RAMIE: tradition drives innovation-feasibility of a robotic-assisted intra-thoracic anastomosis

Abstract

Due to the difficulties in the intra-thoracic esophagogastric anastomosis creation, totally minimally invasive Ivor Lewis esophagectomy (MIE) did not encountered a large diffusion, preferring hybrid techniques or cervical anastomosis. Robot-assisted minimally invasive esophagectomy (RAMIE) has gained popularity due to an easy reproducibility of the open anastomotic technique. In this feasibility study, we described the RAMIE technique introduced in our Center, providing innovative details for a mechanical end-to-end anastomosis. With patient in prone position, esophagectomy is conducted through the meso-esophagus plan. Robotic hand-sewn purse-string is realized above Azygos vein. A 4-cm thoracotomy in the fifth intercostal space is performed by enlarging the trocar incision. The tubulization is performed to create an access pouch for the introduction of the circular stapler. After the creation of the end-to-end anastomosis, the access pouch is resected and a robotic over-sewn is realized. From January 2020 until July 2020, ten patients were enrolled. No restriction in term of age, BMI, ASA grade or previous surgery were applied. Median operative time was 700 min. R0 resection was achieved in all cases with a good lymph node harvesting. No anastomotic leak or stricture were observed. One chyle leak was treated conservatively. Median length of stay was 8 days and 90 days mortality was 0%. This study evidenced how robotic surgery allowed us to perform the same anastomosis of our open technique with good oncological results and morbidity and length of stay comparable with our previous results. Of note, longer operative time has been recorded. Further studies after the completion of the learning curve are necessary to address more definite conclusions.

Keywords: Ivor lewis; RAMIE; Robotic surgery.

Fig. 1

a Abdominal port placement and disposition of surgeons in the abdominal phase (S: surgeon, first operator, A assistant, C camera operator). b Thoracic port placement in prone position (R robot arm, A assistant port, ICS intercostal space)

Fig. 2

a Abdominal gastric tubulization, b abdominal gastric tubulization, and c thoracic completion of tubulization

Fig. 3

a Gastric conduit with the circular stapler inserter through the access pouch. The tip of the stapler comes closer to the greater curve edge. This maneuvre together with the oblique section of the conduit’s tip results in the formation of one small anterior dog-ear that will be covered with the anastomotic over-sewn. b The classic anastomosis on the posterior wall results in a small ischemic area on the antimesenteric side (black arrow)