port [Figure 2].
 Perform initial assessment of entire anatomy once the endoscope port is inserted (focus on
liver for malignancy). Check for optimal port sites and adhesions, then place remaining ports
under direct vision.

Figure 2: da Vinci Gastrectomy port placement

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 Instrument Ports:
 da Vinci Camera Port, 12 mm (BBlluuee): Place port midline just below umbilicus (at lower
crease).
 da Vinci Instrument Port , 8 mm (YYeellloow w): Place port 1 cm below costal angle, as far lateral
as possible on patient‟s left side. Port should be 1 cm above level of bowel when viewed
internally from endosocope.
 da Vinci Instrument Port , 8 mm (GGrreeeenn): Place port 2-4 cm superior to umbilicus,
equidistant between Instrument Arm  and the endoscope port, on patient‟s right side.
 3rd da Vinci Instrument Port , 8 mm (RReedd): Place port 1 cm below costal angle, as far
lateral as possible on patient‟s right side. Port should be 1 cm above level of bowel when
viewed internally from endosocope.

Assistant Ports:
 Assistant Port (A), 12 mm ( ): Place port 1 cm superior to umbilicus, equidistant between
and 1-2 cm below a diagonal line from Instrument Arm  and the endoscope port on patient‟s
left side.

Tips
 Use heated insufflation for best visualization
 Maintain at least 8 cm between all ports
 Insert camera and inspect upper abdominal quadrants before placing other ports
 Place ports under direct visualization with patient in final position (15 reverse Trendelenburg)
 Position remote center (thick black band on robotic cannula) at level of peritoneum
 Place instrument arm  and  first, under visual guidance. They should be placed ~1 cm above
the level of the bowel [Figure 3]. Bring ports  and  more medial for larger patients
 The placement of instrument arm  is higher on larger patients to achieve the proper angle
with the Harmonic ACE Curved Shears required for the proximal pancreatic lymph node
dissection (11p). If the patient is thin, place the port more caudally to avoid collisions
 Maximize distance between  and  to minimize collisions
 Following docking, lift the camera cannula slightly anterior to "tent" the port site

Figure 3: Instrument arm , 1-2 cm above bowel.

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 3c. Patient Cart Docking

NOTE: The patient cart will be docked after liver retraction (see procedure step 5a) has been
achieved. Nevertheless, adjusting and aligning the camera arm and “sweet spot” can be performed
prior to docking.

Step 1: Adjust Camera Arm Set-Up Joint

 When using all three da Vinci instrument arms, position the camera arm set-up joint toward the
side of the patient with just one instrument arm (red arrow below) [Figure 4]. This
configuration will help maximize the space between arms and minimize collisions.
Set-up joint

Figure 4: Positioning of camera set-up joint for the 4-arm approach

Step 2: Determining "Sweet Spot”

 The “sweet spot” maximizes the range of motion for the instrument arms.
 Confirm “sweet spot” prior to docking.
 da Vinci S and Si Systems - The blue arrow should align within the blue marker on the second joint or
assure a ~90°angle between the 1st and 3rd joint on the camera arm [Figure 5].

90°
a b

Figure 5: “Sweet Spot” on da Vinci S and Si camera arm

da Vinci® Gastrectomy Procedure Guide PN 873058 Rev B 8/13 Page 11 of 54

Step 3: Align Camera Arm
 Align the camera arm, camera arm set-up joint, column and target anatomy.
 A straight line should be achieved by aligning the clutch button, the 3rd
joint of the camera arm and the gray dot in “da Vinci” on the center
column [Figure 6].

Figure 6: Align camera

Step 4: Roll in Patient Cart arm

 Be sure to coordinate with anesthesia before rolling up patient cart.
 Patient is placed in the 15 reverse Trendelenburg position right before rolling in the patient
cart. Push aside overhead lights and equipment to maintain sterility of the patient cart. The
arms of the patient cart should be positioned high enough to clear the height of the patient's
head.
 The patient cart is rolled up and positioned over the patient‟s head, aligned with endoscope
port.
 Once the correct location of the camera arm within its “sweet spot” is reached, the patient
cart can be locked. The base of the cart will usually “straddle” the base of the operating table.

