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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_536_Библиотеки_им_академика_М_И_Перельмана.pdf
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Fig. 16.8 Dissection of the subcarinal esophagus (a, b). Division of the mesoesophagus and esophageal lymphadenectomy (c, d). Dissection (e,
f) and division between clips (g) of the thoracic duct between the aorta and azygos vein. Hiatus and pericard sac with diseccion of the 111 lymph
nodes between the inferior cava vein and pericard sac reflexion (h)
F. M. Navarro et al.
Fig. 16.9 Lymphadenectomy of the stations 4R and 2R. Dissection of the right vagal nerve supracarinally and a vessel loop is passed around
(a). Dissection of the right recurrent nerve in the subclavian artery (b) and lymphadenectomy (c, d). Schematic view (e)
(9) Dissection continues in proximal direction to dissect
the supracarinal area. By traction of the stump of the
right vagal nerve, the nerve is dissected free supracarinally and a vessel loop is passed around for traction
(Fig. 16.9). Lymph nodes of the station 4R (from the
carina to the right subclavian artery) are gently dissected between the right vagal nerve and the trachea
by means of a sealing device (Fig. 16.9). The lymph
nodes are kept attached to the esophagus. Thereafter,
the right laryngeal recurrent nerve is visualized by
vagal traction recurring at the right subclavian artery,
and lymphadenectomy of the station 2R is performed
(Fig. 16.9). Lymphadenectomy is not just picking
some lymph nodes but “en bloc,” the lymph nodes
remain attached to the specimen.
(10) By traction of the esophagus, dissection is performed
between the esophagus and the trachea up to the left
edge of the trachea. Dissection takes place by means
of the hook and sealing device taking care do not
touch the trachea or bronchi (Fig. 16.10). A sling is
placed around the esophagus, closed by a Hemo Lock
®
clip and an Endoloop ® system attached to it. The
Endoloop ® is exteriorized in order to keep traction of
the esophagus (Fig. 16.11). In this way, by traction of
the esophagus, the band is almost vertical and is prepared to be dissected. By traction of the esophagus, a
Fig. 16.10 Band created between trachea and esophagus to be dissected (a, b)
13516 Three-Stage McKeown Minimally Invasive Esophagectomy Procedure …
Fig. 16.11 Sling is placed around the esophagus (a). Dissection of the left supraaortic area (b–d)
Fig. 16.12 Dissection between the trachea and base of the band (a). Left laryngeal recurrent nerve is visualized and dissected (b, c)
band can be visualized from the esophagus to the left
paratracheal and supraaortic area (Fig. 16.11).
(11) Dissection is performed along the left aspect of the
trachea (with some pressure on it), and continue
to dissect the basis of the band in order to visualize
and dissect the left recurrent laryngeal nerve (LRLN)
(Fig. 16.12).
(12) Afterwards, the band is dissected free from the esoph-
agus in proximal direction, and sometimes the esophagus could be sectioned in order to facilitate lymph
node dissection (Fig. 16.13). The tissue of stations 2L
and 4L is dissected free from the thoracic duct (had to
be clipped) and the left subclavian artery (Fig. 16.14).
Dissection continues up to the aorta arch (Fig. 16.15)
where the esophagus is freed and the LRLN completment dissect (Fig. 16.16). In this way, stations 2L
and 4L are kept attached to the specimen. Dissection
of the esophagus continues; the left vagal nerve is
divided distally of the left bronchus, followed by lymphadenectomy of the carina (station 7) and left bronchus (Fig. 16.17). Furthermore, the esophagus is freed
from the left bronchus and station number 5 (aorta
window) is sampled (Fig. 16.17).
(13) The esophagus is dissected, the thoracic cavity
drained, trocars retrieved, and ports closed. Patient is
placed for the laparoscopy (supine decubitus) and cervical phase of the intervention.
(14) Five trocars are introduced in the upper abdomen
(Fig. 16.18).
