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13 Management ofAchalasia: ADisease Hard toSwallow
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from the bougie being inserted and has antiemetic properties. Emesis can generate a high pressure within the esophagus, leading to perforation of the mucosa. Analgesia can be provided with oral narcotics such as Hycet. No intravenous pain medication is needed. A multimodal approach for analgesia is used. In our practice, it is not necessary to obtain a postoperative swallow study unless the patient was noted to have an intraoperative mucosal injury, in which case a contrast esophagram should be obtained with gastrogran followed by barium. Patients can be discharged within 24h on a clear liquid diet and advance to a soft diet at home. Patients should be provided with education to return for evaluation in the emergency department with symptoms of chest pain, shortness of breath, or persistent nausea. Patients are seen in clinic postoperatively, and a Eckardt score is performed comparing it to preoperative score. Our practice is to place these patients on a proton pump inhibi­tor. While not a standard recommendation, this approach remains common practice. Acid reux is a known occurrence after surgical or endoscopic myotomy, resulting from the disruption of the natural antireux barrier. Although the incidence of pos­tintervention acid reux is well documented, the lack of a precise denition stems from varied diagnostic criteria. Moreover, both subjective and objective measure­ments of acid reux in these patients tend to decrease over time. Considering this information, current guidelines suggest conducting endoscopic surveillance around 12months after myotomy and POEM procedures [48].

References

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16. Law YY, et al. Intraoperative diagnosis and treatment of Achalasia using EndoFLIP during Heller Myotomy and Dor fundoplication. Surg Endosc. 2022;36(4):2365–72.
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doi.org/10.4292/wjgpt.v6.i4.145.
20. Nijhuis O, etal. European guidelines on achalasia: United European Gastroenterology and European Society of Neurogastroenterology and Motility recommendations. United Eur Gastroenterol J. 2020;8(1):13–33. https://doi.org/10.1177/2050640620903213.
21. Jung etal. Korean Society of Neurogastroenterology and Motility. 2019 Seoul consensus on esophageal achalasia guidelines. J Neurogastroenterol Motil. 2020;26(2):180–203. https://doi.
org/10.5056/jnm20014. Erratum in: J Neurogastroenterol Motil. 2021;27(3):441–442
22. Leyden, etal. Endoscopic pneumatic dilation versus botulinum toxin injection in the manage­ment of primary achalasia. Cochrane Database Syst Rev. 2014;2014(12):CD005046. https://
doi.org/10.1002/14651858.CD005046.pub3.
23. Zaninotto, etal. Randomized controlled trial of botulinum toxin versus laparoscopic heller myotomy for esophageal achalasia. Ann Surg. 2004;239(3):364–70. https://doi.org/10.1097/01.
sla.0000114217.52941.c5.
24. Van Hoeij, etal. Complications of botulinum toxin injections for treatment of esophageal motility disorders. Dis Esophagus. 2017;30(3):1–5. https://doi.org/10.1111/dote.12491.
25. Smith CD, etal. Endoscopic therapy for achalasia before Heller myotomy results in worse out­comes than heller myotomy alone. Ann Surg. 2006;243(5):579–84; discussion 584–6. https://
doi.org/10.1097/01.sla.0000217524.75529.2d.
26. Tan S, etal. Efcacy and safety of peroral endoscopic myotomy in achalasia patients with failed previous intervention: a systematic review and meta-analysis. Gut Liver. 2021;15(2):153–67.
https://doi.org/10.5009/gnl19234.
27. Javed, et al. Durability of pneumatic dilation monotherapy in treatment-naive achalasia patients. BMC Gastroenterol. 2019;19(1):181. https://doi.org/10.1186/s12876- 019- 1104- z.
28. Boeckxstaens, etal. European Achalasia Trial Investigators. Pneumatic dilation versus lapa­roscopic Heller’s myotomy for idiopathic achalasia. N Engl J Med. 2011;364(19):1807–16.
https://doi.org/10.1056/NEJMoa1010502.
29. Moonen A, etal. Long-term results of the European achalasia trial: a multicentre random­ized controlled trial comparing pneumatic dilation versus laparoscopic Heller myotomy. Gut. 2016;65(5):732–9. https://doi.org/10.1136/gutjnl- 2015- 310602.
