Robotic Ivor-Lewis esophagectomy in 15 steps

摘要

Central MessageRobotic Ivor-Lewis esophagectomy can be distilled into a series of reproducible steps. Robotic Ivor-Lewis esophagectomy can be distilled into a series of reproducible steps. The technique of robotic Ivor-Lewis esophagectomy with intracorporeal anastomosis is demonstrated in 15 steps. Each step is outlined by short text and narrated video segments. The case demonstrated is a gentleman with a clinical stage T3 N1 M0 distal esophageal adenocarcinoma who underwent neoadjuvant chemotherapy and radiotherapy. 1.Division of gastroesophageal and phrenoesophageal ligaments and right crural dissection. Port placement is detailed in Video 1. An energy device is used to divide the gastrohepatic ligament and the esophagus is dissected from the right crus. Dissection is carried anteriorly where the phrenoesophageal ligament is divided.2.Division of left gastroepiploic artery and vein. The left gastroepiploic artery and vein are dissected and surrounding lymph nodes are swept toward the stomach; they can be removed at this time or with the specimen later. The artery and vein are divided with a vascular cartridge stapler.3.Preparation of right gastroepiploic pedicle. The right gastroepiploic artery and vein are identified, the lesser sac is entered, and a healthy pedicle of right gastroepiploic adipose is created. Dissection continues towards the pylorus and then cranially along the stomach's greater curvature.4.Creation of pedicled omental flap and division of short gastric arteries and veins. A pedicled omental flap is designed based on right gastroepiploic and short gastric arterial inflow, and the highest short gastric vessels are divided.5.Mediastinal dissection. A Penrose drain is placed around the esophagus, approximated to itself, and used for retraction to circumferentially dissect the mediastinal esophagus to the level of the inferior pulmonary veins. The Penrose is tucked into the mediastinum.6.Creation of gastric conduit. The lesser curvature adipose is divided between the caudal 2 branches of the right gastric artery and a 4-cm wide conduit is created with serial applications of green staple cartridges. The conduit is never itself directly grasped.7.Treatment of the pylorus (chemical pyloroplasty). The pylorus can be treated in various ways. Here, botulism toxin is injected laparoscopically into several regions of its muscle.8.Laparoscopic feeding jejunostomy tube. A 14F jejunostomy tube is placed 40 cm from the ligament of Treitz, shown here using T fasteners. 9.Division of inferior pulmonary ligament and station 9 nodal dissection. Port placement is detailed in Video 1. The inferior pulmonary ligament is divided and station 9 lymph nodes are removed.10.Entry into mediastinum, dissection of distal esophagus, station 8 nodal dissection. The mediastinum is entered and the Penrose drain is retrieved and used for retraction to dissect the distal esophagus. Station 8 lymph does are removed and/or dissected in such a way that they are removed with the specimen.11.Dissection of mid-esophagus and station 7/8/10 lymph nodes. The mid-esophagus is dissected from the airway with precise application of energy. Station 7, 8, and 10 lymph nodes are removed.12.Division of azygous vein, dissection of upper esophagus, station 2/4 nodal dissection. The azygous vein is divided with a vascular stapler cartridge and the upper esophagus is dissected. A paratracheal nodal dissection is completed.13.Completion of conduit and removal of specimen. The conduit is delivered into the thorax and it is separated from the specimen with green staple cartridges. The specimen is removed through the assistant port incision.14.Anastomosis. The staple line of the upper thoracic esophagus is removed sharply, the geometry of the anastomosis is planned, and a small gastrotomy is made on the conduit. A green cartridge unites the esophagus and conduit and the common enterotomy is closed, here using two running layers.15.Omental flap buttress. The omental fla