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Page 4 of 8 Triantafyllou et al. Mini-invasive Surg 2023;7:31 https://dx.doi.org/10.20517/2574-1225.2023.48

Table 1. Available techniques and different types of esophageal resection and reconstruction
Type of Location of Approach Anastomotic technique
esophagectomy anastomosis
Transhiatal (2-field) Cervical Laparotomy/laparoscopy/robotic gastric Hand-sewn/semi-
phase mechanical/mechanical (circular)
Ivor Lewis (2-field) Intrathoracic Thoracotomy/thoracoscopy/robotic chest Hand-sewn/mechanical (linear/circular
phase stapler)
McKeown (3-stage) Cervical Hybrid/totally open/MIE/RAMIE Hand-sewn/semi-
mechanical/mechanical (circular)

MIE: Minimally invasive esophagectomy; RAMIE: robot-assisted minimally invasive esophagectomy.

Figure 2. The different options for robot-assisted reconstruction after esophageal resection. (A) Hand-sewn anastomosis; (B) circular
stapling; (C) linear stapling. Yellow arrow: circular stapler; blue arrow: anvil; orange arrow: linear stapler.

On the other hand, using the circular stapler had to overcome the awkward ankle of introducing the
instrument through the chest and safely performing a purse string notch for positioning the anvil either
perorally or through the chest wall [24-26] . Anvil graspers for improved adjustment, appropriate sizes of
circular staplers, and a better understanding of how to eliminate tension between tissues during
thoracoscopy, as opposed to the conventional thoracotomy, have gradually encouraged more surgeons to
adopt the technique. The procedure is completed with a linear stapler or suturing of the defect in the
gastrotomy side. The most complex step is the attachment of the circular stapler within the mediastinum,
which requires the undocking of the robot to complete the anastomosis manually .
[18]
The modified Orringer linear stapling technique is another option that consists of an end-to-side double
stapling or side-to-side anastomosis following an esophagotomy (above, below, or at the level of the
esophageal stapler line) and gastrotomy for insertion of the stapler [27,28] . A smaller load of the stapler is
usually advised for easier manipulation and firing of the instrument within the mediastinum, forming the
posterior side of the anastomosis with the stapler. The defect is then sutured and, again, several ways and
the use of different sutures have been described; 3-0 V-loc (Covidien), 3-0 Vicryl (Ethicon), and 4-0
Stratafix (Ethicon) are being used among others. Throughout the years, the previous experience has proved
that mobilisation of the esophageal stump became necessary, aiming to form a tension-free anastomosis .
[29]
Compared to the other two techniques, the linear stapling forms the widest anastomosis, which may
account for the lower incidence of postoperative stenosis and strictures .
[30]