BAOJ Medical and Nursing

Using of Robot-Assisted Single Incision with Single Port Platform for Resection of Gastric Duplication Cyst

Cheng-Ming Peng1,2, Hsin-Cheng Liu1, Yang Yao Kun1, Ching-Lung Hsieh1, Wei-Hsin Chen1, Yi-JuiLiu2,3* and Ruey-Hwang Chou4,5*

1Da Vinci Minimally Invasive Surgery Center, Chung Shan Medical University Hospital, Taichung 40201, Taiwan2Ph.D. Program of Electrical and Communications Engineering, Feng Chia University, Taichung 40724, Taiwan

3Department of Automatic Control Engineering, Feng Chia University, Taichung 40724, Taiwan4Graduate Institute of Cancer Biology and Center for Molecular Medicine, China Medical University, Taichung 40454, Taiwan

5Department of Biotechnology, Asia University, Taichung41354, Taiwan

Cheng-Ming Peng, et al, BAOJ Med Nursing 2016 2: 32: 022

*Corresponding author: Yi-Jui Liu, Address: No.100, Wen-Hwa Road, Seatwen, Taichung 40724, Taiwan, ext. 7935, Tel: +886-4-2451-7250; E-mail: erliu@fcu.edu.tw

Ruey-Hwang Chou, Address: No.6, Hsueh-Shih Road, Taichung, 40454, Taiwan, ext. 3928, Tel: +886-4-2205-2121; E-mail: rhchou@mail.cmu.edu.tw

Sub Date: July 25, 2016, Acc Date: August 9, 2016, Pub Date: August 10, 2016.

Citation: Cheng-Ming Peng, Hsin-Cheng Liu, Yang Yao Kun, Ching-Lung Hsieh, Wei-Hsin Chen, Yi-JuiLiu and Ruey-Hwang Chou (2016) Using of Robot-Assisted Single Incision with Single Port Platform for Resection of Gastric Duplication Cyst. BAOJ Med Nursing 2: 022.

Copyright: © 2016 Cheng-Ming Peng, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

BAOJ Med Nursing, an open access journal Volume 2; Issue 3; 022

Case Report

AbstractBackground

Gastric duplication cyst (GDC) is not a common disease but most of the lesions can be treated by minimal invasive surgery (MIS). Single incision MIS needs more manual skills than conventional multiport operation. The advantage of better operation course is 3-dimensional vision and dedicate instrument, robot-assisted single incision operation has. This paper aims to evaluate the feasibility and safety of the robot-assisted single incision with single port platform for resection of gastric duplication.

Methods

The patient was supinely placed in reverse Trendelenburg position. The assistant surgeon was located between patient’s legs. Under general anesthesia a trans-umbilical 4.0cm skin incision was made. A single incision advanced access platform with Glove Port® (Nelis, S. Korea) combined with the da Vinci Si Surgical System (Intuitive Surgical, Sunnyvale, CA, USA) was performed. The three arms, No. 1, No.2, and da Vinci scope, were in dwelled through the Glove Port®. Pneumoperitoneum of 12mmHg was established through the port. A rigid 30-degree up scope was used during operation. After adequate dissection, the cystic lesion was resected en-bloc with Endo GIATM 30mm Tri-Staple (Covidien) without drain. Finally, umbilical incision was closed in layers.

Results

The operation took one hour with few blood lost. The patient got hospital discharge three days after operation smoothly. No complications were observed in clinic for six months.

Conclusions

Robot-assisted gastric resection using single port platform is feasible and safe surgery method. The total procedures by da Vinci Robotic system are safe and easily performed to resect gastric duplication in selected patients.

Keywords: Single Incision; Single Port; Robotic Surgery; Gastrointestinal Resection

IntroductionIn the past decade, minimally invasive surgery has been louched for minimizing the surgical trauma using reducing numbers and size of the ports. Recently, a novel technique using single port laparoscopy has been described [1]. Single port laparoscopy is executed by a single incision length 11 to 20mm in the umbilicus, reducing the surgical impact of minimally invasive surgery associated with conventional surgery [2]. Generally, the majority of laparoscopic single-port surgery is commonly used for cholecystectomy. Due to instrument upgraded, it could also be used in more complex operations, such as stomach, liver and pancreas resection [3-5].

