Robotic Enucleation of Giant Esophageal Leiomyoma

The authors present the clinical case of a 37-year-old man with a medical history of diabetes mellitus type I and acute biliary pancreatitis who consulted for dysphagia and abdominal pain. Chest radiography showed a mass in the posterior mediastinum and computerized tomography showed a tumor in the middle third of the esophagus measuring more than 10 cm of crania-caudal axis and more than 5 cm of transversal axis. The barium swallow study showed that the middle third of the esophagus was displaced towards the right side and had a large filling defect. The endoscopic ultrasonography guided biopsy confirmed the suspicion of leiomyoma.

The patient was scheduled for robotic enucleation of the leiomyoma. The authors performed a 4-arm technique with a 10 mm auxiliary port. First, the pulmonary ligament was sectioned with the Maryland bipolar forceps in order to mobilize the lung and facilitate esophageal visualization. Second, the mediastinal pleural was divided anteriorly to expose the anterior aspect of the esophagus and facilitate its mobilization. The azygous vein was dissected and divided with an endostapler. The mediastinal pleural was also divided posteriorly. A myotomy of the muscular layer of the esophagus was performed with Maryland bipolar forceps in order to expose and visualize the tumor. Lesions of the mucosa should be avoided during this maneuver.

Once the leiomyoma was identified, the myotomy was prolonged cranially and caudally and blunt dissection and cauterization of adhesions between the tumor and the muscular and mucosa layers was carried out in order to free the tumor. Several tractor sutures were placed in different points of the tumor. Pulling these sutures, the surgeon could mobilize the tumor and better expose points of adhesions and tension. In this particular case, the leiomyoma was lobulated. First the lower and bigger part of the tumor was dissected, liberated from the esophagus with blunt dissection and cauterization with Maryland bipolar forceps in order to avoid mucosa injuries. Once liberated from the esophagus, the specimen was inserted into an endobag. Later, the upper and smaller part of the tumor was removed in the same manner. After complete removal of the tumor, the mucosa was perfectly visualized, and an air bolus was introduced in the esophagus through the nasogastric tube in order to check the absence of esophageal leaks. Suture of the myotomy was performed with a 3/0 barbed V-loc suture. Barbed sutures facilitate the closure of the myotomy by making unnecessary to knot the suture and providing a correct tension. Finally, the nasogastric tube was removed, and a 24 F chest tube was inserted into the pleural cavity.

The postoperative period was uneventful and barium swallow study showed no leaks and a dilatation of the middle third of the esophagus.

References

1. Choong CK, Meyers BF. Benign esophageal tumors: introduction, incidence, classification, and clinical features. Semin Thorac Cardiovasc Surg. 2003;15:3-8.
2. Inderhees S, Tank J, Stein HJ, Dubecz A. [Leiomyoma of the esophagus : A further indication for robotic surgery?]. Chir Z Alle Geb Oper Medizen. 2019;90:125-130.

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