Роботическая или лапароскопическая рукавная резекция желудка: предварительные данные и обзор литературы

Резюме

Актуальность. В последние годы рукавная резекция желудка (РРЖ) приобрела широкую популярность. Благодаря своей безопасности, осуществимости и хорошим результатам лапароскопическая РРЖ (ЛРРЖ) остается одним из самых распространенных методов лечения патологического ожирения. Другим, пока менее распространенным, но также осуществимым методом хирургического лечения при патологическом ожирении является роботическая РРЖ (РРРЖ). Настоящее исследование было проведено с целью выявить и оценить различия этих вмешательств. 

Материал и методы. С мая 2017 по май 2019 г. 34 пациента с патологическим ожирением получили лечение в отделении терапии и хирургии Университета Фоджи; мы сравнили группы пациентов, получивших ЛРРЖ или РРРЖ.

Результаты. Были проанализированы данные 34 пациентов, прошедших РРЖ, из них 25 женщин, медиана возраста составила 42,5 года; 11 получили РРРЖ, 23 ЛРРЖ. Исходно средний индекс массы тела (ИМТ) составил 45,9 кг/м2, масса тела - 128,7 кг. Среднее время операции - 135,9 мин при РРРЖ (включая время соединения) и 107,39 мин при ЛРРЖ (p=0,0449). Медиана продолжительности госпитализации между группами не различалась и составила 5,38 дня (p=0,89). Летальные исходы и случаи конверсии отсутствовали. Только 1 пациенту проведена повторная операция - РРРЖ после неудачного бандажирования желудка. Были зафиксированы 4 послеоперационных осложнения: 1 случай несостоятельности линии шва потребовал хирургического вмешательства, 2 кровотечения и 1 инфицирование порта, потребовавшие применения медикаментозной терапии. За период наблюдения продолжительностью 1 мес частота снижения избыточной массы тела у 34 пациентов составила 19,43%: 16,42% в группе РРРЖ и 21,64% в группе ЛРРЖ (p=0,1969); за период наблюдения до 6 мес частота снижение избыточной массы тела у 11 пациентов увеличилась до 44%: 42,75% в группе РРРЖ и 46,19% в группе ЛРРЖ (p=0,6951). Обсуждение. Обнаружено 14 статей, опубликованных с 2011 по 2016 г., описывающих ЛРРЖ и РРРЖ как два альтернативных метода бариатрической хирургии. Статьи, включенные в настоящее исследование, позволили повысить оценку безопасности, эффективности и рентабельности каждого метода. Настоящее исследование демонстрирует, что РРРЖ и ЛРРЖ характеризуются хорошей переносимостью и эффективностью.

Заключение. Статистически значимых отличий продолжительности госпитализации, частоты снижения избыточной массы тела и развития осложнений при применении обеих методик не отмечено; среднее время длительности оперативного вмешательства в группе РРРЖ превышало аналогичный показатель группы ЛРРЖ, и это отличие было статистически значимо. РРРЖ - безопасное и эффективное вмешательство, характеризующееся удовлетворительными результатами, сравнимыми с ЛРРЖ. Для более точной сравнительной оценки необходимо провести более длительные исследования на большей выборке пациентов.

Ключевые слова:рукавная резекция желудка, бариатрическая хирургия, роботическая хирургия, лапароскопическая хирургия, ожирение, да Винчи

Финансирование. Исследование не имело спонсорской поддержки
Конфликт интересов. Тарталья Н., Павоне Д., Петрузелли Ф., Ди Лашья А., Вовола Ф., Маддалена Ф., Чианчи П., Ферсини А., Пачилли М., Амбрози А. заявляют, что у них нет конфликта интересов.
Этическое одобрение. Все процедуры, выполняемые в исследования с участием людей, проведены в соответствии с этическими стандартами институционального и/или национального исследовательского комитета и Хельсинкской декларации 1964 г. и последующих поправок к ней или сопоставимых этических норм.
Информированное согласие. Было получено информированное согласие от каждого участника, включенного в исследование.
Для цитирования: Тарталья Н., Павоне Д., Петрузелли Ф., Ди Лашья А., Вовола Ф., Маддалена Ф., Чианчи П., Ферсини А., Пачилли М., Амбрози А. Роботическая или лапароскопическая рукавная резекция желудка: предварительные данные и обзор литературы // Клиническая и экспериментальная хирургия. Журнал имени академика Б.В. Петровского. 2020. Т. 8, № 4. С. 7-15. DOI: https://doi.org/10.33029/2308-1198-2020-8-5-7-15 

