Robotic equipment: what do we need for a robotic-assisted minimally invasive esophagectomy (RAMIE)?

INTRODUCTION

Surgical resection is the cornerstone for local control and long-term survival of patients with locally advanced esophageal cancer treated by multimodality therapy. The evolution of minimally invasive esophagectomy (MIE) to include telerobotics has contributed to expanding the capabilities of performing this complex operation through minimally invasive techniques. Robotic surgery enhances several key aspects of minimally invasive surgery, such as enhanced vision, stable view, and highest precision due to articulated instrumentation and scaling of motion.¹ Cohort studies have shown that robot-assisted minimally invasive esophagectomy (RAMIE) is feasible and safe.² Robotic movements are intuitive where the instrument tips move in the same direction as the surgeon’s hands. It allows for a greater range of motion and precision that is not seen with laparoscopic instruments. Herein, we describe our positioning, port placement, and instruments used during a transthoracic (Ivor Lewis type) RAMIE.

EQUIPMENT PREFERENCE CARD

Robotic platform: daVinci Xi Robotic Surgical System with 30-degree camera system and fluorescence imaging (Firefly, Intuitive Surgical, Sunnyvale, CA, USA).

Robotic supplies/instrumentation:

1. Three 8-mm trocars and one 12-mm robotic stapling trocar with insufflation caps

2. Instruments: Fenestrated bipolar forceps, permanent cautery spatula, tip-up fenestrated grasper, robotic vessel sealer, large Hem-o-lok clip applier, large mega needle driver, endowrist Stapler 30-mm curved-tip, endowrist stapler 45-mm curved tip

Nonrobotic supplies/instrumentation:

1. CO₂ insufflation and tubing

2. Laparoscopic suction irrigator (5 mm)

3. ¼” Penrose drain

4. Nathanson liver retractor

5. Endostitch Suturing Device (Medtronic)

6. Wound protector

ROOM LAYOUT

The operating room arrangement should allow for the daVinci robot to have space to be moved toward the operating table. The daVinci Xi robot can be docked from either side of the operating table for both the abdominal and thoracic portion of the procedure. We prefer docking from the left for both portions of the procedure. The final room layout should support all participants of the procedure (Fig. 1).

Fig. 1.

Room layout. The daVinci Xi robot is docked from the left. The surgical table and robotic cart are arranged on the opposite side of the robot to allow for space to maneuver the robot as it approaches the table. The configuration remains the same during both phases of surgery, although the assistant stands on the right side of the patient during abdominal portion and to the left side during the chest phase.

POSITIONING

Abdominal portion

The patient is placed in the supine position. Both arms are padded and tucked at the patient’s sides, and a footboard is placed for support during reverse Trendelenburg positioning (Fig. 2a). Esophagogastroscopy is performed in every case by the operating surgeons to assess the status of the esophagus with respect to location of the tumor, response to preoperative treatment (if applicable), and any concurrent esophageal or gastric conditions. The suitability of the stomach to serve as the conduit for reconstruction is also evaluated.

Fig. 2.

(a) Abdominal positioning. Patient is supine with arms tucked. Incisions are marked out for the placement of the robotics arms. (b) Thoracic positioning. Patient is placed in the left lateral decubitus position, slightly tilted anterior. Incisions marked for port placements.

Thoracic portion

Following completion of the abdominal phase, the patient is placed in a left lateral decubitus position and tilted slightly prone. The patient is placed with the midthorax positioned over the break, and the table is flexed in order to maximally separate the rib spaces. A beanbag is used to stabilize the patient, and the up arm is placed in 90-degree abduction and flexion at the elbow. (Fig. 2b).

PORT PLACEMENT

Abdominal portion

A Veress needle is used in the left upper quadrant (LUQ) to insufflate the abdomen. Once insufflated to a pressure of 15 mm Hg, a midline robotic 8-mm port above the level of the umbilicus is placed. Two other 8-mm ports are then placed at the left mid clavicular line and at the left costal margins. A 12-mm port is placed at the mid right clavicular line. A 5-mm incision is made below the xiphoid process and a Nathanson liver retractor is inserted. Lastly a 5-mm assistant port is placed between Arms 1 and 2 (Fig. 3). Following port placement, the daVinci robot is then docked from the left side of the table.

Fig. 3.

Abdominal port placement. A 12-mm port is used in the Arm 1 position; 8 mm ports are used for Arms 2–4. Arm 2 is utilized as the camera port. If needed, a port, usually 5 mm, can be placed between Arm 1 and 2 and slightly inferior.