Step 5: Dock Arms

 Ensure camera port, target anatomy and patient cart center column are aligned.
 Position camera cannula mount over the camera port and dock [Figure 7].
 Use port and arm clutch maneuvers to dock remaining instrument arms.
 Maximize spacing between arms  and  by spreading these arms as far apart as possible (red
arrow) [Figure 8].
 Maximize spacing between arm  and the camera arm by spreading arm  as wide as possible
(yellow arrow) [Figure 8].
 Keep instruments in the center of their range of motion.

Page 12 of 54 da Vinci® Gastrectomy Procedure Guide PN 873058 Rev B 8/13

Figure 7: Docking the aligned camera arm followed by docking of the instrument arms

Figure 8: Docked patient cart with optimized arm position ready for use

da Vinci® Gastrectomy Procedure Guide PN 873058 Rev B 8/13 Page 13 of 54

 a b

c d

Figures 9 a-d: Oblique, overhead, foot and side views of docked patient cart

Page 14 of 54 da Vinci® Gastrectomy Procedure Guide PN 873058 Rev B 8/13

4. PROCEDURE STEPS – Gastrectomy (Distal & Total) With D2 Lymph Node Dissection

4a. Anatomy & Procedure Overview: A Word on Lymph Nodes

Figures 10 and 11 show an overview of the anatomy and lymph node classification for distal and total
gastrectomy with D2 lymph node dissection, respectively.

Figure 10: Overview of surgical anatomy and D2 lymph node dissection for distal gastrectomy.4

da Vinci® Gastrectomy Procedure Guide PN 873058 Rev B 8/13 Page 15 of 54

 Figure 11: Overview of surgical anatomy and D2 lymph node dissection for total gastrectomy.4

Tips to Avoid Intraoperative Complications

 Create adequate exposure
 Use proper traction and countertraction
 Develop the correct planes
 Standardize the assistant‟s role, or utilize the surgical autonomy capabilities of the da Vinci System
to minimize the assistant‟s role
 Beware of the variations of vasculature and anatomy
 Control bleeding with the bipolar instrument and gauze
 Minimize tissue manipulation (stomach, bowel, pancreas) to avoid trauma to patient

Page 16 of 54 da Vinci® Gastrectomy Procedure Guide PN 873058 Rev B 8/13

Overall Procedure Tips
 Begin laparoscopically with liver retraction and preoperative clip placement
 Work anteriorly to posteriorly, performing dissections on easier areas first and then moving to
deeper areas
 Approach surgery from patient‟s right side
 Try to take lymph nodes en-bloc
 Move tissues to create angles for Harmonic & stapler (i.e., lift stomach up for stapler, use Cadiere
to create proper angles for Harmonic)
 Bipolar set to 70 W, but only use on specimen side
 Use 2 Large Clip Appliers for efficiency
 Mainly use 30° down scope, as you will be operating only in upper two quadrants of abdomen

4b. Step 1: Retract Liver

Retracting the liver is essential for clear visualization. Utilizing a suture and a gauze pad as a
„sling‟ for static retraction allows the third instrument arm to be free for dynamic use and
localized static retraction where necessary.

Instrumentation & Settings

 30 down endoscope, laparoscopic curved fenestrated graspers, 2-0 Prolene on straight
needle, gauze.

Steps
 Insert 4x4 gauze pad through assistant port.
 Insert a 2-0 Prolene suture through the skin on the right side of the faliciform ligament (as
viewed from internally). Pierce through faliciform ligament and then bring around and
under the left liver lobe.
 Pierce the gauze pad and the left lobe of liver and bring the needle back through skin
[Figure 12].

Figure 12: Creating the liver retraction sling by piercing the left lobe of the liver.

 Using laparoscopic graspers position the gauze pad around the suture to serve as sling.
 Pull up toward abdominal wall and tie off externally to achieve maximal visual field during
surgery [Figure 13].

da Vinci® Gastrectomy Procedure Guide PN 873058 Rev B 8/13 Page 17 of 54

 Figure 13: Complete liver retraction sling.

Tips
 Gauze serves to protect the liver from injury by the suture material
 Hold the distal 2/3 of the needle for optimum control while piercing the liver
 If liver retraction is too close to or too far from distal margin, the lobe will be in view

4c. Step 2: Preoperative Clip Placement

Metal clips are placed internally on the greater and lesser curvature to delineate the location
of the transection when coordinated with the internal clips placed via preoperative endoscopy.