Obesity has been recognized as a global epidemic by WHO, followed by many empirical evidences to prove its infectiousness. The overweight and obesity pandemic that affects the world surpasses 2 billion people [1]. According to the World Health Organization, more than 1.9 billion adults were overweight in 2016 and over 600 million with obesity [2]. Historically, the medical community defined excess weight and its associated health consequences using population-based anthropometric measurements, (i.e., sex-specific body weight and height using life insurance tables) [3-4]. However, these data only represented insured individuals based on normative standards without considering adiposity, and clinicians eventually abandoned these tables in favor of body mass index (BMI), which is a measure of body weight adjusted for height [weight (kg)/height (m2)].

In adults, classification systems [5] and obesity guidelines [6, 7] define healthy body weight as a BMI between 18.5 and 24.9 kg/m2, overweight between 25.0 and 29.9 kg/m2, and obesity ≥30 kg/m2.

Bariatric surgery procedures are indicated for patients with clinically severe obesity. Currently, these procedures are the most successful and durable treatment for obesity.

Bariatric surgery is recognized as the most effective treatment for morbid obesity, maintaining a stable weight reduction in the long term and reducing comorbidities, with a favorable impact on mortality [8-11].

Sleeve gastrectomy (SG) began to be used in 1988 as a variation of biliopancreatic diversion (BPD) with duodenal switch [12-14]. In contrast to the BPD described by Scopinaro et al. [15-17] in which a horizontal gastrectomy was performed, the pylorus and duodenum were preserved in SG, yielding a reduction in dumping symptoms and marginal ulcers. In addition, gastrectomy was more restrictive, permitting a decline in the malabsorptive component and nutritional secondary effects [13].

Available data shows peri-operative patient oriented advantages of laparoscopy when compared with open surgery, and these include a shorter hospital stay, decreased postoperative pain, enhanced postoperative recovery, and other parameters [15]. However, conventional laparoscopy comes with certain general technical limitations, which are amplified by the complexities that accompany obese patients. In terms of surgical challenges, these include space constraints, often caused by increased liver size and intra-abdominal fat, and a thick abdominal wall, which aggravates difficulties in handling manual instruments used in minimally invasive surgery. In addition, obese patients often suffer from concomitant metabolic syndrome and other significant comorbidities that might lead to difficulties during anesthesia as well as an increased risk for post-operative complications [18-20]. In that context, current literature shows that the overall complication rates of laparoscopic bariatric surgery are as great as 20%, and leak rates are as great as 5.1% [21-23].

Advantages of using the robotic system can include not only faster recovery, reduced pain, and a shorter hospital stay, but also, for the surgeon, greater dexterity and precision in tissue manipulation in anatomical regions that are difficult to access, resulting in fewer conversions [24], and probably fewer short term complications in several surgical fields, including bariatric surgery [25-27].

Methods

From May 2017 to May 2019, 34 patients with morbid obesity are admitted to the Department of Medical and Surgical Science, University of Foggia and we have compared patients undergoing robotic bariatric surgery with the group submitted to conventional laparoscopic surgery. Inclusion criteria are: age ≥18 years, body mass index (BMI) of ≥35-39 kg/mwith one obesity-associated co-morbidity or BMI ≥40 kg/m2. Before surgery, patients completed a standardized psychological and physical assessment which includes blood chemistry tests, chest X-ray, electrocardiogram, nutritional examination, cardiological examination, spirometry, esophagus-gastro-duodenoscopy, psychiatric examination.

Surgical Technique

The patient is placed in supine position with the arms extended, the robot is docked on the left of the patient, while anesthesia is positioned over the head of the patient. Prior to docking the robot, the patient is placed in the reverse Trendelenburg position at 15°-20°. Four trocars for robotic arms plus an assistant AirSeal trocar are placed. The camera trocar, which is a 12 mm long trocar, is positioned above the umbilicus. Two 8 mm robotic trocars, are positioned at the anterior axillary line on both sides and just above the level of the camera port and another 5 mm robotic trocar on the left hemiclavear line just below the costal arch. A 12 mm AirSeal port for the assistant is then placed approximately halfway between the line from the umbilical port to the left robotic port (fig. 1-2).