30. Boeckxstaens G, etal. 10-year follow-up results of the European Achalasia Trial: a multicentre randomized controlled trial comparing pneumatic dilation with laparoscopic Heller myotomy. Gut. 2023:gutjnl-2023-331374. https://doi.org/10.1136/gutjnl- 2023- 331374.
31. Cheng, etal. Laparoscopic Heller myotomy is not superior to pneumatic dilation in the man­agement of primary achalasia: conclusions of a systematic review and meta-analysis of ran­domized controlled trials. Medicine (Baltimore). 2017;96(7):e5525. https://doi.org/10.1097/
MD.0000000000005525.
32. El-Magd EA, etal. Pre-operative endoscopic balloon dilatation and its impact on outcome of laparoscopic Heller cardiomyotomy for patients with achalasia: does the frequency and inter­val matter? Surg Endosc. 2023;37(10):7667–75. https://doi.org/10.1007/s00464- 023- 10314- 4.
33. Ponds, etal. Effect of peroral endoscopic myotomy vs pneumatic dilation on symptom severity and treatment outcomes among treatment-naive patients with achalasia: a randomized clinical trial. JAMA. 2019;322(2):134–44. https://doi.org/10.1001/jama.2019.8859.
M. Belisle et al.
13 Management ofAchalasia: ADisease Hard toSwallow
34. Werner, etal. Endoscopic or surgical myotomy in patients with idiopathic achalasia. N Engl J Med. 2019;381(23):2219–29. https://doi.org/10.1056/NEJMoa1905380.
35. Saleh, etal. The efcacy of peroral endoscopic myotomy vs pneumatic dilation as treatment for patients with achalasia suffering from persistent or recurrent symptoms after laparoscopic Heller myotomy: a randomized clinical trial. Gastroenterology. 2023;164(7):1108–1118.e3.
https://doi.org/10.1053/j.gastro.2023.02.048.
36. Pesce M, etal. Modern achalasia: diagnosis, classication, and treatment. J Neurogastroenterol Motil. 2023;29(4):419–27. https://doi.org/10.5056/jnm23125.
37. Fisichella PM, etal. From Heller to POEM (1914–2014): a 100-year history of surgery for achalasia. J Gastrointest Surg. 2014;18:1870–5. https://doi.org/10.1007/s11605- 014- 2547- 8.
38. Chiruvella A, etal. Masters program foregut pathway: robotic Heller. The SAGES manual of robotic surgery. Cham: Springer; 2018. https://doi.org/10.1007/978- 3- 319- 51362- 14.
39. Richards, etal. Heller myotomy versus Heller myotomy with Dor fundoplication for achalasia: a prospective randomized double-blind clinical trial. Ann Surg. 2004;240(3):405–12; discus­sion 412–5. https://doi.org/10.1097/01.sla.0000136940.32255.51.
40. Campos GM, et al. Endoscopic and surgical treatments for achalasia: a system­atic review and meta-analysis. Ann Surg. 2009;249(1):45–57. https://doi.org/10.1097/
SLA.0b013e31818e43ab.
41. Zaninotto G, etal. The 2018 ISDE achalasia guidelines. Dis Esophagus. 2018;31(9):doy071.
https://doi.org/10.1093/dote/doy071.
42. Wright AS, etal. Long-term outcomes conrm the superior efcacy of extended Heller myot­omy with Toupet fundoplication for achalasia. Surg Endosc. 2007;21(5):713–8. https://doi.
org/10.1007/s00464- 006- 9165- 9.
43. Tomasko, etal. Quality of life comparing dor and toupet after heller myotomy for achalasia. JSLS. 2014;18(3):e2014.00191. https://doi.org/10.4293/JSLS.2014.00191.
44. Torres-Villalobos, etal. Dor vs Toupet fundoplication after laparoscopic Heller myotomy: long-term randomized controlled trial evaluated by high-resolution manometry. J Gastrointest Surg. 2018;22:13–22. https://doi.org/10.1007/s11605- 017- 3578- 8.
45. Broman K, etal. Heller myotomy versus Heller myotomy with Dor fundoplication for acha­lasia: long-term symptomatic follow-up of a prospective randomized controlled trial. Surg Endosc. 2018;32(4):1668–74. https://doi.org/10.1007/s00464- 017- 5845- x.
46. Lindeboom M, et al. Gastric emptying and vagus nerve function after laparoscopic partial fundoplication. Ann Surg. 2004;240(5):785–90. https://doi.org/10.1097/01.
sla.0000143124.30911.0f.
