198: ROBOTIC ASSISTED TRANS CERVICAL ESOPHAGECTOMY (RACE PROCEDURE): DESCRIPTION OF THE SURGICAL TECHNIQUE AND PRELIMINARY RESULTS

Abstract

Abstract Background and aim A combined trans-hiatal and transcervical approach to perform esophagectomy has been described in the literature for patients who are not candidates for a transthoracic approach. In this context, the technical limitations of conventional laparoscopy might be overcome by the application of robotic systems such as the DaVinci Xi. We aimed at describing the technical details and the feasibility of our technique for the robotic-assisted trans-cervical esophagectomy (RACE) and a preliminary case series. Methods In the abdominal phase the DaVinci Xi is docked using the standard 5-trocar configuration used for Ivor-Lewis esophagectomy. After gastric mobilization, tubulization and D2 lymphadenectomy, the dissection is advanced trans-hiatally until the tracheal carina. Infra-tracheal lymph-node dissection is normally feasible from the abdomen. A left cervical incision and neck lymph node dissection are performed, the esophagus is encircled. The robot is docked at the neck using a gel port with a 3-trocar configuration and an assistant-trocar for suction. The upper mediastinal preparation starts by dissecting the esophagus from the mediastinal pleura bilaterally, the pars membranacea anteriorly and the aortic arch proceeding caudally. Dissection of the left recurrent laryngeal nerve (l-RLN) lymph nodes can be achieved; care should be taken to avoid nerve injuries. Proceeding caudally, the tracheal dissection is advanced to the left bronchus. The azygos vein is encountered at the right tracheobronchial angle. Dissection of bronchial lymph nodes is performed bilaterally, the plane is connected to the previous abdominal plane. After retrieval of the specimen an end-to-side circular stapled anastomosis is performed at the neck. Results The procedure was completed in 4 patients with mid-esophageal squamous cell carcinoma who were not candidate for a trans-thoracic approach due to cardio-pulmonary comorbidities. Median hospital stay was 14 (9–18) days, median ICU stay was 4 (1–6) days. Left vocal cord palsy requiring rehabilitation therapy occurred in 2 patients (50%). No postoperative mortality was recorded. R0 resection was achieved in all patients with a median of 19 (15–22) retrieved lymph nodes. Conclusion RACE using the robotic system is feasible and provides an adequate surgical radicality. The procedure is safe, although the rate of RLN injury is higher.