Instrumentation & Settings

 30 down endoscope, laparoscopic graspers, laparoscopic clip applier, metal clips, Gentian
violet or vital dye marker, portable X-ray machine
 Maryland Bipolar Forceps

Steps
 Place 2 clips on the left side of the stomach, lesser curvature
 Place an additional 2 clips on the greater curvature side close to the gastric wall [Figure
14]

Page 18 of 54 da Vinci® Gastrectomy Procedure Guide PN 873058 Rev B 8/13

Figure 14: Intraoperative clip placement on the lesser and greater curvature side of the resection line.

 Bring in portable X-ray machine to take image of clip placement compared to internal clips
placed preoperatively [Figure 15]

Figure 15: Portable X-ray machine for intraoperative clip placement images

da Vinci® Gastrectomy Procedure Guide PN 873058 Rev B 8/13 Page 19 of 54

  Consult preoperative and intraoperative images to determine resection line [Figure 16]

B
Figure 16: A) Endoscopic view of preoperative clip placement. B) Intraoperative X-ray of clip
placement and measurement of distance to preoperative clips.

 Dock the patient cart

 Remove any adhesions
 Mark transection line on stomach using Gentian violet or vital dye [Figure 17]

Figure 17: Draw area on stomach to mark transection line

Page 20 of 54 da Vinci® Gastrectomy Procedure Guide PN 873058 Rev B 8/13

Figure 18: Illustration of distal gastrectomy transection lines and internal clip placement demarcating
tumor

4d. Step 3: Left Dissection & Greater Curvature Mobilization

The procedure begins by dividing the omentum off of the greater curvature from the
gastrocolic ligament to the gastrosplenic ligament (working from medial to lateral). The left
gastroepiploic vessels are divided at their root. Lymph nodes 4s and 4d are taken for a distal
gastrectomy. The short gastric vessels are divided for a total gastrectomy in addition to
dissecting lymph nodes 10, 11d, and 2.

Instrumentation & Settings

 30 down endoscope, large Hem-o-lok clips
 Harmonic Curved Shears , Maryland Bipolar Forceps , Cadiere Forceps , swap  or 
for Large Clip Applier when necessary
 Valleylab™ Force™ FX (monopolar Pure Cut 35 W, monopolar coag fulgurate 35 W, bipolar
standard 70W), Ethicon Harmonic ultrasound (min 3, max 5)

Steps
 Begin dissection of the omentum in the middle of the greater curvature (least amount of
vessels here) [Figure 19].

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 Figure 19: Begin left side dissection with division of omentum from greater curvature

 Divide omentum 4-5 cm from the margin of the greater curvature to preserve the omentum
in early stage cancer cases.
 Continue dissection towards the left gastroepiploic artery and vein [Figure 20].

Figure 20: Identify left gastroepiploic artery and vein

 Apply one clip to the remnant side using the Large Clip Applier and divide the left
gastroepiploic artery and vein at their root using the Harmonic shears [Figure 21].

Page 22 of 54 da Vinci® Gastrectomy Procedure Guide PN 873058 Rev B 8/13

 Figure 21: Apply clip to left gastroepiploic artery on remnant side

 Divide connections to spleen to prevent tearing the splenic capsule during anastamosis. Use
clips and transection line as a guide.
 Continue dissection along greater curvature toward pylorus to complete the 4s and 4d
lymph node dissection.

Total Gastrectomy
o Continue dissection superiorly along greater curvature to expose and divide the
short gastric arteries [Figure 22].

Figure 22: Total gastrectomy - uppermost part of short gastric artery for total gastrectomy, left side dissection

o Take the lymph node 10 while preserving the splenic artery [Figure 23].
o Separate the gastrosplenic artery (LN 11d) up to the left side of the esophageal
hiatus (LN 2).

da Vinci® Gastrectomy Procedure Guide PN 873058 Rev B 8/13 Page 23 of 54

 Figure 23: Lymph node 10 dissection with spleen preservation

Tips
 Insert a 4x4 gauze sponge to be used by the assistant or console surgeon for tissue
retraction or “sweeping.” This can also help with local hemostasis.
 Look for pulsations in the omentum to help identify left gastroepiploic artery.
 The short gastric arteries are typically preserved in a distal gastrectomy. However, if the
tumor is located higher, the 1st-2nd short gastrics may need to be divided for proper margins
and to create enough space for the resection and anastomosis.
 Move Harmonic shears to the right hand if having difficulty reaching or attaining the proper
angles for the dissection around short gastric arteries (LN 10) and (LN 2).