47. Oelschlager BK, et al. Vagotomy during hiatal hernia repair: a benign esophageal length­ening procedure. J Gastrointest Surg. 2008;12(7):1155–62. https://doi.org/10.1007/
s11605- 008- 0520- 0.
48. Joelson AM.Management of GERD after myotomy for achalasia. Foregut (Thousand Oaks, Calif.) (2634–5161). 2022;2(4):425.
157

Robotic Esophagectomy

14
EvangelosTagkalos andPeterP.Grimminger

Introduction

Worldwide, esophageal cancer is one of the most common tumors, with approxi­mately 600,000 new cases each year [1, 2]. The highest incidence rates are found in China, Iran, Kazakhstan, South Africa, and South America, with rates of up to 545 per 100,000 population per year. It is also the sixth leading cause of cancer-related death, with nearly 550,000 deaths worldwide each year, compared to 400,000 deaths in 2012 [1, 2]. Both squamous cell carcinoma (SCC) and adenocarcinoma (AC) are responsible for the increasing prevalence of esophageal cancer, representing the two most common types. While SCC remains the most common type of esophageal cancer worldwide, there has been a decline in this type in Western countries and a signicant increase in AC, including AC of the esophagogastric junction [1]. Esophageal carcinoma has a tendency to metastasize to regional lymph nodes in its early stages. The likelihood of regional lymph node metastases occurring is directly correlated with the depth of invasion into the esophageal wall. Distant metastases are more frequent in the liver, but can also occur in other organs such as the lungs, brain, adrenal glands or bones, as well as nonregional lymph nodes, depending on the location of the carcinoma. The surgical approach for the esophagus depends on its anatomical course from the pharynx to the upper abdomen. Reconstruction can be done using the stomach, a segment of the small intestine (only for short-segment
E. Tagkalos Department of General, Visceral and Transplant Surgery, University Medical Center Mainz, Mainz, Germany
UGIRA-Fellow 2022–2023in Chang Gung Memorial Hospital, Taoyuan, Taiwan e-mail: evangelos.tagkalos@unimedizin-mainz.de
P. P. Grimminger (*) Departmen of General-, Visceral- and Transplant Surgery, University Medical Centre of the Johannes Gutenberg-University Mainz, Mainz, Germany e-mail: peter.grimminger@unimedizin-mainz.de
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2025 S. Samreen et al. (eds.), The SAGES Manual of Robotic Surgery,
https://doi.org/10.1007/978-3-031-86927-3_14
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defects), or a section of the colon, in order of their suitability. The stomach is the most suitable replacement organ from a surgical and anatomical point of view for a reconstruction by means of a gastric pull-up. Furthermore, it requires only a single anastomosis (esophagogastrostomy).
The risk of surgery, especially the transthoracic esophageal resection, is rela­tively high due to several factors [35]. Patients often have comorbidities such as chronic obstructive pulmonary disease or previous cardiac disease, which are linked to risk factors such as smoking and alcohol consumption. The required abdomino­thoracic 2-cavity-procedure places a signicant burden on the body. The duration of an abdomino-thoracic esophageal resection typically ranges from 4 to 6h, depend­ing on the level of difculty. This places it in the upper third of the spectrum of operating times for visceral surgery. The procedure is carried out in close proximity to sensitive structures such as the aorta, coeliac trunk, pulmonary veins, azygos vein, pars membranacea of trachea, right main bronchus, pericardium, left atrium, vagus nerve, recurrent laryngeal nerve, and thoracic duct. Structures can be dam­aged either directly or indirectly (e.g., through thermal means) during surgery or in the early postoperative period due to leakage of aggressive gastric acid, bile acid, pancreatic enzymes, or due to inammatory processes. Complications of the trans­thoracic esophagectomy with gastric pull-up reconstruction include anastomotic insufciency, pneumonia, hemorrhage, chylothorax, lesion of the recurrent laryn­geal nerve causing hoarseness, esophago-tracheal or esophago-bronchial stula, conduit-necrosis, arrhythmia, and enterothorax [3, 4, 6, 7]. The incidence of anasto- motic insufciency, a common surgical complication, is estimated to be between
7.2% and 35%. Large cohort analyses report 30- and 90-day mortality rates of
2.4–8.9% depending on the expertise and frequency of the clinic in performing esophageal resections, although leading world centers demonstrate 90-day rates below 1% [812]. Esophagectomy is a technically demanding operation that pro­duces substantial trauma for the patient. The open procedure has been the only rel­evant approach for many decades, but it was associated with high morbidity and mortality rates exceeding 20% in small-volume centers during the last decade [1]. However, the shift from open surgery to minimally invasive approaches has resulted in reduced morbidity and mortality rates. Curative therapeutic strategies for esopha­geal AC and AC of the esophagogastric junction mainly involve transthoracic esophagectomy with abdominal and thoracic lymph node dissection after chemo­therapy or chemoradiation in the case of locally advanced disease.
