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14517 Robot-Assisted Minimally Invasive Esophagectomy (RAMIE)
Fig. 17.3 Starting the dissection along the pulmonary ligament, the pleura is opened at different levels from the diaphragm up to the azygos
vein arch. Schematic (a) and close views (b, c)
Fig. 17.4 The azygos vein is ligated using robotically applied Hem-o-lok® clips and sectioned. Schematic (a) and close views (b, c, d)
Fig. 17.5 Opening the pleura up to the thoracic apex above the azygos arch. Schematic (a) and close views (b, c, d)
The right vagal nerve is dissected and cut below the
level of the carina to preserve its pulmonary branches and
serves as a lateral boundary of the paratracheal lymph node
dissection. Subsequently, the parietal pleura is dissected
at the posterior side along the azygos vein (Fig. 17.8a, b)
and the dissection continues between the azygos vein and
the descending aorta, where the periesophageal fascia or
meso-esophagus has to be opened (Fig. 17.9a, b). Lymph
node dissection is performed en bloc with the esophagus from the aorta and along the avascular plain over the
periesophageal lymph nodes and the thoracic duct from
the diaphragm up to the thoracic inlet. Finally, an infracarinal lymphadenectomy is performed (Fig. 17.12a–c).
Lymphadenectomy will include the paratracheal (lymph
node station 2R and 2L), tracheobronchial (lymph node
station 4), aortopulmonary window (station 5), carinal (station 7, Fig. 4), and periesophageal (station 8) lymph nodes.
Aortoesophageal vessels are clipped and divided by the
assisting surgeon. A thoracic tube is left in place and the
thoracic wounds closed in two layers.
pericard. At the level of the diaphragm, the thoracic duct is
clipped with a 10-mm endoscopic clipping device (Endo
ClipTM II; Covidien, Mansfield, Massachusetts, USA)
17.2.3 Laparoscopic Phase: Positioning
(Fig. 17.10a, b). A Penrose drain is placed around the
esophagus and retracted by the assistant (Fig. 17.11a, b),
to facilitate esophageal mobilization. In this way, the
esophagus can be resected en bloc with the surrounding
After completion of the thoracoscopic phase, the patient
is put in supine position for the abdominal phase (2nd
stage). A laparoscopic approach is used without the
146 R. van Hillegersberg et al.
Fig. 17.6 Right paratracheal lymphadenectomy is performed between the right vagal nerve and the trachea preserving the vagal and the right
recurrent nerve. Schematic (a) and close views (b, c)
Fig. 17.7 Dissection is performed between trachea and esophagus from the right side to the left side. Schematic (a) and close views (b, c)
Fig. 17.8 Dissection
between the descending aorta
and azygos vein, including
the thoracic duct. Schematic
(a) and close views (b)
Fig. 17.9 Dissection and division of the meso-esophagus. The parietal pleura is dissected at the posterior side along the azygos vein. Lymph
node dissection is performed en bloc with the esophagus from the aorta and along the avascular plain over the pericardium. Schematic (a) and
close views (b)
Fig. 17.10 Clipping and cut
of the distal thoracic duct.
Schematic (a) and close
views (b)
Fig. 17.11 Complete
dissection of the esophagus.
A Penrose drain is placed
around the esophagus and
retracted by the assistant
to facilitate esophageal
mobilization. Schematic (a)
and close views (b)
14717 Robot-Assisted Minimally Invasive Esophagectomy (RAMIE)
Fig. 17.12 The esophagus is resected en bloc with the surrounding mediastinal lymph nodes and the thoracic duct from the diaphragm up to the
thoracic inlet. Schematic (a) and close views (b, c)
Fig. 17.13 Esophagus layers
are stitched together (a). Gastric
conduit is open (b)
robotic system. The camera is inserted through the 12-mm
left paraumbilical trocar port. All other ports are created
under direct vision. A 12-mm working port is placed at
the right midclavicular line at the umbilical level for the
introduction of the harmonic scalpel. Two 5-mm assisting
trocar ports are used as working ports placed subcostally
and a 12-mm trocar is placed right in the flank for the liver
retractor.
