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Page 2 of 12 Hambright et al. Mini-invasive Surg 2024;8:19 https://dx.doi.org/10.20517/2574-1225.2024.08

INTRODUCTION
The esophagectomy has been a fundamental treatment for esophageal neoplastic disease since the early 20th
century. As medicine evolved, so did the technique. In 1996, Dr. Jim Luketich reported the first fully
minimally invasive esophagectomy (MIE). The efficacy of the minimally invasive approach in
esophagectomy surgery was scrutinized in a 2012 multicenter randomized controlled trial conducted by
[1]
Biere et al. . According to their findings, patients subjected to MIE exhibited notably reduced rates of in-
hospital pulmonary infections (34% vs. 12%, P = 0.005), shorter average hospitalization stays (14 vs. 11 days,
[1]
P = 0.04), and comparable rates of anastomotic leakages . Subsequent to this, a systematic review and meta-
analysis, published in 2019 that encompassed 55 studies with over 14,000 patients, described that the
minimally invasive approach yielded a five-year mortality rate of 18%, lower than that associated with the
open approach . These studies collectively provide evidence supporting that minimally invasive surgery
[2]
stands as not only a secure option for esophagectomies but conceivably the preferred and safest approach.

The introduction and Food and Drug Administration (FDA) approval of the Da Vinci surgical system in
2000 saw robotics becoming a cornerstone of minimally invasive surgery. In 2002, the first reported robotic
[3]
esophagectomy was completed by Melvin et al. . Since then, the advantages of robotic assisted MIE
(RAMIE) have been demonstrated in studies such as the famous “ROBOT trial”, published by Van der Sluis
[4,5]
et al. in 2012 and updated by a long-term follow-up study in 2020 . In a meta-analysis published in 2022,
patients who underwent RAMIE showed significantly lower rates of pulmonary complications, wound
[6]
infections, blood loss, and shorter hospital stays when compared to open esophagectomies . This gives us
evidence that a robotic approach is a safe and effective means for minimally invasive esophagectomies.

To further expand on the validity of the robotic approach, in 2019, Jin et al. published a systemic review and
meta-analysis on comparing RAMIE to conventional MIE . In this review of eight case-control studies that
[7]
looked at over 1,800 esophagectomy patients, it was found that patients undergoing the RAMIE approach
[7]
had significantly less estimated blood loss and lower rates of recurrent laryngeal nerve injury .
While robotic esophagectomy has proven effective, the optimization of the technical details of such an
operation has elicited greater debate. In this article, we will discuss conduit creation during robotic Ivor
Lewis (transthoracic) esophagogastrostomy, specifically optimal conduit diameter size, the use of
indocyanine green (ICG) fluorescence to evaluate perfusion, and ideal anastomotic techniques to reduce
rates of anastomotic leaks and strictures.

DIAMETER OF CONDUIT
A critical factor to consider in conduit creation is the diameter of the conduit. Selecting the correct diameter
is crucial to prevent post-operative reflux, anastomotic stricture, and anastomotic leakage. In standard
practice, most gastric conduits range from three to five centimeters in diameter, with < 3 cm considered
narrow and > 5 cm considered wide. A 2020 study by Zhu et al. indicated that gastric conduits > 5 cm in
diameter were independently associated with benign anastomotic stricture, particularly in circularly stapled
anastomoses . As summarized in Table 1, the findings of the first three studies [Zhu et al. (2020), Shen et al.
[8]
(2014), and Zhen et al. (2016)] indicate that gastric conduits 3 cm in width had lower rates of anastomotic
leaks compared to their wider (> 5 cm width) comparison group (8.7% vs. 17.3%, P = 0.041). Additionally,
conduits < 3 cm in width were associated with lower rates of delayed gastric emptying compared to both a
medium width group (3-5 cm) and a wide width group (> 5 cm) [8-10] . This topic is still an area of active
research, and more information is needed to arrive at a conclusive determination regarding the
consequences of different conduit diameter choices.