Robotic Esophagectomy

Robotic esophagectomy is a procedure performed to treat esophageal cancer by surgically removing the diseased portion of the esophagus (the foot-long tube connecting the back of the throat to the stomach). Robot-assisted surgery is increasingly being used to treat this condition, since it allows for the complete mobilisation of the intra-abdominal esophagus and stomach without the need for a large abdominal incision resulting in less post-operative discomfort and scarring and faster recovery.

Robotic Adrenalectomy

Surgical removal of the adrenal glands is the proposed treatment for patients with adrenal masses that produce an increased amount of hormones and for primary adrenal tumours suspected of malignancy.

In the past, the open technique for adrenalectomy required a large incision of 15-30 cm in the abdominal wall, kidney or back. Today, thanks to minimally traumatic surgery, robotic adrenalectomy can be performed through 4 incisions, 7 mm each.

After robotic adrenalectomy, patients leave the hospital within one to two days and return to work much faster than patients recovering from the corresponding open surgery.

Robotic adrenalectomy is the evolution of laparoscopy, mainly because it aims to overcome some of the limitations of laparoscopic techniques.

The main advantages of robotic adrenalectomy include:

• the high precision and small size of the tools, which are able to mimic the human wrist and
• three-dimensional, stereoscopic high-resolution field imaging (3D, HD 1080i).

Only when considering the anatomical difficulty of these operations, in which all the vascular branches surrounding the organ must be carefully identified, we will be able to understand the necessity of robotic adrenalectomy.

Maintaining all the advantages of a minimally invasive method, robotic adrenalectomy offers less stress and faster recovery, fewer intraoperative blood loss, reduced postoperative pain, minimised post-operative complications associated with trauma, lower rates of postoperative respiratory and cardiovascular complications, better aesthetic effect, shorter duration of hospitalisation and rapid return to work.

Robotic SingleSite Cholecystectomy

Single site surgery is at the forefront of minimally invasive surgery. With the development of technology, the design of thinner flexible tools, and the adaptation of the da Vinci XI HD, Edition 2019 robotic system to a dedicated platform, single site surgery is now gaining acceptance and popularity.

Single site Robotic Cholecystectomy is performed at the hospitals of Athens Medical Group using the da Vinci Xi HD robotic system.

The surgery is performed entirely through a 1.5 cm incision while its average duration is 40 minutes. Wound minimisation, thanks to robotic cholecystectomy, eliminates post-operative discomfort for the patient and shortens recovery.

For the patient who wants to minimise scarring, single site Robotic Cholecystectomy offers the best choice.

In the classical laparoscopy for cholecystectomy four incisions are required to introduce all the necessary tools as well as the special camera, the laparoscope into the abdomen.

Today, with Single Site Robotic Surgery, the laparoscope and all the tools come through a single small incision on the navel.

The preparation of the patient for robotic cholecystectomy generally follows the same principles as conventional laparoscopy.

Robotic Gastrectomy

Minimally traumatic surgery is currently proposed by internationally recognised surgical teams as a means of improving postoperative effects in patients undergoing gastrectomy for stomach cancer, especially when the disease is at an early stage.

Unfortunately, conventional laparoscopic techniques are not widely accepted due to the technical difficulties that arise, particularly from non – experienced groups and especially during lymph node cleansing.

Lymph node cleansing has been shown to be feasible endoscopically. However, even when it is performed by experienced surgeons, it remains a technically difficult procedure, associated with increased rates of intraoperative problems, such as bleeding especially during preparation around large vessels (liver, abdominal and spleen arteries).

As there is an ever increasing literature claiming that extensive lymphadenectomy can be applied with low morbidity, oncology centers of international repute suggest the da Vinci robotic system as a means of facilitating the endoscopic approach of gastrectomy and lymph node removal for cancer.

The robotic system greatly facilitates the recognition of anatomy, mobilisation and preparation of the stomach, localisation and cleansing of the lymph nodes, and the avoidance of complications during surgery.

A benign lesion of the gastric wall can be removed by wedge-shaped resection, that is, without removing part of the stomach: the gastric wall is opened, the mass is removed to healthy limits and the wall is stiched by means of the robotic system.

