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Revision Notes: Robotic Ivor-Lewis Esophagectomy (RAMIE)

Patient Context •⁠ ⁠Diagnosis: Distal esophageal adenocarcinoma •⁠ ⁠Procedure: Robotic-assisted Ivor-Lewis Esophagectomy

Abdominal Phase

1.⁠ ⁠Mobilization of Gastroepiploic Ligament:

  • Dissection extended to the right, visualizing hemangioma in the liver.
  • Harmonic scalpel used to release the left diaphragmatic crus.
  • Posterior esophageal attachments released.

2.⁠ ⁠Lymphadenectomy:

  • Left gastric artery and surrounding lymph nodes dissected.
  • Precise dissection along common hepatic artery and splenic artery with the robotic assistance.
  • Skeletonization of celiac axis (left gastric artery, common hepatic artery, and splenic artery).

3.⁠ ⁠Mobilization of Gastric Conduit:

  • Short gastric arteries (ischemic region) dissected up to left diaphragmatic crus.
  • Mobilization of posterior stomach and attachments to pancreas.
  • Only right gastroepiploic artery left to supply gastric conduit.

4.⁠ ⁠Stapling and Preparation:

  • Left gastric artery transected using a vascular stapler.
  • Mobilization extended to gastroduodenal artery and pylorus.
  • Penrose drain passed around the esophagus for further mobilization.

5.⁠ ⁠Blood Flow Assessment:

  • Firefly imaging used to confirm gastric conduit perfusion.

Thoracic Phase

1.⁠ ⁠Esophageal Mobilization:

  • Inferior pulmonary ligament dissected up to the pulmonary veins.
  • Lung retracted medially to expose posterior hilum and subcarinal space.
  • Subcarinal lymphadenectomy performed using Maryland bipolar to avoid thermal injury to the airway.
  • Azygos vein dissected and transected.
  • Perforating vessels from aorta to esophagus were controlled.

2.⁠ ⁠Esophageal Transection:

  • Esophagus transected at azygos vein level; margins sent for pathology.
  • No-touch technique used for gastric conduit delivery into the chest.
  • Penrose drain used for retraction and specimen retrieval.

Anastomosis

1.⁠ ⁠Gastric Conduit Delivery:

  • Gastric conduit pulled into the chest using a marking stitch to guide its limit.
  • Gastrotomy created on the greater curvature.

2.⁠ ⁠Stapler Anastomosis:

  • Orvil system (25 mm) introduced through the esophageal stump.
  • Circular stapler (EEA) used to join the esophagus and gastric conduit.
  • Anastomosis checked for integrity.

3.⁠ ⁠Postoperative Preparations:

  • Nasogastric (NG) tube inserted.
  • Conduit stapled using a green load stapler.
  • Gastric conduit tacked to diaphragmatic hiatus to prevent hernia.
  • Aortic washer placed for future imaging and anastomosis visualization.
  • Pleura covering used for the anastomosis.

This outline provides the key steps and details for quick review and revision, focusing on the essential aspects of the Robotic Ivor-Lewis Esophagectomy.