Robotic Fourth-Arm Enucleation of an Esophageal Leiomyoma and Review of Literature

Robotic-assisted surgery for esophageal submucosal tumors: a single-center case series

Esophageal submucosal tumors (SMTs) are rare heterogenous clinical entities. The surgical resection can be performed in different surgical approaches. However, the robotic surgical strategy is poorly documented in the treatment of SMTs. We present our series of operated esophageal SMTs approached via robotic-assisted surgery. Six patients with symptomatic esophageal submucosal tumors underwent robotic surgery within a 3-year period. The performed procedures were robotic-assisted enucleation, robotic esophagectomy (RAMIE) and reverse hybrid robotic esophagectomy. Patients’ clinical data, intra/postoperative outcomes, and histopathological features were retrieved from the institution’s prospective database. Five of six patients were scheduled for upfront surgery: four underwent robotic enucleation (three leiomyoma and one suspected GIST) and one underwent reverse hybrid robotic esophagectomy (suspected GIST). One patient, diagnosed with GIST, was treated with neoadjuvant Imatinib therapy, before undergoing a RAMIE. No major intra-operative complications were recorded. Median length of stay was 7 days (6–50), with a longer post-operative course in patients who underwent esophagectomy. Clavien–Dindo > 3a complications occurred in two patients, aspiration pneumonia and delayed gastric emptying. The final histopathological and immuno-histochemical diagnosis were leiomyoma, well-differentiated GIST, low-grade fibromyxoid sarcoma and Schwannoma. Robotic-assisted surgery seems to be a promising option for surgical treatment strategies of benign or borderline esophageal submucosal tumors.

Robotic enucleation of oesophageal leiomyoma technique and surgical outcomes

Introduction:

Complete enucleation of oesophageal leiomyoma is the treatment of choice, traditionally performed by open surgery. Minimally invasive thoracoscopic approaches have been proposed as an alternative to thoracotomy. Robotic surgical systems with improved dexterity, tremor filtration and stereoscopic vision are advancement over conventional thoracoscopy and may make the preservation of mucosal integrity relatively easier. We present herein our technique of robotic-assisted thoracoscopic (RATS) enucleation of oesophageal leiomyoma along with surgical outcomes and intermediate follow-up of 11 cases.

Materials and Methods:

The present study retrospectively reviews patients undergoing robotic portal oesophageal leiomyomectomy from March 2012 to October 2019. The collected data were analysed for demographic details, clinical presentation, size, shape, tumour location, operating time, post-operative complications, length of hospital stay and recurrence on follow-up.

Results:

Twelve patients underwent robotic portal oesophageal leiomyomectomy with a clinical diagnosis of oesophageal leiomyoma. Of these, 11 patients were included in the study. The average operative time was 110 min, with a mean blood loss of 26 ml. There was no conversion in this series. At a median follow-up of 44 months (range 6–78 months), all patients were symptom-free with no recurrence or diverticula.

Conclusion:

Our series demonstrates the safety and feasibility of RATS oesophageal enucleation with good short and intermediate outcomes. In our opinion, the robotic system's technical advantages are particularly beneficial for oesophageal leiomyoma enucleation.

Robot-assisted thoracoscopic enucleation for a large esophageal leiomyoma: a case report

Background

Video-assisted thoracoscopic surgery (VATS) is being used to treat esophageal submucosal tumors (SMTs) all over the world. However, this technique is difficult when the tumor is large and located on the left side wall of the esophagus, within the upper mediastinum. This is because, with VATS, the surgical forceps have a limited range of motion. Robot-assisted thoracoscopic surgery (RATS) using the da Vinci surgical system may be extremely useful for enucleation of esophageal SMTs within the narrow upper mediastinum.

Case presentation

A female in her thirties experiencing epigastric pain visited our hospital and was diagnosed with a large esophageal leiomyoma within the upper mediastinum. From its size (10 cm), it was judged to have malignant potential. We performed SMT enucleation using RATS with a da Vinci surgical system Xi. This was our second case using this system. The patient was placed in the left lateral position. Four da Vinci trocars (8 mm) were inserted into the 10th, 7th, 5th and 3rd intercostal spaces (ICS), and an assist port was added in the 5th ICS. We opened the superior mediastinal pleura cranially and caudally from the arch of the azygos vein and expanded the superior mediastinum after dividing the azygos vein. We made an incision in the muscular layer of the esophagus and, using a monopolar hook and monopolar scissors, enucleated the esophageal tumor in a protective manner so as not to damage its capsule or mucosa while applying appropriate robot-specific counter traction. We then sewed up the muscularis using 4–0 Vicryl, inserting the endoscope into the thoracic esophagus to substitute for a bougie. In addition, the pleura was sutured using barbed suture. The surgical procedure was straightforward and smooth. The patient was discharged on postoperative day 4 with no surgical complications. The tumor was definitively diagnosed pathologically from paraffin sections as a benign esophageal leiomyoma.

