Robot-assisted thoracoscopic enucleation for a large esophageal leiomyoma: a case report

Abstract

Background Video-assisted thoracoscopic surgery (VATS) is being used to treat esophageal submucosal tumors (SMTs) all over the world. However, this technique is difficult when the tumor is large and located on the left side wall of the esophagus, within the upper mediastinum. This is because, with VATS, the surgical forceps have a limited range of motion. Robot-assisted thoracoscopic surgery (RATS) using the da Vinci surgical system may be extremely useful for enucleation of esophageal SMTs within the narrow upper mediastinum. Case presentation A female in her thirties experiencing epigastric pain visited our hospital and was diagnosed with a large esophageal leiomyoma within the upper mediastinum. From its size (10 cm), it was judged to have malignant potential. We performed SMT enucleation using RATS with a da Vinci surgical system Xi. This was our second case using this system. The patient was placed in the left lateral position. Four da Vinci trocars (8 mm) were inserted into the 10th, 7th, 5th and 3rd intercostal spaces (ICS), and an assist port was added in the 5th ICS. We opened the superior mediastinal pleura cranially and caudally from the arch of the azygos vein and expanded the superior mediastinum after dividing the azygos vein. We made an incision in the muscular layer of the esophagus and, using a monopolar hook and monopolar scissors, enucleated the esophageal tumor in a protective manner so as not to damage its capsule or mucosa while applying appropriate robot-specific counter traction. We then sewed up the muscularis using 4–0 Vicryl, inserting the endoscope into the thoracic esophagus to substitute for a bougie. In addition, the pleura was sutured using barbed suture. The surgical procedure was straightforward and smooth. The patient was discharged on postoperative day 4 with no surgical complications. The tumor was definitively diagnosed pathologically from paraffin sections as a benign esophageal leiomyoma. Conclusions RATS enables more delicate and precise esophageal SMT enucleation without surgical complications, though various challenges remain to be overcome.

Surgical Treatment for Esophageal Leiomyoma: 13 Years of Experience in a High-Volume Tertiary Hospital

“…With the fast development of robot-assisted thoracoscopic surgery (RATS), more and more difficult surgeries can be conducted with the advantages of robots including a 3-dimensional surgical view and extremely flexible robot hands. Studies also verified the advantages of RATS for esophageal leiomyoma ( 28 , 29 ). RATS application could be explored further in the future.…”

Circumferential esophageal leiomyoma: Management by combined robotic surgery and intraoperative endoscopy

“…However, when the tumor is large, the use of video-assisted thoracoscopic surgery may result difficult due to only two-dimensional vision and straight rigid instruments. 5 In our case, the widely known advantages of robot-assisted thoracic surgery, as magnified threedimensional vision and wrist-like mobility of the robot appliance, 6,7 allowed a safe enucleation of the leiomyoma that encircled the esophagus and made closure of the esophageal muscular layer easier. Some authors have reported a significant reduction in the incidence of injuries to the esophageal mucosa during enucleation of esophageal leiomyoma by robot-assisted thoracic surgery.…”

Robotic-Assisted Thoracoscopic (RATS) Enucleation of Esophageal Mesenchymal Tumors and Foregut Cysts

“…Our study is the largest case series to date on robotic-assisted thoracoscopic enucleation of esophageal mesenchymal tumors and cysts. There have been 35 cases reported to date ( Table 1 ) [ 3 , 6 , 7 , 8 , 10 , 11 , 12 , 13 , 14 , 15 , 16 , 17 , 18 , 19 , 20 , 21 ]. In total, 22 (62.8%) patients were diagnosed with leiomyoma, 6 (17.1%) patients had foregut cysts, and 1 (2.8%) patient had schwannoma.…”

“…The authors emphasized overcoming the spatial limitation posed by video-assisted thoracoscopic surgery while preserving the benefits of minimal invasiveness. Although it has been attempted by several reports for esophageal mesenchymal tumors of different sizes and locations ( Table 1 ) [ 7 , 8 , 9 ], its clinical value has not been fully understood in the literature. This study aimed to present the first case series in the literature for the perioperative and long-term clinical outcome of robotic-assisted thoracoscopic enucleation.…”