Implementation of robot-assisted Ivor Lewis procedure: Robotic hand-sewn, linear or circular technique?

Robotic- assisted minimally invasive Ivor-Lewis handsewn anastomosis technique and outcomes from a large-volume European centre

In minimally invasive transthoracic esophagectomy, intrathoracic anastomoses are usually performed with stapling devices to avoid a technically challenging handsewn technique in the upper mediastinum. Few have published about handsewn anastomotic techniques due to the technically demanding requirements for suturing with rigid instruments in the thoracic cavity. With robot-assisted minimally invasive esophagectomy (RAMIE), the robot provides increased dexterity, enabling construction of a hand-sewn intrathoracic anastomosis. This study aimed to evaluate the outcomes of our technique for hand-sewn intrathoracic anastomosis in RAMIE, following the initial learning phase between 2016 and 2018 in UMC Utrecht. Patients who underwent RAMIE with a robot-assisted hand-sewn intrathoracic anastomosis were included in this retrospective study. Data were extracted from a prospectively maintained institutional database. Key technique steps included esophageal stay-sutures, use of barbed sutures for the anastomosis, placement of tension-releasing stitches, and covering of the anastomosis with omentum. The primary outcome was anastomotic leakage; secondary outcomes included anastomotic stricture rate and duration of anastomosis construction. Between 1 November 2019 and 30 May 2023, 89 consecutive patients were included. Anastomotic leakage (defined by the Esophageal Complications Consensus Group) occurred in 11 patients (12.4%), which involved a grade I leak in four patients (4.5%), grade II leak in one patient (1.1%), and grade III leakage in six patients (6.7%). The median duration of anastomosis creation was 33 minutes (range, 23-55 minutes). Stricture rate was 32.6% (29 patients) at 1 year post-operatively for which dilation was needed for all patients. This study shows that a robot-assisted hand-sewn intrathoracic anastomosis in RAMIE is feasible, safe, and reliable.

Fashioning esophagogastric anastomosis in robotic Ivor-Lewis esophagectomy: a multicenter experience

BACKGROUND

The aim of the present study is to compare outcomes of the robotic hand-sewn, linear- and circular-stapled techniques performed to create an intrathoracic esophagogastric anastomosis in patients who underwent Ivor-Lewis esophagectomy.

METHODS

Patients who underwent a planned Ivor-Lewis esophagectomy were retrospectively analysed from prospectively maintained databases. Only patients who underwent a robotic thoracic approach with the creation of an intrathoracic esophagogastric anastomosis were included in the study. Patients were divided into three groups: hand-sewn-, circular stapled-, and linear-stapled anastomosis group. Demographic information and surgery-related data were extracted. The primary outcome was the rate of anastomotic leakages (AL) in the three groups. Moreover, the rate of grade A, B and C anastomotic leakage were evaluated. In addition, patients of each group were divided in subgroups according to the characteristics of anastomotic fashioning technique.

RESULTS

Two hundred and thirty patients were enrolled in the study. No significant differences were found between the three groups about AL rate (p = 0.137). Considering the management of the AL for each of the three groups, no significant differences were found. Evaluating the correlation between AL rate and the characteristics of anastomotic fashioning technique, no significant differences were found.

CONCLUSIONS

No standardized anastomotic fashioning technique has yet been generally accepted. This study could be considered a call to perform ad hoc high-quality studies involving high-volume centers for upper gastrointestinal surgery to evaluate what is the most advantageous anastomotic technique.

Fully Robotic Side-to-Side Linear-Stapled Anastomosis During Robotic Ivor Lewis Esophagectomy

BACKGROUND

The adoption of robotic surgery for esophageal cancer has been expanding rapidly over the recent years. In the setting of two-field esophagectomy, different techniques exist for intrathoracic esophagogastric anastomosis, although the superiority of one over another has not been clearly demonstrated. Potential benefits in terms of anastomotic leakage and stenosis have been reported in association with a linear-stapled anastomosis as compared to the more widespread techniques of circular mechanical and hand-sewn reconstructions, however, there is still limited reported evidence on its application to robotic surgery. We here report our fully robotic technique of side-to-side, semi-mechanical anastomosis.

METHODS

All consecutive patients undergoing fully robotic esophagectomy featuring intrathoracic side-to-side stapled anastomosis by a single surgical team were included in this analysis. Operative technique is detailed, and perioperative data are assessed.

RESULTS

A total of 49 patients were included. There were no intraoperative complications and no conversion occurred. The rate of overall postoperative morbidity was 25, 14% being the relative rate of major complications. With anastomotic-related morbidity in particular, one patient developed minor anastomotic leakage.

CONCLUSIONS

Our experience demonstrates that a linear, side-to-side fully robotic stapled anastomosis can be created with a high technical success and minimal incidence of anastomosis-related morbidity.

