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Page 6 of 19 Ackerman et al. Mini-invasive Surg 2021;5:14 https://dx.doi.org/10.20517/2574-1225.2021.02

tumor unresectable [Figure 2].

Retrogastric dissection
To expose the left gastric vascular pedicle, the stomach is retracted anteriorly by passing the robotic assist
arm posterior to the stomach, medial to the left gastric pedicle, and into the lesser sac with the bedside
assistant elevating the gastroesophageal junction [Figure 3]. The origin of the left gastric artery and vein are
identified, and the lymphatic tissue is reflected with the specimen [Figure 4]. The lymphadenectomy
continues along the splenic and common hepatic vascular pedicles to complete the celiac dissection. The left
gastric artery and vein are divided with a robotic vascular staple load [Figure 5]. Initial short gastric
dissection is initiated from a retrogastric approach and continues along the gastrosplenic hilum [Figure 6].

Greater curvature dissection
The robotic assist arm and bedside assist arm are advanced posterior to the stomach towards the left upper
quadrant to expose the short gastric vessels in the retrogastric plane. Greater curve dissection, along with
completion of the gastrosplenic ligament dissection initiated from the retrogastric approach, is continued
along the fundus from proximal to distal while individually ligating the short gastric vessels with ultrasonic
shears. Especially in patients with preoperative radiotherapy, a pedicled omental flap can be created along
two sequential omental branches off the gastroepiploic arcade during this portion of the mobilization (not
shown). The retrogastric attachments to the retroperitoneum are divided. The dissection continues along
the greater curve of the stomach to approximately the pylorus. The lesser curve of the stomach is then
gently grasped with arm 4 in an area that will be included with the specimen and is retracted towards the
hiatus/liver. Taking care to avoid injuring the gastroepiploic vascular arcade, the dissection continues along
the greater curve of the stomach and omentum, completely freeing the attachments that restrict
mobilization of the stomach. A partial or complete Kocher maneuver may be completed if desired by the
surgeon. The remaining retroantral attachments are divided. Adequate tension-free mobilization is
confirmed by ensuring that the pylorus reaches the right crus of the diaphragm.

Conduit creation
The pylorus is identified and a site on the stomach approximately 5-6 cm proximal to the pylorus is
identified as the distal aspect of the gastric tube. The stomach is oriented for conduit creation with the arm 4
robot assist retracting the fundus towards the apex of the left hemidiaphragm, thus clearly delineating the
orientation and lay of the future conduit [Figure 7]. Once the conduit is initiated, the robotic right-hand
arm 3 “hooks” and retract the neo-lesser curve inferiorly to provide traction and better reveal the
anticipated staple path to create a linear conduit. The first robotic stapler firing is a vascular load and
traverses and ligates the lesser curve vasculature [Figure 8]. A 3 cm gastric conduit is then created with
multiple fires of the robotic stapler parallel to the greater curve of the stomach [Figure 9]. Care should be
taken to keep the staple line parallel to the short gastric line for proper orientation. The proximal tip of the
conduit should be divided at a point that allows for adequate conduit length but maintains an appropriate
oncologic margin. The tip of the conduit is tacked to the specimen in anatomic orientation with a
horizontal mattress suture and the omental flap (if created) is tacked to the tip of the conduit. A marking
stitch is placed on the conduit staple line at the junction between the future subdiaphragmatic antral
reservoir and the supradiaphragmatic neo-esophagus. The specimen and proximal conduit may be tucked
into the mediastinum. A cruroplasty is not routinely performed unless the hiatus is exceptionally enlarged.

Pyloroplasty
The role of pyloroplasty is debated but is frequently performed. When performed, a Heineke-Mikulicz
pyloroplasty is utilized. The pylorus is identified, using endoscopy if necessary. Stay sutures are placed at the