From September 2019 to January 2020, 25 patients with various esophageal diseases were treated with robot assisted minimally invasive therapy using DaVinci® Xi system(Intuitive Surgical, China). Obtain informed consent from all patients before using the DaVinci® Xi system. This group includes 15 patients with esophageal cancer and 10 patients with various types of esophageal benign diseases. Before operation, all patients were examined by contrast-enhanced CT of chest and abdomen, color ultrasound of abdominal organs and SPECT. PET-CT was not performed routinely. Four cases of upper mediastinal lymph nodes were reported by chest enhanced CT. In all esophageal cancer patients, 6 patients with lower esophageal cancer underwent resection of esophageal carcinoma through left thoracotomy and lymph node dissection, then diaphragm was cut, stomach was separated in the abdominal cavity and left gastric lymph node and celiac lymph node dissection was performed. In 5 patients, the upper edge of tumor was below the plane of inferior pulmonary vein, so that we did not routinely clean the upper mediastinal lymph node, and finally the stomach and esophagus were anastomosed under the aortic arch; Another patient's chest enhanced CT showed 1.2cm lymph nodes in the upper mediastinum. We performed upper mediastinal lymph node dissection under mediastinoscopy, and then the stomach and esophagus were anastomosed in the neck, which we call robot based Sweet operation. In the other 9 cases, 3 cases underwent McKeown operation because of the visible lymph nodes in the upper mediastinum. In the other 6 cases, Ivor Lewis operation was performed, in which 1 case was converted to left thoracogastrostomy due to the extensive adhesion of the right thoracic cavity. Other benign diseases included esophageal leiomyomectomy in 3 cases, esophageal diverticulum in 1 case, hiatal hernia in 4 cases, esophageal cyst in 1 case, achalasia in 1 case. All patients were selected to ventilate the left or right lung by double lumen tracheal tube. After operation, they were awake in the operating room and pulled out the tracheal tube to return to the observation room of the thoracic surgery ward.
Operation of esophageal cancer
Ivor Lewis or McKeown
Chest operation
General anesthesia, double lumen endotracheal intubation, one lung ventilation, left lying position or side prone position. 4-hole method is adopted. First, an 8mm incision was made in the posterior axillary line of the 5th or 6th intercostal space. After thoracoscopic examination confirmed that there was no metastasis, an 8mm port was placed between the posterior axillary line of the 9th space and the scapular line, and another 8mm port was placed in the middle axillary line of the 3rd or 4th space. 5 cm auxiliary holes were set in the anterior axillary line of the seventh space. Then the robots dock.
In the case of McKeown's operation, the esophagus is free from the thoracic entrance to the esophageal hiatus, and the lymph nodes in the thoracic area are cleaned. The thoracic duct is ligated selectively. The azygos vein arch is cut off and the lymph nodes beside the recurrent laryngeal nerve are cleaned. If there is no obvious bleeding after thoracic surgery, a long tube like traction bag shall be reserved. The upper end shall be sutured and tied at the top of the free esophagus, and the lower end shall be sutured and tied at the bottom. One 28F thoracic drainage tube was placed, and the anesthesiologist was instructed to suck sputum and expand the lung, and then the incision of thoracic operation was closed layer by layer.
If it's Ivor Lewis operation: free esophagus from the plane of azygos vein to the direction of esophageal hiatus, carry out lymph node dissection in the chest area, routinely disconnect the azygos vein, carry out lymph node dissection beside the bilateral recurrent laryngeal nerve, selectively ligate the thoracic duct, then cut the esophagus vertically under the planned gastroesophageal anastomosis, expose the lumen, place the anvil base of the anastomat, disconnect the esophagus, and make a purse stitch on the upper cut end of esophagus, knot and fix the anvil base of the stapler. The tube stomach was lifted from the esophageal hiatus to the thoracic cavity, and the tube stomach and the specimen were separated by ultrasonic knife. The specimens were taken out from the auxiliary incision, and then a 25 mm circular stapler was inserted. Indocyanine green (12.5mg) was injected intravenously to evaluate the blood supply of the gastric tube. The well blood supply of the tubular gastric region was selected as the anastomotic region, and the circular stapler was inserted into the chest cavity for intracavitary anastomosis. Endo Gia™ 60 mm gold load closes the incision in the upper part of the tubular stomach. After no obvious bleeding, wash the chest, place a 28F chest drainage tube through the 10th costal space, and ask the anesthesiologist to suck sputum and expand the lung, and then close the surgical incision layer by layer. Routine placement of nasogastric tube.