For stomach masses, peripheral gastrectomy is performed, while for more central masses, subcutaneous or total gastrectomy is performed along with lymph node cleansing.

Robotic Pancreatectomy

Surgery is critical in the management of pancreas cancer, and great advances in the surgical management of that disease have been made in the last few decades.

Most recently, minimally invasive approaches have been applied to pancreas surgery, including the use of the da Vinci robot. These minimally invasive approaches allow for smaller incisions, a shorter hospital stay, and a quicker return to normal activities.

In addition, for those in need of additional treatments after surgery such as chemotherapy or radiation therapy, robotic surgery and other minimally invasive approaches can allow for less delay in starting treatments as the patient recovers from surgery.

Pancreatic surgery with spleen preservation, is a difficult field. The difficulty is doubled when the pancreatic head is approached in a Whipple surgery.

The safety and stability of the Xi HD robotic system is more useful than ever in the case of pancreatic surgery.

Significant international medical success has been achieved at the hospitals of Athens Medical Group with the performance of robotic Whipple surgery, with absolute success in two patients aged 58 and 84 years with jaundice-producing pancreas.

The surgical team performed a specialised preoperative test in which the precise location of the tumour (in both cases was located in the pancreas) and the vasculature of the area was studied in detail.

During this preoperative check, the anatomy of the entire area, in a three-dimensional model, was imprinted on the clinic’s computer. There, the surgery was designed step by step, with the aid of a preoperative rehearsal.

With special treatment, the necessary information was transferred to the DaVinci Xi HD Robotic System in order to be used as Augmented Reality Aided Robotic Surgery.

In the context classical surgery these patients would have been considered unsuitable for surgery, mainly because of the general situation in one case and the age in the other.

In the cases of these two patients the anastomoses were performed within the abdomen, avoiding large incisions.

The final result was 5 cuts of 5 mm each and one of 3 cm. Both patients were discharged within a week without problems.

Robotic Splenectomy

Robotic splenectomy is a daily practice in the Robotic Surgery department with surgeons regarded as some of the most experienced in the world in dealing both in adults and children.

Minimally traumatic splenectomy (laparoscopic or robotic) is indicated in the following cases:

• hematological diseases such as: idiopathic thrombocytopenic purpura, thrombotic thrombocytopenic purpura, myeloid metaplasia, hereditary spherocytosis, sickle cell anemia, Mediterranean anemia, autoimmune hemolytic anemia,
• injuries,
• spleen neoplasms,
• cysts,
• pseudocysts,
• lymphoma,
• secondary hyperplasia,
• splenic abscesses.

Preoperatively robotic splenectomy requires proper tests. Imaging methods (ultrasound, CT or MRI) determine the anatomy of the area. Thanks to daVinci’s TILEPRO technology, digital angiography images can be displayed within the robotic system for better orientation of the surgeon in navigation.

During robotic splenectomy, the spleen is removed and the peritoneal cavity and intra-abdominal organs are checked in detail.

The main advantages of the robotic splenectomy method are that the surgery is bloodless, postoperative pain is minimised, the patient’s stay in the hospital is significantly reduced, the probability of complications is reduced and the aesthetic effect is better.

Robotic Colectomy

Colectomy is the surgical removal of part or all of the large intestine.

In the total colectomy, the entire colon is removed and the auricular anastomosis is made, thus the small intestine with the anus is joined (Pouch).

In some, rare cases, permanent ileostomy occurs.

In partial (partial) colectomy, only the part of the intestine where the problem is detected is removed.

Classical “open” colectomies are particularly traumatic operations as the surgeon is forced to carry a large incision in the abdomen to access many of the viscera in order to reach the large intestine.

Thus, “surgical trauma” is important and patients experience a frequent and difficult recovery period.

In laparoscopic colectomies, the surgeon makes 4 or 5 small incisions of 5 mm each, and from which the specialised laparoscopic surgical instruments are introduced.

The laparoscope, a tiny telescope attached to a camcorder allows the surgeon to see the patient’s internal organs enlarged on a television screen.

