Technical details of the hand-sewn and circular-stapled anastomosis in robot-assisted minimally invasive esophagectomy

Abstract

SUMMARY The circular mechanical and hand-sewn intrathoracic anastomosis are most often used in robot-assisted minimally invasive esophagectomy (RAMIE). The aim of this study was to describe the technical details of both techniques that were pioneered in two high volume centers for RAMIE. A prospectively maintained database was used to identify patients with esophageal cancer who underwent RAMIE with intrathoracic anastomosis. The primary outcome was anastomotic leakage, which was analyzed using a moving average curve. For the hand-sewn anastomosis, video recordings were reviewed to evaluate number of sutures and distances between the anastomosis and the longitudinal staple line or gastric conduit tip. Between 2016 and 2019, a total of 68 patients with a hand-sewn anastomosis and 60 patients with a circular-stapled anastomosis were included in the study. For the hand-sewn anastomosis, the moving average curve for anastomotic leakage (including grade 1–3) started at a rate of 40% (cases 1–10) and ended at 10% (cases 59–68). For the circular-stapled anastomosis, the moving average started at 10% (cases 1–10) and ended at 20% (cases 51–60). This study showed the technical details and refinements that were applied in developing two different anastomotic techniques for RAMIE. Results markedly improved during the period of development with specific changes in technique for the hand-sewn anastomosis. The circular-stapled anastomosis showed a more stable rate of performance.

Robotic-assisted minimally invasive Ivor Lewis esophagectomy within the prospective multicenter German da Vinci Xi registry trial

“…The current results from leading esophagus surgery centers support the use of a circular stapler esophagogastrostomy, especially for minimally invasive intrathoracic anastomosis [5,22]. The stapler diameter should be selected according to the individual anatomical situation of the patient but with preference for the largest possible diameter; however, a significant difference regarding anastomotic leakage and stricture was not identified between 25-and 28-mm diameter sizes [29].…”

“…Although several techniques of reconstruction after MIE have been reported, the majority of European centers favor minimally invasive intrathoracic esophagogastrostomy [14,35]. The use of a circular stapler appears to be advantageous with regard to the AL rate, although this question has not yet been conclusively clarified [5]. Experienced centers have published the first larger single-center reports of RAMIE with excellent oncological results and low mortality rates of 1-3% [25,33].…”

Technical details for a robot-assisted hand-sewn esophago-gastric anastomosis during minimally invasive Ivor Lewis esophagectomy

“…In this regard, as Robot-Assisted Surgery (RAS) has been developed to overcome some of the main drawbacks of pure laparoscopy, especially the bi-dimensional vision and the kinematics limitations; by allowing a finer dissection into mediastinum and more precise suturing, it is expected to bring advantages also for fashioning esophago-gastric anastomosis [10][11][12][13][14][15]. However so far, no data are available to confirm if this expectation for RAS does translate into tangible results for esophageal surgery.…”

Strategiewechsel zur minimal-invasiven Ösophagektomie – Ergebnisse an einem zertifizierten Zentrum

“…Entscheidend für das Outcome scheint auch die Anastomosentechnik zu sein. So erwies sich in mehreren Studien die Rekonstruktion nach Ivor Lewis mit Magenschlauchhochzug und hoher intrathorakaler Zirkularstapleranastomose im Vergleich zu anderen Rekonstruktionstechniken als überlegen [5,26]. Aufgrund der dreidimensionalen Sicht, einer zitterfreien Bewegungsübertragung und dem größeren Freiheitsgrad der Instrumente im Thorax und Mediastinum sind roboterassistierte Verfahren den konventionellen minimalinvasiven Verfahren möglicherweise überlegen [11].…”