148 R. van Hillegersberg et al.
Fig. 17.14 Posterior layers
are sutured by continuous
suture by means of V-Lock
(a, b)
Fig. 17.15 Posterior layer is
completed (a, b)
®
Fig. 17.16 Anterior layer is
sutured (continuous suturing
by V-Lock
®
) (a, b)
17.2.4 Laparoscopic Phase: Operative Procedure
The laparoscopic phase can be performed by conventionally
laparoscopic or laparoscopy assisted by a ROBOT.
The procedure implies.
(1) Lymphadenectomy of the celiac trunk (D2 or D1+ ).
(2) Dissection of the greater curvature and creation of the
gastric conduit.
(3) Hiatal dissection.
(4) Gastric conduit advancement to the thoracic cavity and
performance of the anastomosis.
(5) Anastomosis can be performed conventionally or
robot-assisted
Pneumoperitoneum is created with CO
insufflation of
2
12 mm Hg. First, the abdominal cavity and the liver are
inspected for possible metastases followed by the opening of the hepatogastric ligament. The greater and lesser
curvatures are dissected with ultrasonic harmonic scalpel
(Ultracision, Ethicon Endo-Surgery, Johnson & Johnson,
New Brunswick, New Jersey, USA) with careful sparing
of the right gastroepiploic vessels. Abdominal lymphadenectomy includes lymph nodes surrounding the left gastric artery, the splenic artery, common hepatic artery, and
the lesser omental lymph nodes. The left gastric artery is
ligated with Hem-o-lok (Teleflex Medical, Weck Drive,
NC) and transected at its origin.
Thereafter, the distal esophagus is dissected from
the right and left crura by opening of the hiatus. The
Fig. 17.17 Seromuscular
extra stitch as reinforcement
(a, b)
Fig. 17.18 Omentum plasty to cover the anastomosis
Fig. 17.19 Hiatal approximation
14917 Robot-Assisted Minimally Invasive Esophagectomy (RAMIE)
intra-abdominal CO2 level is reduced to 6 mm Hg to avoid
excessive intrathoracic pressure, and a chest tube is placed
in the left pleural sinus to prevent a pressure pneumothorax.
17.2.5 Cervical Phase
Through a left-sided vertical incision along the sternocleidoid muscle, the cervical phase (3rd stage) of
esophagectomy is initiated to facilitate mobilization of the
cervical esophagus. The inferior thyroid artery is ligated.
The esophagus is dissected and a cord is sutured to the
proximal part of the specimen to enable pull-up of the
gastric conduit along the anatomical tract of the esophagus through the mediastinum under laparoscopic view. No
formal cervical lymph node dissection is carried out, but
a cervical lymphadenectomy is performed if lymph node
metastases are suspected macroscopically during the cervical phase of esophagectomy.
Pneumoperitoneum is installed and the esophagus and
the surrounding lymph nodes are pulled through the hiatus
into the abdomen under direct laparoscopic vision. The left
paraumbilical port is widened to a 7-cm transverse transabdominal incision for removal of the resection specimen
and stomach using a wound protector. A gastric conduit
5 cm wide is created with GIA linear staplers (GIATM 80,
3_8 mm; Medtronic, Minneapolis, Minnesota). The staples
are oversewn with 3–0 polydioxanone. The esophagus and
cardia resection resection specimen are sent for pathological examination and the paratracheal, subcarinal, periesophageal, and left gastric artery lymph niode stations were
marked in the resection specimen.
150 R. van Hillegersberg et al.
The gastric conduit is pulled up through the mediastinum
along the original anatomic tract of the esophagus with the
aid of a laparoscopic camera bag used as a protector. A cervical end-to-side anastomosis is created between the gastric
tube and the cervical esophagus using 3/0 polydioxanone
single-layer running sutures. The excess gastric tubing is
removed using a GIA linear stapler and sent in for pathological analysis.