4e. Step 4: Right Dissection & Infrapyloric Dissection

The procedure continues to the right side by dissecting along the middle colic artery to the
root of the superior mesenteric vessels while exposing the head of the pancreas and dissecting
lymph node 6. For a distal gastrectomy requiring D2 lymph node dissection 14v is also taken.
This step is completed once the right gastroepiploic vein and artery are identified and ligated.

Instrumentation & Settings

 30 down endoscope, large Hem-o-lok clips
 Harmonic Curved Shears , Maryland Bipolar , Cadiere Forceps , swap  or  for Large
Clip Applier when necessary
 Valleylab Force FX (monopolar pure cut 35 W, monopolar coag fulgurate 35 W, bipolar standard
70W), Ethicon® Harmonic ultrasound (min 3, max 5)

Steps
 Identify the middle colic artery and follow the pulsations to the root of the superior mesenteric
artery.
 For distal cancers only, expose the head of the pancreas and remove the soft tissues at the
root of the superior mesenteric vessels (LN 14v) [Figure 24].
 Identify the gastroceliac trunk (drains into superior mesenteric vessels) and dissect lymph node
6 using the Harmonic shears and the Maryland Bipolar Forceps.

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 Figure 24: Dissecting the soft tissues at the root of the superior mesenteric vessels for 14v

 Approach and expose the right side of the right gastroepiploic vein while preserving the
venous drainage to the pancreas head.
 Divide the right gastroepiploic vein using 1 clip from the Large Clip Applier and the
Harmonic shears [Figure 25].
 Continue dissection to expose, clip x3, and divide the right gastroepiploic artery.

Figure 25: Application of the clips and division of the right gastroepiploic vein (left) and artery (right).

 Mobilize the duodenum from the pancreas to prepare for the duodenal transection [Figure
26]. Be sure to coagulate the many small vessels from the head of the pancreas to the
duodenum.
 Dissection goes up to the bifurcation of the posterior pancreatic duodenal and the
gastroduodenal arteries [Figure 27].

da Vinci® Gastrectomy Procedure Guide PN 873058 Rev B 8/13 Page 25 of 54

 Figure 26: Mobilizing the duodenum from pancreas

Figure 27: Complete infrapancreatic dissection

Tips
 If the landmarks (middle colic artery) can not be seen (such as in obese patients), dissect
the opposite side first.
 3D visualization helps to distinguish the pancreatic tissue from the surrounding soft tissue.
 Minimize interactions with the pancreas to avoid post operative pancreatitis.
 Individual ligation of the right gastroepiploic artery and infrapyloric artery is ideal when
possible.
 It is important to coagulate vessels to ensure a clean surgical field.

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4f. Step 5: Suprapyloric Dissection & Duodenum Division
In preparation for the duodenal transection, the area above the pancreas and duodenum are
further dissected. The EndoWrist instruments are then used to help guide the linear stapler for
the approximation and transection of the duodenum.

Instrumentation & Settings

 30 down endoscope, large Hem-o-lok clips, Echelon Endolinear stapler with 60 mm blue
cartridge, fibrin mesh, gauze
 Harmonic Curved Shears , Maryland Bipolar , Cadiere Forceps , swap  or  for Large
Clip Applier when necessary
 Valleylab Force FX (monopolar Pure Cut 35 W, monopolar coag fulgurate 35 W, bipolar standard
70W), Ethicon Harmonic ultrasound (min 3, max 5)

Steps
 Place gauze on top of the pancreas below the duodenum to help create the supraduodenal
dissection plane while preventing injuries to the pancreas [Figure 28].

Figure 28: Placing gauze below duodenum for supraduodenal dissection

 Divide the supraduodenal vessels and dissect along gastroduodenal artery.

 Continue dissection to identify and expose the right gastric vessels.
 Assistant brings in 60 mm endolinear stapler through the assistant port.
 Use EndoWrist instruments to position stapler across duodenum ~1-2 cm distal to pylorus
[Figure 29].
 Approximate and transect the duodenum ensuring that there is no tension on the duodenum
[Figure 30].
 Apply Surgicel™ or fibrin mesh on the duodenal stump for hemostasis control.