Abdominal operation
In supine position, the pneumoperitoneum needle enters the abdominal cavity 8 mm above the umbilicus of the anterior midline. The camera is plugged into a 8mm port. After laparoscopy showed no metastatic disease, the remaining three ports were placed on the same line parallel to the navel (the left paramediastinal incision position, the left paramediastinal incision position and the right paramediastinal incision position). A 5 mm port was made at the lateral side of the right paramedian incision to insert the liver retractor. Endo Gia™ is placed in port the left paramediastinal incision position. The auxiliary port (also used for jejunostomy) is located in the median left incision. Then the robots dock.
Cut the gastrocolic ligament along the great curvature of the stomach, keep away from and protect the gastroepiploic vessels. A blood vessel occluder is used to clamp the short gastric vessels. Dissect the left and right phrenic feet. The esophagus is circled with a rubber ring for traction. The left gastric artery was exposed and dissected to the celiac artery. The seventh and ninth station of celiac lymph nodes were excised. The hepatic and splenic arteries were dissected and the tenth group of lymph nodes were cleaned. The left gastric artery was cut off with a vascular stapler. After transection of the abdominal esophagus, the Da Vinci mechanical arm was removed, and small incision on the right paramediastinal incision position was extended 3 cm under the costal arch to pull the stomach out of the abdominal cavity. EndoGIA was used to make the tubular stomach, and then it was sent back to the abdominal cavity to suture the small incision and recover the pneumoperitoneum.
In the case of Ivor Lewis operation, suture the upper end of the tubular stomach and the esophageal stump with two stitches in case of pulling the stomach to the chest during the following thoracic operation.
In the case of McKeown's operation, pull the traction bag reserved during the thoracic operation down to the abdominal cavity, sterilize the neck simultaneously, and make a left oblique incision at the inner boundary of sternocleidomastoid muscle. The hyoid muscle of scapula was routinely ligated and cut off. The cervical esophagus is exposed from the inside of the carotid sheath.
The left laryngeal reflux nerve was identified, protected and confirmed. After the cervical esophagus was completely free, the esophagus was cut 5cm below the circular pharyngeal muscle, and the distal esophagus which had been completely free during the thoracic operation was pulled out of the body from the neck, and the upper end of the reserved traction bag was pulled out of the neck. A long double joint instrument is inserted into the abdominal cavity from the neck traction bag, and the tube stomach is pulled from the abdomen without torsion to the neck incision with the help of laparoscopy, and the anastomosis is performed in the neck with manual suture technology or circular stapler. In the other group, pyloroplasty and jejunostomy were performed. The trocar was taken out from the auxiliary mouth, and we make a purse stitch with a 000 suture on the jejunal side wall 15 cm from the distal end of the Treitz ligament. Two stitches were sutured at the same time on the abdominal edge of the auxiliary mouth. The percutaneous puncture guide tube with guide wire of Kimberly Clark was inserted into jejunum from the auxiliary incision, the jejunum tube was placed, the guide wire was pulled out, the purse string was sewed in a circle, and the suture was at the edge of the auxiliary incision.
The Sweet surgery under the robot
General anesthesia, double-lumen endotracheal intubation. The patient was placed in the right lateral decubitus position. First, an 8mm incision was made in the 5th intercostal space of the left midaxillary line as the first observation port. If thoracoscopy confirmed no evidence of metastasis, then, make an incision of about 8mm in the left anterior intercostal axillary line and the eighth intercostal axillary line on the left and place the electrocoagulation hook and bipolar forceps, respectively(Figure 1).
