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laparoscopic suctioning device and an atraumatic bowel grasper are used through this port. Notably, this
same port is used for specimen extraction. The robotic system is positioned just above the patient’s right
shoulder (see Figures 1 and 2).

The THE operation steps
Resection
Kocher maneuver
To initiate the surgical procedure, the Kocher maneuver is employed. It serves to mobilize the duodenum
effectively and minimize any manipulation that could lead to injuries. Atraumatic bowel graspers, a
fenestrated bipolar, and energized scissors are used to initiate and execute this maneuver. The maneuver
begins by identifying the vena cava within the foramen of Winslow. The duodenum is then mobilized
towards the left, allowing the pylorus to approach the hiatus. Particular attention is paid to avoiding any
damage to the right gastric artery to ensure proper blood supply to and from the gastric conduit. There is no
requirement to dismantle the Ligament of Treitz during this process.

Crural and gastric dissection
Next, the crural dissection and accompanying gastric mobilization commence. The gastro-hepatic ligament
is opened in a stellate fashion, employing the same instruments of energized scissors, atraumatic bowel
grasper and the fenestrated bipolar forceps. Afterward, the gastro-colonic omentum is carefully divided,
being mindful not to injure the gastroepiploic vessels as the dissection proceeds toward the left crus.
Subsequently, the short gastric vessels of the spleen are taken down. The dissection then progresses up and
down the left crus, slightly extending into the mediastinum. This can be accomplished using just energized
scissors and a fenestrated bipolar alone. Additionally, the dorsal attachments between the stomach and the
ventral surface of the pancreas are taken down to allow free movement of the stomach towards the
esophageal hiatus. Once this stage of the operation is completed, we proceed with pyloromyotomy.

Pyloromyotomy
This task is achieved using a hook cautery, fenestrated bipolar forceps, and a Maryland dissector. Starting
from the distal stomach over the pylorus, a shallow incision is made using a hook cautery. The pylorus
muscles are then divided while avoiding an injury to the submucosa. In the event of an inadvertent opening
of the duodenal or gastric mucosa, a pyloroplasty is undertaken. However, such instances are rare as
pyloromyotomy proves to be a highly efficient and expeditious procedure.

Division of the left gastric vessels and lymphadenectomy
Following the pyloromyotomy, the left gastric vessels are stapled and a thorough lymphadenectomy is
undertaken. The stomach is elevated anteriorly to expose the left gastric artery and vein. By employing a
hook cautery, the trifurcation of the celiac axis is dissected adequately to locate the left gastric artery at its
origin. All lymph nodes surrounding the celiac trunk are meticulously removed, encompassing nodes along
the common hepatic artery, the splenic artery, the left gastric vessels, peripancreatic lymph nodes, peri-
distal esophageal lymph nodes, and lymph nodes near the proximal stomach. Utilizing a vascular stapler,
the left gastric vessels are then divided at the trifurcation point.

Mediastinal dissection and neck dissection
The dissection is then carried into the mediastinum. The mediastinal dissection coincides with the
circumferential dissection of the esophagus at the neck by the bedside surgeon. The esophagus is divided
with an Endo GIA stapler at the neck while the surgeon at the console carries on the mediastinal
TM
dissection. At this stage, we transition to a vessel sealer in the mediastinum, although in certain cases, a