[Robot-assisted Minimally Invasive Oesophagectomy - Surgical Variants of Intrathoracic Circular Stapled Oesophagogastric Anastomosis]

INTRODUCTION

Anastomotic insufficiency after oesophagectomy contributes significantly to morbidity and mortality of affected patients. A safe surgical technique can reduce the incidence of such anastomotic insufficiencies.

INDICATION

In the treatment of oesophageal cancer, the German guideline recommends minimally invasive or hybrid surgical procedures. In most cases, Ivor-Lewis oesophagectomy and continuity reconstruction using a gastric sleeve are performed. Circular stapler anastomosis seems to be superior.

METHOD

The preparation of the anastomosis starts intra-abdominally with mobilisation of the stomach and sparing of the gastroepiploic vessels. After the subsequent intrathoracic mobilisation of the oesophagus, the actual anastomosis construction can take place. Here, the oesophagus is either transected with a stapler closure or openly with scissors. This is followed by a purse-string suture on the open oesophageal stump. Alternatively, partial oesophageal opening with prior purse-string suture may later facilitate insertion of the stapler anvil. The anvil is placed in the oesophageal stump via minithoracotomy or alternatively transorally using a special gastric tube system. Subsequently, the anvil is fixated using the previously performed purse-string suture. Now the gastric sleeve can be pulled into the thorax. The oesophagus and small gastric curvature are placed extrathoracically through the minithoracotomy and a circular stapler is inserted into the gastric tube via an opening of the small curvature. The anastomosis then must be placed remotely from the gastroepiploic arcade. After construction of the anastomosis, the gastric sleeve is separated using a linear stapler. Eventually, the oesophagus and small gastric curvature can be completely recovered. Optionally, an additional suturing over the anastomosis and dissection margin of the gastric sleeve can be performed.

CONCLUSION

In robot-assisted oesophagectomy, the reconstruction of continuity with a circular stapler anastomosis is quite possible and seems comparatively easier to learn. Nevertheless, variations are still possible within this procedure. However, there is no scientific evidence on the advantage for any method in a direct comparison.

Robot-assisted esophagectomy with robot-sewn intrathoracic anastomosis (Ivor Lewis): surgical technique and early results

Esophagectomy is the selected treatment for nonmetastatic esophageal and esophagogastric junction cancer, although high perioperative morbidity and mortality incur. Robot-assisted minimally invasive esophagectomy (RAMIE) effectively reduces cardiopulmonary complications compared to open esophagectomy and offers a technical advantage, especially for lymph node dissection and intrathoracic anastomosis. This article aims at describing our initial experience of Ivor Lewis RAMIE, focusing on the technique's main steps and robotic-sewn esophagogastrostomy. Prospectively collected data from all consecutive patients who underwent Ivor Lewis RAMIE for cancer was reviewed. Reconstruction was performed with a gastric conduit pull-up and a robotic-sewn intrathoracic anastomosis. Intraoperative and postoperative complications were recorded as prescribed by the Esophagectomy Complications Consensus Group (ECCG). Thirty patients underwent Ivor Lewis RAMIE with complete mediastinal lymph node dissection and robot-sewn anastomosis. No intraoperative complications nor conversion occurred. Pulmonary complications totaled 26.7%. Anastomotic leakage (ECCG, type III) and conduit necrosis (ECCG, type III) both occurred in one patient (3.3%). Chylothorax appeared in 2 patients (6.7%) (ECCG, Type IIA). Anastomotic stricture, successfully treated with endoscopic dilatations, occurred in 8 cases (26.7%). Median overall postoperative stay was 11 days (range, 6-51 days). 30 day and 90 day mortality was 0%. R0 resection was performed in 96.7% of patients with a median number of 47 retrieved lymph nodes. RAMIE with robot-sewn intrathoracic anastomosis appears to be feasible, safe and effective, with favorable perioperative results. Nevertheless, further high-quality studies are needed to define the best anastomotic technique for Ivor Lewis RAMIE.

Continuously sutured versus linear-stapled anastomosis in robot-assisted hybrid Ivor Lewis esophageal surgery following neoadjuvant chemoradiotherapy: a single-center cohort study

BACKGROUND

Esophageal cancer surgery is technically highly demanding. During the past decade robot-assisted surgery has successfully been introduced in esophageal cancer treatment. Various techniques are being evaluated in different centers. In particular, advantages and disadvantages of continuously sutured (COSU) or linear-stapled (LIST) gastroesophageal anastomoses are debated. Here, we comparatively analyzed perioperative morbidities and short-term outcomes in patients undergoing hybrid robot-assisted esophageal surgery following neoadjuvant chemoradiotherapy (nCRT), with COSU or LIST anastomoses in a single center.