Although there are many benefits of single-port laparoscopic operation, there are still few papers related to the method for gastrointestinal resections. Because the conventional laparoscopic single-port surgery has limited manual space [2,6], most operators have to overcome poor triangulation of instruments [1,4]. A novel single-site platform with the da Vinci Si Surgical System (Intuitive Surgical, Sunnyvale, CA, USA) has been successfully performed on some operations, including cholecystectomy, partial nephrectomy and myomectomy [7,8]. The use of a novel single-port platform

BAOJ Med Nursing, an open access journal Volume 2; Issue 3; 022

Page 2 of 4Citation: Cheng-Ming Peng, Hsin-Cheng Liu, Yang Yao Kun, Ching-Lung Hsieh, Wei-Hsin Chen, Yi-JuiLiu and Ruey-Hwang Chou (2016) Using of Robot-Assisted Single Incision with Single Port Platform for Resection of Gastric Duplication Cyst. BAOJ Med Nursing 2: 022.

based on Glove Port® is introduced to perform more complex operation and preclude the use of articulated instruments.

Duplications of the gastrointestinal system can be found throughout the gastrointestinal tract with frequency about 10%. However, because of the bleeding risk and malignant changes, surgical treatment is usually recommended for symptomatic cysts [9]. The objectives of this paper were to present technical details and evaluate the feasibility and safety of da Vinci Robot-assisted single incision with single port platform in one patient with gastric duplication.

MethodsThe 40-year-old woman has presented with epigastric pain since half a year. Measured 4.2 cm cystic lesion was found by ultrasonography. The further abdominal magnetic resonance imaging (MRI) revealed a well-defined homogenous tumor without prominent contrast enhancement over epigastric space, abutting esophagus, gastric cardia and caudate lobe of liver (Figure 1), suggesting enteric duplication cyst.

Figure 1: Awell-defined homogenous tumor without prominent contrast enhancement over epigastric space, abutting esophagus, gastric cardia and caudate lobe of liver. The tumor size was4.2x3.0 cm in size. (GD: gastric duplication, white arrow)

The sentence as above - The patient was placed in a supine and reverse Trendelenburg position with assistant surgeon between patient’s legs. The patient-side cart was placed on the patient’s cranial side. Under general anesthesia, a 4.0cm skin incision was made at umbilicus. A single-incision advanced access platform with Glove Port® (Nelis, S. Korea) was introduced through the wound. Three robotic arms (8-12mm) and one assistant port (12 mm) were introduced through the single port device (Figure 2). Pneumoperitoneum was established with CO2 at 12 mmHg. A 30-degree up scope was used during the operation.

ResultsAs shown at Figure 3, the left lobe of liver was lifted with robot

arm or assistance. The dense adhesions between the cystic lesion, esophagus and left lobe of liver were dissected. The cystic lesion was connected gastric wall and the diagnosis of gastric duplication was confirmed. After precise dissection, the gastric cystic lesion was resected en-bloc with Endo GIATM 30mm Tri-Staple® (Figure 4).

Figure 2: A single-incision advanced access platform with Glove Port®

(Nelis, S. Korea).

InstrumentportslayoutonGlove Porta. ®: clockwise from the top, a 12mm roboticcamera port, an 8.5mm robotic instrument ports, No.1, an 12mm laparoscopic assistant port, and No.2., an 8.5mm robotic instrument port.

Glove portb. ®was attached to the platform with three working ports (da Vinci No.1, No. 2 and camera port).

Figure 3. Robotic assisted single-port resection of gastric duplication

a. The internal view showed a cystic lesionadjacent to the left lobe of liver with a clear dissection plane;

b. The blunt dissection revealed that the cystic lesion fused with gastric wall and gastric duplication was diagnosed;

c. The internal view showedthat the gastric duplication was resected with Endo-GIATMTri-staple;

d. The resected line in esophageal and cardia line.

BAOJ Med Nursing, an open access journal Volume 2; Issue 3; 022

Page 3 of 4Citation: Cheng-Ming Peng, Hsin-Cheng Liu, Yang Yao Kun, Ching-Lung Hsieh, Wei-Hsin Chen, Yi-JuiLiu and Ruey-Hwang Chou (2016) Using of Robot-Assisted Single Incision with Single Port Platform for Resection of Gastric Duplication Cyst. BAOJ Med Nursing 2: 022.

