Robotic Ivor Lewis Esophagectomy after Gastric Band Placement

This article and accompanying video present a case of a robotic assisted Ivor-Lewis esophagectomy after gastric band placement.

The patient was a sixty-seven-year-old man who had previously undergone placement of laparoscopic gastric band for weight loss approximately twenty years prior to this procedure. Under a routine surveillance esophagogastroduodenoscopy, he was found to have a long segment Barrett’s esophagus. A biopsy of the gastroesophageal junction demonstrated intestinal metaplasia with high grade dysplasia, along with high suspicion for adenocarcinoma. The patient was taken for an endoscopic mucosal resection.  

Final pathology demonstrated endoscopic mucosal resection from 32–38cm with multifocal invasive moderately to poorly differentiated adenocarcinoma with invasion into the submucosa. Thus, staging was performed and demonstrated a clinical stage IIA tumor. The patient was then treated with neoadjuvant radiation and chemotherapy. He received 200 centigray over 25 fractions for a total of 5,000 centigray. Next, he received carboplatin and paclitaxel chemotherapy. A repeat pet-CT was then performed, demonstrating a complete metabolic response.  

At this point, the patient was referred to thoracic surgery for evaluation. Once there, he was given the option to continue observation with repeat PET-CT or proceed with surgical resection. The patient chose to proceed with surgical resection. So he was taken to the operating room for a robotic assisted Ivor-Lewis esophagectomy. It began by placing standard robotic ports into the abdomen and retracting the liver for hiatal exposure. Then the hiatus dissection was started with the vessel sealer by dividing the gastrohepatic ligament. Next, the scar tissue was divided using the vessel sealer to identify the right and left crura and proximal esophagus. The dissection was then taken to the greater curvature of the stomach. Then, again using the vessel sealer, the omentum was divided, as well as the short gastric arteries. This dissection was made somewhat difficult because of the patient’s large body habitus.  

The posterior dissection of the conduit was next, ensuring complete mobilization of the posterior surface of the stomach. This was done with care to protect the gastroepiploic artery. Next, came removal of the band. It was dissected free and then divided with scissors. Next, further scar tissue was dissected circumferentially until the band was completely free. The band was then removed and placed to the side. The hiatal dissection continued to ensure circumferential dissection of the proximal GE junction.  

After that, the crura of the diaphragm become clearer and the operators were able to complete the dissection into the mediastinum. This dissection was made slightly more difficult because of the patient’s previous surgery. The hiatus was then divided further to allow mobilization of the conduit into the mediastinum. Once the mobilization is complete, the operators moved onto dissection of the left gastric pedicle. This dissection was facilitated by use of spatula cautery. Then, the vessels were completely encircled. Once this was complete, the vessels were stapled. After the left gastrics were divided, the specimen was mobilized further and any dissection that was unable to be completed prior up to the diaphragmatic hiatus was then completed.  

Next, the Botox administration was moved to the pylorus. This was facilitated by the robotic arm as well as the bedside operator. Forty units were then placed into the pylorus. The operators then proceeded with the formation of the conduit using successive staplings. Once the conduit was completely formed, it was sewn to the specimen to allow it to be transferred into the mediastinum. At this point, the intra-abdominal portion was complete and the operators moved on to jejunostomy tube (J-tube) placement. The robot was undocked and then redocked to allow placement of the J-tube. A point was chosen on the jejunum after identifying the ligament of Treitz and advancing approximately 50cm down. The jejunum was then brought up to the abdominal wall. Next, a V-Loc suture was used to Stamm the jejunum to the abdominal wall. A needle was then inserted into the chosen point on the jejunum and a pigtail catheter feeding tube was placed into the jejunum using the Seldinger technique. The Stamm was then completed with a running V-Loc suture.  

At this point, the port from the gastric band was then removed, and the entire band removed from this incision. All incisions were then closed. The patient was then positioned in a lateral decubitus position. Next, the standard thoracic ports were placed into the right chest and the dissection began. The operators began by identifying the azygous vein and dissecting it free from the surrounding tissues. They were then able to encircle it and divide it. They then divided the pleura over the esophagus from the previous point in the lower mediastinum up past the azygous vein. The specimen was then brought into the chest, followed by the entire conduit that had been sutured to the specimen. Care was taken not to twist the conduit, and the operators then checked to make sure that the conduit was of adequate length to reach past the anastomotic site.  

Dissection of the esophagus was continued more proximally, and the esophagus was opened at the chosen point for the anastomosis. The specimen was then removed using a bag. They then dissected more proximally on the esophagus to ensure this was a tension-free anastomosis.  

The anastomosis began using interrupted silk sutures for the outer back wall layer. Then the conduit was opened to the same length as the width of the divided esophagus. This was done while making sure that suction was readily available. The stapler was then inserted and fired to form the inside back wall of the anastomosis. The front wall inner layer was performed using a V-Loc suture. This was sewn in a running fashion using several sutures. The nasogastric tube was advanced, and the inner layer was completed. The front wall and outer layer were then competed using interrupted silk sutures in a mattress technique.  

At this point, the anastomosis was complete and green dye was injected to ensure that the conduit was being perfused. Intercostal nerve blocks were then placed using Exparel. Then, a 28 French chest tube and flat Jackson Pratt drain were inserted into the chest. The lung was expanded, and the wounds were then closed. 

A final pathology on the specimen showed complete response with no cancer identified. The patient had a routine recovery following surgery and was able to be discharged within seven days.  

Reference

1. Rossidis G, Browning R, Hochwald SN, Abbas H, Kim T, Ben-David K. Minimally invasive esophagectomy is safe in patients with previous gastric bypass. Surg Obes Relat Dis. 2014 Jan-Feb;10(1):95-100. doi: 10.1016/j.soard.2013.03.015. Epub 2013 Apr 22. PMID: 23791535.

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