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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_794_Библиотеки_им_академика_М_И_Перельмана.pdf
Robotic-Assisted Minimally Invasive Esophagectomy
(RAMIE): Ivor Lewis
Inderpal S. Sarkaria, Nabil P. Rizk
It has become increasingly recognized that minimally invasive esophagectomy (MIE) approaches
have comparable oncologic and functional outcomes as open approaches. Additionally, a growing
body of literature – including one prospective, randomized, controlled study – suggests that MIE
provides improvements in pulmonary and wound complications and short-term pain indices,
compared with open surgery.
Although the experience with robotic-assisted MIE (RAMIE) is relatively limited compared
with standard MIE, experience with RAMIE is increasing. Published studies cite a wide range of
surgical approaches featuring robotic assistance, most commonly with robotic assistance used for
thoracoscopic esophageal mobilization. A smaller number of studies have described combined
laparoscopic and thoracoscopic robotic esophagectomy with an anastomosis performed in either
the neck or the chest. At our institution, we have developed and standardized one such RAMIE
approach that uses a four-arm robotic platform for both the Ivor Lewis and McKeown (threehole) approaches. e Ivor Lewis approach, which is most commonly performed in our service,
is described here.
Indications and Contraindications
Indications
e malignant and benign indications for RAMIE are similar to those for open and standard MIE
Ivor Lewis resections. Malignant indications are largely based on tumor location and size and
represent the predominant indications for esophageal resection. In the North American population, these most commonly consist of distal and midesophageal adenocarcinomas. For patients
with distal squamous cell carcinomas, Ivor Lewis resection may be considered; however, given the
higher incidence of multifocal disease among these patients, we favor McKeown esophagectomy.
For patients with midesophageal squamous cell tumors and those with proximal tumors of any
histologic type, we perform a McKeown resection. Benign indications are less common and generally represent advanced esophageal disease with signicant organ dysfunction. Patients with the
following diagnoses are most suitable for a RAMIE approach:
Distal esophageal adenocarcinomas and squamous cell carcinomas
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Midesophageal adenocarcinomas
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End-stage achalasia
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Recalcitrant benign strictures of the middle and distal esophagus
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Contraindications
e contraindications for RAMIE (versus open surgery) are similar to those for standard MIE.
Although these contraindications may be relative across institutions, we have not performed MIE
for the following cases:
Patients requiring colon interposition
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Patients with proximal esophageal tumors possibly requiring laryngectomy
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Patients with extensive adhesions not amenable to minimally invasive approaches
-
Our relative contraindications for the Ivor Lewis RAMIE approach are identical to those for
standard MIE and open resections at our institution:
Proximal and midesophageal squamous cell carcinomas
-
Proximal esophageal adenocarcinomas
-
P.-A. Clavien, M. G. Sarr, Y. Fong, M. Miyazaki (Eds.), Atlas of Upper Gastrointestinal and Hepato-Pancreato-Biliary Surger y,
DOI 10.1007/978-3-662-46546-2_38, © Springer-Verlag Berlin Heidelberg 2016
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Section II • Esophagus, Stomach, and Duodenum
Preoperative Workup
Patients with biopsy-conrmed esophageal carcinoma undergo preoperative evaluation to assess their tness for surgery. Staging assessment includes computed tomography scanning of the
chest, abdomen, and pelvis; endoscopic ultrasound; and 18-uorodeoxyglucose positron emission
tomography (PET) scanning. In appropriate patients with limited disease, tumors conned to
the mucosa (T1a or less) undergo endoscopic mucosal resection and ablation of remaining Barrett’s mucosa or dysplasia. Patients not amenable to endoscopic therapy and those with clinically
early-stage invasive lesions (T1b or T2, with no evidence of local lymph node metastases) are
recommended for surgery. Patients with clinically advanced local-regional disease (T3 and/or N1,
N2, or N3) are referred for induction chemotherapy and radiation, followed by surgical resection
approximately 4 to 6weeks aer completion of neoadjuvant treatment.
