Page 151 - Read Online

Page 10 of 14 Khaitan et al. Mini-invasive Surg 2020;4:51 I http://dx.doi.org/10.20517/2574-1225.2020.34

omohyoid muscle is divided, the inferior thyroid artery ligated and divided, and the strap muscles dissected
to allow access to the esophagus. No cautery or metal retractors are used in the region of the TE groove
to avoid inadvertent injury to the RLN. Blunt and sharp dissection is performed circumferentially around
the cervical esophagus. If dense adhesions are encountered at the thoracic inlet, a mediastinoscope can
be employed via the cervical incision to facilitate adhesiolysis under direct visualization. Such efforts
allow precise dissection and prevent inadvertent injury to the azygos. Next, the specimen and conduit are
pulled into the neck in proper orientation, and the stomach is divided at or below the transition stitch. The
proximal and distal margins are checked for metaplasia, dysplasia, or malignancy prior to completing the
anastomosis.

The anastomosis is performed either in a completely hand-sewn fashion or by utilizing a hybrid technique,
whereby the posterior aspect is started with a GIA stapler and the common opening is closed anteriorly in
a hand-sewn fashion. A nasogastric tube is passed under direct visualization prior to closing the anterior
wall. A drain is placed in the neck to monitor for leaks. The conduit is then tacked to the crura with two
2-0 Ethibond sutures. After ensuring hemostasis, pneumoperitoneum is released, and all incisions are
closed in layers.

POSTOPERATIVE COURSE
After surgery, the patient is admitted to an intensive or intermediate care unit for one to two days and
stepped down to a regular surgical unit once clinically stable. Enteral feeds are started via the feeding
jejunostomy tube on postoperative day 1 and advanced to goal over the course of the next few days.
The nasogastric tube is discontinued after return of bowel function and when output is at an acceptably
low level. The chest tube is typically removed on postoperative day 4 or 5, depending on the volume
and character of drainage. The patient is discharged once they have reached their benchmarks and are
tolerating goal tube feeds. The patient is kept NPO until a swallow study is performed as an outpatient on
postoperative day 14. This protocol promotes early discharge while allowing small, clinically insignificant
anastomotic leaks to seal.

LYMPH NODE DISSECTION IN RAMIE
The extent of lymph node dissection has been an important topic in the thoracic surgical literature. Unlike
resections for colorectal cancer, no definite cut-off has been established to define adequate lymph node
harvest for esophageal or esophagogastric junction carcinoma; different reports have determined varying
thresholds. Of importance is the fact that the aggregate lymph node count does not take into consideration
the location of the nodal basins harvested, such as whether they are in the abdomen, chest, or neck. A
better measure of the adequacy of lymphadenectomy, therefore, is the rate of locoregional recurrence
following esophagectomy by the various approaches.

Recent large cohort studies have found an average harvest of 25-29 regional nodes during RAMIE [15,21,22] .
Rates of locoregional recurrence, however, are not well defined, as the studies do not differentiate local and
distant recurrences when determining disease-free survival. When compared to open or traditional MIE,
locoregional recurrence rates following RAMIE have been reported to be comparable or lower [5,23] . Robotic
surgical platforms may offer advantages in dissection along the RLN in the apex of the chest, performed
with the patient in either the prone or lateral decubitus position [24,25] . A number of publications have also
confirmed the lower incidence of RLN neuropraxia and vocal cord paralysis with RAMIE when compared
to traditional MIE [26,27] .

DISCUSSION
With increasing exposure to robotic surgical techniques and with continual improvements in robotic
design and technology, including the introduction of robotic staplers and energy devices, the number of