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CHAPTER 24 Robot-Assisted, Two-Stage, Three-Field Esophagolymphadenectomy—Video 24

Introduction

The da Vinci S system has three components: an operating console for the surgeon; a praying mantis–like chassis from which spring the robotic video unit and the three robotic arms; and the electronic communication tower system between the console and the chassis (Figure 24-1).

Figure 24-1 A, Intuitive Surgical’s da Vinci system. B, Typical operating room setup.

Approach to Robot-Assisted Esophagolymphadenectomy

Order of Operative Steps

The order of the steps of the operation are as follows: in the thoracic phase, patient positioning, port placement, docking, en bloc esophageal mobilization and wide nodal resection, cervical lymphadenectomy, thoracic duct ligation, and drain placement; then isolation of the cervical esophagus; in the abdominal phase, patient positioning, port placement, docking, placement of a feeding jejunostomy, celiac axis lymphadenectomy, and creation of a gastric conduit; and esophagogastric anastomosis.

Key Points

♦ A thoracotomy tray should be in the operating room at all times.

♦ A ring clamp with a heavy sponge or Surgicel attached should be available for immediate use at all times (Figure 24-2).

♦ Use continuous intrathoracic carbon dioxide insufflation to enhance the robot-assisted surgery. Keep the intrathoracic carbon dioxide pressure between 10 and 15 mm Hg to minimize a decrease in venous return and cardiac compliance.

♦ Small lymphatic tributaries seen under high robotic magnification are endoclipped through the accessory port or robotically.

Figure 24-2 Ring clamp with attached Surgicel.

Robot-Assisted Esophagolymphadenectomy (Video 24)

Step 1. Thoracic-Phase Patient Positioning

♦ The patient is intubated with a double-lumen endotracheal tube, positioned laterally to slightly face down, and strapped securely to the operating table.

♦ The right arm is well padded and positioned over the ear immediately adjacent to the face with the elbow below the horizontal plane of the right shoulder.

♦ Tilt the operating table as far anteriorly as possible so that the patient is positioned 30 to 45 degrees from prone (Figure 24-3).

Figure 24-3 The patient is intubated with a double-lumen endotracheal tube, and the body is positioned in the left lateral decubitus position and slightly forward.

Step 2. Thoracic-Phase Port Placement

♦ Make five puncture wounds in the right mid-anterolateral chest. Place a 12-mm trocar for the viewing port in the fifth or sixth intercostal space in the posterior axillary line. Place an 8-mm trocar for the right robotic arm in the posterior axillary line just anterior to the border of the scapula in the third or fourth intercostal space. Place an additional 8-mm trocar for the left robotic arm in the seventh or eighth intercostal space in the posterior axillary line, each of the two robotic arms approximately one hand bredth away from the videoscope port (Figure 24-4).

♦ Place two accessory ports at the level of the anterior axillary line: a 5-mm port at the level of the third intercostal space and a 12-mm port at the level of the sixth or seventh intercostal space. The upper port is used for suctioning and grasping instruments, and the lower port is used for placing a fan retractor for the lung, suctioning and grasping instruments, and introducing the sutures used for the thoracic duct ligation.

Figure 24-4 A and B, Port placement in the thoracic phase.

Step 3. Thoracic-Phase Docking

♦ Roll the robot into position. Place the robotic arms through the 8-mm trocars, and place the 0-degree videoscope through the 12-mm viewing port (Figure 24-5).

♦ Carbon dioxide is insufflated to a pressure of 10 mm Hg to evacuate electrocautery smoke and to compress the lung away from the surgical site.

Figure 24-5 Positioning of the patient after docking.

Step 4. En Bloc Esophageal Mobilization and Wide Nodal Resection

♦ Exposure: Direct the camera toward the pericardial bulge just cephalad to the inferior pulmonary vein.

♦ Set the videoscope in a 0-degree position.