METHODS

Following standardized, effective, nCRT, 53 patients underwent a hybrid Ivor Lewis robot-assisted esophagectomy with COSU (n = 32) or LIST (n = 21) gastroesophageal anastomoses. Study endpoints were intra- and postoperative complications, in-hospital morbidity and mortality. Duration of operation, intensive care unit (ICU) and overall hospital stay were also evaluated. Furthermore, rates of rehospitalization, endoscopies, anastomotic stenosis and recurrence were assessed in a 90-day follow-up.

RESULTS

Demographics, ASA scores and tumor characteristics were comparable in the two groups. Median duration of operation was similar in patients with COSU and LIST anastomosis (467 vs. 453 min, IQR 420-521 vs. 416-469, p = 0.0611). Major complications were observed in 4/32 (12.5%) and 4/21 (19%) patients with COSU or LIST anastomosis, respectively (p = 0.697). Anastomotic leakage was observed in 3/32 (9.3%) and 2/21 (9.5%) (p = 1.0) patients with COSU or LIST anastomosis, respectively. Pleural empyema occurred in 1/32 (3.1%) and 2/21 (9.5%) (p = 0.555) patients, respectively. Mortality was similar in the two groups (1/32, 3.1% and 1/21, 4.7%, p = 1.0). Median ICU stay did not differ in patients with COSU or LIST anastomosis (p = 0.255), whereas a slightly, but significantly (p = 0.0393) shorter overall hospital stay was observed for COSU, as compared to LIST cohort (median: 20 vs. 21 days, IQR 17-22 vs. 18-28).

CONCLUSIONS

COSU is not inferior to LIST in the performance of gastroesophageal anastomosis in hybrid Ivor Lewis operations following nCRT.

Robot-assisted Ivor Lewis Esophagectomy (RAILE): A review of surgical techniques and clinical outcomes

In the past 20 years, robotic system has gradually found a place in esophagectomy which is a demanding procedure in the deep and narrow thoracic cavity containing crucial functional structures. Ivor Lewis esophagectomy (ILE) is a mainstream surgery type for esophagectomy and is widely accepted for its capability in lymphadenectomy and relatively mitigated trauma. As a minimally invasive technique, robot-assisted Ivor Lewis esophagectomy (RAILE) has been frequently compared with the video-assisted procedure and the traditional open procedure. However, high-quality evidence elucidating the advantages and drawbacks of RAILE is still lacking. In this article, we will review the surgical techniques, both short and long-term outcomes, the learning curve, and explicate the current progress and clinical efficacy of RAILE.

Double-Docking Technique, an Optimized Process for Intrathoracic Esophagogastrostomy in Robot-Assisted Ivor Lewis Esophagectomy

Background

Though robotic Ivor Lewis esophagectomy has been increasingly applied, intrathoracic esophagogastrostomy is still a technical barrier. In this retrospective study, we introduced a double-docking technique for intrathoracic esophagogastrostomy to optimize surgical exposure and facilitate intrathoracic anastomosis. Moreover, we compared the clinical outcomes between the double-docking technique and anastomosis with a single-docking procedure in robotic Ivor Lewis esophagectomy.

Methods

From March 2017 to September 2020, the clinical data of 68 patients who underwent robotic Ivor Lewis esophagectomy were reviewed, including 23 patients who underwent the double-docking technique (double-docking group) and 45 patients who underwent single-docking robotic esophagectomy (single-docking group). All patients were diagnosed with esophageal cancer or gastro-esophageal junction by biopsy before surgery. The technical details of the double-docking technique are described in this article.

Results

There was no difference in the patient demographics data between the two groups. The median surgical time in the double-docking group was slightly shorter than in the classic group without statistical difference (380 vs. 395 min, p = 0.368). In the double-docking group, the median blood loss was 90 mL, the median number of lymph nodes harvested was 17, and the R0 resection rates were 100% (23/23). There were no differences in the surgical outcomes between the two groups.

Conclusions

Based on our experience, the double-docking technique provides good surgical exposure when fashioning anastomosis, and such a technique does not increase the surgical time. Therefore, we believe that the double-docking technique is a safe and effective method for intrathoracic esophagogastrostomy while providing good exposure and ensuring the convenience and reliability of intrathoracic anastomosis.

Technical details for a robot-assisted hand-sewn esophago-gastric anastomosis during minimally invasive Ivor Lewis esophagectomy

Background

Minimally invasive Ivor Lewis esophagectomy (MIILE) provides better outcomes than open techniques, particularly in terms of post-operative recovery and pulmonary complications. However, in addition to requiring advanced technical skills, thoracoscopic access makes it hard to perform esophagogastric anastomosis safely, and the reported rates of anastomotic leak vary from 5 to 16%. Several minimally invasive esophago-gastric anastomotic techniques have been described, but to date strong evidence to support one technique over the others is still lacking. We herein report the technical details and preliminary results of a new robot-assisted hand-sewn esophago-gastric anastomosis technique.

