Optimizing the technical results of robotic esophagectomy: conduit creation and esophagogastric anastomoses

The esophagectomy, first done over a century ago, has evolved from open procedures to minimally invasive techniques. As minimally invasive surgery has progressed in both safety and efficiency since its inception, it is becoming increasingly favored and continues to demonstrate advantageous outcomes over open techniques. In terms of operative decisions, conduit diameter choice is crucial in esophagectomy. Narrower conduits (≤ 3 cm) seem to be more efficacious, and less prone to stricture than their wider counterparts (> 5 cm). Perfusion assessment, notably with indocyanine green (ICG), is still a topic of debate among surgeons with conflicting opinions on ICG’s impact. There are varying results in leak rates; however, the use of ICG in determining anastomotic site seems to exert some influence on surgical decision-making. Anastomotic techniques, such as circular stapling and linear stapling, have shown to be preferred over more traditional hand-sewn methods. At our institution, a completely robotic approach is used with creation of a 3-4 cm wide conduit and hybrid-type anastomosis. ICG is used to guide conduit transection and gastrotomy for anastomosis. Our experience shows that this approach offers an excellent combination of safety and reproducibility.