The Shift toMinimally Invasive Esophagectomy
In the last decade, a number of randomized control trials have shown that minimally invasive techniques, such as hybrid (HE), minimally invasive (MIE), and robotic­assisted (RAMIE) esophagectomy, provide signicant benets compared with open procedures. The studies from Haverkamp etal. [13] and the updated version from de Groot etal. [14], which investigated the worldwide trends in surgical techniques for the treatment of esophageal- and gastroesophageal-junction cancer, showed a
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clear shift to minimally invasive techniques—from only 15% in 2007 to 79% in 2021—which mirrors the results of the following RCTs.
The MIRO trial, which compared open esophagectomy (OTE) and HE, con­cluded that the HE group had a 50% lower risk of major pulmonary complications compared to the OTE group. After 3years of follow-up, the HE group showed a trend toward improved overall and disease-free survival (67.0% versus 55%, and 57% versus 48%) [15].
MIE, rst described in 1995, was an evolution of HE that aimed to reduce surgi­cal trauma, including the thoracic minimally invasive access. The rst RCT compar­ing MIE with OTE, the TIME trial, was published in 2012. The study showed signicantly fewer postoperative complications after MIE [16].
The ROBOT trial, the rst RCT to compare OTE with RAMIE, was published in
2019. The authors concluded that RAMIE was associated with fewer postoperative complications than OTE, with 59% of the RAMIE group experiencing postopera­tive complications compared to 80% of the OTE group (p = 0.02). In addition, RAMIE was associated with a lower median blood loss (400 ml vs. 568 ml, p<0.001) and a lower incidence of postoperative pulmonary (RR 0.54; 95% CI,
0.34–0.85; p=0.005) and cardiac (RR 0.47; 95% CI, 0.27–0.83; p=0.006) compli­cations [17].
The RAMIE trial, a multicenter Chinese RCT comparing MIE and RAMIE in patients with SCC, showed that both RAMIE and MIE were safe and feasible for the treatment of SCC and that RAMIE achieved shorter operative times with higher lymph node dissection (p=0.016) in patients who received neoadjuvant therapy [18].
The second completed RCT comparing MIE to RAMIE in SCC patients was also a multicenter Asian study (Taiwan/China). Preliminary results reported at the rst Upper-GI Robotic Association (UGIRA) Congress in Taipei in 2023 reported lower RLN palsy rates for RAMIE.
The third RCT comparing MIE to RAMIE and the rst to include Western patients with AC of the intrathoracic esophagus or gastroesophageal junction, the ROBOT-2 trial, is still recruiting. Primary endpoint is the number of resected lymph nodes according to the TIGER protocol [19].
In anticipation of the long-term results of the last three RCTs on overall and disease-free survival between MIE and RAMIE, a small number of nonrandomized studies suggest a potential advantage of RAMIE. A very recent two-center study between Taiwan and Germany, which compared 945 consecutive patients who underwent MIE or RAMIE for esophageal cancer— the largest in the literature to date comparing these two techniques—according to Textbook Outcome Procedure (TBO) achievement rates, showed that RAMIE produced statistically signicantly higher TBO rates (53.3% vs. 42.2%; p< 0.001). In the same study, patients who achieved a TBO had a statistically signicantly longer median overall survival (109months vs. 21months; p<0.001) as well as disease-free survival (87months vs. 13months; p<0.001) than those who did not achieve a TBO [20].
Another neuralgic issue with RAMIE is its learning curve. The rst assessments of RAMIE learning curve were published by Hernandez etal. and Sarkaria etal [21, 22]. They concluded that the learning effect was observed after 20 and 30–45 cases,
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respectively. The latter studies did not provide a clear cut-off point for completion of the learning curves. Van der Sluis etal. evaluated the learning curve of RAMIE using the cumulative sum method (CUSUM) for a proctor and a novice surgeon undergoing proctoring in 312 cases. According to the authors, the proctor required 70 procedures and 55months to achieve prociency, while the proctored novice surgeon completed the learning phase after 15 supervised and 9 unsupervised/independent cases (24 cases in 13months) [23]. The authors conclude that proctoring can signicantly reduce the number of cases and the time required to complete the learning curve. It should be noted that RAMIE is a procedure with standardized settings in many centers worldwide.
