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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_541_Библиотеки_им_академика_М_И_Перельмана.pdf
Robotic Esophagectomy: Ivor Lewis
PeterP.Grimminger, GiovanniCapovilla,
andEvangelosTagkalos
13
Introduction
Transthoracic esophageal resection with gastric conduit
reconstruction (Ivor Lewis esophagectomy) represents a
widely adopted approach for the treatment of junctional and
thoracic esophageal cancer. The Ivor Lewis procedure consists of an abdominal phase including a D2 level lymphadenectomy followed by the preparation of a gastric conduit and
the thoracic phase involving the esophageal resection, the
mediastinal lymphadenectomy, and the esophagogastric
anastomosis. The procedure can nowadays be performed
using a laparoscopic-thoracoscopic approach (fully mini-
mally invasive esophagectomy– MIE), with superior shortterm outcomes and equivalent oncologic results compared to
the conventional open approach. The robot-assisted mini-
mally invasive thoraco-laparoscopic esophagectomy
(RAMIE) has recently been developed to overcome the technical complexity of MIE [1]. The robotic approach offers the
advantages of the magnied three-dimensional vision and
the use of intracorporeally articulated instruments, thus facilitating the technically demanding dissection phase required
during esophagectomy [2]. A recent randomized trial demonstrated the superiority of RAMIE compared to the conven-
tional open approach [3]. The results of a prospective
randomized trial comparing RAMIE and conventional MIE
are awaited.
We present here our technique for RAMIE using the da
Vinci Xi
CA, USA) [4]. Briey, a gastric conduit is prepared by stapling the stomach along the lesser curvature (Endo GIA™,
Covidien, Manseld, MA, USA) and preserving the right
gastric vessels and the gastroepiploic arcade to guarantee an
adequate vascularization of the gastric conduit. Ideally, a
lymphadenectomy of the D2 level should be performed. The
thoracic phase consists of freeing the esophagus along with
the lower, middle, and upper mediastinal lymph nodes,
resecting the specimen and performing an end-to-side esophagogastric gastric anastomosis using a circular stapler
(CEEA™, Covidien, Manseld, MA, USA) (Figs. 13.1,
13.2, 13.3, 13.4, 13.5, 13.6, 13.7, 13.8, 13.9, 13.10, 13.11,
13.12, 13.13, 13.14, 13.15, 13.16, 13.17, 13.18, 13.19, 13.20,
13.21, 13.22, 13.23, 13.24, 13.25, 13.26, 13.27, 13.28, 13.29,
13.30, 13.31, 13.32, 13.33, 13.34, 13.35, 13.36, 13.37, 13.38,
13.39, 13.40, 13.41, 13.42, 13.43, 13.44, 13.45, 13.46, 13.47,
13.48, 13.49, 13.50, 13.51, 13.52, 13.53, 13.54, 13.55, 13.56,
and 13.57).
®
Surgical System (Intuitive Surgical, Sunnyvale,
P. P. Grimminger (*) · G. Capovilla · E. Tagkalos
Department of General-, Visceral- and Transplant Surgery,
University Medical Center Mainz, Mainz, Germany
e-mail: peter.grimminger@unimedizin-mainz.de
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2022
O. Y. Kudsi, P. P. Grimminger (eds.), Atlas of Robotic Upper Gastrointestinal Surgery,
https://doi.org/10.1007/978-3-030-86578-8_13
125
126
Fig. 13.1 Trocar position: the patient is placed in a normal supine position with a 15° reverse Trendelenburg. Pneumoperitoneum is applied
with a Veress needle in the upper left abdominal quadrant, 2–3cm above
the umbilical line. Upon removal of the Veress needle, a 8mm trocar is
placed to be used for the energy dissection device (Vessel Sealer Extend
or Monopolar-Hook). The 8mm midline camera trocar is placed a certain
distance above the umbilicus, depending on the location of the stomach
in the CT scan. A 12mm trocar used for the Fenestrated Bipolar Forceps
and the Stapler is placed in the upper right quadrant. A fenestrated Tip-Up
grasper is introduced with the third arm, through another 8mm trocar
placed in the right lateral subcostal area. Finally, a 12mm assistant trocar
is placed in the left lateral subcostal area and used for retraction, suction,
and introduction/removal of any material during the dissection. The da
Vinci® Xi robotic system is positioned on the right side of the patient.
