Viewed from the perspective of the anesthesiologist, the robot is placed on the right side of the room and the console with the camera screen and various energy sources on the left side. Initially the patient bed is placed in a neutral position for the intubation and any endoscopy components.

For this part of the procedure, the bed is turned 90° to the right as viewed from the anesthesia side (towards the robot). The patient is positioned with the right arm extended 45° on an arm board and the left arm is tucked by the side, with the body shifted such that the head is at the very top of the table and the right side of the body at the right edge of the table. This allows for optimal robotic arm use especially in tall patients, as well as appropriate use of the liver retractor. A foot board with padding is placed (Fig. 17.2).

The total number of ports placed for the abdominal phase is most commonly seven, and occasionally eight; four ports are for the robot, one for the liver retractor, and two to three for bedside retraction, suctioning, suture passing, and stapling. The initial port placed is a 12-mm mid-line immediately supra-umbilical camera port placed under direct vision, thru which a pneumoperitoneum is established with 15 mmHg of CO₂ pressure. A 12-mm 30° robotic camera is introduced, and the patient is placed in steep reverse Trendelenburg. Then, under direct vision, the additional ports are placed. Starting superiorly and on the left side, a left lateral 5-mm robotic port to be used for a grasper (Schertl Grasper, Intuitive Surgical) is placed about 3–4 cm below the sub-costal margin sufficiently lateral to be just anterior to the left colon (fourth robotic arm); a left mid-clavicular 8-mm port for the robotic ultrasonic shears (Harmonic Scalpel, Ethicon) is placed about 13–15 cm from the xyphoid (first robotic arm). Using these two ports and laparoscopic graspers, the hepatic flexure is retracted inferiorly and medially to expose the lateral most aspect of the right colon peritoneal reflexion immediately below the costal margin, where a 5 mm port is placed for the liver retractor (Diamond Flex, Snowden Pencer); the liver retractor is now placed under the left lobe of the liver and retracted anteriorly; a fourth 8 mm robotic port for a bipolar atraumatic grasper (Fenestrated Bipolar Grasper, Intuitive Surgical) is then placed in the right mid-clavicular area approximately 2–3 cm below the sub-costal margin (second robotic arm). We consistently place two additional bedside assistant ports on the right side at the level of the umbilicus, including a 5 mm port approximately 5 cm from the umbilicus and a 12 mm port approximately 10 cm from the umbilicus; lastly and occasionally (especially in obese patients), we also place an additional 5 mm port approximately 5 cm to the left of midline at the level of the umbilicus (Fig. 17.3a).

After excluding any evidence of disease which would render the patient unresectable, the gastroesophageal (GE) junction is dissected off of the right and left crura laterally, and pericardium anteriorly with an en bloc resection to encompass all disease as needed, carefully avoiding entry into the pleural cavity which on occasion can cause hemodynamic instability and for which a tube thoracostomy might be necessary. The posterior aspect of the GE junction is then dissected off of the aorta, fully exposing the left and right crura, and thus fully mobilizing the GE junction. Attention is then turned to the retro-gastric component of the procedure which is accomplished initially thru exposure in the lesser sac from the lesser curve side. The stomach is retracted anteriorly and caudally using the Schertl grasper (fourth robotic arm), and with suctioning and additional exposure from the bedside assistant, the celiac axis, splenic artery, and common hepatic artery are skeletonized of their nodal tissue in an en bloc fashion. The left gastric artery and vein are then exposed and divided with an endovascular stapler. With continued retro-gastric exposure and anterior stomach retraction, we continue to dissect the most proximal aspect of the gastric fundus from its posterior and lateral attachments, ultimately exposing and transecting most of the short gastric arteries from the retro-gastric approach in the process (Fig. 17.3b–d).