Procedure
Room setup and patient positioning
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For both the abdominal and the thoracic phases, the robotic instrumentation cart is set up on the
patient’s right side. We use a four-arm robotic platform with two operating consoles. Two attending surgeons are present for all cases – one at the bedside and one at the robotic console – with
an advanced surgical trainee at the second operating console. Single-lung isolation with doublelumen tube intubation is performed during the thoracoscopic phase. To assess the position of the
tumor, upper endoscopy is performed before the patient is positioned.
For the abdominal phase, the patient is placed supine on the table, with a footboard in place.
e patient’s arms are placed at 45°, and the patient is shied to the right side of the bed to allow
appropriate use of the liver retractor. e le arm may be tucked to minimize interaction with
the robotic assistant arm. e table is turned 90° to allow placement of the robotic cart and arms
(da Vinci Surgical Robot; Intuitive Surgical; Sunnyvale, CA, USA) directly over the midline of the
patient (.
are docked to the ports. For the thoracic phase, the patient is placed in exion, in the standard le
lateral decubitus position, with the right side up and the upper arm in a neutral position. e bed
is turned approximately 60°, and the robotic cart is brought in obliquely over the right shoulder
(
. Fig. 38.1b).
Fig. 38.1a
). e patient is placed in reverse Trendelenburg position, and the robotic arms
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Chapter • Robotic-Assisted Minimally Invasive Esophagectomy (RAMIE): Ivor Lewis
. Fig.38.1
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Section II • Esophagus, Stomach, and Duodenum
Port placement
For the abdominal phase, a supraumbilical 12-mm camera port is placed, and pneumoperitoneum
is established with CO2 at a pressure of 15 mm Hg. A 12-mm, 30° robotic camera is used. Additional ports are placed under direct vision, including a le lateral 5-mm subcostal port for use
by the 5-mm robotic atraumatic grasper (Schertl Grasper; Intuitive Surgical); a le midclavicular
8-mm port, placed 13 to 15 cm from the xiphoid, for use by the robotic ultrasonic shears (Harmonic Scalpel; Ethicon; Somerville, NJ, USA); a right lateral 5-mm subcostal port for placement
of the liver retractor (Diamond Flex; Snowden Pencer; San Diego, CA, USA); an 8-mm right
midclavicular, midabdominal port for use by the bipolar atraumatic grasper (Fenestrated Bipolar
Grasper; Intuitive Surgical); and a right paraumbilical 10-mm port for suction, retraction, stapling,
and passage of sutures by the bedside assistant (. Fig. 38.2a). To minimize robotic arm collisions,
a distance of at least 9 to 10 cm is maintained between robotic ports.
For the thoracic phase, right lung isolation is performed, a Veress needle is placed within
the chest, and pneumothorax is established with CO2 at a pressure of 8 mm Hg. Establishing a
pneumothorax is helpful in attening the diaphragm and exposing the hiatus. A 12-mm camera
port is placed in the eighth or ninth interspace, in the posterior axillary line. Additional ports are
placed under direct vision, including a 5-mm port in the third intercostal space, in the mid- to
posterior axillary line, for use by the 5-mm robotic atraumatic grasper; an 8-mm robotic port in
the h intercostal space for use by the robotic ultrasonic shears; an additional 8-mm port laterally
in approximately the ninth or tenth interspace (positioned over the hiatus) for use by the robotic
bipolar grasper; and a 12-mm assistant port laterally at the diaphragmatic insertion for suction,
retraction, stapling, and passage of sutures by the bedside assistant (
. Fig. 38.2b).
