Prone Position Thoracoscopic Hand-Sewn Esophago-Gastric Anastomosis During 2-Stage Totally Minimally Invasive Esophagectomy for Cancer. Surgical Technique

Abstract Background Minimally invasive esophagectomy has been introduced in the 2000s in an effort to reduce post-operative pulmonary and cardiac complications. 2-stage totally minimally invasive esophagectomy combines laparoscopic abdominal phase followed by thoracoscopic thoracic phase. The rate limiting step of this approach is the construction of esophago-gastric anastomosis. Herein, we aim to present our anastomotic technique on hand-sewn esophago-gastric anastomosis in prone position, utilizing 3D-assisted thoracoscopy. Methods This is prospective analysis of consecutive patients that underwent 2-stage totally minimally invasive esophagectomy for esophageal and gastro-esophageal junction Siewert type I-II cancers from the same surgical team, over a period of 6 years and more than 250 consecutive esophagectomies. All operations were identical in terms of patient positioning, lymphadenectomy and type of anastomosis formed. The anastomosis was hand-sewn in prone position, in 2-layers, using barbed sutures, with utilization of 3D-assisted thoracoscopy. Thorough technique and key steps of this anastomotic technique are provided. Results Median operative time was 280 minutes while median suturing time for the esophago-gastric anastomosis was 45 minutes. Anastomosis was thoracoscopic, hand-sewn constructed in prone position in all cases. There was no conversion to open. Anastomotic leak complicated n=6 patients (2%); n=5 were type I anastomotic leaks, requiring no intervention and n=1 was type II, which was treated with thoracoscopic lavage and chest drains followed by endoVAC therapy. Conclusion Formation of the esophago-gastric anastomosis is the rate limiting step of 2-stage totally minimally invasive esophagectomy. Most surgeons prefer the construction utilizing mechanical staplers. Our anastomotic technique, present a safe and effective anastomosis, with favorable clinical outcomes. It can be reproduced safely and effectively, offering all the advantages of manual anastomosis and significant reduction of devastating post-operative anastomotic leakage. https://wetransfer.com/downloads/bdf3a3496197daf79ccf5b05f71ba64920240309175850/a4da3be742fd3199e102e553c8a4011e20240309175918/c14cc2