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Ackerman et al. Mini-invasive Surg 2021;5:14 https://dx.doi.org/10.20517/2574-1225.2021.02 Page 13 of 19

Figure 14. The posterior esophagus is mobilized along the spine while clipping any tissue potentially containing the thoracic duct or one
of its branches. The robot assist (arm 4) can provide medial retraction on the esophagus away from the aorta. S: Spine; Ao: aorta; E:
esophagus.

Figure 15. Circumferential dissection proximal to the azygous vein “hugs” the esophagus. E: Esophagus; T: trachea.

Completion of esophageal dissection
With the robotic assist (arm 4) elevating the esophagus, the esophagus is mobilized from the left pleura
along its length to complete the circumferential esophageal mobilization with en bloc lymphadenectomy.
The esophagus is divided with either a scissor or ultrasonic shears at a level appropriate for a sound
oncologic margin. This may be as high as the thoracic inlet, but generally 2-3 cm proximal to the azygous
vein for lower esophageal tumors [Figure 16]. The proximal stomach and the gastric conduit are pulled into
the chest and the tacking suture is removed. The proximal conduit is temporarily sutured to the diaphragm
to prevent retraction back into the abdomen.

Specimen removal and conduit preparation
The posterior robotic arm 1 is undocked and the port is removed. The incision is extended to approximately
4 cm and a small wound protector is inserted. Alternatively, a specimen retrieval bag can be inserted
through the 12 mm bedside assist port, and the incision upsized on retrieval. The specimen is sent for
frozen pathologic analysis of margins, which should be confirmed as benign prior to reconstruction.

Anastomosis
We utilize an extra-long circular end-to-end anastomotic (EEA) 28 mm stapler (DST XL 28mm EEA,