♦ Using the hook electrocautery, and/or ultrasonic shears, and Caudier grasper (Intuitive Surgical, Sunnyvale, Calif), initiate dissection along the anterior aspect of the esophagus at the pericardial bulge, just cephalad to the superior aspect of the inferior pulmonary vein (Figure 24-6).

♦ Continue the dissection inferiorly to the esophageal hiatus, with the inferior pulmonary ligament and adherent lung taken down as necessary for access to the periesophageal nodes, completely cleaning the pericardium, hiatus, and left pleura (Figure 24-7).

♦ Clear both hila of nodal tissue, and take them contiguously with the specimen (Figure 24-8).

♦ Take the periaortic-spinal-azygous nodes and if necessary the thoracic duct en bloc.

♦ Continue the dissection along the azygous vein, which is preserved when the vein is uninvolved.

Figure 24-6 Initial dissection of the mid-esophagus.

Figure 24-7 The posterior view shows wide nodal resection performed en bloc with the esophagus. The shaded area represents the intended borders of the resection. The surgical goal was wide and continuous resection of all of the periesophageal lymphatic tissue.

Figure 24-8 Dissection of the carina and hilum.

Step 5. Cervical Lymphadenectomy

♦ Exposure: Direct the camera toward the thoracic inlet.

♦ Set the videoscope in the 0-degree position.

♦ Resect the supra-azygous esophagus and periesophageal tissue into the thoracic apex, well into the neck. Over the intended resection area, score the pleura with the hook electrocautery. Transect the associated peritracheal nodes and the right vagus nerve with the ultrasonic shears, reducing the potential of electrical transmission to the recurrent laryngeal nerve.

♦ Completely clean the posterior and rightward aspect of the trachea and the thoracic peritracheal and cervical spaces of periesophageal tissue, and continue the dissection into the thoracic inlet to the level of the inferior laryngeal cartilage (Figure 24-9).

Figure 24-9 Dissection of the thoracic inlet.

Step 6. Thoracic Duct Ligation

♦ Exposure: Direct the camera toward the esophageal hiatus.

♦ Set the videoscope in a 0-degree down position.

♦ At the level of the diaphragm, the thoracic duct is triply ligated with 2-0 Ethibond suture, cut to an 8-cm length, encompassing all of the tissue between the azygous vein and the aorta.

Step 7. Drain Placement

♦ At the conclusion of the thoracic phase, place two drains: a 19-French, round, fluted Silastic drain (Blake, Ethicon Incorporated, Johnson & Johnson) through the lower accessory trocar along the diaphragm and a 15-French drain to the superior aspect of the thoracic cavity through the upper accessory trocar (Figure 24-10).

♦ Remove the robotic arms, and move the robot away from the patient.

♦ Close the thoracic trocar sites with 3-0 Vicryl sutures with an SH needle.

Figure 24-10 Drain placement during the thoracic phase.

Step 8. Isolation of the Cervical Esophagus

♦ Position the patient supinely, and reintubate with a single-lumen endotracheal tube. Turn the head upward and to the right, exposing the left side of the neck.

♦ Place the upper extremities by the sides, and keep the legs together.

♦ Make an oblique 5-cm transverse incision in the left neck 3 cm above the medial left clavicle.

♦ Continue the dissection deeply and medially toward the spine, transecting the omohyoid muscle for exposure.

♦ Encircle the previously mobilized and dissected esophagus with a Penrose drain, and pack the incision with an antibiotic-soaked surgical laparotomy pad to prevent carbon dioxide from later escaping from the peritoneal cavity.

♦ This initial dissection allows manipulation of the esophagus and unhindered withdrawal of the specimen later in the procedure.

Step 9. Abdominal-Phase Patient Positioning

♦ The patient is positioned supinely with the upper extremities placed by the sides and the legs kept together.

Step 10. Abdominal-Phase Port Placement

♦ A total of six abdominal puncture wounds are made. Place two 8-mm ports 8 cm subcostally at the right and left mid-clavicular lines for the robotic arms. Place an additional 12-mm trocar for the viewing port just cephalad to the umbilicus, maintaining a distance of 10 to 12 cm from either of the robotic arms (Figure 24-11).