Fig. 1. Trocars position in robotic approach

Fig. 2. Robotic sleeve gastrectomy

The pylorus must be identified as a first step. Approximately 6 cm proximal to the pylorus, the vascular attachment of the gastrocolic ligament is divided with the use of an energy source such as the Harmonic scalpel. Once it is decided the area where the dissection is going to begin, the console surgeon grasps the stomach with a bowel grasper and gently elevates it while the assistant provides counter traction of the gastrocolic ligament. To avoid injuries of the underlying colon it is important to stay close to the stomach. Once the lesser sac is entered, the dexterity of the console surgeon's left grasper allows easier orientation of the Harmonic scalpel along the greater curvature. Another option is to tuck the left grasper under the stomach and elevating it for further exposure. The dissection continues to cephalic toward the angle of His and the short gastric vessels. Once the short gastric vessels are located, we must be very careful to avoid trouble some bleeding. Here is where the high definition, three dimensional view of the robot provides an important advantage. Another option is to divide the short gastric vessels after completing the gastric stapling portion, which allows the specimen to be retracted laterally and the vessels to be approached medially, which often provides a better and safer exposure for dividing the gastrosplenic attachments and the short gastric vessels. After the short gastric vessels are divided at the upper pole of the spleen, the attachments between the fundus and left crus must be divided in order to avoid a large fundus at the superior portion of the stomach (neofundus) and to clearly identify the gastroesophageal junction and to avoid stapling close to this area. Mobilization is not complete until the lesser curvature vessels are identified from the posterior aspect of the stomach. This will avoid a larger than intended sleeve construction. Once the vessels are divided and the stomach is well mobilized, the creation of the gastric sleeve begins. First the anesthesiologist has to remove every orogastric tube or probe and pass carefully the 40 Fr orogastric bougie which will be used to calibrate the gastric pouch.

The assistant surgeon provides lateral traction of the stomach, while the console surgeon, with the aid of the articulating bowel grasper, guides the bougie into the proximal duodenum. Once the calibration bougie is in place, the transection begins. It is important to pay attention to the angle of the stapler and its proximity to the incisura angularis. Because of the tissue thickness in this area, the first firing should be performed with a green cartridge of 60 mm stapler. The console surgeon again retracts the tip of the bougie medially toward the duodenum with the articulating left-hand grasper and lateral retraction of the greater curvature with the right hand. The assistant bedside surgeon then introduces the stapler. The stapler is placed across the antrum in a more horizontal than vertical orientation. This technique allows a "wide turn" at the area of the incisura, obviating a stricture or spiraling. The transection continues proximally along the lateral edge of the bougie while maintaining lateral symmetrical traction. This is important to avoid letting the staple line to spiral either anteriorly or posteriorly because this can lead to a functional obstruction. This step is greatly facilitated by the dexterity and maneuverability of the robotic wristed instruments. The final critical step is the completion of the transection at the angle of His. Most bariatric surgeons generally stay away from the gastroesophageal junction during the last staple firing in order to avoid a leak in this area which can be catastrophic. However, leaving too large a fundus can also be a problem because it can lead to insufficient weight loss or incapacitating gastroesophageal reflux this portion of the transection can be performed with a gold cartridge.

A tubular drain is placed and the resected stomach is removed via the umbilical site. As always, this fascial site should be closed to prevent an immediate postoperative incarcerated incisional hernia.

 Results

We have analyzed 34 patients underwent sleeve gastrectomy with a mean age of 42.5 years, 8.82% aged <29 years, 32,35% aged between 30 and 39 years, 29.41% aged between 40 and 49 years, 26.47% aged between 50 and 59 years and 2.94% aged >60 years. 25 patients were female; 11 treated with robotic approach and 23 with laparoscopic approach. The initial mean body mass index (BMI) was 45.9 kg/m2 (mean robotic BMI was 46.68 kg/m2 and mean laparoscopic BMI was 45.53 kg/m2) and initial mean weight was 128.7 kg. The mean operative time was 116.61 min: 135.90 min for RSG (including docking time) and 107.39 min for lSG (p=0.0449) (fig. 3). The median length of stay was 5.38 days: 5.45 days for robotic group and 5.34 days for laparoscopic group (p=0.89). Mortality and conversions were nil. We have reported only 1 case of re-do surgery in a patient underwent to RSG after failure of gastric banding. We have observed only 4 cases of post-operative complications: 1 leak treated with surgical approach and 1 endoluminal bleeding treated with medical therapy in patients underwent to lSG, 1 abdominal bleeding and 1 port-site infection underwent to medical treatment in patients underwent. Follow-up at 1 month (fig. 4) from the recovery in 34 patients has showed an EWL (excess weight loss) 19.43%: 16.42% for robotic group and 21.64% for laparoscopic one (p=0.1969); follow up at 6 months (fig. 5) in 11 patients has detected an EWL 44%: 42.75% for robotic group and 46.19% for laparoscopic one (p=0.6951).

