Robotic assisted esophagectomy

This video presents in detail the robotic dissection of the oesophagus via a trans-thoracic approach. A mediastinal lymphadenectomy is also performed. Combined with a laparoscopic gastric mobilisation, a total minimally invasive approach to oesophagectomy is possible.

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Robotic assisted esophagectomy

Authors

Abstract

This video presents in detail the robotic dissection of the oesophagus via a trans-thoracic approach. A mediastinal lymphadenectomy is also performed. Combined with a laparoscopic gastric mobilisation, a total minimally invasive approach to oesophagectomy is possible.

Classification

complex cases, robotic

Keywords

robotic surgery, oesophagectomy

Media type

Surgical video

Duration

11'00''

Publication

2006-11

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E-publication

WeBSurg.com, Nov 2006;6(11).
URL: http://www.websurg.com/doi-vd01en2017.htm

Robotic assisted esophagectomy

2. Characteristics of the procedure 01'07''

Robot-assisted minimally invasive surgery allows for precise dissection and manipulation in a confined operating space. As a result, this technology may aid in the performance of a thoracoscopic extended mediastinal lymphadenectomy. The robot offers three-dimensional magnified vision and articulated instruments allowing a precise dissection of the peri-esophageal tissue along all the vital structures. The prone position allows mobilization of the esophagus with only 3 trocars because the lung which is partially deflated does not lock the access. With the patient in a prone position, bleeding does not obscure the operative field.

3. Parietal pleura 03'07''

The parietal pleura is divided on both sides of the azygos vein. The articulation of the robotic instruments within the pleural cavity improves the surgeon’s dexterity and reduces trocar movements. The mediastinal pleura is divided. Again, the articulated instruments facilitate the dissection without limitation from the costal margin. The esophagus is mobilized from the aorta and lymph nodes may be identified. Dissection is then continued with standard lymphadenectomy. The parietal pleura was then divided at the posterior side along the azygos vein and thoracic duct. The azygos vein is dissected and ligated with sutures and clips. This step is certainly facilitated by the robot’s articulations. The articulated hook appears as a safe and precise instrument to carry on the esophageal and lymph node dissection. The mediastinal pleura above the azygos vein is lifted up from the parenchymal lymph node dissection.

4. Pretracheal lymph node dissection 05'07''

In cases of esophageal cancer, extended trans-thoracic resection offers the best chance for tumor clearance and long-term survival. However, the morbidity rate associated with open trans-thoracic esophageal lymphadenectomy is very high. This is caused primarily by a high number of pulmonary complications. Because minimally invasive surgery induces less surgical trauma and immunologic stress, it may potentially reduce the postoperative complication rates. Various approaches have been investigated, each with its specific technical advantages and difficulties. In general, minimally invasive esophagectomy is a feasible but a technically demanding procedure. The advantages reported so far are a substantially reduced blood loss and a shorter ICU and hospital stay. The mediastinal pleura above the azygos vein is lifted up for the pretracheal lymph node dissection. The tumor and adjacent lymph nodes are dissected “en bloc” with coagulation of the aorto-esophageal vessels. The left mediastinal pleura is opened and resected.

5. Mobilization of the esophagus 08'47''

Mobilization of the esophagus is extended towards the thoracic inlet and to the diaphragmatic reflections. The specimen included the lower and middle mediastinal, subcarinal and right side pretracheal nodes. A 24 French chest tube is placed and the lung is insufflated under direct vision. The thoracoscopic procedure is combined with laparoscopic abdominal dissection of the stomach for creation of the gastric conduit and performance of a coeliac lymph node dissection.

6. End of the procedure 09'28''

The laparoscopic abdominal phase is performed without robot assistance because initial experimental studies show the large ranges of the robotic arms would limit the use of the robotic system in this part of the procedure. In conclusion, robotic assisted thoracoscopic esophageal lymphadenectomy for esophageal cancer is feasible. Robot assistance allows precise dissection in the mediastinum. This approach has the potential to reduce postoperative complications with optimal surgical “en bloc” dissection of the tumor and peri-esophageal tissues.