Methods

From January 2018 to December 2020, 12 cases of laparoscopic/thoracoscopic Ivor Lewis esophagectomy with robot-assisted hand-sewn esophago-gastric anastomosis were performed. The gastric conduit was prepared and tailored taking care of vascularization with a complete resection of the gastric fundus. The anastomosis consisted of a robot-assisted, hand-sewn four layers of absorbable monofilament running barbed suture (V-lock). The posterior outer layer incorporated the gastric and esophageal staple lines.

Results

The post-operative course was uneventful in nine cases. Two patients developed chyloperitoneum, one patient a Sars-Cov-2 infection, and one patient a late anastomotic stricture. In all cases, there were no anastomotic leaks or delayed gastric conduit emptying. The median post-operative stay was 13 days (min 7, max 37 days); the longest in-hospital stay was recorded in patients who developed chyloperitoneum.

Conclusion

Despite the small series, we believe that our technique looks to be promising, safe, and reproducible. Some key points may be useful to guarantee a low complications rate after MIILE, particularly regarding anastomotic leaks and delayed emptying: the resection of the gastric fundus, the use of robot assistance, the incorporation of the staple lines in the posterior aspect of the anastomosis, and the use of barbed suture. Further cases are needed to validate the preliminary, but very encouraging, results.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00464-021-08715-4.

Pretreatment-assisted robot intrathoracic layered anastomosis: our exploration in Ivor-Lewis esophagectomy

Background

Minimal invasive Ivor-Lewis esophagectomy (MIIVE) with intrathoracic esophago-gastric anastomosis (EGA) is still under exploration and the preferred technique for intrathoracic anastomosis has not been established.

Methods

We retrospectively reviewed 43 consecutive patients who underwent MIIVE using the series technique called pretreatment-assisted robot intrathoracic layered anastomosis (PRILA), performed by a single surgeon between September 2018 and December 2020. The operative outcomes were analyzed.

Results

The mean total operation time had been reduced from 446.38±54.775 minutes (range, 354-552) in the first year to 347.70±60.420 minutes (range, 249-450) later. There were no conversions to thoracotomy. All the patients achieved R0 resection. No patient suffered from anastomotic leakage. There was no 30-day mortality. The median length of postoperative stay was 10.0 days.

Conclusions

PRILA further visualizes and streamlines the process of minimal invasive intrathoracic EGA, thus ensuring the precise anastomosis. It could be considered as a feasible alternative for intrathoracic EGA in MIILE.

Video-Assisted Thoracic Surgery Intrathoracic Anastomosis Technique

The extracorporeal anastomosis technique for video-assisted thoracoscopic surgery (VATS) intrathoracic esophagogastric anastomosis is a convenient, easy technique to use in VATS esophagectomy. The surgeon can assess the viability and the status of the gastric conduit, and the introduction of a circular stapler can be easily done under direct vision extracorporeally, enabling easy and simple VATS intrathoracic anastomosis between the esophagus and the gastric conduit.

Robotic resection for esophageal cancer

Background

In the surgical treatment of esophageal cancer, complete tumor resection is the most important factor and determines long-term survival. With an increase in robotic expertise in other fields of surgery, robotic-assisted minimally invasive esophagectomy (RAMIE) was born. Currently, there is a lack of convincing data on the extent of expected benefits (perioperative and oncologic outcomes and/or quality of life). Some evidence exists that patients’ overall quality of life and physical function improves, with less fatigue and pain 3 months after surgery. We aimed to review the available literature regarding robotic esophagectomy, compare perioperative, oncologic, and quality of life outcomes with open and minimally invasive approaches, and give a brief overview of our standardized four-arm RAMIE technique and explore future directions.

Methods

A Medline (PubMed) search was conducted including the following key words: esophagectomy, minimally invasive esophagectomy, robotic esophagectomy, Ivor Lewis and McKeown. We present the history, different techniques used, outcomes, and the standardization of robotic esophagectomy.

Results

Robotic esophagectomy offers a steeper learning curve with fewer complications but comparable oncological results compared to conventional minimally invasive esophagectomy.

Conclusions

Available studies suggest that RAMIE is associated with benefits regarding length of stay, clinical outcomes, and quality of life—if patients are treated in an experienced center with a standardized technique for robotic esophagectomy—making it a potentially beneficial tool in the treatment of esophageal cancer. However, center-wide standardization and prospective data collection will be a necessity to prove superiority of robotic esophagectomy.