♦ Place two additional 5-mm trocars beneath each costal margin in the anterior axillary line. Place another 12-mm port at the right mid-clavicular line at the umbilicus level (see Figure 24-11).

Figure 24-11 Port placement during the abdominal phase.

Step 11. Abdominal-Phase Docking

♦ Roll the robot into position. Place the robotic arms through the 8-mm trocars, and place the 30-degree down videoscope through the 12-mm viewing port.

♦ Inflate the abdomen with carbon dioxide to a pressure of 15 mm Hg.

Step 12. Placement of a Feeding Jejunostomy

♦ Before gastric dissection, place a laparoscopic feeding tube 20 cm from the ligament of Treitz, with transcutaneously placed 10-French T fasteners (Ross Flexiflow Lap J, Ross Products Division, Abbott Laboratories, Columbus, Ohio).

Step 13. Celiac Axis Lymphadenectomy

♦ Exposure: Direct the camera toward the esophageal hiatus.

♦ Set the videoscope in the 30-degree down position.

♦ Lymph nodes are resected from the splenic hilum along the splenic artery to the origin of the left gastric artery and along the common hepatic artery up to the dissection plane completed in the thoracic phase of the procedure.

Step 14. Creation of a Gastric Conduit

♦ Exposure: Direct the camera toward the esophageal hiatus.

♦ Set the videoscope in the 30-degree down position.

♦ Place a liver retractor exposing the esophageal hiatus through the right 5-mm accessory port.

♦ Using the SonoSurg (Intuitive Surgical), transect the lesser omentum from the base of the liver up to the esophageal hiatus. Take the short gastric arteries, but preserve the right gastroepiploic arcade along its entirely to the right gastroepiploic vein at the transverse mesentery.

♦ Transect the pyloric attachments to free the pylorus, allowing mobilization sufficient tissue to reach toward the esophageal hiatus. No Kocher maneuver or pyloroplasty is performed.

♦ Approximately 4 to 5 cm cephalad from the origin of the right gastric artery along the lesser gastric curve, clear the gastric wall of perigastric tissue.

♦ Using 8 to 10 firings of an Ethicon 45 × 4.1-mm linear endostapler, create a 4-cm-wide (from the greater curvature) right gastroepiploic arterial arcade–supplied gastric tube (Figure 24-12).

♦ Suture the most cephalad aspect of the gastric tube to the most distal aspect of the specimen with two widely spaced figure-of-eight sutures (Figure 24-13).

♦ Briefly discontinue the ventilator and chest drain suction, and use the Penrose drain encircling the esophagus at the neck as a handle to pull the specimen up through the neck incision.

♦ Suture the intraperitoneal portion of the anterior gastric conduit serosa to each esophageal hiatus crus with two figure-of-eight, 3-0 Ethibond sutures to reduce the risk of later periconduit herniation.

♦ Move the robot away form the patient to allow access to the left neck incision site. Close the abdominal trocar sites with 3-0 Vicryl sutures (Figure 24-14).

Figure 24-12 Gastric tube creation.

Figure 24-13 Attachment of the proximal gastric tube to the specimen.

Figure 24-14 Completion of the abdominal phase.

Step 15. Esophagogastric Anastomosis

♦ At the incision in the left side of the neck, transect the specimen, and perform a stapled esophagogastrostomy. Create a side-to-side, functional end-to-end stapled anastomosis with a 45 × 4.1-mm linear endostapler and a 60 × 4.1-mm transverse stapler. This fashioned a 4 to 5 × 6-cm triangular anastomosis (Figure 24-15).

♦ Carefully place the nasogastric tube through the anastomosis before it is completed.

♦ Place a soft, multiholed drain in the neck beneath the platysma, avoiding the perimeter of the anastomosis.

♦ Close the cervical wound with interrupted 3-0 Vicryl sutures. A healed cervical wound is shown in Figure 24-16.