Place another 1cm port between the anterior axillary line and the midaxillary line of the third intercostal space as an auxiliary port. Then the robot is docked, and the docking direction is the operation area with the direction of diaphragm and abdominal cavity. The CO2 artificial pneumothorax pressure was set to 8 mm Hg.
Open the diaphragm through the liver and splenic sulcus and hang the diaphragm from the lateral chest wall with a silk thread(Figure 2A), explore the abdominal cavity, loosen the fibers of the side of the cardia, and free the cardia, and clean the lymph nodes next to the cardia, and then dissect the small curvature of the stomach to separate the liver and stomach ligament and skeletalize the left gastric blood vessel, clip and disconnect the left gastric blood vessel with a single hemolock (Figure 2D), dissect the lymph nodes next to the left gastric blood vessel, then loosen the spleen and gastric ligament, dissect and disconnect the short gastric blood vessel (Figure 2C),Pull the gastric body upwards, loosen along the surface of the pancreas and sever the blood vessels behind the stomach, and continue to free the gastrocolonic ligament along the greater curvature of the stomach to the pylorus (Figure 2C), paying attention to retaining the right blood supply to the gastric omentum. After checking the abdominal cavity for no bleeding points, temporarily remove the robot arm.
A 5cm long incision was made on the left side of the 9th intercostal axillary line as the second auxiliary incision, and the incision protector was placed. The stomach was lifted to the outside of the body through the incision, and the stomach was unfolded to a untwisted state. The disposable straight-line cutting suture device was used to cut from the greater curvature side of the stomach at the bottom of the stomach to the lesser curvature side of the stomach, and a tubular stomach of suitable width was made, the diaphragm was closed, and the tubular stomach was lifted up as far as possible and sutured with the diaphragm foot for several stitches. A 8mm long incision was made on the left side of the 7th intercostal axillary midline for the second observation hole to put the robot camera system, and then the robot docking was carried out again. The direction of docking was in the direction of tracheal carina and upper mediastinum as the operation area.
If it is lower esophageal cancer and there is no metastasis of upper mediastinal lymph nodes in PET-CT before operation, free the esophagus upward to the level below the aortic arch, and clean the lymph nodes beside the esophagus and under the carina. Then cut the esophagus about 2 cm below the expected anastomosis plane, expose the lumen, place the stapler anvil base, disconnect the esophagus, A purse string suture was made at the broken end of esophagus by hand, and the anvil base of stapler was tied and fixed. Then, the specimens were taken out from the second auxiliary incision and a 25 mm circular stapler was placed. The blood supply of the gastric tube was evaluated by intravenous injection of indocyanine green (12.5mg). The well blood supply of the gastric tube was selected as the anastomotic area, and the circular stapler was placed into the chest cavity for intracavitary anastomosis. The linear cutting closure device closes the upper broken end of the tube stomach. After no obvious bleeding, wash the chest, place a 28F chest drainage tube through the second observation hole, and ask the anesthesiologist to suck sputum and expand the lung, and then close the surgical incision layer by layer. Routine placement of nasogastric tube.
In the case of upper and middle esophageal cancer, Dissection of esophagus is performed upward to the level behind the aortic arch, and clean the lymph nodes of the left upper mediastinum, the side of the esophagus and under the carina . Draw the esophagus from the back of the aortic arch to the upper mediastinum, reserve the second observation hole and the first auxiliary port in the chest, and suture the rest of the incision completely. The robot arm was removed after no bleeding was observed. Tilt the operating table back to 50 degrees, move the left upper limb from the head to the back, sterilize the neck and chest again, put the neck incision into the mediastinoscope, and clean the bilateral upper mediastinum and bilateral paralaryngeal recurrent nerve lymph nodes. Mediastinoscopy, assisted by thoracoscopy, lifted the tubular stomach from the right side of the aortic arch to the left neck for manual or mechanical anastomosis.
