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Page 10 of 12 Hambright et al. Mini-invasive Surg 2024;8:19 https://dx.doi.org/10.20517/2574-1225.2024.08

Cervical phase
An incision parallel and anterior to the left sternocleidomastoid is made in the lower third of the neck. The
omohyoid muscle is divided. Excessive retraction and the use of electrocautery are avoided as the esophagus
is approached, to avoid injury to the recurrent laryngeal nerve. The location of the carotid sheath should be
noted. The dissection is carried towards the tracheoesophageal groove and inferiorly towards the thoracic
inlet. The clear space from the intrathoracic dissection is encountered, and the Penrose drain is located and
used to pull the cervical esophagus into the surgical field. The esophagus is divided sharply. Attention
should be given to avoiding unexpected retraction of either end of the esophagus after division. The
esophagogastrectomy specimen is gently pulled up through the cervical incision. Care needs to be ensured
to avoid tearing of the gastric conduit during this step. The conduit is divided from the specimen with a
stapler. A posterior gastrostomy is performed in the conduit, and a side-to-side anastomosis is performed
using the full length of a 45 mm stapler to create the common channel. The opening is then approximated
with interrupted sutures, and a stapler is fired transversely to close it. The anastomosis is pushed back
towards the thoracic inlet, and the incision is closed in layers. No drain is placed.

CONCLUSIONS
The technical methods to minimize the rate of complications such as pneumonia, respiratory failure, leak,
stricture, and conduit necrosis following esophagectomy are widely debated. To mitigate these risks, the
approach supported by the current literature appears to be a minimally invasive surgical approach using a
gastric conduit between 3-5 cm in diameter with ICG assessment of conduit perfusion and a stapled
transthoracic anastomosis. However, there are many ways to perform esophagectomy with excellent results.
At our institution, we use a completely robotic approach with creation of a 3-4 cm wide conduit and hybrid-
type anastomosis, with ICG fluorescence used to guide conduit transection and localization of the
gastrotomy for anastomosis; this approach demonstrates an excellent combination of safety and
reproducibility. We published our results for 85 patients undergoing robotic esophagectomy in 2016 which
demonstrated perioperative morbidity in 36%, mean operating time of 6 h, R0 resection in 99%, a single
patient requiring conversion to thoracotomy, median hospital stay of 8 days, 7.1% rate of anastomotic or
conduit complication, and a 3.5% 30-day mortality rate . Continued study is necessary to determine the
[33]
optimum strategy with regard to conduit diameter, conduit perfusion, and anastomotic technique during
esophagectomy.

DECLARATIONS
Authors’ contributions
Authored the introduction, conduit diameter, ICG fluorescence, and anastomotic technique portion:
Hambright B
Wrote the “How we do it” section, including abdominal, thoracic, and cervical phases; provided edits to all
portions of the paper and oversaw the project: Wei B
Contributed to the conclusion: Hambright B, Wei B

Availability of data and materials
All reference material can be found cited in the references section. Due to the nature of this manuscript,
there is no data to be provided.

Financial support and sponsorship
None.