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Triantafyllou et al. Mini-invasive Surg 2023;7:31 https://dx.doi.org/10.20517/2574-1225.2023.48 Page 3 of 8

Figure 1. Capturing the long history of esophagectomy, from the open to the robotic approach. THE: Transhiatal esophagectomy; TTE:
transthoracic esophagectomy.

dissections in RAMIE patients has been reported [18-20] .

The optimal anastomotic technique has not been widely agreed upon, and a great technical discrepancy
among different centres and countries has been documented. Given the variety of available surgical
approaches, the preferences for the reconstruction during esophagectomy reported in international studies
are difficult to interpret [Table 1]. It seems that the mechanical anastomotic technique has become more
popular (73%) than the hand-sewn anastomosis (27%), especially in centres that have abandoned the open
[4]
approach . Mechanical stapling in neck anastomoses has shown lower leak rates compared to hand-sewn
techniques; on the other hand, these rates were found to be equal in chest anastomoses regardless of the
approach.

The history of transition from the open to the thoracoscopic and robotic anastomosis among different units
varies and is mainly based on the previous experience of each surgeon or institution on the open technique.
Hence, many esophageal surgeons either transferred their skills from bariatric surgery -gastric bypasses and
gastrojejunal anastomoses- to stapling or suturing the esophagogastric reconstruction during video-assisted
thoracoscopy or RAMIE or preserved their familiar approach of anastomosing similarly to their experience
in open transthoracic esophagectomy.

PRESENT AND FUTURE
Several lessons have been learned from the preliminary and long-term results of MIE. The Ivor Lewis
esophagectomy with an intrathoracic anastomosis seems to be the predominant type in the Western world
currently, according to the results of the Esodata Database (estimated approximately 64% of the
resections) . The skills and critical steps of performing the anastomosis developed in MIE have been
[1]
transferred to the robotic setup; therefore, the three main types of anastomosis have been preserved and
mastered worldwide with evolving modifications [Figure 2]. All three approaches require an experienced
assistant next to the operating table responsible for the trocar placement, the docking procedure, correcting
any corruption/conflict of the robotic arms and switching the instruments needed for each surgical step
with accuracy, safety, and without causing any delays.

The totally hand-sewn anastomosis is technically challenging because of the limited freedom of movement
in the mediastinum. The barbed sutures enhanced the hand-sewn continuous one-layer esophagogastric
anastomosis. Nevertheless, this technique lost its popularity, especially after the wide application of MIE,
[21]
according to the analysis of the EsoBenchmark Database . All in all, only 19% of the total number of
esophagectomies in expert European centres are completed with a hand-sewn anastomosis, as published in
a recent consensus. This percentage is exclusively referred to as cervical anastomoses, leaving a percentage
of 81% for intrathoracic anastomosis . Another review showed that only 126 esophagectomies with hand-
[22]
sewn anastomosis have been reported as a total number of cases in the literature underlying the importance
of retracting the tissues with the fourth robotic arm. A few authors find it helpful to place four full-thickness
stay sutures (at 3, 6, 9, and 12 o’clock of the anastomosis) before starting the running sutures (either one or
two between 3 and 9 o’clock) .
[23]