Challenges of conversion from robotic surgery for vascular complications

摘要

A 67-year-old female with endometrial adenocarcinoma sustained an aortic injury during robotically assisted retroperitoneal lymphadenectomy. Repair could not be performed laparoscopically, but graspers were used to maintain hemostasis while conversion to open surgery was initiated. Safety mechanisms locked the graspers in place, preventing tissue release and resulting in additional aortic injury. Forceful removal of the graspers was eventually successful, and definitive aortic repair was then performed. Vascular surgeons who are not familiar with robotic surgery techniques should be aware that removal of robotic hardware requires stepwise algorithms, which, if performed out of order, may introduce significant challenges. A 67-year-old female with endometrial adenocarcinoma sustained an aortic injury during robotically assisted retroperitoneal lymphadenectomy. Repair could not be performed laparoscopically, but graspers were used to maintain hemostasis while conversion to open surgery was initiated. Safety mechanisms locked the graspers in place, preventing tissue release and resulting in additional aortic injury. Forceful removal of the graspers was eventually successful, and definitive aortic repair was then performed. Vascular surgeons who are not familiar with robotic surgery techniques should be aware that removal of robotic hardware requires stepwise algorithms, which, if performed out of order, may introduce significant challenges. Introduction:Vascular injuries during robotically assisted-laparoscopic surgery are rare [1Brierley G. Arshad I. Shakir F. Visvathanan D. Arambage K. Vascular injury during laparoscopic gynaecological surgery: a methodological approach for prevention and management.The Obsterician & Gynaecologist. 2020; 22: 191-198Crossref Google Scholar,2Perutelli A. Garibaldi S. Gargini A. Baldacci C. Basile S. Salerno M.G. Robotic management of major vessel injury during pelvic lymphadenectomy.J Minim Invasive Gynecol. 2013 Jan-Feb; 20 (PMID: 23312253): 115-118https://doi.org/10.1016/j.jmig.2012.08.780Abstract Full Text Full Text PDF PubMed Scopus (1) Google Scholar]. Minimally invasive surgeons may perform various maneuvers to gain laparoscopic control of bleeding from vessel injury [3Castillo O.A. Peacock L. Vitagliano G. Pinto I. Portalier P. Laparoscopic repair of an iliac artery injury during radical cystoprostatectomy.Surg Laparosc Endosc Percutan Tech. 2008 Jun; 18 (PMID: 18574427): 315-318https://doi.org/10.1097/SLE.0b013e31815c2604Crossref Scopus (9) Google Scholar,4England E.C. Spear C.R. Huang D.D. Weinberg J. Bogert J.N. Gillespie T. et al.REBOA as a rescue strategy for catastrophic vascular injury during robotic surgery.J Robot Surg. 2020 Jun; 14 (Epub 2019 Aug 29. PMID: 31463880): 473-477https://doi.org/10.1007/s11701-019-01011-3Crossref Scopus (6) Google Scholar,5Jafari M.D. Pigazzi A. Techniques for laparoscopic repair of major intraoperative vascular injury: case reports and review of literature.Surg Endosc. 2013 Aug; 27 (Epub 2013 Feb 14. PMID: 23407911): 3021-3027https://doi.org/10.1007/s00464-013-2845-3Crossref Scopus (10) Google Scholar]. Despite these strategies, open conversion is occasionally necessary, with an estimated incidence of 1%. To convert to open surgery, the robot must be removed from the operative field, which introduces complexities specific to the Da Vinci Robot (Intuitive Surgical, Sunnyvale, CA, USA). This case highlights these challenges.Case report:A 67-year-old female with a history of endometrial adenocarcinoma underwent elective robotically assisted laparoscopic retroperitoneal surgery. During lymphadenectomy, the inferior mesenteric artery was partially avulsed. Laparoscopic techniques using bipolar/vessel sealing devices, and robotic suture ligation were unsuccessful in gaining hemostasis. The robotic graspers were successfully positioned to apply direct compression to tamponade the aortic injuries, but the artery could not be repaired. To facilitate laparotomy