A jejunostomy feeding tube (Freka® FCJ-Set-Fresenius
Kabi AG, Bad Homburg vd H., Germany) is placed at the
level of the transverse incision, and cervical and abdominal wounds are closed. The abdomen is closed in layers
with PDS loop for the fascia and skin intracutaneously with
monocryl. Patients are transferred to the intensive care unit
(ICU) after the surgical procedure.
17.3 Future Directions
Since the introduction of RAMIE, we have gained considerable experience with the use of the da Vinci robot in over
300 cases. However, we are continuously trying to improve
RAMIE and pushing the limits by technical modifications
and trying to operate more advanced cases. Recent progress, such as the hand-sewn intrathoracic anastomosis,
RAMIE for upper esophageal cancer with paratracheal
lymph node metastases and cT4b tumors are described here.
anastomosis, which is confirmed by the outcomes of our
first experiences with the robotic-hand-sewn intrathoracic
anastomosis.
17.5 The Steps to Perform an Intrathoracic Gastroesophageal Anastomosis (see Videos 17.1–17.3)
1. Esophagus layers are stitched together (mucosa and
muscular). Gastric conduit is open (Fig. 17.17a, b).
2. Posterior layers are sutured by continuous suture by
means of V-Lock® (Fig. 17.18a, b).
3. Posterior layer is completed (Fig. 17.19a, b).
4. Hereafter an extra seromuscular anterior stitch is used
as reinforcement. An Omentum plasty is used to cover
the anastomosis and the hiatus is approximated with a
hiatoplasty.
The aforementioned technical advantages were also beneficial in esophagectomy for upper esophageal cancer. The
upper mediastinum and thoracic aperture can be reached
with an excellent 3D view and magnified observation of the
operative field. In this way, we were able to achieve an R0
resection in 28 out of 29 patients (97%) with upper esophageal tumors and paratracheal lymph node involvement
(unpublished data).
17.4 Hand-Sewn Intrathoracic Anastomosis and Upper Esophageal Cancer
Until recently, we performed a three-stage esophagectomy
(McKeown procedure) with a cervical hand-sewn endto-side esophagogastric anastomosis without the use of a
robot. The incidence of anastomotic leakage after RAMIE
with cervical esophagogastrostomy was reported to be relatively high (15–30%) [13]. Furthermore, intrathoracic manifestations of anastomotic leakage occur in more than half of
patients with cervical anastomotic leakage. The incidence
of leakage from intrathoracic anastomosis was reported to
be lower [14]. Therefore, we started performing a two-stage
(Ivor Lewis) procedure with a robotic-hand-sewn end-toside intrathoracic anastomosis for distal esophageal tumors.
Constructing an intrathoracic anastomosis in the upper thoracic aperture during conventional thoracoscopy might be
technically challenging. The robot overcomes these technical problems due to the endowristed intracorporeal instruments, tremor filtering, and its three-dimensional view of
the surgical field [15]. Therefore, in our opinion the robot
contributes to a high-quality hand-sewn intrathoracic
17.6 cT4b Esophageal Cancer
Until recently, patients with cT4b tumors were considered
inoperable, and guidelines recommend definitive chemoradiotherapy (dCRT) as the treatment of choice. Definitive
chemoradiotherapy is associated with a high rate of esophageal stenosis and esophageal perforation [16]. Furthermore,
functional results are poor and recurrence occurs frequently
in up to 41% [17] of the patients. Therefore, we started salvage surgery in patients with cT4b esophageal tumors after
long-course chemoradiotherapy.
After long-course chemoradiotherapy. Patients are
restaged with positron emission tomography–computed
tomography and endobronchial ultrasound. Patients are
selected for salvage surgery if tumor ingrowth in the surrounding organs had reduced. We believe that the enlarged
3D image allows for a very precise dissection of the irradiated tumor tissue from the trachea, bronchi, and aorta. The
level of precision makes the dissection in downstaged T4b
tumors feasible. We are awaiting the long-term oncologic
and functional results with this approach for cT4b patients
before it can be recommended for all patients.