Figure 24-15 A-C, Neck anastomosis.

Figure 24-16 Healed cervical wound.

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CHAPTER 24 Robot-Assisted, Two-Stage, Three-Field Esophagolymphadenectomy—Video 24

Introduction

The da Vinci S system has three components: an operating console for the surgeon; a praying mantis–like chassis from which spring the robotic video unit and the three robotic arms; and the electronic communication tower system between the console and the chassis (Figure 24-1).

Figure 24-1 A, Intuitive Surgical’s da Vinci system. B, Typical operating room setup.

Approach to Robot-Assisted Esophagolymphadenectomy

Order of Operative Steps

The order of the steps of the operation are as follows: in the thoracic phase, patient positioning, port placement, docking, en bloc esophageal mobilization and wide nodal resection, cervical lymphadenectomy, thoracic duct ligation, and drain placement; then isolation of the cervical esophagus; in the abdominal phase, patient positioning, port placement, docking, placement of a feeding jejunostomy, celiac axis lymphadenectomy, and creation of a gastric conduit; and esophagogastric anastomosis.

Key Points

♦ A thoracotomy tray should be in the operating room at all times.

♦ A ring clamp with a heavy sponge or Surgicel attached should be available for immediate use at all times (Figure 24-2).

♦ Use continuous intrathoracic carbon dioxide insufflation to enhance the robot-assisted surgery. Keep the intrathoracic carbon dioxide pressure between 10 and 15 mm Hg to minimize a decrease in venous return and cardiac compliance.

♦ Small lymphatic tributaries seen under high robotic magnification are endoclipped through the accessory port or robotically.

Figure 24-2 Ring clamp with attached Surgicel.

Robot-Assisted Esophagolymphadenectomy (Video 24)

Step 1. Thoracic-Phase Patient Positioning

♦ The patient is intubated with a double-lumen endotracheal tube, positioned laterally to slightly face down, and strapped securely to the operating table.

♦ The right arm is well padded and positioned over the ear immediately adjacent to the face with the elbow below the horizontal plane of the right shoulder.

♦ Tilt the operating table as far anteriorly as possible so that the patient is positioned 30 to 45 degrees from prone (Figure 24-3).

Figure 24-3 The patient is intubated with a double-lumen endotracheal tube, and the body is positioned in the left lateral decubitus position and slightly forward.

Step 2. Thoracic-Phase Port Placement

♦ Make five puncture wounds in the right mid-anterolateral chest. Place a 12-mm trocar for the viewing port in the fifth or sixth intercostal space in the posterior axillary line. Place an 8-mm trocar for the right robotic arm in the posterior axillary line just anterior to the border of the scapula in the third or fourth intercostal space. Place an additional 8-mm trocar for the left robotic arm in the seventh or eighth intercostal space in the posterior axillary line, each of the two robotic arms approximately one hand bredth away from the videoscope port (Figure 24-4).

♦ Place two accessory ports at the level of the anterior axillary line: a 5-mm port at the level of the third intercostal space and a 12-mm port at the level of the sixth or seventh intercostal space. The upper port is used for suctioning and grasping instruments, and the lower port is used for placing a fan retractor for the lung, suctioning and grasping instruments, and introducing the sutures used for the thoracic duct ligation.

Figure 24-4 A and B, Port placement in the thoracic phase.

Step 3. Thoracic-Phase Docking

♦ Roll the robot into position. Place the robotic arms through the 8-mm trocars, and place the 0-degree videoscope through the 12-mm viewing port (Figure 24-5).

♦ Carbon dioxide is insufflated to a pressure of 10 mm Hg to evacuate electrocautery smoke and to compress the lung away from the surgical site.

Figure 24-5 Positioning of the patient after docking.

Step 4. En Bloc Esophageal Mobilization and Wide Nodal Resection

♦ Exposure: Direct the camera toward the pericardial bulge just cephalad to the inferior pulmonary vein.

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