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Step1
5 mm
8 mm
port
. Fig.38.2
5 mm
8 mm
8 mm
port
port
12 mm
12 mm
8 mm
port
5 mm
8 mm
port
12 mm
12 mm
Abdominal Phase
Hiatal and retrogastric dissection
Initial dissection is begun by opening the lesser sac and dissecting the anterior right and le crura
(. Fig. 38.3). For lower esophageal tumors, portions of the right or le crus should be resected en
bloc with the esophagus if tumor involvement is identied. To avoid entry into the pleural spaces,
which may cause hemodynamic compromise and loss of intraperitoneal CO2 insuation, excessive early mediastinal dissection should be minimized at this time. If hemodynamic compromise
Chapter • Robotic-Assisted Minimally Invasive Esophagectomy (RAMIE): Ivor Lewis
Step1 (continued)
or loss of intraperitoneal CO2 insuation occurs, the surgeon should consider a low threshold
for the initiation of tube thoracostomy.
. Fig.38.3
Exposure to the le gastric vascular pedicle and the lesser sac is achieved through the lesser
gastric curve, with anterior retraction using the robotic assistant arm and caudal retraction by
the bedside assistant. e celiac axis is skeletonized and the surrounding lymph node–bearing
tissues are cleared, with dissection along the superior border of the pancreas and splenic artery,
posteriorly to the retroperitoneum, medially along the common hepatic artery, and cranially
toward the hiatus. e presence of bulky celiac adenopathy with persistent disease may preclude
Section II • Esophagus, Stomach, and Duodenum
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Step1 (continued)
resection if the adenopathy is not surgically removable. e dissected lymph node packet is
removed separately or is lied anteriorly toward the specimen, along the le gastric vascular
pedicle, which is divided using an endovascular stapler (.
stomach using the robotic assistant arm allows for exposure and additional dissection of the le
crus from the lesser gastric curve.
Fig. 38.4
). Gentle retraction of the
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. Fig.38.4
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Chapter • Robotic-Assisted Minimally Invasive Esophagectomy (RAMIE): Ivor Lewis
Step2
Gastric mobilization
e termination of the gastroepiploic arcade is identied, and the short gastric arteries are divided
using the ultrasonic shears. e lesser sac is entered through the greater omentum, and gastric
mobilization is completed to the level of the pylorus, with great care to visualize and preserve the
right gastroepiploic vascular arcade. e le lateral robotic assistant arm can be used to bluntly retract the greater curve of the stomach medially and superiorly, to better visualize the gastroepiploic
vasculature (. Fig. 38.5) and to expose and lyse retroperitoneal and gastropancreatic adhesions.
Step3
. Fig.38.5
Pyloroplasty
e robotic assistant arm with the atraumatic grasper is used to gently retract the gastric antrum
leward to expose the pylorus. Retraction stitches are placed laterally across the pyloric muscle,
pylorotomy is performed using the ultrasonic shears, and the defect is closed transversely with
interrupted sutures (
. Fig. 38.6).
. Fig.38.6
Section II • Esophagus, Stomach, and Duodenum
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Step4
Gastric conduit formation
e nasogastric tube is withdrawn into the esophagus. e robotic assistant arm is used to gently
grasp the tip of the gastric fundus along the line of the divided short gastric arteries and toward
the le upper quadrant. e right robotic arm with an additional atraumatic grasper (Cadierre
Forceps; Intuitive Surgical) is used to provide gentle inferior traction on the antrum, thus straightening the greater gastric curve (. Fig. 38.7). An endovascular stapler is used to divide the lesser
curve vasculature at a point approximating the incisura. e gastric tube is constructed and is
divided from the specimen by multiple res of the endoGI stapler, with care to maintain proper
orientation of the evolving gastric conduit at all times. e proximal gastric tube is reapproximated
to the specimen with heavy suture to allow properly oriented entry through the hiatus into the
chest during the thoracoscopic phase of the operation.
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Step5
. Fig.38.7
Thoracic Phase
En bloc esophageal mobilization
Complete en bloc mobilization of the esophagus is performed with clearance of all adjacent lymph
node bearing tissue at the hiatus posteriorly along the aorta, anteriorly along the pericardium and
airway, and posteriorly along the contralateral pleura.
