Esophageal Surgery

Advanced esophageal procedures, previously requiring large open and at times thoracic incisions, can now be performed minimally invasively providing decreased pain and hospital time to the patient. The general rules for all the esophageal procedures performed via the abdomen are similar. For the trocar placement, the first port placed is 12 mm, and is placed using a gasless optical technique. It is positioned two fingerbreadths lateral to the umbilicus and one palm width inferior to the left subcostal margin. The position of this port is optimal for viewing the gastroesophageal junction, and the size is appropriate for the robotic camera. One 8-mm robotic port is then placed just inferior to the left costal margin in the midclavicular line. A 12-mm port is then inserted again inferior to the left costal margin but in the anterior axillary line. The large size of this port is essential for the insertion of stapling devices, and clip appliers by the assistant if needed. The extreme lateral position is necessary for proper retraction, and avoidance of collisions with the robotic arms. A Nathanson liver retractor is then inserted just inferior to the xiphoid process. The liver is then retracted anteriorly, exposing the esophageal hiatus, and another 8-mm robotic port is inserted inferior to the right costal margin in the midclavicular line. The room setting and the position of the robotic system is similar in all the advanced esophageal procedures (Fig. 9.1). In the following esophageal procedures, with exception of the Nissen fundoplication, we found benefits in the robotic assisted approach when comparing with the laparo-scopic technique. Although the Nissen fundoplication is a very useful procedure to learn robotic surgery, in our experience it has been shown to prolong the operative time with similar postoperative results.

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