Technique of Robotic Assisted Minimally Invasive Esophagectomy

<p><strong>Thoracic phase </strong></p> <p>The patient is placed in a standard left lateral decubitus position. The robotic ports are sequentially inserted camera 12 mm port right 8th and bipolar 5 mm ports right 9th, the monopolar port in the 5th and the assistant port was under direct vision. The intrathoracic pressure is set at 6 to 8 mmHg. Robotic port training and docking is done. The pleura over the esophagus anteriorly and posteriorly are opened. The esophagus is mobilized circumferentially from the hiatus to the level of the azygos vein, ensuring that all node bearing tissues are harvested with the esophagus. Harvesting of the subcarinal lymph nodes is done. Along the posterior pleura, clips are used liberally to ligate large lymphatic and arterial perforating vessels from the thoracic duct and aorta, respectively. Hiatal dissection is then completed. The deep medial dissection is completed along the contralateral pleura and greatly facilitated by lateral retraction of the specimen by encircling esophagus with tape. Care must be taken to avoid injury to the left mainstem during this dissection in case not fully visualized at the time of the subcarinal dissection. The esophagus is mobilized towards the thoracic inlet with division of the vagus nerves at the level of the azygos vein to prevent traction injuries to the recurrent laryngeal nerve. The azygos vein is clipped and divided. Esophagus dissection is completed circumferentially from hiatus to thorax inlet with periesophageal and subcarinal nodal dissection removal. ICD is kept and closure of port site is done.</p> <p><strong>Abdominal phase </strong></p> <p>Patient&rsquo;s position is changed to supine. 12 mm right hypochondriac port and 10 mm right lumbar region; 5 mm ports supraumbilical and left hypochondriac region. Hepatogastric ligament divided crus is identified, and lower esophagus &amp; GE junction is dissected circumferentially. D2 nodal dissection is done and gastrocolic omentum is divided till hiatus and lesser sac is entered. Left gastric vessels are clipped and divided. Gastric conduit based on gastroepiploic arcade is fashioned using endo GIA triple line staple. Drain is kept and closure of port site wounds is done.</p> <p><strong>Cervical phase </strong></p> <p>Left supraclavicular transverse incision is given. Recurrent laryngeal nerve is identified and preserved. Esophagus is then identified. Gastric conduit is brought up into neck incision and total radical esophagectomy is completed. End-to-end esophago gastric conduit anastamosis is done using 3-0 vicryl interrupted sutures over a ryles tube in a single layer. The drain is kept and closure of neck wound is completed.</p>