Conclusions

RATS enables more delicate and precise esophageal SMT enucleation without surgical complications, though various challenges remain to be overcome.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40792-021-01212-9.

[Leiomyoma of the esophagus : A further indication for robotic surgery?]

BACKGROUND

Leiomyomas of the esophagus are rare tumors but the most common benign lesion of the esophagus originating from smooth muscle cells. The symptoms are mainly determined by the size of the tumor and are caused by dysphagia and/or retrosternal pain. The majority of patients are however asymptomatic. The diagnostics include esophagoscopy, endosonography and chest computed tomography. Surgery is considered the treatment of choice and ideally involves enucleation of the tumor but may lead to esophagectomy. In addition to the classical open procedures, minimally invasive procedures are also used. Regardless of the selected procedure, a lesion of the mucosa should be avoided.

OBJECTIVE

A review of the literature on thoracoscopic and robotic resections in the treatment of leiomyomas was carried out and an illustration of a clinical case is presented.

MATERIAL AND METHODS

A review of minimally invasive surgical treatment of esophageal leiomyomas is presented. The literature search was carried out in PubMed for publications of thoracoscopic and robotic-assisted thoracic enucleation of leiomyomas of the esophagus. In addition, the robotic-assisted thoracic enucleation of a horseshoe-shaped leiomyoma in the middle third of the esophagus is described.

RESULTS

The enucleation of the esophageal leiomyoma was carried out through a right-sided robotic-assisted operation with one lung ventilation. The surgery time was 143 min. There were no intraoperative or postoperative complications. On the 3rd postoperative day a light diet was started and the thorax drainage was removed. Histopathology confirmed a leiomyoma. The patient was discharged on the 5th postoperative day and free of complaints.

CONCLUSION

Robotic-assisted surgery for leiomyomas of the esophagus is a safe procedure. Taking the available data into account, robotic-assisted thoracic enucleation of leiomyomas was characterized by less mucosal lesions, general complications and a lower conversion rate as well as a shorter hospital stay compared to classical thoracoscopic enucleation. Thus, robotic-assisted surgery can be the method of choice for leiomyomas of the esophagus.

Robotic-assisted enucleation of a large lower esophageal leiomyoma and review of literature

Leiomyoma is the most common benign esophageal neoplasm. Different invasive surgical approaches have been described for management of such lesions. The literature is reviewed and a robotic assisted left thoracoscopic enucleation with the patient in the right side position is described. A 40-year-old male patient, otherwise healthy, found to have a lower midiastinal mass on screening X-ray, is described. Physical examination and blood tests were within normal limits. Diagnostic work-up included: computerized tomography (CT) scanning of the chest and midiastinum that revealed a 40 × 30 mm mass of the distal esophagus, an upper gastrointestinal endoscopy showed a lower protruding esophageal submucosal mass with intact mucosa, a filling defect was apparent on esophagography. Endoscopic ultrasonography (EUS) showed the same findings, biopsies were taken and leimyoma was diagnosed. Under general anesthesia with a double-lumen endotracheal tube, the patient was positioned on his right side. A 30 robotic scope was introduced in the left 7th intercostal space on the posterior axillary line. Two 8-mm robotic trocars were inserted in the left 5th and 9th intercostals spaces on the same line. Operative field was clearly exposed and an additional 5-mm ethicon trocar was inserted. The inferior pulmonary ligament was released, the parietal pleural space opened, proximal and distal control was achieved using Penrose. The muscular layer of the lower esophagus was opened by coagulation hook, the lesion was enucleated without mucosal penetration. Intraoperative endoscopy permitted localization of the lesion and ensured mucosal integrity. The muscular layer was not closed and the chest drain was left. Total operative time was 200 min and blood loss was less than 20 mL. A Gastrograffin swallow on the first post-operative day showed good esophageal clearance and absence of leak, the patient was allowed a liquid diet. He was discharged on the third post-operative day in a good general condition, benign pathology was confirmed.