Postoperative care
Patients began tube feeding on the 3rd day after surgery and continued to take it until they were able to tolerate oral administration. All patients underwent upper gastrointestinal angiography on the 6th day after operation. If no leak is identified, the nasogastric tube of the patient will be stopped on the 7th day after the operation, and the patient will take pure liquid food for 1 day under the condition of limited volume, and gradually take soft food on the 8th to 9th day after the operation. The chest tube is usually removed 5 days after surgery. If a patient is diagnosed with delayed gastric emptying , they will be told to use gastric motility drugs, limit food intake or even fast water for a period of time until the function of the stomach is restored.
Esophageal leiomyoma (Figure 3)
The position and direction of the observation port and the mechanical arm should be selected according to the position of the tumor. For larger leiomyomas, the Da Vinci robot can easily find and safely remove them. The detailed display of three-dimensional high-definition can remove leiomyoma from esophageal mucosa accurately. Our experience is that if the tumor is on the left side of the esophagus, unless it is on the right side of the aortic arch, the robot can put the instrument from the left chest, which can avoid the excessive free range of the esophagus after the instrument is placed from the right chest, and avoid the overturning of the esophagus. If the tumor is on the front side or the back side or the right side of the esophagus, it is very convenient to put the instrument from the right chest. Esophagoscopy must be performed at the same time in both groups. Some patients were found to have a small leiomyoma under the esophageal mucosa, but they were afraid of complications due to endoscopic treatment, or they also suffered from achalasia or hiatal hernia and received minimally invasive robot surgery. At this time, it is very necessary to cooperate with two endoscopes to find the tumor during the operation. Esophagoscopy can accurately locate the tumor location, and the robot can quickly find the location from the outside through the touch from the esophageal cavity. After three-dimensional magnification, mm level leiomyoma can be clearly displayed and safely removed. After resection, air blowing test should be carried out to confirm the integrity of esophageal mucosa.
Achalasia and hiatal hernia(Figure4)
With the help of robots, these two diseases can be easily carried out through the thoracic cavity, especially when the hiatal hernia is large and combined with short esophagus, or when these two diseases are combined with esophageal diverticulum or leiomyoma, it is very difficult to operate through the abdominal cavity. A 1cm long incision was made in the 5th intercostal space of the left axillary midline as the first observation port. Then, the electrocoagulation hook and bipolar forceps were respectively placed in the front of the axillary line of the 5th intercostal space and the posterior line of the axillary line of the 8th intercostal space with a length of about 8mm. If necessary, the bipolar inlay was replaced with a needle holder. Another 1cm port was placed between the axillary front and the axillary midline of the third intercostal space as the auxiliary port. Then the robot docking, docking direction in the direction of diaphragm and abdominal cavity as the operation area. Flexible suture and stripping are very conducive to myotomy and organ suture, which has a great advantage compared with thoracoscopic surgery.
Esophageal diverticulum(Figure 5)
The robot docking is the same as the cardia achalasia, the auxiliary port is placed with a device to pull the esophagus with a belt, and the esophagus is turned according to the position. The diverticulum is freed to the neck of diverticulum using the electric hook, and the muscularis of the diverticulum neck is cut layer by layer to the submucosa, and then the diverticulum was removed with a cutting closure. The transverse smooth muscle bundles at the lower end of the mucosal incision margin were cut off, and the longitudinal smooth muscle was sutured for several stitches to embed the mucosal stump. No leaks were found during endoscopy. Remove the robotic arm and release the drainage tube.
Esophageal cyst(Figure 6)
Robot docking is the same as achalasia, but no auxiliary port is needed. The diameter of the lesion was about 5 cm, which was located in the lower part of the esophagus of the costal sinus of the posterior diaphragm. For better exposure, the middle of the diaphragm is fixed to the chest wall and the lung ligament is separated with a cauterizing hook. The cyst was separated from the adjacent muscle tissue, removed, and finally removed from the pouch (Fig. 4). Again, the muscle layer of the esophagus is repaired by a single stitch fashion.