The position of the assistant is on the patient’s left side
P. P. Grimminger et al.
Fig. 13.3 The lesser omentum is opened, and the dissection is carried
out toward the right diaphragmatic crus
Fig. 13.2 The initial setting includes the use of the fenestrated bipolar
forceps on the left arm and the Vessel Sealer on the right arm. The third
robotic arm is equipped with a Tip-Up grasper and used to retract the
left liver lobe
Fig. 13.4 The space between the right diaphragmatic crus and the pericardial fat is developed. The pericardial fat tissue is retracted to the left
to provide tension and improve the eld vision. The lower esophagus is
completely freed on the right side. During this phase the lymph nodes
of station 1 are collected and will be retrieved en bloc with the
specimen
13 Robotic Esophagectomy: Ivor Lewis
127
Fig. 13.5 In the next step, the greater omentum is retracted caudally,
and the gastroepiploic arcade is identied along the greater curvature
Fig. 13.6 The greater omentum is dissected, and a partial omentectomy is carried out along the greater curvature, toward the spleen.
Direct vision of the gastroepiploic arcade can easily be acquired at the
posterior aspect of the greater gastric curvature
Fig. 13.7 The left gastroepiploic vessels are encountered and transected. The gastroepiploic arcade is preserved to provide an adequate
vascularization of the gastric conduit. Lymph nodes of station 4sb and,
above the left gastroepiploic artery, 4sa are retrieved during this phase
and will be extracted en bloc with the specimen
Fig. 13.8 The mobilization of the gastric fundus is completed by
dividing the short gastric vessels. During this phase the stomach can be
gently retracted toward the right using the third robotic arm (Tip Up
grasper); the assistant can retract the fat pad toward the left side to provide tension
128
P. P. Grimminger et al.
Fig. 13.9 Once fully mobilized from the spleen, the fundus can be
retracted medially to access the left diaphragmatic crus. Lymph nodes
of station 4sa are retrieved during this phase and will be extracted en
bloc with the specimen
Fig. 13.10 The esophagus can be fully released from the left crus after
complete dissection of lymph nodes station 2. The dissection plane is
connected to the previously developed hiatal dissection plane on the
right side
Fig. 13.11 The stomach is retracted cranially, and the partial omentectomy is continued toward the right gastroepiploic vessels
Fig. 13.12 During this phase any residual gastropancreatic ligament
or adhesions with the transverse mesocolon are divided to achieve complete mobilization of the stomach
13 Robotic Esophagectomy: Ivor Lewis
129
Fig. 13.13 The dissection is carried out toward the pylorus. The right
gastroepiploic vessels are visualized and spared as they provide the vascularization to the gastric conduit. Care should be taken in separating
the posterior gastric wall from the transverse mesocolon in this phase
Fig. 13.14 During this step the antrum can be lifted up in order to
bring the gastroepiploic vessels in orthogonal position and facilitate the
dissection. The gastric mobilization should be extended toward the gallbladder until the postpyloric duodenum is visualized. The gastroduodenal artery is often visualized
Fig. 13.15 The fat tissue is dissected from the lesser curvature to prepare the stomach for tubulization