15117 Robot-Assisted Minimally Invasive Esophagectomy (RAMIE)
17.7 Conclusion
Robot-assisted surgical procedures may overcome the technical limitations of standard laparoscopic and thoracoscopic
procedures. The surgeon, who controls the console of the da
Vinci robot, has a tenfold magnified 3D view of the surgical
field. The articulated arms and instruments allow for more
degrees of freedom of movement and the tremor of the surgeon is filtered out. These combined factors facilitate a precise radical dissection of the esophagus and periesophageal
tissue along vital structures, such as the aorta, trachea, pulmonary vein, and laryngeal recurrent nerve. Furthermore,
a proper and accurate lymph node dissection can be performed, which may result in lower tumor recurrence [13].
Robot-assisted esophagectomy was shown to be a feasi-
ble and safe technique.
In 2015, we reported that RAMIE was oncologically
effective, with a high percentage of R0 radical resections
and adequate lymphadenectomy. RAMIE provided good
local control with a low percentage of local recurrence at
long-term follow-up [11].
Looking for evidence, we have performed the control
randomized ROBOT-trial in order to compare robot-assisted
minimally invasive thoraco-laparoscopic esophagectomy
with open transthoracic esophagectomy as the surgical
treatment for resectable esophageal cancer. The conclusions
of this study have showed that RAMIE has resulted in a
lower percentage of overall surgery-related and cardiopulmonary complications with lower postoperative pain, better
short-term quality of life, and a better short-term postoperative functional recovery compared to Open Transthoracic
Esophagectomy (OTE). Oncological outcomes were comparable and in concordance with the highest standards
nowadays [9]. Since then, it is clear that the RAMIE performed by qualified Upper GI surgeons is oncologically a
safe operation.
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Cervical Esophagogastric Anastomosis
M. Asunción Acosta and Salvador Navarro Soto
18
18.1 Introduction
The question about what type of cervical esophagogastric
anastomosis after esophageal resection is better, hand-sewn
or stapled, remains controversial in spite of many studies,
some of them randomized.
Vilela Castro et al. have performed a systematic review
and meta-analysis comparing both surgical anastomoses.
They have included 13 randomized trials, totaling 1778
patients, 889 in the hand-sewn group and 889 in the stapler
group [1, 2].
The stapled anastomosis reduced bleeding and operating
time when compared to hand-sewn anastomosis. However,
stapled anastomosis increased significantly the risk of anastomotic stricture, pulmonary complications, and mortality.
Moreover, there was no significant difference in relation to
anastomotic leak between both the techniques.
In spite of this, surgeons think there is no hard evidence
for what is the best anastomosis and are still choosing one
or the other technique influenced by tradition or own experience. Nevertheless, there are important modifications,
such as the one introduced by Orringer [3] or the current
Japanese triangulation technique [4].
18.2 Description of the Operative Technique (see Video 18.1)
Cervical approach is performed usually on the left side
through a length incision on the medial aspect of the sternocleidomastoid muscle.
The platysma muscle is open, the omohyoid muscle is
divided, and the middle thyroid vein and inferior thyroid
artery are ligated and divided. After this, care should be
taken not to damage the recurrent laryngeal nerve by avoiding retractors on the tracheal side of the wound, using only
the fingers. After opening the cervical fascia, the esophagus
is palpated and dissected very gently, and retracted to the
surface of the wound. A Penrose drain can be used for this.
Once the esophagus is completely freed, the gastric
conduit or the specimen with the gastric conduit is exteriorized, depending on the surgical procedure performed.
Anastomosis is then performed.
18.3 Stapled Anastomosis
The key steps to perform a stapled anastomosis are
1. Retrieval of the specimen and gastric conduit through the
cervical wound (Fig. 18.1a, b).
