Step by Step Intrathoracic Hand-Sewn Esophagogastric Anastomosis During Totally Robotic Minimally Invasive Two-Stage Esophagectomy

Abstract Background In every esophagectomy, regardless of the approach, the creation of the anastomosis is a critical step. In minimally invasive esophagectomy, to avoid challenges of thoracoscopic suturing in the upper mediastinum most surgeons use stapling devices or even decide to do a cervical anastomosis. However, in robot-assisted minimally invasive esophagectomy, the surgeon benefits from increased dexterity that facilitates to perform a hand-sewn intrathoracic anastomosis. Methods A 67-year-old man with esophageal adenocarcinoma, staged as a T3N1 underwent neoadjuvant chemotherapy, followed by a fully robotic minimally invasive Ivor-Lewis esophagectomy (robotic surgery during both the abdominal and thoracic phase). For the thoracic phase, the patient was placed in left sided semi-prone position. An 8 mm robotic trocar is inserted in the 6th intercostal space for the camera. Two other 8mm robotic trocars were inserted in the 4th, 8th and a 12mm 10th intercostal space. The anastomosis was constructed at the level, just above the azygos vein. Results The esophagogastric anastomosis was performed with an end-to-end construction. A barbed 3.0 suture was used to close the posterior wall by a single-layer running hand-sewn technique. The esophagostomy and the gastrostomy were performed using vascular scissors. A 36Fr Faucher was placed to expose de inner layer during the esophagostomy. A second posterior continuous full-thickness layer was performed using barbed 3.0 suture. Finally, an anterior wall full-thickness layer was performed using the same suture. To protect the anastomosis an omental wrap was applied. Conclusions Totally robotic minimally invasive esophagectomy for the treatment of esophageal cancer is on the rise. It offers all the advances of minimally invasive techniques, like reduced rates of pulmonary and cardiac complications associated with open thoracotomy and shorter length of stay. Intrathoracic esophagogastric anastomosis still remains challenging and it is considered as the most difficult step of the procedure. Robotic transthoracic manual anastomosis has appeared to overcome this difficulties. https://www.dropbox.com/scl/fi/km4oo66hhnb00k45e7ecq/Stepbystepmanual.mp4?rlkey=eb074cf3sj796byijqza0zoq6&dl=0