(15) Gastrocolic ligament is opened and working first in
direction to the hiatus and afterwards to the pylorus,
the stomach is mobilized completely with preservation
136
Fig. 16.13 Proximal esophagus is skeletonized from the band, and it could be sectioned by a stapler (a, b)
F. M. Navarro et al.
Fig. 16.14 Thoracic duct is dissected at this level and clipped (a). The lymph nodes are dissected from the left subclavian artery (b)
Fig. 16.15 Dissection of the
lymphadenectomy specimen
(2L and 4L) up to the aorta
arch (a, b)
of the gastroepiploic vessels from the cardias to the
duodenum (Fig. 16.19).
(16) Extensive lymphadenectomy of the celiac trunk
and branches (D1+ ) is performed through the gastrohepatic ligament after dividing the pars flaccida. After dissection and division of the left gastric
artery and vein, dissection continues up to the hiatus (Fig. 16.20). In this part of the intervention, you
can perform first the lymphadenectomy followed
by the gastrolysis or first the gastrolysis followed by
lymphadenectomy.
(17) Last part of the dissection is the lymphadenectomy of
the hiatal area in which the hiatus is enlarged anteriorly, and carefully a communication is made with the
thoracic dissection area (Fig. 16.21). Take care that all
the specimen, esophagus, and stomach are completely
free.
13716 Three-Stage McKeown Minimally Invasive Esophagectomy Procedure …
Fig. 16.16 Dissection of
the left recurrent laryngeal
nerve at the level of the aortic
arch. Close (a) and schematic
view (b)
Fig. 16.17 Left vagal nerve is dissected (a). Lymphadenectomy of the carina (b) and the left bronchus (c) is performed. Esophagus is freed
from the left bronchus and sampling of lymph node station 5 (d)
Fig. 16.18 Laparoscopy and positions of trocars
(18) A 3–4 cm gastric tube is created by means of a linear
stapler device (Fig. 16.22), leaving a bridge between
the specimen and the gastric tube (other option is to
divide the stomach completely and to attach the gastric tube to the specimen by means of one or two
stitches (Fig. 16.23). Other option will be to create the
gastric tube totally extracorporeally through a wellprotected supraumbilical incision of 7 cm. In this case,
gastric tube is fixed to the nasogastric tube introduced
by the cervical region.
(19) After cervical dissection of the esophagus, the gas-
tric conduit is ascended through the hiatus to the neck
under laparoscopic control (Fig. 16.24).
(20) Through the neck, the specimen and the gastric tube
can now be exteriorized (Fig. 16.25).
(21) Now, the proximal esophagus is divided (Fig. 16.26),
and after resection of the specimen, an esophagogastric anastomosis will be performed.
138
Fig. 16.19 Dissection of the stomach with preservation of the gastroepiploic vessels. Gastrocolic ligament is opened (a, b). Mobilization of the
stomach with preservation of gastroepiploic vessels (c–g). Kocher maneuver (h)
F. M. Navarro et al.
Fig. 16.20 Lymphadenectomy type D+1 of the celiac trunk. Pars flaccida is divided (a, b). Right gastric artery is divided (c, d). Left gastric
artery is divided (e, f)
Fig. 16.21 Dissection of
the hiatal area. Close (a) and
schematic view (b)
Fig. 16.22 Creation of the
gastric conduit. Close (a) and
schematic view (b)
13916 Three-Stage McKeown Minimally Invasive Esophagectomy Procedure …
140
F. M. Navarro et al.
Fig. 16.23 Gastric conduit is fixed to the specimen by stitches
Fig. 16.24 Gastric conduit is ascended through the hiatus into the cervical wound under laparoscopic control. Close (a) and schematic view (b,
c)
Fig. 16.25 Gastric conduit in the neck before esophagogastric
anastomosis
References
14116 Three-Stage McKeown Minimally Invasive Esophagectomy Procedure …
Fig. 16.26 Proximal esophagus is divided at the cervical incision
before esophagogastric anastomosis is performed
1. Cuesta MA, Scheepers JJ, Dekker JW and van der Peet DL.
Minimally invasive esophagectomy step by step: how to do it. In:
Miguel A. Cuesta, editor. Minimally invasive surgery for upper
abdominal cancer. Springer, London; 2017. p. 121139.
