Robotic Thoracic Enucleation of Esophageal Leiomyoma

Minimally invasive surgery is a reality in most surgical specialties. With new technological improvements, new instruments, better video support, anesthesia refinement, and robotic platforms allowing 3D view and extension of the surgeon’s hands, challenging cases are now suitable to this approach.

Although rare, the esophageal leiomyoma is the most common benign tumor of the esophagus (1). Surgical treatment is the gold standard option, and enucleation without opening the mucosa layer is recommended (2).

This video presents a case of a thirty-two-year-old man with no medical reports who developed symptoms of dysphagia six months prior, prompting a search for medical consultation. A digestive endoscopy showed a lesion of subepithelial appearance in the middle esophagus. A computerized tomography scan revealed a mediastinal homogeneous nodular expansive formation, well delimited and with regular contours, without separation with the right lateral wall of the middle third of the esophagus, and measuring approximately 2.7 x 2.4 x 2.4 cm. Echoendoscopy with biopsy indicated that the lesion had continuity with the muscular layer of the esophageal wall, was hypoechoic with homogeneous echogenicity, well delimited, and measured approximately 23 mm on the longest axis. The biopsy confirmed esophageal leiomyoma.

After discussion of the treatment options with the patient and multidisciplinary team, a robotic-assisted thoracoscopic surgery (RATS) was performed using a Da Vinci X surgical platform with four 8 mm ports for the robotic arms and one 15 mm port for the assistant on a right-side approach.

The surgery began with the passage of a 32 Fr Fouchet gastric tube for better exposure of the esophagus. Surgeons then proceeded by opening the posterior mediastinal pleura below the azygos vein and in front of the vagus nerve. After complete exposure of the lesion, the muscular layer was dissected vertically up to the tumor. The circumferential dissection with traction and countertraction allowed the team to safely complete the resection without opening the esophageal mucosa.

After that, a suture of the muscular layer with interrupted sutures using PDS 3.0 was made with gentle pull of the gastric catheter and no air leak on saline instillation test. Surgeons routinely performed the intercostal analgesic block.

The procedure was uneventful, and the patient was discharged on the second postoperative day. The final anatomopathological result confirmed esophageal leiomyoma.

The robotic approach was a safe and efficient pathway in this case, and should always be an option for the previously technically challenging cases demanding video thoracic surgery with sutures (3,4).

References

1. Jiang W, Rice TW, Goldblum JR. Esophageal leiomyoma: experience from a single institution: Esophageal leiomyoma. Dis Esophagus. 2013 Feb;26(2):167–74.
2. Mutrie CJ, Donahue DM, Wain JC, Wright CD, Gaissert HA, Grillo HC, et al. Esophageal Leiomyoma: A 40-Year Experience. Ann Thorac Surg. 2005 Apr;79(4):1122–5.
3. Khalaileh A, Savetsky I, Adileh M, Elazary R, Abu-Gazala M, Abu Gazala S, et al. Robotic-assisted enucleation of a large lower esophageal leiomyoma and review of literature: Robotic enucleation of esophageal leiomyoma. Int J Med Robot. 2013 Sep;9(3):253–7.
4. Ramos D, Priego P, Coll M, Cornejo M de los Á, Galindo J, Rodríguez Velasco G, et al. Comparative study between open and minimally invasive approach in the surgical management of esophageal leiomyoma. Rev Esp Enfermedades Dig [Internet]. 2015 [cited 2022 Dec 1];108. Available from: http://online.reed.es/fichaArticulo.aspx?iarf=224688768-749235413278

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