OGC O05 Linear stapled technique for robotic assisted minimally invasive oesophagectomy and gastrectomy: technique, stepwise introduction, reproducibility and outcomes

Abstract

Abstract Background Robotic-assisted surgery (RAS) for oesophagectomy and gastrectomy is gaining in popularity. Compared to open oesophagectomy and conventional minimally invasive techniques, RAS is associated with decreased rates of complications, increased harvested lymph nodes and shorter length-of-stay. However, high anastomotic leak rates (20-27%) have been seen within randomised trials and case series, with up to 50% early in some published series. We present our technique for a linear anastomosis and the results of its staged introduction. Methods Initially developed by a single surgeon at open surgery, it was adapted to thoracoscopic procedures and then reproduced during RAS by several surgeons across two centres. Using a prospectively maintained database we reviewed the first sixty-three cases utilising a modified linear anastomosis technique for oesophageal anastomosis. Outcomes, with particular focus on the anastomosis were reviewed. We also describe in detail the technical steps involved in our technique for a side-to-side linear semi-mechanical stapled anastomosis using a tri-stapler with a 2-layer V-lock closure of the common enterotomy, during robotic surgery (video). Results Sixty-one patients had a two-stage oesophagectomy (one for benign disease), one with colonic reconstruction and two total gastrectomy. Median age was 63 (range 47-85). 89% (55/62) were adenocarcinomas, the remainder squamous cell carcinomas. The anastomosis was performed via an open approach initially in 11, thoracoscopically in 4, then robotically in 48 (including the gastrectomies). The first 20 anastomoses were performed by one surgeon, who then proctored four others. Two Type I anastomotic leaks (3.2%) and two Type I conduit necrosis occurred. There was no in hospital mortality. Non-anastomotic complications occurred in 28/63 (44.4%) of patients, most commonly respiratory (15/63, 23.8%). Conclusions We report a reproducible technique for semi-mechanical linear stapled anastomosis and its safe introduction into oesophageal and gastric resections including RAS, with anastomotic leak rates below the internationally reported rates, even in the early phase of its introduction in open, thoracoscopic and RAS. This technique, combined with training and mentorship may help more centres safely introduce a RAS oesophago-gastric programme, and improve patient outcomes.