Fig. 13.16 The rst stapler (SureFormTM Stapler, Intuitive, Sunnyvale,
California, USA) is applied approximately between the distal third and
the proximal two thirds of the lesser curvature
130
P. P. Grimminger et al.
Fig. 13.17 Normally between three and four res of the 60mm stapler
(blue or black magazines) are used
Fig. 13.18 A 4–5cm tissue connection to the fundus is left, in order to
later pull up the stomach by traction on the dissected esophagus
Fig. 13.19 After tubulization, the lesser curvature can be lifted cranially, thus improving the exposition for the subsequent
lymphadenectomy
Fig. 13.20 The lymphadenectomy is started by dissecting the fat tissue medially from the right gastric artery
13 Robotic Esophagectomy: Ivor Lewis
131
Fig. 13.21 Following the right gastric artery, the proper hepatic artery
is identied. Dissection of the surrounding fat tissue is carried out
toward the celiac trunk medially. The origin of the gastroduodenal
artery from the common hepatic artery is identied. In this phase we
prefer to use the Permanent Cautery Hook (monopolar). Station 12
lymph nodes are collected during this phase and will be extracted en
bloc with the nal specimen
Fig. 13.23 The sovra-pancreatic fat is dissected medially along the
superior border of the pancreatic body, and the celiac trunk and the
proximal portion of the splenic artery are identied. Gentle cranial traction on the lesser gastric curvature facilitates the exposition of the left
gastric vein. Station 9 and 11p lymph nodes are collected during this
phase
Fig. 13.22 Dissection of the anterior and posteromedial aspect of the
common hepatic artery allows the retrieval of station 8 lymph nodes
that will be resected en bloc with the nal specimen
Fig. 13.24 After division of the gastric vein, the left gastric artery is
identied and dissected posteriorly. During this phase the fat tissue
surrounding the celiac trunk, the left gastric vessels, and the splenic
artery is dissected and lifted cranially. This maneuver permits the
retrieval of station 9, 7 and 11p lymph nodes that will be resected en
bloc with the nal specimen
132
P. P. Grimminger et al.
Fig. 13.25 After division of the left gastric artery, the dissection of the
fat tissue is carried out posteriorly until the plane of the right and left
diaphragmatic crura is reached
Fig. 13.26 After adequate mobilization of the lower esophagus and
lymphadenectomy of pericardial lymph nodes, complete visualization
of the left and right diaphragmatic crura and the aortal plane and the
surrounding structures should be achieved
Fig. 13.27 For the thoracic phase of RAMIE, the patient is positioned
in a semi-prone position. We normally prefer the patient to be tilted
from the left-lateral position 45° toward the prone position. By using a
dual-lumen endotracheal tube, the right lung is not ventilated. The rst
12mm assistant trocar is placed in the 5° intercostal space along the
anterior axillary line and will be used for retraction, suction, and introduction/removal of any material during the dissection. The 8mm camera trocar is placed in the 6° intercostal space between the middle and
anterior axillary line. The Vessel Sealer Extend and the Monopolar
Hook are introduced through an 8mm trocar placed at the 4° intercostal
space along the posterior axillary line. Another 12mm trocar is placed
in the 8° intercostal space, at the posterior axillary line, and is used for
the Fenestrated Bipolar Forceps and the Linear Stapler. Finally, an
8 mm trocar is placed inferiorly, in the 10° intercostal space, at the
posterior axillary line; this trocar will be used for the Synchro Seal and
Tip-Up Grasper, for dissection and to achieve retraction of the lung. The
®
da Vinci
Xi robotic system is positioned on the right side of the patient.
The position of the assistant is on the patient’s left side
Fig. 13.28 The dissection is started from the inferior pulmonary ligament. The parietal pleura is incised along the anterior side of the esophagus on the pericardial layer
13 Robotic Esophagectomy: Ivor Lewis
133
Fig. 13.29 The dissection is extended toward the azygos vein arch,
which is clearly identiable
Fig. 13.30 The parietal pleura is further dissected above the azygos
arch. This maneuver allows the retrieval of the right paratracheal lymph
nodes
Fig. 13.31 The dissection is conducted above the azygos until visualization of the esophagus above is achieved
Fig. 13.32 Dissection at the posterior aspect of the azygos is conducted to develop a space for its transection. During this maneuver care
should be taken to avoid bleeding from a bronchial artery that can be
found underneath the azygos arch
134
P. P. Grimminger et al.
Fig. 13.33 The azygos is then clipped using Hem-o-lok (Teleex
Medical, Weck Drive, NC) and divided using a vessel sealer
Fig. 13.34 To complete the dissection, the bronchial artery is selectively divided
Fig. 13.35 The dissection is continued in a cranial-to-caudal direction
at the posterior side of the esophagus along the azygos vein
Fig. 13.36 The dissection is conducted until the aortal layer is reached.
This dissection layer allows the retrieval of the paraesophageal lymph
nodes