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Bongiolatti et al. Mini-invasive Surg 2020;4:41 I http://dx.doi.org/10.20517/2574-1225.2020.28 Page 3 of 11

Trans-hiatal RAMIE
In this approach, the robotic platform is used only for gastrolysis, abdominal lymph node dissection,
[19]
esophageal and mediastinal dissection and gastric tube reconstruction . The anastomosis is performed in
the neck [23,24] . The absence of thoracic incisions seems to be associated with lower post-operative respiratory
complications and thus, this procedure could be proposed to patients with comorbidities such as chronic
[19]
obstructive pulmonary disease and impaired lung function . The mediastinal lymph node dissection
[19]
includes only the para-esophageal and subcarinal stations .
Trans-thoracic RAMIE with intrathoracic anastomosis (Ivor-Lewis procedure -ILE-)
With the patient supine, the first abdominal step includes complete mobilization of the stomach, preserving
the blood supply from the right gastro-epiploic artery, celiac and splenic lymphadenectomy, hiatal and low
mediastinal dissections and finally, gastric tube tailoring. Next, the thoracic phase is frequently performed
in a full-lateral left decubitus, semi-prone or prone position with or without single-lung ventilation [24-27] .
The prone position is associated with low pressure capnothorax that could decrease the incidence of post-
operative respiratory complications, but some concerns could arise in the event of conversion. Nowadays,
the preferred patient position is semi-prone [14,18,28] . Usually, four or five access ports are used anteriorly
to the latissimus dorsi muscle [14,18,28,29] . The surgical steps are: complete intrathoracic mobilization of the
esophagus; para-esophageal, subcarinal and para-tracheal lymph node dissection; and lastly, esophago-
gastric anastomosis above or at the level of the azygos vein [25-29] . Several types of anastomosis can be
constructed in the chest and the choice depends on the surgeon’s experience, skills and preference. Hand-
sewn anastomosis can be performed with the robotic platform, but it did not show clear advantages in
terms of reduced incidence of anastomotic leak or stricture, and is associated with longer operative times .
[20]
The last Xi DaVinci® platform is armed with robotic staplers and some surgeons have shifted from hand-
sewn to mechanical anastomosis .
[30]

Trans-thoracic RAMIE with cervical anastomosis (McKeown procedure -MKE-)
Three-field esophagectomy starts with complete mediastinal mobilization, radical thoracic
[31]
lymphadenectomy and esophageal dissection in the upper region of the chest . As for the Ivor Lewis
procedure, the McKeown’s thoracic phase could be performed through the left lateral decubitus or prone
position [21,27,29,30] . After the thoracic phase, gastrolysis, celiac lymph node dissection and gastric conduit
construction can be performed in the abdomen [21,29,30] . The gastric conduit is then pulled-up through the
posterior mediastinum and the esophago-gastric anastomosis is performed in the neck [14,21] . The robotic
platform ensures greater exposure for dissection of the upper region of the chest, reducing potential injury
to vascular, respiratory (trachea and main bronchi) or nervous structures (vagus and recurrent laryngeal
nerves) [14,32] .

Technical aspects of anastomosis
After three-field and trans-hiatal esophagectomy, the preferred techniques of cervical anastomosis are
hand-sewn end-to-side and linear-stapled side-to-side anastomosis (modified Collard, Orringer) [33,34] .

According to the literature, esophagogastric anastomosis using the modified Collard method has lower
rates of anastomotic leakage (0%-18.4% vs. 0%-27%) and stricture (0%-65.1% vs. 0%-89.9%) .
[35]
The minimally-invasive intrathoracic anastomosis is considered a more challenging technique due to
the reduced degree of freedom and less space for instrument handling and staplers. However, with the
development of new equipment and the evolution of robotic platforms, some intrathoracic anastomosis
[28]
techniques are now available: hand-sewn [25,26,36,37] , circular-stapled , linear-stapled and trans-oral circular-
stapled .
[38]