Fig. 3. Operative time

Fig. 4. EWL at 1 months

Discussion

The concept of robotic surgery appeared in the 90's with the main objective of rendering possible distant procedures in battle fields, launching the principles of "telesurgery" [28-29]. Since its military applicability did not develop as initially expected, robotic surgery technology was modified towards the development of equipment which could align the excellent quality of high definition 3D-image, the intuitive movements of the open surgery and the precision, refinement and minimally invasive aspects of laparoscopic surgery. This combination seems to be very useful and beneficial in advanced and complex gastrointestinal surgeries, such as bariatric surgery [30-33].

Full mobilization of the greater gastric curvature can sometimes be quite tricky, especially as dissection approaches the uppermost part of the gastro-splenic ligament, and can become even more difficult when a sliding hernia is present. Failure to mobilize the herniated part of the stomach from the left crus results in retention of part of the gastric fundus, which in turn is considered one of the main reasons for poor postoperative excess weight loss. Additionally, an unclear view of this area during the application of the stapler can lead to a partial esophageal resection, predisposing in this way to a high leak from the staple line. All these technical difficulties can be even more pronounced when operating on super obese patients. The application of the robotic surgical system to lSG can help the surgeon overcome all these potential problems [34].

This literature review identified 14 articles [35-38] describing lSG and RSG as two alternative bariatric procedures, measuring the patients' outcomes and published between 2011 and 2016 (tabl. 1, 2). The articles included in this study bring us closer to linking the implementation of either method with improved standards of safety, efficiency and cost-effectiveness. The present study demonstrates that RSG and lSG are well-tolerated, feasible and effective surgical approaches.

Table 1. Characteristics of the studies that were finally included in the review for RSG (robotic sleeve gastrectomy) and LSG (laparoscopic sleeve gastrectomy)

Note. N/A not available, R retrospective, P prospective, LSG laparoscopic sleeve gastrectomy, RSG robotic sleeve gastrectomy, OT operative time, LOS length of stay

Table 2. Comparison of reported series of the intraoperative parameters and outcomes of every study for RSG (robotic sleeve gastrectomy) and LSG (laparoscopic sleeve gastrectomy)

Note. N/A not available, R retrospective, P prospective, LSG laparoscopic sleeve gastrectomy, RSG robotic sleeve gastrectomy, OT operative time, LOS length of stay.

We have compared mean age, mean preoperative BMI (kg/m2), bougie diameter (Fr), length of hospital stay (days), mean operative time (min), conversion rate (%), EWL 1 month (%), EWL 6 months (%).

According to previous studies [49-50], robot-assisted procedures are associated with greater mean operative time, due to the increased setup time. This is in accordance with our outcomes. In fact, in our study, mean operative time was greater in the RSG group. Mean length of hospital stay was significantly greater in the RSG group in these studies, instead in our experience was the same for both group. Moreover, both techniques are associated with small and comparable rates of complications and conversions, being significantly safe. Since stapling phase, in both groups, is not robotic, it would be interesting to examine the technique of oversewing or buttressing. However, the available data were not sufficient to address this technical aspect. leaks and hemorrhage are the main risks of bariatric procedures, due to the long stapled lines and gastrointestinal anastomosis. According to our findings, the incidence of complications were comparable between the two groups. No significant differences were reported for % EWL at 1    month and 6 month was comparable between the 2    methods.

Conclusions

The key advantage of the currently available robotic technology for minimally invasive bariatric surgery is the technical ease of complex laparoscopic maneuvers. In our study there aren't significant differences between the robotic and laparoscopic groups in terms of length of stay, EWL and complications, except for the mean operative time that is slightly higher in the robotic group and this difference is statistically significant. RSG proved to be a safe and efficient procedure, with satisfactory results comparable to LSG. longer and larger studies are needed for a better comparative evaluation.

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ГЛАВНЫЙ РЕДАКТОР
ГЛАВНЫЙ РЕДАКТОР
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Медицина сегодня
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