2. Stitch between the specimen and gastric conduit is cut
(Fig. 18.2a, b).
3. Linear endostapler section 60 of the proximal end of the
Electronic supplementary material The online version of this
chapter (https://doi.org/10.1007/978-3-030-55176-6_18) contains
supplementary material, which is available to authorized users.
M. A. Acosta (*)
Unidad de Cirugia Esofago-gàstrica, Hospital Universitario de
Gran Canaria “Dr. Negrìn”, Las Palmas, Gran Canaria, Spain
e-mail: maacosta03@yahoo.es
S. Navarro Soto
Department of Surgery, Parc Taulí, Sabadell, Barcelona, Spain
© 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_18
esophagus, at the cervical level, completing the extrac-
tion of the surgical specimen.
The esophageal stump and the proximal end of the gas-
troplasty are prepared for the cervical anastomosis
(Fig. 18.3a, b).
4. Opening is performed at the end of the esophagus and
the gastric conduit (Fig. 18.4a, b).
5. Linear stapler 60 mm is introduced through both open-
ings in order to perform a side-to-side esophagogastric
conduit anastomosis (Fig. 18.5a, b).
153
154 M. A. Acosta and S. Navarro Soto
Fig. 18.1 Retrieval of the
specimen and gastric conduit
through the cervical wound.
Close (a) and schematic
views (b)
18.4 Hand-Sewn Anastomosis
The key steps to perform a hand-sewn anastomosis are
1. Gastric conduit is oversewn with continuous reabsorb-
able 3.0 suture. The gastric conduit is exteriorized
through the cervical wound (Fig. 18.8a, b).
2. The two ends of the anastomosis are put together.
Gastric conduit posterior and proximal esophagus anteri-
orly (Fig. 18.9a).
The nasogastric tube is passed through the cervical
esophagus and externalized in the surgical field. A stitch
is passed and tied to have it referenced. The end of the
nasogastric tube is then reintroduced proximally, leav-
ing the end thread exposed, to be pulled when the gastric
Fig. 18.2 Stitch between the specimen and gastric conduit is cut
6. Guided nasogastric tube is passed, under direct vision,
through the cervical esophagogastric anastomosis, ensuring good distal passage to the gastroplasty (Fig. 18.6a, b).
7. The anterior opening is closed by means of a 60 mm
linear stapler (placed perpendicular to the anastomosis)
(Fig. 18.7a–e).
8. Check up the patency of anastomosis by palpation.
duct is opened (Fig. 18.9b).
3. Put a reference stitch at the medial aspect of both ends.
A horizontal opening is made 4 cm from the tip of the
gastric conduit (perpendicular to the stapled line of the
plasty) (Fig. 18.10a, b).
4. Posterior line is sutured by continuous suture with reabsorbable 3.0 thread (Fig. 18.11).
5. Check up the patency of both the openings (Fig. 18.12a, b).
6. Retrieve the end of the nasogastric tube from the proximal esophageal stump, cut the reference stitch, and pass
Fig. 18.3 Section of
proximal esophagus by
linear stapler. Close (a) and
schematic views (b)
Fig. 18.4 Opening is performed at the end of the esophagus and the
gastric conduit
15518 Cervical Esophagogastric Anastomosis
the tip of the nasogastric tube through the esophagogastric anastomosis, towards the distal part of the gastroplasty (Fig. 18.13a, b).
7. Anterior suture is made by continuous reabsorbable 3.0
suture from medial to lateral (Fig. 18.14).
8. Check up the patency of the anastomosis (Fig. 18.15).
9. A penrose-type cervical drain will be left near the esophagogastric anastomosis. Finally, the cervicotomy will be
closed.
Fig. 18.5 Linear stapler
60 mm is introduced through
both openings. Close (a) and
schematic views (b)
Fig. 18.6 Nasogastric
tube is introduced through
anastomosis. Close (a) and
schematic views (b)