2. Cuesta MA, Review of different approaches of the left recurrent
laryngeal nerve area for lymphadenectomy during minimally invasive esophagectomy. JTD. 2018; 11(Suppl 5 April 2019):766–70.
3. Kawakubo H, Takeuchi H, Kitagawa Y. Current status and future
perspectives on Minimally Invasive Esophagectomy. Korean J
Thorac Cardiovasc Surg. 2013;46:241–8.
4. Lin M, Shen Y, Feng M, et al. Minimally invasive esophagectomy:
Chinese experiences. J Vis Surg. 2016;2:125.
Robot-Assisted Minimally Invasive Esophagectomy (RAMIE)
Richard van Hillegersberg, Pieter C. van der Sluis
and Jelle P. Ruurda
17
17.1 Introduction
The standard treatment for locally advanced esophageal
cancer with curative intent is multimodality treatment containing either preoperative chemoradiation or perioperative chemotherapy followed by open esophagectomy [1, 2].
However, the open transthoracic esophagectomy is associated with high morbidity and mortality [3, 4].
Minimally invasive esophagectomy (MIE) was designed
to improve the outcome of esophagectomy. Systematic
reviews and results from three randomized controlled trials,
comparing total (laparoscopy and thoracoscopy in prone)
or hybrid (Laparoscopy and thoracotomy) MIE or RAMIE
(laparoscopy and RAMIE thoracoscopy) to open transthoracic esophagectomy, showed decreased blood loss, fewer
postoperative complications, especially pulmonary infections and shorter hospital stay, with comparable short-term
oncologic results [5–9].
However, MIE is not widely applied yet. Technical limitations and concerns about oncologic efficacy have been
the main reasons for a limited application of this technique.
Hence, the open procedure remains the preferred approach
in most centers worldwide [2].
Robot-assisted minimally invasive thoraco-laparoscopic
esophagectomy (RAMIE) was developed in 2003 in the
University Medical Center Utrecht (UMC Utrecht) to overcome the technical limitations of conventional MIE with the
Electronic supplementary material The online version of this
chapter (https://doi.org/10.1007/978-3-030-55176-6_17) contains
supplementary material, which is available to authorized users.
R. van Hillegersberg (*) · P. C. van der Sluis · J. P. Ruurda
Department of Surgical Oncology, University Medical Center
Utrecht, Utrecht, The Netherlands
e-mail: r.vanhillegersberg@umcutrecht.nl
P. C. van der Sluis
e-mail: p.c.vandersluis@umcutrecht.nl
availability of three-dimensional vision and the use of more
sophisticated precision instruments. RAMIE was shown
to be feasible and safe in a cohort of Western European
patients with advanced esophageal cancer in both the literature and our own results [10, 11]. Furthermore, RAMIE
was oncologically effective, with a high percentage of R0
radical resections (95%) and adequate lymphadenectomy.
RAMIE provided good local control with a low percentage of local recurrence at long-term follow-up [10–12]. The
most frequently performed procedure has been the 3-stage
MIE McKeown with cervical anastomosis.
Currently, there are new procedures in minimally invasive esophageal surgery that it seems will be better performed using the RAMIE such as the high hand-sewn
intrathoracic anastomosis in upper esophageal cancer and
the resection of cT4b esophageal cancer.
17.2 Description of the Surgical Technique
(Robot-Assisted Minimally Invasive
Thoraco-Laparoscopic Esophagectomy
(RAMIE) at UMC Utrecht)
There are two standard RAMIE procedures, the first is the
2-stage Ivor Lewis RAMIE in which first we start with the
laparoscopic phase that includes the lymphadenectomy of
the celiac trunk and the creation of the gastric conduit, followed by the RAMIE thoracoscopy in which the esophageal
dissection is performed along with lymphadenectomy of the
paraesophageal, infracarinal, and both RLN Lymph node
stations if indicated followed by hand-sewn intrathoracic
anastomosis.
