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Esophagectomy is associated with high morbidity and mortality rates, not only because it involves the manipulation of both abdominal and thoracic-mediastinal structures but also because the patients are often malnourished or suffer from a variety of co-morbidities.
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During the early 1990s, minimally invasive approaches, either transthoracic or laparoscopic-transhiatal, were proposed as a way to reduce morbidity and mortality associated with this operation. Still, the difficult manipulation of the rigid instruments in the upper mediastinum and the two-dimensional vision limited the application of these approaches. Moreover, they are not advisable for all surgeons because advanced skills in both open and minimally invasive techniques are mandatory.
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The application of robotic techniques overcomes the deficiencies of laparoscopy and thoracoscopy. It offers high-definition three-dimensional vision and full range of motion of the articulated instruments, allowing precise dissection in a confined operating space.
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A mobile cart with four arms holds the robotic instruments that are inserted through specific trocars. The surgeon is located at a remote console that transmits the surgeon’s finger and hand movements to the instruments of the da Vinci robot. Finally, standard laparoscopic equipment allows the assistant surgeon to follow the operation through a laparoscopic camera ( Fig. 28-1 ).
Figure 28-1
(From Intuitive Surgical Inc, Sunnyvale, CA.)
Step 1
Surgical Anatomy
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Knowledge of the anatomy of the esophagus and its relationships is critical for minimally invasive and robotic-assisted esophagectomy. Each anatomic portion of the esophagus is best dissected through a different approach, so this is extremely important in order to plan the operation.
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The cervical esophagus and the proximal 3 to 4 cm of the thoracic esophagus are best approached through the cervical incision. Anteriorly the cervical esophagus is closely related to the trachea. At this point, blunt dissection is recommended to avoid the injury of the left recurrent nerve, which lies in the groove between the trachea and the esophagus.
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The abdominal esophagus and distal thoracic esophagus are best manipulated from the abdominal approach; thus laparoscopic dissection is usually preferred. Dissection of the esophageal hiatus is performed easily, and the length of laparoscopic instruments allows approach of the distal esophagus up to the level of the carina.
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Proximal thoracic esophagus is the most difficult portion to dissect with minimally invasive techniques. Anteriorly it is closely related to the trachea and main left bronchus, and posteriorly it must be separated from the thoracic aorta. The thoracic duct ascends posteriorly and to the right of the thoracic esophagus up to the level of T5, where it ascends on the left side of the esophagus. Video-assisted thoracoscopic techniques allow an easier dissection through direct visualization of the esophagus, but they involve a more invasive technique, requiring a small thoracotomy and insertion of two chest tubes. A laparoscopic approach is more difficult because vision is limited; the upper mediastinum is a narrow space that makes dissection from adjacent structures difficult. Robotic-assisted minimally invasive techniques allow better visualization of the operative field, and a fuller range of motion of its articulated instruments makes dissection easier.
Step 2
Preoperative Considerations
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Preoperative evaluation at the anesthesia clinic is advisable for all patients to define the patient’s functional status and operative risk. Smoking cessation is advised in all patients.
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Deep vein thrombosis prophylaxis is accomplished with intraoperative and postoperative pneumatic compression stockings and subcutaneous heparin.
Step 3
Operative Steps
1
Transhiatal Approach
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Patient positioning: The patient is placed in a modified dorsal lithotomy, reverse Trendelenburg position, with the patient’s head turned slightly to the right during the surgical procedure.
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Robot positioning: The da Vinci robot is docked over the left shoulder of the patient. Operating room setup is shown in Figure 28-2 .
Figure 28-2
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Port placement ( Fig. 28-3 )
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Laparoscopic camera: A 12-mm optically guided trocar is placed in the midportion of the abdomen, approximately one third of the distance between the umbilicus and the xiphoid.
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Working ports: An additional right-sided, subcostal, reusable robotic 8-mm trocar is placed. Similarly, a left-sided, subcostal, reusable 8-mm trocar is placed. These serve as working ports. These ports will hold the robot trocars during the robotic dissection of the upper mediastinum.
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Additional ports: One right-sided 5-mm trocar is placed for an articulated liver retractor, and a left-sided 5-mm trocar is placed on the left-hand side of the patient for an auxiliary retraction port, which will be performed by the first assistant.
Figure 28-3
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Laparoscopic Dissection
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The esophageal hiatus is exposed by retracting the left lobe of the liver upward, using a Nathanson Liver Retractor (Mediflex Surgical Products, Islandia, NY). The dissection is started at the lesser omentum, and progressed towards the gastroesophageal junction (GEJ). The phrenoesophageal ligament is taken down beginning at the right crus of the diaphragm. We continue our dissection around the hiatus until the right crus is completely exposed. Next we move our dissection to the left-hand side of the hiatus. A retroesophageal window is created, and a band is passed and placed circumferentially around the distal esophagus and clipped anteriorly for downward traction of the GEJ ( Fig. 28-4 ).