The stomach is retracted to the right and caudally by the bedside assistant by grasping the gastric fat pad, thus exposing the greater curvature. The course of the right gastroepiploic artery and its termination can be clearly identified with this retraction, and any remaining short gastric arteries are divided using the ultrasonic shears. While maintaining this exposure, the lesser sac is entered thru a new window placed in the greater omentum at about the half way point of the extant of the right gastroepiploic artery. The schertl (fourth robotic arm) is then placed thru this window and is initially used to retract the greater omentum towards the left lateral abdominal wall. This clearly exposes the distal gastroepiploic artery, which is separated caudally from the omentum using the ultrasonic shears. Once this dissection is complete, the fourth robotic arm grasper is advanced behind the fundus to gently lift the stomach anteriorly, caudally, and towards the left; this clearly exposes the proximal extent of the gastroepiploic artery and any remaining retroperitoneal adhesions. With this view, the remaining stomach is completely mobilized to the level of the retro-pyloric position of the gastroepiploic artery (Fig. 17.4a).

Unlike our previously described procedure, we no longer routinely perform a gastric emptying procedure.

The nasogastric tube is withdrawn to about 30 cm from the incisors. The stomach is positioned by using robotic fourth arm to grasp the tip fundus on the short gastric artery line and retracting caudally towards the left upper quadrant, and using the third robotic arm and an atraumatic grasper (Cadierre Forceps, Intuitive Surgical) to place downward traction on the antrum. An endovascular stapler is introduced thru the 12 mm port to divide the remaining lesser curve vasculature, sacrificing about three to four branches of the right gastric artery, while angling the stapler towards the incisura. The gastric tube is then fashioned using multiple firings of an endo-gastrointestinal stapler, creating a conduit approximately 5–6 cm in diameter. After completely separating the conduit from the GE junction, they are temporarily re-attached using a heavy suture while maintaining proper orientation, in anticipation of future delivery in the chest (Fig. 17.4b).

We routinely place a feeding jejeunostomy. However, because of the positioning of the robot arms, it is technically not feasible to place a jejeunostomy robotically, so typically at this point we convert to a laparoscopic approach, and using the previously placed ports, place a feeding tube in the standard manner approximately 30 cm from the ligament of Treitz.

For this part of the procedure, the bed which was oriented at 90°, is rotated back to about 70°. The patient is placed in a full left lateral decubitus position, and the bed is flexed. The right arm is positioned so that the patient’s elbow is the least prominent possible (Fig. 17.5).

A total of five ports are placed, four robotic and one assistant port. After right lung isolation, a Veress needle is temporarily placed into the chest at approximately the mid-scapula line in the fifth intercostal space for CO₂ insufflation to 8 mmHg. A 12 mm camera port is placed in the posterior axillary line in the ninth interspace. Under direct visualization, a 5 mm robotic port for the Schertl is placed in the third interspace in the posterior axillary line (fourth arm); an 8 mm robotic port for a spatula is placed in the sixth interspace between the mid and posterior axillary line (first arm); an 8 mm robotic port for the bipolar grasper is placed slightly posterior to the scapular tip at approximately the ninth interspace (positioned immediately above the GE junction) (second robotic arm); and a 12 mm assistant port is placed mid-way between the camera port and posterior robotic port, as low as possible and immediately above the diaphragmatic insertion, to be used for a suction irrigator, graspers, and staplers (Fig. 17.6a).