In the case of robotic colectomy the surgical field is stable and the surgeon feels great freedom in his hands.

In addition, with robotic colectomy, intra-abdominal anastomosis (joining the colon after removal of the affected part) is performed with greater comfort and safety than laparoscopy.

Recent studies have suggested that robotics can provide lymphatic cleansing around the lesion area, potentially offering an oncological advantage in the case of malignancy.

The new firefly technology “illuminates” the affected lymph nodes.

Conclusively, robotic colectomy offers smaller surgical trauma, less blood loss, faster restoration of bowel function, less postoperative pain, aesthetically better result, shorter hospital stay, faster return to a solid food diet, shorter return to daily activities and probably better oncological results.

OTHER Applications of Robotic Surgery

Gastroesophageal Reflux Disease

Some of the most common diseases of the gastrointestinal tract that are treated using the Robotic System is gastroesophageal reflux disease and hiatal hernia.

The worst complication of gastroesophageal refux disease is the development of Barrett’s esophagus (pre-cancerous condition) or even adenocarcinoma. This is prevented the reflux is stopped surgically.

Until recently, the surgery required a large incision in the abdomen that caused post-operative pain while the recovery took six weeks or more. Today all this belongs to the past thanks to robotic stomach tholoplasty surgery.

Prior to the robotic tholoplasty operation, a careful and complete esophageal study is performed with manometry, pH-meter and gastroscopy.

Robotic tholoplasty surgery is about the strengthening of the sphincter valve between the esophagus and the stomach by wrapping the highest point of the stomach around the lower esophagus.

Also, the hiatal hernia is removed and corrected. As in laparoscopy, during robotic surgery 4-5 small incisions (5 mm each) are made on the skin without cutting the muscles of the abdominal wall.

The laparoscope, which is connected to a dual HD camera, enters the abdomen, giving the surgeon an enlarged stereoscopic image of the internal organs in the special robotic console.

Studies have shown that patients are relieved of gastroesophageal reflux symptoms or have a clear improvement right after surgery.

The intraoperative complications of Robotic Tholoplasty are null to experienced surgeons. The great advantages of robotics are: reduced postoperative pain, less hospitalisation, quick return to work and improved aesthetic result.

Over 97% of patients are fully satisfied and these are patients who often recommend surgery to other sufferers.

Esophageal Achalasia

Esophageal achalasia is characterised by the absence of peristaltic movements in the lower part of the esophagus and by the incomplete relaxation of the lower esophageal sphincter after swallowing.

The use of a robotic system in esophageal achalasis has shown not only that it has results comparable to those of laparoscopic operations, i.e. less postoperative pain and less recovery time, but also it can eliminate the likelihood of complications.

Hernias

The most appropriate and effective treatment approach for hernias is robotic surgery with grid placement. Laparoscopic or robotic hernia restoration has significant advantages over classical open surgery.

The robotic laparoscope’s camera shows a three-dimensional image of the patient’s internal organs in magnification and high resolution. So the hernia repair surgery is completely bloodless, as the vessels are easily identified and cauterised.

In each case a grid is placed. The small, almost invisible, 5-6 mm incision through which the robotic tools enter, is made only on the skin and not on the muscles as required in classical open surgery.

In robotic surgery there is almost total absence of postoperative pain. The patient’s stay in the hospital is limited to a range of only a few hours, up to a maximum of one day. The patient can walk and sit on the same day of the operation, and the return to work and day-to-day activities takes place very quickly.

During robotic hernia restoration, inflammation, or postoperative infections occur rarely. In fact, all signs of the surgery disappear completely over the course of a few weeks.

Bilateral inguinal hernia can be restored using with the same incisions. Also, robotic surgery is ideal for:

• restoring inguinal hernia that has relapsed after previous “open” surgery.
• strengthening the abdominal wall in athletes (Injury to the inguinal country accounts for between 2 and 5% of all sports injuries). Early diagnosis and proper treatment of hernia are of great importance in order to avoid chronic problems, with disastrous consequences for the athletes’ career.