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 Figure 29: Using the Cadiere (instrument arm ) and the Maryland Bipolar Forceps to help position the
endolinear stapler 1-2 cm below pylorus across duodenum.

Figure 30: Approximation (left) and transection (right) of 60 mm linear stapler across duodenum.

Tips
 Place gauze below the dissected pyloric area for safe and easy dissection above the
duodenum.
 Only dissect around duodenum to avoid inadvertently stapling pylorus
 Transect duodenum before clipping right gastric artery

4g. Step 6: Suprapancreatic Division & Lesser Curvature Mobilization

After transection of the duodenum, the right gastric artery and vein are exposed and divided. The
lesser omentum is divided, soft tissues around the hepatic arteries are dissected (LN 5, 7, 8, 9,
12a), the soft tissues up to the diaphragmatic crus are dissected (LN 1, 3), and the lymph nodes
around the splenic artery are taken (11p).

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Instrumentation & Settings
 30 down endoscope, large Hem-o-lok clips, Echelon endolinear stapler with 60 mm blue
cartridge, gauze
 Harmonic ACE Curved Shears, Maryland Bipolar , Cadiere Forceps , swap  or  for
Large Clip Applier when necessary
 Valleylab Force FX (monopolar Pure Cut 35 W, monopolar coag fulgurate 35 W, bipolar standard
70W), Ethicon Harmonic ultrasound (min 3, max 5)

Steps
 Identify the root of the right gastric artery and vein and skeletonize around the vessels to
ensure proper clip application [Figures 31, 32].

Figure 31: Skeletonization of right gastric artery

Figure 32: Right gastric artery

 Clip and transect the right gastric vein and artery at their roots.
 Retract the liver using the instrument arm , padded by gauze to prepare the dissection of
the gastrohepatic ligament. Releasing this area will aid in the dissection of the left gastric
vessels.
 Dissect the soft tissues and posterior attachments along the gastro-hepatic ligament toward
the left side of the esophagus-hiatus area [Figure 33a, b].

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 B

A C
Figure 33 a-c: Dividing gastrohepatic ligament (a, b) and hepatoduodenal ligament (c) to release the
area for easier soft tissue dissection around the portal and left gastric vessels

 Slightly reduce the liver retraction when approaching the medial side of the proper
hepatic artery. Dissect the soft tissues around the artery to begin 8, 12a.
 Retract the common hepatic artery by grasping the tissues (containing the vagus nerve)
around the artery to expose the portal vein [Figure 34].

Figure 34: Exposure of portal vein

 Complete the dissection of the soft tissues (LN 8, 9, 12a) around the proper and common
hepatic artery and portal vein until the left gastric vein is identified [Figure 35].

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Figure 35: Complete dissection of lymph nodes 8 and 12a around common and proper hepatic artery
(Medial side of portal vein is pictured)

 Identify and prepare the left gastric vein on the posterior side of the common hepatic
artery for clip placement and transection [Figure 36].

Figure 36: Identify and prepare left gastric vein for clip placement

 Place three clips on the left gastric vein using the two Large Clip Appliers
interchangeably.
 Divide the left gastric vein and continue the dissection along the plane of the common
hepatic artery (connecting the dissection to the previous one) for lymph node 9 [Figure
37].

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 Figure 37: Dissecting root of left gastric artery, lymph nodes 7,9

 Skeletonize the left gastric artery, noting that there are many nerve tissues around this artery.
D2 lymph node dissection does not lend itself to nerve preservation.
 Place four clips on the left gastric artery: three on the patient side and one on the specimen
side [Figure 38].

Figure 38: Ligating the left gastric artery

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 Carefully divide the left gastric artery using the Harmonic Curved Shears [Figure 39].

Figure 39: Dividing the left gastric artery

 Division of the left gastric artery is important as it allows for a more effective exposure for the
dissection of lymph node 11p.
 Use the Cadiere (instrument arm ) to provide the necessary counter-traction and the
Maryland Bipolar to create the proper angles necessary for dissection of the soft tissues along
the superior border of the pancreas and the proximal part of the splenic artery (lymph node
11p) [Figures 40, 41].

