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Khaitan et al. Mini-invasive Surg 2020;4:51 I http://dx.doi.org/10.20517/2574-1225.2020.34 Page 7 of 14

Abdominal dissection
The patient is positioned supine and the double lumen endotracheal tube is switched to a single lumen
tube. The patient’s neck is extended and turned slightly to the right, exposing the left lower anterior neck.
The neck, anterior chest, and abdomen are prepped and draped in routine sterile fashion. The abdominal
ports are placed as for an Ivor Lewis RAMIE [Figure 4A]. Four robotic ports (one 12 mm and three 8 mm)
are typically employed; a 12 mm right upper quadrant port is needed to create a gastric conduit with the
use of a robotic stapler.

The abdomen is entered with either a Hassan or Optiview technique with a 0-degree, 5 mm camera in the
left upper quadrant. This port is later converted to an 8 mm robotic port. Once in the peritoneum, the
abdomen is insufflated with carbon dioxide to a pressure of 15 mmHg. Three additional robotic ports (one
8 mm midline, one 8 mm left lateral quadrant, and one 12 mm right upper quadrant) are placed under
direct visualization. These ports are placed equidistant from the xiphoid process. A 5 mm liver retractor
port can be employed either laterally in the right upper quadrant or near the subxiphoid process. Finally,
an assistant 12 mm valveless port is placed low in the pelvis typically on the patient’s right side, in order to
facilitate placement of a feeding jejunostomy in the left lower quadrant.

The dissection is started with creation of the gastric conduit. The gastrocolic ligament is divided along
the greater curvature of the stomach with a robotic vessel sealer while preserving the right gastroepiploic
arterial arcade [Figure 4B]. Once the right gastroepiploic trunk tapers proximally along the greater
curvature, the dissection plane is moved closer to the stomach and the short gastric vessels are divided
[Figure 4C]. Next, posterior dissection of the stomach is completed [Figure 4D], and the peritoneum over
the left and right crus is stripped and swept away with the surgical specimen. Dissection is continued into
the mediastinum until the inferior Penrose drain, placed during the thoracic phase of the procedure, is
encountered and delivered into the surgical field.

The left gastric artery is identified and divided using a robotic vascular stapler. The pars flaccida is divided,
and a 4-5 cm gastric conduit is created [Figure 4E] with serial firings of the robotic 45 mm blue or green
load staplers [Figure 4F]. Additional conduit length can be achieved by gently stretching the stomach
longitudinally as the robotic stapler is fired. Using near-infrared imaging, IV ICG can be administered to
allow identification of the transition point of perfusion along the conduit. A stitch can be placed to mark
this point, guiding creation of the esophagogastric anastomosis at a region of adequate gastric perfusion
[Figure 4G]. Lastly, the conduit is marked to ensure delivery of the conduit to the neck without torsion as it
is pulled up through the mediastinum [Figure 4H].

Our practice is to perform a pyloric drainage procedure. A Heineke-Mikulicz pyloroplasty is completed as
described previously and buttressed with a tongue of the omentum [Figure 4I]. A Kocher maneuver may be
performed if the pylorus does not reach the diaphragmatic hiatus. A 12-14 Fr feeding jejunostomy is placed
in the proximal jejunum and brought out to the skin in the left lower quadrant.

Left cervical dissection and anastomotic development
A five cm oblique incision is made anterior to the left sternocleidomastoid (SCM) muscle extending
cephalad from the sternal notch. The platysma is divided and the left SCM is retracted laterally. Using
electrocautery, the left omohyoid muscle is transected and the strap muscles divided as needed to provide
exposure of the cervical esophagus. The left inferior thyroid artery may need to be clamped, divided, and
ligated as it frequently impairs this exposure. Division and ligation of the vessel should be performed as
far laterally as possible to avoid injury to the left recurrent laryngeal nerve (RLN). Injury to this nerve is
also prevented by avoiding electrocautery and placement of either metal pickups or retractors in the region
of the left tracheo-esophageal (TE) groove. The assistant’s index finger, rather than a metal retractor, is