A Novel Double Stapled Robotic Assisted Minimally Invasive Ivor Lewis Esophagectomy

The patient is a sixty-two-year-old male with notable past medical history of GERD who was diagnosed with T3N1 esophageal adenocarcinoma during an endoscopy for dysphagia. Endoscopic evaluation demonstrated gross changes and luminal narrowing of the distal esophagus. A PET CT scan further showed increased uptake at the distal esophagus and was concerning for a tumor. The patient subsequently received induction chemotherapy and radiation, with an esophagectomy to follow. Given the location of the tumor, the decision for an Ivor Lewis esophagectomy was made.

To begin, the patient was placed in a supine position with a foot board in place. A Veress needle was inserted at Palmer’s point and the abdomen was insufflated to 15 mmHg. An 8 mm port was then placed 11 cm inferior to the subxiphoid. This served as the camera port. Two 8 mm ports were placed to the patient’s left, both 7 cm from the adjacent port. One 12mm port was placed the patient’s right, also 7 cm away. The 12 mm port would be used to staple the left gastric artery and for preparation of the conduit. A 5 mm subxiphoid incision was then made for the Nathanson liver retractor, which allowed for better exposure of the diaphragmatic crura. The patient was then placed in steep reverse Trendelenburg position.

Next, a four-quadrant evaluation of the abdomen was made to rule out metastatic disease. A Cadière forceps was inserted in arm one, a camera in arm two, a vessel sealer in arm three, and a tip-up grasper in arm four. No assistant port was utilized. Dissection then began along the greater curvature, approximately three centimeters from the right gastroepiploic artery. This artery was better identified using ICG green and firefly technology. Using the vessel sealer, the omentum was divided beginning at the mid-portion of the greater curvature, preserving an omental flap toward the distal end of the conduit. Mobilization continued up to the short gastric arteries where dissection migrated closer to the stomach. The course of the left gastroepiploic artery was identified and ligated using a vessel sealer energy device. Care was taken to avoid injury to the spleen.

Attention was then turned to the lesser curve. The lesser sac was opened by dividing the gastrohepatic ligament, taking care to identify and preserve the right gastric artery and replaced left hepatic artery, as appropriate. Dissection continued up to the level of the right crus along the phrenoesophageal ligament to allow for further mobility. Surgeons then turned to the left gastric artery and vein, which were identified by reflecting the stomach superiorly and toward the patient’s left. The left gastric vessels were then divided using a 30 white load stapler through arm number four. The stomach was then reflected superiorly to expose and dissect the posterior stomach from the pancreas. All retrogastric adhesions from the crura to the pylorus were dissected. The stomach was verified to be mobile down to the level of the pylorus. The team did not perform a pyloroplasty. Instead, a preoperative endoscopic Botox injection followed by balloon dilation was performed.

Once sufficient intraperitoneal dissection was made, surgeons turned their attention to the mediastinal dissection. Due to the known positive node for this patient, significant adhesions were present and were taken down. The esophagogastric junction was then mobilized circumferentially. Dissection was carried into the mediastinum cranially, using a combination of blunt dissection and electrocautery and allowing for exposure and mobilization of the midesophagus. The esophagus was fully mobilized off of the aorta, pericardium, and both pleura. The dissection continued to the level of the carina, dissecting and removing lymph nodes as identified. The right crus was partially divided to facilitate ease of passage of the gastric conduit. Bilateral pleura were opened and a left-sided chest tube was placed.

Next, the gastric conduit was formed, separating the esophagus and proximal stomach using a series of SureForm Green 45 mm loads. It began from the incisura and extending up to the cardia of the stomach. When creating the conduit, the stomach was without tension and care was taken to ensure equal distance anteriorly and posteriorly to prevent the formation of a spiral conduit. The conduit was created to be approximately four centimeters in size. ICG was used to evaluate the vascular bed of the conduit. The staple line nearly transected at the level of the cardia, however, a small amount of the conduit remained attached to the proximal stomach to allow for a later delivery into the chest. The abdomen was then inspected for hemostasis. All ports and the liver retractor were removed under direct visualization and the port sites were closed. This concluded the abdominal portion of the operation.
To begin the next portion of the surgery, the patient was repositioned in the left lateral decubitus position and prepped and draped in a sterile fashion. Prior to incision, surgeons performed a bronchoscopy to verify that the double lumen ET tube remained in place. The right lung was deflated. After confirmation, an 8 mm port was placed over the eighth rib in the posterior axillary line to act as the camera port. A 12 mm port was then placed in the ninth space posteriorly, serving as the left hand and the port to staple the azygous. A second 12 mm port was placed in the fifth interspace anteriorly to be used for dissection and stapling the anastomosis. An 8 mm fourth hand was placed anteriorly into the third interspace, which would mostly be used as an assistant. Surgeons did not use a thoracoscopic assistant port. The port site at the fifth intercostal space was planned to be extended when the specimen was removed.

The team began by dividing the inferior pulmonary ligament and diaphragmatic adhesions were divided as needed. The paraoesophageal and pulmonary ligament lymph nodes were identified, resected, and sent for analysis. Further lymphadenopathy at station 7 was performed through a combination of blunt dissection and electrocautery. Station 4R nodes were also obtained. Dissection was moved superiorly, where the azygos vein was identified, mobilized, and ligated using a white vascular staple load through arm one. Dissection then continued superiorly, mobilizing the esophagus circumferentially up to the level of the thoracic inlet along the posterior plane. A Penrose drain was used to aid in retracting the esophagus for sufficient mobilization. Dissection remained close to the esophagus and the aorto-esophageal arteries were ligated using the vessel sealer.

With the esophagus sufficiently mobilized, the gastric conduit was brought up into the thoracic cavity. Surgeons assessed the staple line and ensured proper orientation of the conduit. A green 45 load was fired along the staple line to divide the specimen from the conduit. The conduit was then lined up with the esophagus to assess for sufficient length. A tacking stitch was placed in the proximal esophagus and used as a lever. The proximal portion of the pathologic specimen was transected below the level of the azygos vein. The specimen was then removed and was determined to be negative for malignancy at the margins. 

Next, the 12 mm port was redocked in this incision. To perform the double stapled end-to-end anastomosis, a tacking suture was placed on the distal conduit. The conduit was brought up and aligned next to the proximal esophagus. A gastrotomy was created in the conduit along the lesser curve adjacent to the staple line. One silk suture was placed between the six o’clock position of the esophagus and the 12 o’clock position of the gastrotomy on the conduit. The posterior staple line was created with a 60 mm linear stapler placed into the open end of the esophagus and into a small gastrotomy created in the tip of the conduit, positioned on the mesenteric side. The placement of the stapler along the greater curvature positions the anastomosis along the most vascularized portion of the conduit, creating a more balanced blood supply and avoiding creation of a watershed area that could risk the anastomotic integrity. The remaining anterior opening was closed with a 60 mm linear stapler, positioned transversely to the posterior staple line to complete a wide V-shaped anastomosis. The anastomotic segment was allowed to retract tension free into the esophageal bed. An EGD was performed to examine the anastomosis, which was noted to be intact, with a negative leak test. The omentum was then laid over the conduit and secured. A 19 Fr Blake drain was positioned adjacent to the anastomosis, beneath the flap, and a 28 Fr chest tube was placed posterior. The port sites were then closed, and this concluded the operation.

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