Figure 40: Start of soft tissue dissection along splenic artery using all three arms for exposure and
creating the proper angles

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 Figure 41: Progressing with the dissection of 11p, taking care not to damage the pancreas

 Use the instrument arm  padded with gauze to move the pancreas down. This provides
the best possible exposure for the soft tissues containing 11p. [Figure 42]

Figure 42: Using instrument arm , retract pancreas down exposing the splenic artery

 Dissect along superior border of pancreas and splenic artery until the posterior gastric
artery is reached to ensure removal of 11p [Figure 43, 44].
o Note: dissect at least 5 cm along the splenic artery for patients who do not have a
posterior gastric artery.
 Ligate (clip x2) and divide the posterior gastric artery for a total gastrectomy.

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 Figure 43: Dissecting along splenic artery

Figure 44: Complete dissection of suprapancreatic area

 Retroperitoneal attachment of stomach is detached to right diaphragmatic crus, completing

the removal of the perigastric lymph nodes (LN 1, 3) [Figure 45].

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 Figure 45: Dividing lesser omentum up to right side of esophageal hiatus

 Approach the lesser curvature side to complete the celiac lymph node dissection (LN 9).
 Complete the soft tissue dissection along the lesser curvature until the transection line is
reached [Figure 46].

Figure 46: Soft tissue and lymph node dissection is complete when the transection line is reached.

Tips
 Use gauze to help retract the liver with instrument arm  to avoid liver injury.
 Do not use active blade of Harmonic in direct contact with vessels; rotate the Harmonic ACE
Curved Shears away from vessels while skeletonizing.
 Utilize the articulation and grasping capabilities of the Cadiere and Maryland to help create
the proper dissection angles for the non-wristed Harmonic.
 Rotate the camera to see the posterior side of the left gastric artery.
 Switch the Cadiere and the Harmonic instrument arms if needed to achieve the proper
angle for dissection.
 Maintain dissection plane by using grasping capabilities of the Harmonic to help regrasp the
tissue
 There are two ways to remove lymph nodes 1 and 3: (1) Posterior side approach described,
(2) Anterior wall of stomach, which keeps the dissection plane from before.

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4h. Step 7: Gastric Resection
The stomach is transected using endolinear staplers from the assistant port for a distal
gastrectomy, or further mobilized and the esophagus transected using the Harmonic ACE Curved
Shears for a total gastrectomy.

Instrumentation & Settings

 30 down endoscope, large Hem-o-lok clips, Echelon Endolinear Stapler with 60 mm blue
cartridge, gauze, LapBag, bulldogs
 Harmonic ACE Curved Shears, Maryland Bipolar , Cadiere Forceps , swap  or  for
Large Clip Applier when necessary
 Valleylab Force FX (monopolar Pure Cut 35 W, monopolar coag fulgurate 35 W, bipolar standard
70W), Ethicon Harmonic ultrasound (min 3, max 5)

Distal Gastrectomy
 Introduce the Echelon Endolinear Stapler with 60 mm blue load through the assistant port.
 Use the EndoWrist grasping instruments to orient the stomach resection line within the jaws of
the stapler and fire first load [Figure 47].

Figure 47: Orient the stomach within the jaws of the stapler

 Load another 60 mm blue cartridge onto the Echelon Endolinear Stapler and again use the
EndoWrist grasping instruments to orient the tissue within the jaws [Figure 48]. Be certain to
maintain a straight line and to ensure that the staple tip is free of tissue.

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 Figure 48: Second load of the stapler for gastric transection. Note the bottom of the staple jaw (blue
cartridge) can be seen to ensure the tip is clear of tissue.

 Remove the stapler and have the assistant bring in the LapBag through the assistant port.
 Use the Endowrist instruments to place the resected stomach and dissected lymph nodes (en
bloc) into the specimen bag, tie off, and place aside for later removal [Figure 49].

Figure 49: LapBag for specimen removal.

Tips
 It can be difficult to create space for stapler when the patient is small/thin. Pull back
assistant cannula and utilize EndoWrist instruments to place tissue on stapler.
 Use bipolar on staple line if bleeding.

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Steps - Total Gastrectomy:

Figure 50: Schematic of total gastrectomy resection lines, tumor location and placement of bulldogs for
esophageal transection

 Continue the dissection from Step 6 to completely mobilize the esophagus [Figure 51].

Figure 51: Mobilize the esophagus.

 The assistant places two bulldog clamps across the esophagus and the Harmonic ACE
Curved Shears are used to transect the esophagus between the clamps [Figure 52].

