Robot-Assisted Total Gastrectomy with Radical Lymphadenectomy in a Patient with Replaced Left Hepatic Artery

Authors
Lin Jinlin, Lee June, Ching Siok Siong, Annalisa Ng Ya-Lyn, Wong Siang Yih Andrew

Affiliations Department of Surgery, Changi General Hospital

Introduction
Gastrectomy with radical lymphadenectomy (D2) is the standard treatment for patients with gastric adenocarcinoma. The use of minimally invasive approach to gastrectomy has been shown to result in better short-term outcomes (e.g. pain, recovery time, length of hospital stay and wound complications) with comparable long-term oncological outcomes (e.g. overall survival and disease free survival). However, the use of conventional laparoscopic approach to perform present several challenges, especially in patients with aberrant anatomy. The use of robotic platform could overcome some of these challenges with enhanced visualization, improved dexterity, and stability for dissection.

Methods/Results
We present a case of a patient with esophago-gastric junction (EGJ) adenocarcinoma. Staging investigations revealed no evidence of locoregional or distal metastases. Aberrant vascular anatomy was also noted on staging CT scan, with the replaced left hepatic artery originating from the left gastric artery. The patient underwent robotic total gastrectomy with radical lymphadenectomy, using the DaVinci Xi Surgical System (Intuitive Surgical Inc., Sunnyvale, CA). The video demonstrates several critical advantages of the robotic platform in the surgery: the use of Firefly fluorescence imaging for tumor localization to ensure adequate resection margins, the fully wristed dexterity from EndoWrist instruments for adequate lymphadenectomy while preserving the replaced left hepatic artery and for performing reconstruction (Roux-en-Y esophago-jejunostomy).

Conclusion
There use of robotic platform enabled us to successfully overcome the challenges in this complex case. Despite the need to overcome the learning curve and the increased financial cost associated with using the robotic platform, it can be useful in complex oncological resection for selected patients.