Background

Minimally invasive Ivor Lewis esophagectomy (MIILE) provides better outcomes than open techniques, particularly in terms of post-operative recovery and pulmonary complications. However, in addition to requiring advanced technical skills, thoracoscopic access makes it hard to perform esophagogastric anastomosis safely, and the reported rates of anastomotic leak vary from 5 to 16%. Several minimally invasive esophago-gastric anastomotic techniques have been described, but to date strong evidence to support one technique over the others is still lacking. We herein report the technical details and preliminary results of a new robot-assisted hand-sewn esophago-gastric anastomosis technique.

Methods

From January 2018 to December 2020, 12 cases of laparoscopic/thoracoscopic Ivor Lewis esophagectomy with robot-assisted hand-sewn esophago-gastric anastomosis were performed. The gastric conduit was prepared and tailored taking care of vascularization with a complete resection of the gastric fundus. The anastomosis consisted of a robot-assisted, hand-sewn four layers of absorbable monofilament running barbed suture (V-lock). The posterior outer layer incorporated the gastric and esophageal staple lines.

Results

The post-operative course was uneventful in nine cases. Two patients developed chyloperitoneum, one patient a Sars-Cov-2 infection, and one patient a late anastomotic stricture. In all cases, there were no anastomotic leaks or delayed gastric conduit emptying. The median post-operative stay was 13 days (min 7, max 37 days); the longest in-hospital stay was recorded in patients who developed chyloperitoneum.

Conclusion

Despite the small series, we believe that our technique looks to be promising, safe, and reproducible. Some key points may be useful to guarantee a low complications rate after MIILE, particularly regarding anastomotic leaks and delayed emptying: the resection of the gastric fundus, the use of robot assistance, the incorporation of the staple lines in the posterior aspect of the anastomosis, and the use of barbed suture. Further cases are needed to validate the preliminary, but very encouraging, results.

中文翻译：

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微创 Ivor Lewis 食管切除术中机器人辅助手工缝制食管胃吻合术的技术细节

背景

微创 Ivor Lewis 食管切除术 (MIILE) 提供比开放技术更好的结果，特别是在术后恢复和肺部并发症方面。然而，除了需要先进的技术技能外，胸腔镜通路也难以安全地进行食管胃吻合术，据报道的吻合口漏发生率从 5% 到 16% 不等。已经描述了几种微创食管胃吻合技术，但迄今为止，仍然缺乏强有力的证据来支持一种技术优于其他技术。我们在此报告一种新的机器人辅助手工缝制食管胃吻合技术的技术细节和初步结果。

方法

2018年1月至2020年12月，实施12例腹腔镜/胸腔镜Ivor Lewis食管切除术机器人辅助手缝食管胃吻合术。胃导管经过准备和定制，以完全切除胃底来处理血管化。吻合包括机器人辅助、手工缝制的四层可吸收单丝运行带刺缝合线（V 型锁）。后外层包含胃和食道钉线。

结果

9 例术后过程平稳。两名患者出现乳糜腹，一名患者感染了 Sars-Cov-2，一名患者出现了晚期吻合口狭窄。在所有情况下，没有吻合口漏或胃导管排空延迟。术后住院时间中位数为 13 天（最短 7 天，最长 37 天）；出现乳糜腹的患者住院时间最长。

结论

尽管系列很小，但我们相信我们的技术看起来很有前途、安全且可重复。一些关键点可能有助于确保 MIILE 术后并发症发生率低，特别是关于吻合口漏和延迟排空：胃底切除、机器人辅助的使用、吻合口后侧的缝合线的结合，以及使用带刺缝合线。需要进一步的案例来验证初步但非常令人鼓舞的结果。