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 Figure 52: Transect esophagus between bulldog clamps.

Tip
 Swap the Harmonic instrument to arm  to attain the proper angle for transection

4i. Step 8: Reconstruction & Closure

The distal gastrectomy is performed with a fully robotic Billroth II reconstruction
(gastrojejunostomy). The total gastrectomy is performed with a partially robotic and partially
extracorporeal Roux-en-Y reconstruction (esophagojejunostomy and jejunojenostomy.)

4ii. Billroth II (Distal)

Instrumentation & Settings
 30 down endoscope, Echelon Endolinear Stapler, 60mm blue cartridges, suction-irrigator
 Harmonic ACE Curved Shears, Maryland Bipolar , Cadiere Forceps 
 Valleylab Force FX (monopolar Pure Cut 35 W, monopolar coag fulgurate 35 W, bipolar standard
70W), Ethicon Harmonic ultrasound (min 3, max 5)

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 Figure 53: Billroth II reconstruction (gastrojejunostomy)

Steps
 Identify the ligament of Treitz.
 Create an enterotomy in the jejunum 15-20 cm from the ligament of Treitz using the Harmonic
Curved Shears [Figure 54].

Figure 54: Enterotomy in jejunum with Harmonic ACE Curved Shears

 Create an enterotomy in the stomach remnant with the Harmonic ACE Curved Shears and have
the assistant use suction to remove any gastric contents [Figure 55].

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 Figure 55: Stomach remnant enterotomy

 Place the Echelon Endolinear Stapler first on the jejunum and then on the stomach using the
EndoWrist grasping instruments [Figure 56]. Approximate and fire the stapler [Figure 57].

Figure 56: Place jejunum and stomach on each jaw of stapler

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 Figure 57: Approximating the gastrojejunostomy

 Close entry hole with another blue load from stapler [Figure 58]

Figure 58: Closing the entry hole with a 60 mm stapler

 Remove the stump from the gastrojejunostomy through the assistant port
 Remove the liver sling, check for hemostasis, suction fluids, and remove all gauze pads,
needles, etc.
 Undock the patient cart and place the camera in the assistant port
 Remove the camera port and extend the incision 2-3 cm for specimen removal
 Check the specimen for margins and separate out lymph nodes [Figure 59]

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 Figure 59: (left) Lymph nodes and (right) specimen for distal gastrectomy

Tip
 If a different angle is required for the gastrojejunostomy or the closing of the common
hole, the instrument arm  cannula can be removed and replaced with a 12 mm
cannula (or the da Vinci stapling cannula kit can be used from the start: PN 420295)

4iii. Roux-en-Y (Total)

Instrumentation & Settings
 30 down endoscope, Endo GIA circular stapler, Echelon Endolinear Stapler with 60 mm white
cartridges, 2-0 polydioxanone suture on SH needle, suction irrigator, Alexis Wound Retractor
 Harmonic ACE Curved Shears , Maryland Bipolar , Cadiere Forceps 
 Valleylab Force FX (monopolar Pure Cut 35 W, monopolar coag fulgurate 35 W, bipolar standard
70W), Ethicon Harmonic ultrasound (min 3, max 5)

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 Figure 60: Schematic of Roux-en-Y reconstruction
Steps
 Place purse string suture around proximal end of esophagus using 2-0 polydioxanone (PDS)
sutures (25 cm long on SH needle) [Figure 61].

Figure 61: Purse string suture placed on esophageal stump.

 Measure 50 cm of jejunum and mark the serosa with Gentian violet or vital dye to distinguish
the efferent (-) and afferent (. . .) loops [Figure 62].

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Figure 62: Serosal marking with Gentian violet or vital dye to identify the efferent (-) and afferent (. . .) loops

 Undock and roll away the patient cart.

 Remove the assistant port and extend the incision 4-5 cm. Place Alexis Wound Retractor over
the incision [Figure 63].

Figure 63: Extending the assistant port 4-5 cm for specimen removal and extracorporeal reconstruction.
Place Alexis Wound Retractor in incision.

 Remove the specimen and gauze pads.

 Cut the jejunum at the marked locations and create the jejunojenostomy with a 60 mm white
cartridge linear staple. Place jejunum back into abdomen [Figure 64].

