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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 9 of 14

stapler. The common opening may be closed with either a TA stapler or using a hand-sewn technique. A
nasogastric tube is passed under direct visualization before completing the anterior wall of the anastomosis.
A drain is left in the cervical bed to monitor for leaks. After placement of two 2-0 sutures securing the
conduit to the diaphragm, pneumoperitoneum is reduced, and the abdominal and neck incisions closed in
layers.

TRANSHIATAL RAMIE
Typically, transhiatal RAMIE is chosen for patients who have mitigating pulmonary or cardiac co-
morbidities and may not tolerate single-lung ventilation. Transhiatal RAMIEs can be technically
challenging given the mediastinal dissection with the robot.

Patient positioning and port placement
The patient is positioned supine, with a single lumen tube, with both arms tucked. The neck is turned to
the patient’s right, and the left neck, chest, abdomen, and pelvis are all prepped and draped in one field. The
robot is docked in the abdomen. Typically, four robotic ports (one 12 mm and three 8 mm) are employed.
The 12 mm port is positioned in the right upper quadrant to allow creation of the gastric conduit with the
use of a robotic stapler. The abdomen is entered either using a Hassan or an 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
remaining robotic ports (one 8 mm midline, one 8 mm left lateral quadrant, and one 12 mm right upper
quadrant) are employed under direction visualization and are positioned equidistant from the xiphoid
process. A 5 mm liver retractor port can either be placed laterally in the right upper quadrant or near the
subxiphoid process. Lastly, an assistant port is positioned low in the pelvis, typically on the patient’s right
side, to facilitate placement of a feeding jejunostomy in the left lower quadrant.

Abdominal portion of the procedure
The abdominal portion begins with creation of the gastric conduit. Gastric mobilization starts with dividing
the greater omentum and preserving the right gastroepiploic arcade. Short gastric vessels are divided, and
the stomach is rotated anteriorly to allow take-down of retrogastric adhesions. Dissection is then carried
over to the lesser omentum. The pars flaccida is opened and the incision extended toward the right crus.
The left gastric and celiac axis nodes are swept up towards the specimen. Hiatal dissection is completed
circumferentially while stripping the peritoneum off the crura.

Under direct visualization, the camera and instruments are advanced into the mediastinum for extensive
mediastinal dissection. Dissection is continued as high as possible in order to facilitate mobilization of the
native esophagus from the neck, which is blind otherwise.

A 4-5 cm gastric conduit is created utilizing sequential stapler fires along the lesser curve. Starting at the
incisura angularis, a vascular load is first employed, followed by serial firing of blue- or green- robotic
staplers while applying gentle longitudinal tension on the conduit. Once the esophagus is completely
transected, the conduit is attached to the specimen for later retrieval in the neck. A Heineke-Mikulicz
pyloroplasty is completed by placing stay sutures on the superior and inferior aspects of the pylorus. The
pylorus is opened longitudinally and closed transversely, ensuring mucosal apposition during closure. The
suture line can be covered with a tongue of omentum. A generous Kocher maneuver can be performed if
the pylorus does not reach the hiatus easily to allow for tension-free delivery of the anastomotic site into
the neck. A 12-14 Fr jejunostomy feeding tube is placed in the left lower quadrant.

Cervical dissection and anastomotic development
With the abdominal ports in place, attention is diverted to the left neck. A 5 cm oblique incision is made
anterior to the left SCM. Dissection is carried down through the platysma using electrocautery. The