Figure 4. Surgical specimen

a. The en-bloccystic lesion 4.2x3.0 cm in size with reddish and smooth lining;

b. The inner view of specimen with mucous.

The insurance of the staple line was confirmed, and the specimen was removed by umbilical access. No abdominal drainage tube was placed. The abdominal fascia and skin were tiered closed.

The patient tolerated enteral intake well after operation day 2. No immediate complication ensued during hospitalization. Patient woman has been dischargedon third postoperative day. Pathology report demonstrated that the GDC was benign lesion, which was same with our predictions from MRI diagnosis before surgery. The microscopic examination of the tissue sections showed gastric duplication cyst lined by ciliated, pseudo stratified smooth muscle layers and mucous glands. Pseudo stratified columnar ciliated epithelium (PCCE) has been observed in the patient with GDC originated from a foregut developmental malformation [10]. Recently, GDC boarded with gastric and respiratory ciliated epithelium was also reported in another 23-year-old man [11]. Outpatient’s follow-up endoscopy after six months showed a band-like protruded scar visualized in esophageal-cardiac (EC) junction (Figure 5). The abdominal skin wound was well healed and no complication was found in the following outpatient.

Figure 5. Follow-up images from an endoscopy

esophageal-cardiac (EC) junction (white arrow)a.

band-like protruded scar (white arrow)b.

Discussion and ConclusionGastric duplication cysts of stomach is about 4% of all alimentary tract duplication [12]. Approximately, the incidences of GD were 35% in ileum, 19% in esophagus, 10% in jejunum, and 7% in colon [13]. In our current case, the gastric duplication was benign cysts according to the pathological examination and no complications

were observed in clinic for six months. Although malignant gastric duplication cysts are rare [14-16], several previous studies have been reported malignant GD as adenocarcinoma [15], neuroendocrine tumor [17] and gastrointestinal stromal tumor [14,18].

Single-port laparoscopy could result in minimizing the scarring, less blood loss, faster recovery time, and reduced pain when compared with the conventional multi-port technique [19-21]. Most of the time; we use umbilicus as the port-site for cosmetic. However, single-incision with minimal invasive operation of high location lesion is much more difficult than conventional multiple-port method owing to limited manual working space and poor instrument triangulation. Arms of da Vinci system have firm and steady fulcrum. Instruments can be kept at adequate triangulation and avoid frequent collision. Besides, three-dimensional vision and dedicated instrument with 540-degree wrist make minimal invasive surgery more intuitive. Operation time decreases at the same time. In selected patients, robot-assisted single incision surgery is a safe and feasible method, which is difficult lesion for conventional laparoscopy. This new single port platform with Glove Port® and the da Vinci Si Surgical System may increase the adoption of single incision operations.

Acknowledgements We appreciate the financial supports by the grants, FCU/CSMU104-001 and CMU104-S-02 from Feng Chia University/Chung Shan Medical University and China Medical University, respectively.

References1. Canes D, Desai MM, Aron M, Haber GP, Goel RK, et al. (2008)

Transumbilical single-port surgery: evolution and current status. Eur Urol 54(5): 1020-1029.

2. Antoniou SA, Pointner R, Granderath FA (2011) Single-incision laparoscopic cholecystectomy: a systematic review. Surg Endosc 25(2): 367-377.

3. Machado MA, Surjan RC, Makdissi FF (2013) First single-port laparoscopic pancreatectomy in Brazil. Arq Gastroenterol 50(4): 310-312.

4. Takahashi T, Takeuchi H, Kawakubo H, Saikawa Y, Wada N, et al. (2012) Single-incision laparoscopic surgery for partial gastrectomy in patients with a gastric submucosal tumor. Am Surg 78(4): 447-450.

5. Machado MA, Makdissi FF, Surjan RC (2014) Single-port for laparoscopic gastric resection with a novel platform. Arq Bras Cir Dig 27(2): 157-159.