Aer division of the inferior pulmonary ligament, dissection is initiated along the pericardium,
adjacent to the inferior vena cava, and is continued medially to the contralateral pleura, with craniolateral lung retraction performed using the robotic assistant arm. e lung is retracted anteriorly
using the robotic assistant arm, and dissection is continued cranially along the posterior hilum. e
airway is identied, and subcarinal lymph node dissection is completed (. Fig. 38.8). To minimize
the risk of thermal injury to the airway from the rigid ultrasonic shears, the robotic bipolar Maryland dissector (Intuitive Surgical) in the right robotic arm is used during subcarinal dissection.
oracoscopic suction by the bedside assistant maintains a clear surgical eld and aids in retraction.
Posterior dissection along the aorta is aided by anterior retraction of the esophagus using the
robotic assistant arm. Lymphatic perforators are liberally clipped and aortoesophageal perforating
arteries are divided using the ultrasonic shears. e thoracic duct may be ligated near the hiatus.
e distal specimen is brought through the hiatus, with the lesser curve staple line of the attached gastric conduit oriented laterally. e specimen and conduit are separated, and the conduit
is temporarily secured to the diaphragm, preventing retraction into the abdomen. e specimen
is retracted craniolaterally, and medial dissection is completed along the contralateral pleura and
le mainstem bronchus.
Chapter • Robotic-Assisted Minimally Invasive Esophagectomy (RAMIE): Ivor Lewis
Step5 (continued)
e dissection is continued cranially above the azygous vein, which is divided. e esophagus
is divided sharply using the shears in the right robotic arm (Monopolar Scissor; Intuitive Surgical),
2 to 3 cm above the azygous vein, and the nasogastric tube is withdrawn proximally under direct
vision into the remaining proximal esophagus. e robotic le-hand 8-mm port is temporarily
removed, the incision is extended 3 to 4 cm in length, and a wound protector device is placed.
e specimen is removed and evaluated by frozen section to assess proximal and distal margins.
. Fig.38.8
Section II • Esophagus, Stomach, and Duodenum
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Step6
Creation of anastomosis
e 28-mm anvil of the circular anastomotic stapler (DST EEA Stapler; Covidien Surgical; Dublin,
Ireland) is placed into the chest through the access incision. In rare cases, a 25-mm anvil may be
required if the esophagus cannot accommodate the larger size. e orice of the open esophagus
is gently retracted and held open using the right robotic arm and assistant arm graspers, and the
anvil is gently inserted using the le robotic arm grasper (Cadierre Forceps; Intuitive Surgical)
(. Fig. 38.9a). Needle drivers are situated in the right and le robotic arms, and a “baseball”
purse-string stitch, with nonbraided permanent suture (0Prolene SH Needle; Ethicon), is placed
to secure the anvil (
anvil. Care is taken to place each suture bite full thickness through esophageal muscle and mucosa.
An additional reinforcing purse-string suture is placed aer the anvil is secured (. Fig. 38.9c).
. Fig. 38.9b). Alternatively, the suture may be placed before insertion of the
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. Fig.38.9
e conduit is released from the diaphragm and brought into the chest. A proximal gastrotomy
is made and is retracted open at three points using the right robotic arm and the assistant arm
graspers, as well as by the bedside assistant. e cartridge of the stapler is introduced through the
mini access incision and placed into the proximal conduit, and the spike is brought out through
the greater curve, just above the vascular arcade (
the anastomosis is created, and the tissue rings of the esophageal and gastric staplers are inspected
for completeness. e nasogastric tube is advanced into the gastric conduit under direct vision,
and the redundant conduit and gastrotomy are resected using the endogastrointestinal stapler.
e procedure is completed with the placement of an apical-posterior chest tube (10French at
Jackson-Pratt drain) adjacent to the anastomosis posteriorly. e nal position of the gastric
conduit is shown with a high intrathoracic anastomosis (. Fig. 38.10b).
. Fig. 38.10a). e spike and anvil are joined,
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