In light of the above data, we will describe the two most commonly used mini­mally invasive robotic-assisted techniques for esophageal resection: Ivor-Lewis and McKeown esophagectomy.

Robotic-Assisted Ivor-Lewis Esophagectomy

The fully robotic minimally invasive “one surgeon–one assistant” 4-arm transabdomi­nal and transthoracic esophagectomy with D2 lymph node dissection and gastric pull­up reconstruction is presented [2426]. The two phases, the abdominal and the thoracic, are described in detail. We recommend this procedure for tumors located in the mid and distal esophagus or at the gastroesophageal junction (Siewert types I and II).
Abdominal Phase
The patient is placed in a normal supine position with a 15° reverse Trendelenburg. The da Vinci® Xi patients’ cart is positioned on the right side of the patient and the surgical assistant on the left. As each patient's anatomy is different, it is recommended that trocar placement be tailored to the patient. To determine this, the camera trocar should be placed in the midline in a position that allows the abdominal phase to be performed without maximum extension of the robotic arm in the upright position (like a ip-up action). After placing the camera trocar (T3), the remaining three robotic trocars are placed as shown in Fig.14.1. The next trocar to be placed is a 12mm (T2) on the upper right at the same level as T3 and almost 6–8cm away from it. The next trocar to be placed is T1in the right lateral subcostal area at least 6–8cm (and at least 2cm below the 10th intercostal space) to the right of T2. T4 is placed in a mirrored position to T2 according to the midline, and nally the assistant port is placed in the left lateral position 1–2cm above T4. After docking the camera to T3, the remaining robot arms 1, 2, and 4 are docked to T1, T2, and T4, respectively (Fig.14.1).
Instrument Placement
T1: Fenestrated tip-up grasper. T2: Fenestrated bipolar forceps using the 8mm reduction cap and robotic stapler
(Sureform; 12mm). T3: Camera. T4: Vessel Sealer or SynchroSeal, monopolar hook or scissors.
15 Robotic Esophagectomy
Fig. 14.1 Trocar placement for the abdominal phase. The distances between T2-T3 and T3-T4 should be the same if possible
163
To start, the fenestrated tip-up grasper is used to retract the liver. After opening the pars accida of the hepatogastric ligament, the dissection is extended toward the right diaphragmatic crus. To facilitate a good surgical plane, the assistant should retract the pericardial fatty tissue to the left of the patient. The right side of the distal esophagus and the gastroesophageal junction should be fully mobilized from the diaphragm. Remember to prepare the lymph nodes at station 1 so that they can be retrieved with the specimen. Pay particular attention to the right pleura, as opening it (if not necessary, e.g., in the case of a bulky gastroesophageal junction tumor) may result in the need for thoracic drainage on the right side. If this is the case, place it in a position where it can later be exchanged with a robotic trocar in the thoracic phase. The next step is to identify the gastroepiploic arcade (right gastroepiploic artery) and carefully dissect the greater omentum. The assistant retracts the omen­tum to the left of the patient and the surgeon provides countertraction to the right (in relation to the gastroepiploic artery, which should always be medial to the surgeon’s instruments to avoid traumatic injury to the vessel). The key to this step is that both the surgeon and the assistant should move gradually, always correcting the plane by adjusting the traction and countertraction. To avoid unnecessary movements that could slow you down or even cause injuries, both the assistant and the surgeon’s left arm can move once the right arm of the surgeon has grasped and secured the tissue to be sealed and cut, providing a stable plane. After repositioning, the tissue can be divided and so on. The short gastric vessels are dissected after the partial omentec­tomy. Try to dissect these vessels away from the stomach to avoid damaging the intramural vascular network of the gastroepiploic arteries. To facilitate better visu­alization of the plane, the stomach should be gently retracted from T1 to the right of the patient using the tip-up grasper. After mobilization of the gastric fundus, the left crus can be freed from the esophagus and the gastroesophageal junction. Try to avoid opening the left pleura at this stage if not necessary. The lymph nodes at sta­tion 2 are prepared so that they can be retrieved with the specimen. When mobiliz­ing the diaphragmatic crus, take particular care not to traumatize the parietal peritoneum to avoid bleeding of the diaphragmatic muscle tissue (Fig.14.2).