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 Figure 64: Create external jejunojenostomy and place back into abdomen

 Cut one fingertip off two different latex gloves. Place Endo GIA Circular Stapler through the
hole in one glove, and the Aesculap anvil holder through the hole in the other one.
 Cover wound retractor with the rubber glove with the anvil holder on it and re-establish
pneumoperitoneum to the abdomen [Figure 65].

Figure 65: Aesculap anvil holder in glove over wound retractor, circular stapler ready to be placed in
similar fashion

 Remove bulldog from esophageal stump.

 Place anvil into proximal end of esophagus. Secure anvil into place using purse string suture
[Figure 66].

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 Figure 66: Inserting (left) and securing (right) circular stapler anvil into place in proximal esophagus

 Remove the glove holding the Aesculap anvil holder.

 Remove the jejunum and make an enterotomy for the Endo GIA Circular Stapler.
 Secure stapler within jejunum by tying a rubber band around the jejunum at the area of
anastomosis and place the jejunum with attached stapler back into the abdomen [Figure 67].

Figure 67: Endo GIA stapler entering jejunum enterotomy

 Attach Endo GIA stapler to the anvil, ensure proper orientation and complete the
esophagojejunostomy [Figure 68].

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 Figure 68: Completing the esophagojejunostomy

 Insert the Echelon Endolinear Stapler with white load to close the entry hole in the jejunum
[Figure 69].

Figure 69: Closing the entry hole into the jejunum

 Remove the liver sling, check for hemostasis, suction up fluids, remove all gauze, remnants,
needles etc.
 Place drain on left side if desired [Figure 70].

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 Figure 70: Drain placed on patient’s left side for total gastrectomy (if desired)

 Transect specimen to check the specimen margins, and separate out nodes [Figure 71].

Figure 71: (left) Lymph node dissection and (right) opened specimen for a total gastrectomy

Tips
 Use camera arm in clutch mode to reposition the camera while laparoscopically suctioning
up fluid, checking for hemostasis, removing gauze pads etc.

5j. Step 9: Closing

 Close extended umbilical port (distal) with 2-0 polydioxanone sutures
 Close extended assistant port (total) with 1-0 polydioxanone sutures
 Close subcutis and cutis with interrupted 3-0 silk sutures and skin staples

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 Figure 72: Closure for a distal gastrectomy (left) and a total gastrectomy (right)

Tip
 Incorporate fascia into suture line to reduce risk of hernia

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5. POSTOPERATIVE CARE

 Postoperative pain management

 Dispense pain medication per usual postoperative regimen
 If patients desire, patient-controlled anesthesia through intravenous pain medication.

 Inpatient hospital follow-up and discharge should be based on surgeon‟s experience and
preference.
o All patients without serious comorbidity are cared for at the general ward after the
operation.
o If tolerable to the patient, water is given from postoperative day two, a liquid diet is
started on postoperative day three, and a soft diet is started on postoperative day
four.
o After one day of soft diet (at least three meals) with no complications, patients are
recommended for discharge.
 Outpatient hospital follow-up
o The first follow-up visit at outpatient clinic/OPD is usually on one week after
discharge.
o In cases of malignancy, following pathology review, counsel the patient concerning the
need for additional therapy or adjuvant radiation with or without chemotherapy as
indicated.
o Regular follow-ups after first visit are scheduled every three months for two years,
every six months for the subsequent three years, then every 12 months.

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APPENDIX A

Cannula Remote Center Setup

To correctly place the remote center, the thick black line on the da Vinci cannula (which indicates the
remote center) should be inserted within the boundaries of the patient‟s body wall. Correct placement
will allow the robotic instrumentation to pivot through the incision with the least friction and highest
precision, which will minimize tissue trauma (Figure a, below).

Correct placement of the cannula should be verified by looking at the cannula tip with the endoscopic
camera (cannulae should always be placed under endoscopic camera view). Only the first thin line at
the distal cannula tip should be visible. This indicates that the remote center is placed correctly within
the boundaries of the patient‟s body wall (Figure b, below).

If the thick black line on the cannula is seen in the endoscopic view, this means that the remote center
is set incorrectly (inserted too deeply). Setting the remote center incorrectly will increase friction,
reduce precision and increase tissue trauma at the port site (Figure c, below).

Figure A1: Proper placement of the instrument’s cannula remote center

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Page 54 of 54 da Vinci® Gastrectomy Procedure Guide PN 873058 Rev B 8/13