The thoracic component is performed essentially as an en bloc approach, with circumferential removal of all tissue off the pericardium and airway medially, and along the aorta and contralateral pleura posteriorly, from the level of the hiatus to the azygous vein. Above the level of the azygous, the dissection is maintained close to the esophageal wall. The initial dissection begins by mobilizing the inferior pulmonary ligament, then using the Schertl (fourth robotic arm) for anterior and superior lung retraction, followed by removal of the parietal pleura off of the vena cava and pericardium extending superiorly behind the inferior pulmonary vein up into the sub-carinal space as well as posteriorly to the level of the contralateral pleura. Minimizing the risk of thermal injury to the airway is critical at this point, especially as the dissection continues to the left mainstem bronchus. At this point the azygous vein is transected with an endovascular stapler. Posterior dissection is then begun along the pleura of the descending azygous vein, with careful identification and preservation of the thoracic duct (if injured, it should be ligated near to the hiatus). Dissection is continued posteriorly until the aortic adventitia followed by the contralateral pleura are identified, and continued inferiorly to the level of the hiatus. Most aorta-esophageal branches can be cauterized with the spatula, but some larger ones might require either clips or bipolar cautery. At the hiatus, the dissection should continue until both crura are completely exposed. Prior to introducing the stomach into the chest, the proximal esophagus should be dissected above the level of the azygous to the desired level of transection (based on both considerations of tumor location as well as expected conduit length). The GE junction along with the attached conduit are then pulled up into the chest. Once the previously placed stitch between the GE junction and gastric conduit is identified, the stitch is cut and the conduit is temporarily secured to the diaphragm with another stitch. The GE junction is grabbed with the fourth robotic arm and pulled laterally and superiorly as the remaining posterior mediastinal attachments are dissected to the level of the planned esophageal transection. The esophagus is the sharply divided with robotic shears thru the first port (Monopolar Scissors, Intuitive Surgical). The second robotic arm and port are removed and the incision is extended to about 4 cm in size, a wound protector is deployed, and the specimen is retrieved. The proximal margin is sent for frozen section (Fig. 17.6).

The proximal esophageal lumen size is visually estimated, and typically a 28 mm anvil (DST EEA Stapler, Covidien Surgical) is introduced into the chest for later use. The second robotic port and robotic arm are placed back into the extended posterior incision. Large needle drivers are then placed on the first and second robotic arms. A running ‘baseball’ purse string stitch is then placed (0 Prolene SH Needle, Ethicon). The needle drivers are switched to a fenestrated bipolar in the second robotic arm and an atraumatic grasper (Cadierre Forceps, Intuitive Surgical) in the first robotic arm. The proximal esophagus is held open with the second and fourth robotic arms, and the Cadierre is used to grab the EEA anvil to position it into the open lumen. The first and second arm are then switched back to large needle holders, and the Prolene suture is securely tied. A second Prolene purse string suture is placed immediately proximal to the first one to reinforce the first one. The temporary diaphragm stitch to the conduit is now cut, and the rest of the conduit is delivered into the chest; this is best done using graspers from robotic arms one and two, carefully grabbing both sides of the stomach staple line (by not pulling the staple line apart, but rather approximating the two graspers) and pulling towards the lateral chest wall rather than apically. Slow gentle tugging invariably allows the conduit to be completely delivered into the chest as documented by identifying the first staple fire on the lesser curvature. Using the spatula and cautery in the first arm, a gastrotomy is made below the most proximal aspect of the staple line of a size sufficient to accommodate the EEA stapler. At this point, the bedside assistant grasps the distal aspect of the gastrotomy thru the 12 mm port site, and the first and fourth robotic arms grasp the gastrotomy opening at 3 o’clock and 11 o’clock, respectively. The second robotic port is removed, and the EEA stapler is introduced thru the wound and into the conduit. Once the stapler is safely advanced into the conduit, the fourth robotic arm releases the stomach and is replaced by a handheld grasper placed thru the second robotic port site by the bedside assistant (it is helpful at this point to have two bedside assistants, one for the two graspers and one for the stapler). The first robotic arm now also releases the stomach. At this point, thru the coordinated movements of the two bedside assistants, the stapler is further advanced into the conduit to a point as distal as possible to create a tension free, side stomach (on the greater curvature) to end esophagus anastomosis. While maintaining proper conduit orientation (staple line facing laterally), and while using the grasper on the first robotic arm on the anvil, the stapling device is deployed, coupled with the anvil (which is controlled by the first robotic arm), and fired. The stapler is then removed, the donuts examined for completeness, and the anastomosis is visually inspected thru the gastrotomy. The nasogastric tube is then advanced under direct vision, and the gastrotomy is closed with an endo-gastrointestinal stapler fired thru the 12 mm port, with the robotic first and second arm graspers holding both sides of the gastrotomy together. If there is sufficient omentum, it is placed between the anastomosis and the airway. We then place a Jackson Pratt drain posterior along the conduit up to the level of the anastomosis, exiting thru the 12 mm port. We also place a chest tube thru the camera port anteriorly to the apex (Fig. 17.7a–c).