Robotic transhiatal esophagectomy

Introduction

Approximately 18,000 people in the US have developed esophageal cancer in 2019. Over the past 35 years, there has been tremendous increase in the incidence of adenocarcinoma of the esophagus. While squamous cell carcinoma has increased three-fold in incidence, adenocarcinoma of the esophagus has increased 56-fold over the past 35 years. Therefore, esophageal cancer as a whole has increased eight-fold.

Whether a patient undergoes an Ivor-Lewis or a transhiatal approach for resection of their esophageal cancer seems to be within the purview of the choice of the surgeon(s). It has long been our choice to utilize the transhiatal approach for esophagectomy. While we admit that the leak rate for the esophagogastrostomy may be higher in the neck, leaks are generally less consequential. ^, We also have found over the years that patients have a faster recovery without having undergone a thoracotomy.

Indications

The advent of robotic surgery has not changed the indications or operative techniques of esophagectomy. Application of the robotic platform and, thereby, the application of minimally invasive surgery to esophagectomy offer hope in minimizing surgical insult to more patients undergoing esophagectomy.

Patient preparation

Thorough informed consent must be obtained. It is our routine to draw pictures for patients and to write down all potential complications, including swallowing problems, voice problems, bleeding, infection (most particularly pneumonia), and failure to control the disease. ^,

Our patients are cared for through a detailed enhanced recovery after surgery (ERAS) protocol, which covers all areas of perioperative care. Patients drink immune-enhancing drinks for 5 days prior to the operation. The protocol also focuses on perioperative pain control, and our patients receive a preoperative epidural injection of Duramorph along with perioperative goal-directed fluid therapy ( Fig. 23.1 ).

Operating room setup and patient positioning

Patients are taken to the operating room and laid supine upon the operating table with their arms out ( Fig. 23.2 ). After achieving general anesthesia with endotracheal intubation, the anesthesiologists place the necessary lines and a urinary catheter is inserted. A nasogastric tube is placed into the stomach and then withdrawn to approximately 25 cm from the incisors. Management of the nasogastric tube during the operation is important. Then, the patients are prepped from bed line to bed line and from their jaws to their groins. Patients are typically placed in the 8–12-degree reverse Trendelenburg position and 4-degree rotation to the left. The higher the body mass index, the higher the necessary degree of reverse Trendelenburg position and tilt to the left.

Key operative steps