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Page 2 of 11 Matto et al. Mini-invasive Surg. 2025;9:19 https://dx.doi.org/10.20517/2574-1225.2025.51

INTRODUCTION
Several recent reviews have shown that minimally invasive esophagectomy (MIE) has exceeded open
esophagectomy in the United States. It has become the standard of care for resectable esophageal cancer in
most tertiary care centers . Work at the University of Pittsburgh has significantly contributed to this
[1]
[2-4]
transition, and this institution’s experience has now exceeded 3,000 MIEs . Robotic-assisted minimally
invasive esophagectomy (RAMIE) has become increasingly used in the treatment of esophageal cancer in
our center and across the world in recent years. Proponents of RAMIE cite many potential advantages,
including a greater lymph node harvest compared to MIE, less postoperative pain, and a lower rate of
pulmonary complications . RAMIE has been shown to be equivalent in terms of anastomotic leak and 30-
[5,6]
[7]
day mortality , but there is minimal level 1 evidence available at this time.
Robotic technology provides 3D visualization, 8 degrees of rotation, and stabilization of tremor, all
advantages in the small confines of the mediastinum. These advantages are reported anecdotally by many
surgeons; however, in studies comparing laparoscopic and robotic surgeries, advantages in patient outcomes
remain to be seen. The objective of this manuscript is to provide a detailed report on the current technique
of RAMIE at the University of Pittsburgh Medical Center (UPMC), highlighting a novel anastomotic
technique and a brief review of our previously published data.

OPERATIVE TECHNIQUE
Abdominal approach
The most common robotic approach performed at UPMC is the Ivor Lewis esophagectomy, which has been
previously described . Patients are initially placed supine with a footboard in place. Prior to incision, upper
[5]
endoscopy and bronchoscopy are performed. Four robotic ports and two non-robotic ports are used. One
non-robotic port is an assist port (12 mm) in the lower right quadrant, next to the umbilicus. The other
non-robotic port is a 5 mm port along the lateral lower right costal margin for the Mediflex liver retractor.
From the patient’s position, the robotic port configuration is as follows: From right to left, arm 1 has the
force bipolar grasper (which can be exchanged for the stapler), arm 2 holds the 30-degree camera, arm 3 has
either an ultrasonic shear or the spatula, and arm 4 has an atraumatic bowel grasper. The lower right
quadrant non-robotic port is a standard laparoscopic assistant port, through which the assistant primarily
uses a suction or grasper. The right robotic port is 12 mm, and the remaining ports are 8 mm. These ports
are in similar locations reported previously .
[5]

The procedure begins with exposing the crus by dividing the gastrohepatic ligament. The esophagus is then
mobilized by incising the phrenoesophageal ligament. The dissection then proceeds to expose the left gastric
artery pedicle by entering the lesser sac. A complete celiac lymphadenectomy is then performed. The short
gastric and left gastric arteries are then divided, taking care to preserve the right gastroepiploic artery. At
this point, indocyanine green (ICG) and near-infrared fluorescence can be used as needed to identify the
gastroepiploic arcade. This technique is not yet our standard of care but is part of an ongoing investigation.
An omental flap can also be created at this point if desired. Our current practice is to use a formal omental
pedicled flap only for cases of preop neoadjuvant chemotherapy and radiation. In other cases, an
approximately 3 cm margin of omental fat is left protecting the gastroepiploic and placed between the
conduit and airway. Recently, we have added a “widening” to the gastric conduit [Figure 1] to enable the
introduction of the end-to-end anastomosis (EEA) stapler handle through the lesser curvature staple line
[Figure 2]. After the instrument is docked and the EEA anastomosis is completed in the chest, the EEA
device is removed, and the widened part of the conduit is restapled to conform to the 3 cm final width of the
conduit [Figure 3]. This creates a true EEA. After ensuring complete gastric mobilization from the hiatus to
the pylorus, the conduit can be created with multiple firings of the stapler [Figure 1]. This should be done