Page 145 - Read Online

Page 4 of 14 Khaitan et al. Mini-invasive Surg 2020;4:51 I http://dx.doi.org/10.20517/2574-1225.2020.34

the near-infrared imaging mode on the robotic console, indocyanine green (ICG) may be administered
intravenously (IV) to define the vascularity of the conduit [Figure 1H]. The literature is equivocal on the
use of ICG, as there is no conclusive evidence demonstrating decreased anastomotic leak rates with this
strategy [17,18] . We typically use 5 mg of ICG injected IV by the anesthesia team followed by a saline flush.
The vascular arcade is analyzed using the near-infrared imaging within one minute after injection. A
stitch is placed at the transition point where a loss of perfusion is noted in the gastric conduit. A Heineke-
Mikulicz pyloroplasty is performed routinely by opening the anterior aspect of the pylorus longitudinally
and closing it transversely using running 2-0 Ethibond stitches (Ethicon Inc., Somerville, NJ). The suture
line is buttressed with a tongue of omentum. A 12-14 Fr feeding jejunostomy tube is placed in the proximal
jejunum and brought out to the skin through a small incision in the left anterior abdominal wall [Figure 1I].

Thoracic portion of the procedure and anastomotic development
After completion of the abdominal phase, the patient is reintubated with a double lumen endotracheal tube
and placed in the left lateral decubitus position. Single lung ventilation is established in the left lung. Four
robotic ports are used to facilitate thoracic mobilization of the esophagus in addition to a fifth valveless
insufflation assistant port [Figure 2A]. Three robotic ports are placed in the eighth intercostal space starting
anterior to the anterior axillary line (12 mm), posterior axillary line (8 mm), and posteriorly approximately
2 cm away from the spine (8 mm). An 8 mm robotic port is placed in the third or fourth intercostal space
anteriorly to allow for upper esophageal mobilization. An assistant 12 mm valveless insufflation port is
placed low in the pleural cavity at about the tenth intercostal space at the level of the diaphragm. The chest
is typically insufflated with carbon dioxide to a pressure of 8-10 mmHg.

Using a curved bipolar instrument, circumferential esophageal mobilization is performed starting from
the level of the hiatus, proceeding superiorly to the level of the azygos vein. Starting at the inferior
pulmonary ligament [Figure 2B], all paraesophageal lymphoid tissue is either removed serially during
the dissection or included with the surgical specimen. Any subcarinal nodal tissue is also dissected; the
bronchus intermedius is typically skeletonized in the process [Figure 2C]. The abdominal Penrose drain is
retrieved and pulled into the chest, ensuring circumferential dissection of the esophagus [Figure 2D]. After
mobilization of the esophagus towards the thoracic inlet, the azygos vein is divided near the superior vena
cava (SVC) using a white vascular load curved tip robotic stapler [Figure 2E].

Once esophageal dissection is completed, the esophagus is divided approximately 2-3 cm superior to
the azygos vein [Figure 2F] and the gastric conduit is pulled into the chest [Figure 2G]. The proximal
esophageal margin is sent for frozen section analysis to ensure that it is negative for metaplasia, dysplasia,
or malignancy [Figure 2H]. A 28 mm end-to-end anastomotic (EEA) stapler anvil is inserted into the
proximal esophagus after removing any staples placed during transection. Running 3-0 vicryl (Ethicon,
Somerville, NJ) “baseball stitch” sutures are positioned around the esophageal edge to secure the anvil in
the proximal esophagus. An additional reinforcing purse string suture may be employed to assure mucosal
apposition around the stem of the anvil during deployment of the stapler. Alternatively, a transoral anvil
TM
(OrVil , Medtronic, Mansfield, Massachusetts) may be passed through the proximal esophageal staple line
[Figure 2I]. The posterior axillary line port is extended into a 4-5 cm access incision to facilitate completion
of the anastomosis (either intracorporeal or extracorporeal; in our case, extracorporeal anastomosis was
performed). Using a soft tissue Alexis retractor, this incision can be opened further. A gastrotomy is then
created in the proximal conduit tip, and the EEA stapler is introduced through it. Once in appropriate
position to engage with the anvil without excessive redundancy in the conduit, the stapler spike is brought
out of the greater curvature of the conduit at or below the transition stitch. After appropriate alignment, the
stapler is docked onto the anvil and fired, creating the anastomosis. Two mucosal “rings”, one esophageal
and one gastric, are confirmed in the EEA stapler once it is removed from the thoracic cavity.