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Hambright et al. Mini-invasive Surg 2024;8:19 https://dx.doi.org/10.20517/2574-1225.2024.08 Page 7 of 12

cessation is strongly encouraged. Generally speaking, arterial lines and central venous lines are NOT part of
our intraoperative preparation of the patient, unless there exist specific reasons for this (e.g., valvular heart
disease, coronary artery disease, poor intravenous access). A Foley catheter is placed due to the extended
length of the operation, which is typically between 4.5 to 6 h (including repositioning).

For an Ivor Lewis esophagectomy, the operation is started in the abdomen, and then finished in the thorax.
For a Mckeown esophagectomy, the operation is started in the thorax, and then finished with the patient
supine with an abdominal approach followed by anastomosis via a cervical incision.

Abdominal phase
For the abdominal phase of the operation, a total of six ports are used: three 8 mm robotic ports, one 12 mm
robotic port in the patient’s right upper quadrant for stapling of the left gastric vessels and conduit creation,
a 12 mm assistant port in the right lower quadrant, and a 5 mm liver retractor port were placed [Figure 1].
After port placement and robot docking, the peritoneum and liver are inspected for metastases. The lesser
sac is entered by penetrating the greater omentum between the stomach and transverse colon, typically at
the midpoint of the stomach. The greater omentum is divided from the transverse colon with a Vessel Sealer
instrument (Intuitive Surgical; Sunnyvale, CA), moving from screen right to screen left, taking care to
preserve the gastroepiploic vessels. A Kocher maneuver is performed to mobilize the duodenum, and the
ability of the pylorus to easily reach the esophageal hiatus is confirmed. Then, the surgeon works from the
initial point of entry into the lesser sac, dividing the tissue between the greater curvature of the stomach and
the colon and/or spleen, working towards the proximal stomach. Attention to the location of the colon and
avoiding thermal injury to the organ is paramount during this process. Extra omentum is left on the
stomach in order to act as an omental flap used to buttress the anastomosis later in the case. The esophageal
hiatus is dissected circumferentially, and the esophagus, along with periesophageal fat and lymphatic tissue,
is dissected several centimeters up into the mediastinum. The posterior location of the aorta is noted and
the structure is avoided during this phase of the operation. The right and left pleural spaces are often
entered during mediastinal dissection; the anesthesia team should be informed of any entry into either
pleural space as higher airway ventilator pressures may be needed to maintain tidal volume once the pleural
space is opened. Hemodynamic instability can be caused by tension capnothorax (even if both pleural
spaces are opened) due to a “one-way valve” effect resulting in continued insufflation of carbon dioxide into
a hemithorax rather than equilibration of pressure across the diaphragm. This is treated by stopping
insufflation and opening up the window to the pleural space, to allow the pressure to equilibrate. Any
adhesions of the stomach to the retroperitoneum that could prevent easy repositioning of the conduit into
the thorax need to be lysed. The left gastric artery and vein are skeletonized (the vein is typically located
anteriorly) and divided with a robotic stapler (white load, 2.5 mm staple height). The pylorus was injected
with 100 units of botulinum toxin diluted into 4 mL of normal saline, 1 mL in each quadrant of the pylorus
anteriorly. A gastric conduit is then fashioned using the robotic stapler (green load, 4.8 mm staple height).
We aim for a 4 cm or so diameter of the conduit, using the 2 cm size of the fenestrated bipolar forceps
(Intuitive Surgical; Sunnyvale, CA) measured from tip to hinge as a guide. The proximal stomach is
typically rotated posteriorly, which can lead to underestimating the width of the conduit at that level. After
the second robotic staple fire on the stomach, a Penrose drain encircled around the distal stomach and
grasped by the assistant with a firm retraction toward the patient’s right lower quadrant, with counter-
traction exerted by the grasper in the accessory arm of the robot, permits maximizing the length of the
created conduit. The end of the staple line for the gastric conduit is located well away from the
esophagogastric junction, typically at least 6 cm in distance from the angle of His along the pathway
following the greater curvature of the stomach. We do not transect the conduit from the specimen in the
abdomen to avoid needing to take extra time to suture the two together and experiencing a risk of suture
breakage. If a Mckeown esophagectomy is being performed, we resect the lesser curvature of the stomach at