The second procedure is the 3-stage RAMIE McKeown
procedure in which the intervention starts with the RAMIE
thoracoscopic esophageal dissection and mediastinal lymphadenectomy, to be follow by laparoscopy (lymphadenectomy of the celiac trunk and creation of the gastric conduit),
to finish with the retrieval of the specimen and the cervical
© Springer Nature Switzerland AG 2021
M. Asunción Acosta et al. (eds.), Atlas of Minimally Invasive Techniques in Upper Gastrointestinal Surgery,
https://doi.org/10.1007/978-3-030-55176-6_17
143
144 R. van Hillegersberg et al.
anastomosis between the gastric conduit and the proximal
esophagus.
The key steps to perform the 3 stage McKeown RAMIE
include the following.
17.2.1 Thoracoscopic Preparation and Positioning
General and thoracic epidural anesthetics are combined to
ensure sufficient intraoperative and postoperative analgesia.
Recently, we started using single-dose and bilateral paravertebral block combined with sufentanil in the context of
our enhanced recovery after the esophagectomy program.
This may provide similar postoperative analgesia and early
discharge avoiding the disadvantages of epidural anesthesia
such as catheter malposition and hypotension.
The patient is intubated with a left-side double-lumen
tube. During the thoracoscopic phase of the operation (1st
stage), patients are positioned in the left lateral decubitus
position, tilted 45° toward the prone position to keep the
collapsed lung from the operating field. The operating table
is flexed, lowering the legs and upper thorax (the patient
is positioned with the xyphoid above the pivoting point of
the table). This extends the thorax maximally and widens
the intercostal space for the introduction of the trocars The
trocars’ positions are marked relatively from the scapula
(Fig. 17.1) The robotic system (da Vinci Si system, Intuitive
Surgical, Inc., Sunnyvale, CA, USA) is placed at the dorsocranial side of the patient (Fig. 17.2a, b).
Before incision, the right lung is collapsed. A 10-mm
camera port is placed at the sixth intercostal space, posterior to the posterior axillary line. Two 8-mm ports are
placed under direct sight anterior to the scapular rim in
the fourth intercostal space and more toward posterior
Fig. 17.2 Operating room setup
in the ninth intercostal space. Two conventional 10-mm
disposable trocars are used in the fifth and seventh intercostal spaces just posterior to the posterior axillary line
(Fig. 17.1a, b). These ports are used for thoracoscopic assistance such as suction, traction, clipping, and insertion of
additional surgical needs. CO2 insufflation of the thoracic
cavity permits excellent vision, without the need for retracting the lung from the operative field. In case of a noncompliant lung, a retractor can be used.
Fig. 17.1 Trocar placement in the thoracic phase. Robotic arms 1
(yellow) and 2 (green), camera (blue), and two assisting ports (white).
MAL (midaxillary line)
17.2.2 Thoracoscopic Phase: Operative Procedure
After the introduction of the trocars, possible pulmonary
adhesions are divided to obtain a clear sight of the operating
field. The pulmonary ligament is divided, the parietal pleura
is dissected at the anterior side of the esophagus from the
diaphragm up to the azygos arch (Fig. 17.3a–c). The azy-
gos vein is ligated using robotically applied Hem-o-lok®
clips (size Large, Teleflex Medical, Limerick, PA, USA).
These clips are endowristed facilitating precise positioning
(Fig. 17.4a–d). Dissection of the parietal pleura is continued above the azygos arch (Fig. 17.5a–d), for a right para-
tracheal lymph node dissection (Fig. 17.6a–c). Dissection is
now performed between the trachea and the esophagus from
the right side to the left side (Fig. 17.7a–c).