6. Morel P, Pugin F, Bucher P, Buchs NC, Hagen ME (2012) Robotic single-incision laparoscopic cholecystectomy. J Robot Surg 6(3): 273-274.

7. Escobar PF, Haber GP, Kaouk J, Kroh M, Chalikonda S, et al. (2011) Single-port surgery: laboratory experience with the daVinci single-site platform. JSLS 15(2): 136-141.

8. Morelli L, Guadagni S, Di Franco G, Palmeri M, Di Candio G, et al. (2015) Da Vinci single site(c) surgical platform in clinical practice: a systematic review. Int J Med Robot:

9. Keckler SJ, Holcomb III GW (2010) Ashcraft's Pediatric Surgery. ALIMENTARY TRACT DUPLICATIONS. Fifth edition ed: Saunders 517-525.

BAOJ Med Nursing, an open access journal Volume 2; Issue 3; 022

Page 4 of 4Citation: Cheng-Ming Peng, Hsin-Cheng Liu, Yang Yao Kun, Ching-Lung Hsieh, Wei-Hsin Chen, Yi-JuiLiu and Ruey-Hwang Chou (2016) Using of Robot-Assisted Single Incision with Single Port Platform for Resection of Gastric Duplication Cyst. BAOJ Med Nursing 2: 022.

10. Jiang W, Zhang B, Fu YB, Wang JW, Gao SL, et al. (2011) Gastric duplication cyst lined by pseudostratified columnar ciliated epithelium: a case report and literature review. Journal of Zhejiang University Science B 12(1): 28-31.

11. Laurent S, Vivario M, Lardinois F (2015) Gastric Duplication Cyst with Respiratory Epithelium: a Rare Entity. Acta chirurgica Belgica 115(5): 379-381.

12. Johnston J, Wheatley GH 3rd, El Sayed HF, Marsh WB, Ellison EC, et al. (2008) Gastric duplication cysts expressing carcinoembryonic antigen mimicking cystic pancreatic neoplasms in two adults. The American surgeon 74(1): 91-94.

13. Scatizzi M, Calistri M, Feroci F, Girardi LR, Moraldi L, et al. (2005) Gastric duplication cyst in an adult: case report. In vivo 19(6): 975-978.

14. Fernandez DC, Machicado J, Davogustto G (2016) Gastrointestinal Stromal Tumor Arising From a Gastric Duplication Cyst. ACG case reports journal 3(3): 175-177.

15. Zheng J, Jing H (2012) Adenocarcinoma arising from a gastric duplication cyst. Surgical oncology 21(2): e97-101.

16. Kim SM, Ha MH, Seo JE, Kim JE, Min BH, et al. (2015) Gastric duplication cysts in adults: a report of three cases. Journal of gastric cancer 15(1): 58-63.

17. Horne G, Ming-Lum C, Kirkpatrick AW, Parker RL (2007) High-grade neuroendocrine carcinoma arising in a gastric duplication cyst: a case report with literature review. International journal of surgical pathology 15(2): 187-191.

18. Lewitowicz P, Matykiewicz J, Koziel D, Gluszek SZ, Sosnowski Z, et al. (2015) Gastric gastrointestinal stromal tumor with incomplete duplication cyst - a case with possibility of neoplasia in fetal-period malformed tissues. Polish journal of pathology : official journal of the Polish Society of Pathologists 66(1): 86-91.

19. Tsimoyiannis EC, Tsimogiannis KE, Pappas-Gogos G, Farantos C, Benetatos N, et al. (2010) Different pain scores in single transumbilical incision laparoscopic cholecystectomy versus classic laparoscopic cholecystectomy: a randomized controlled trial. Surg Endosc 24(8): 1842-1848.

20. Kim TJ, Lee YY, Cha HH, Kim CJ, Choi CH, et al. (2010) Single-port-access laparoscopic-assisted vaginal hysterectomy versus conventional laparoscopic-assisted vaginal hysterectomy: a comparison of perioperative outcomes. Surg Endosc 24(9): 2248-2252.

21. Canes D, Berger A, Aron M, Brandina R, Goldfarb DA, et al. (2010) Laparo-endoscopic single site (LESS) versus standard laparoscopic left donor nephrectomy: matched-pair comparison. Eur Urol 57(1): 95-101.