The next step is to mobilize the stomach from the transverse colon and pancreas. To do this, the assistant should grasp the posterior wall of the stomach and move it upwards toward the abdominal wall. After dissecting the adhesions to the pancreas
164
ab
Fig. 14.2 The mobilization of the abdominal esophagus. The ventral (a) and dorsal (b) situs after complete mobilization. With interrupted lines are demonstrated the diaphragmatic arch (a) and the crus (b). IVC: inferior vena cava
E. Tagkalos and P. P. Grimminger
abc
Fig. 14.3 The creation of the gastric conduit. (a) The rst stapler is inserted sparing the rst branches of the right gastric artery. (b) The second stapler should be positioned parallel to the greater curvature to ensure that the conduit will be neither too narrow nor too wide. (c) The last stapler should leave a 3–4cm tissue connection to the fundus to enable the anastomotic creation in the thoracic part
and freeing the stomach from the mesocolon, the plane moves to the pylorus. This step requires extreme caution as injury to the right gastroepiploic vessels (vascular­ization of the gastric conduit) may be irreparable, making the use of the stomach for reconstruction unnecessary. The assistant (T5) lifts the posterior antrum wall, while the fenestrated bipolar forceps (T2) can be utilized to provide the required counter­traction of the mesocolon (try to have the right gastroepiploic vessels at a 90° angle to your visual axis).
After completing the mobilization of the posterior stomach wall from the pan­creas and separating the adhesions to the mesocolon, the stomach should be mobi­lized from the gallbladder leading to the visualization of the duodenum (pars I). The gastric conduit can now be prepared. Try not to dissect the rst branches of the right gastric artery as they vascularize the intramural network of the lesser curvature. The fatty tissue of the lesser curvature should be dissected down to the stomach so that the stapler can be inserted in a clear gastric front. Through T2, the robotic stapler (SureFormTM Stapler, Intuitive, Sunnyvale, USA) is placed in a position as shown in Fig.14.3 in the distal third of the lesser curvature. The conduit should be neither too narrow to avoid the risk of ischemia, nor too wide to avoid its dilatation in the
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thoracic cavity. At this point, a 3–4cm tissue connection to the fundus should not be dissected, a step that is crucial for the anastomotic technique described later in the thoracic part.
Once the conduit has been constructed, lymph node dissection of the lesser cur­vature and the hepatoduodenal ligament can be performed. To obtain a clear plane, the partially dissected lesser curvature should be lifted cranially. For a more con­trolled dissection, a monopolar hook or scissors can be used at this point. Dissection begins medial to the gastric artery, which is held at a 90° angle to our 6-h axis. After identication of the proper hepatic artery, the gastroduodenal artery, and the com­mon hepatic artery, the lymph node harvest from stations 12 and 8 can be com­pleted. Try not to separate the lymph nodes from the specimen. To obtain the lymph nodes from stations 7, 9, and 11p, the celiac trunk and the splenic artery as well as the cranial pancreatic border are used (Fig.14.4).
The left gastric artery should be prepared and divided at its origin together with the left gastric vein to facilitate dissection. On completion of this step, the stomach, the gastroesophageal junction, and the abdominal esophagus should be fully mobi­lized, allowing a clear view of the aorta, pericardium, and right and left pleura. Once the instruments have been retrieved, the da Vinci® Xi patient trolley undocked, and all trocars removed, the wounds can be closed and the abdominal phase completed.
Thoracic Phase
The patient is placed in the semi-prone position (45° tilt). Collapse of the right lung is achieved by an endotracheal block or a double lumen endotracheal tube. The da Vinci® Xi patient’s cart is positioned to the right side of the operating table and the assistant to the left.
Trocar placement is shown in Fig.14.5. You can start with either the assistant’s 12mm port (T5), which is placed in the 5th intercostal space along the anterior axil­lary line, or the camera trocar T3, which is placed in the 6th intercostal space, 3cm to the left of T5 and a few cm higher. After establishing an intrathoracic pressure of
Fig. 14.4 The preparation of the common hepatic artery as well as the left gastric artery. GDA gastroduodenal artery, ICV inferior vena cava, LN lymph nodes