Thoracic portion

The robotic ports are placed as detailed: The first port inserted is an 8-mm camera port that is placed anteriorly in the 7th intercostal space (ICS) between the tip of the scapula and the posterior axillary line. A 12-mm port is placed posteriorly in the 8th or 9th ICS, posterior to the tip of the scapula. This will serve as the surgeon’s left hand. Two 8-mm ports are placed in the posterior axillary line and spaced evenly superior to the camera port, typically in the 5th and 3rd ICS, respectively. The 5th ICS port is utilized for dissection, and the 3rd ICS port is reserved for retraction both under the control of the surgeon’s right hand (Fig. 4). A 5-mm assistant port is placed between Arms 1 and 2. This can be omitted, but we find an assistant port helps facilitate with extra retraction, suctioning, or retrieval of specimens.

Fig. 4.

Thoracic port placement. A 12 mm is used in the Arm 1 position (Surgeon’s left hand). The camera port, Arm 2 is placed in the 7th intercostal space; an 8-mm port is used. Two other 8-mm ports are used for Arms 3 and 4. If used, a 5-mm assistant port is placed between Arms 1 and 2.

INSTRUMENTS

For both the abdominal and thoracic portions of robotic MIE, a standard set of robotic instruments are employed for the majority of the case. Once the robotic arms are docked, in Arm 1 of the daVinci Xi Robot system (left hand), a dynamic retracting instrument is used. Options include the Cadiere, Prograsp, or Fenestrated bipolar forceps. We favor the fenestrated bipolar forceps as it allows for the grasping and manipulation of tissues, as well as bipolar coagulation when needed. In addition, the tip of the instrument is less traumatic than other bipolar options, such as a Maryland bipolar forceps. A 30-degree camera is used in Arm 2 in the angle-down position. In Arm 3, a dissecting instrument is placed. The choices here include monopolar alternatives, such as the spatula, hook, or scissors, or bipolar options, such as the Maryland or thoracic dissector. Each instrument will have different thermal spreads depending on the power setting and duration of application. A study by Hefermehl et al.³ showed that overall, monopolar instruments have a higher mean of thermal spread than bipolar instruments. In spite of this, the monopolar spatula is preferred because of the speed and familiarity of the dissection. In our experience, we have better control with the spatula, and it can be directed to pinpoint areas. Other institutions use hook cautery. Overall, there is not much difference as they are both monopolar instruments. In Arm 4 (right hand), a more static retracting option is placed. We utilize the tip-up fenestrated grasper, which also has a longer jaw length, then the other graspers and is also atraumatic on the tissue, able to grasp without tearing (Fig. 5).⁴

Fig. 5.

Common robotic instruments and tray setup.

Fig. 6.

Additional instruments used during RAMIE.

ADDITIONAL INSTRUMENTATION DURING THE ABDOMINAL PHASE

1. When dividing the omentum off the stomach in the lesser sac, as well as when taking down the short gastric vessels, use of an ultrasonic energy instrument, such as the harmonic scalpel or vessel sealer is idea for hemostasis. The vessel sealer is our preferred choice because it retains 7 degrees of freedom of articulation and does not have thermal spread.

2. Once the distal esophagus is circumferentially mobilized, a ¼” Penrose drain is placed around it, and a large hemolock clip is placed through Arm 3 to hold the ends of the Penrose together to facilitate identification in the lower right hemithorax.

3. Robotic staplers are introduced through Arm 1 to divide the left gastric pedicle (curved tip 30-mm vascular [white] load) and for formation of the gastric conduit (45-mm-large [green or black] loads).

4. The feeding jejunostomy can be performed robotically or laparoscopically. If done robotically, some authors have described changing the instrument and camera positions. We prefer the laparoscopic approach because in our experience it is very simple and much quicker.

ADDITIONAL INSTRUMENTATION DURING THORACIC PORTION

1. The azygos vein (vascular load), proximal esophagus (green load), and remainder of the gastric conduit (green load) are divided with the robotic stapler introduced through Arm 1.

2. The anastomosis is fashioned side-to-side, using the modified Orringer linear stapling technique. Following intravenous ICG administration and Firefly fluorescence imaging assessment of the gastric conduit perfusion, a suitable location on the stomach is chosen, and the gastric conduit is opened with the monopolar spatula. The esophagus is similarly opened above the staple line, and posterior aspect of the anastomosis is constructed by using a 30-mm, green load of the robotic stapler. The common enterotomy is then sutured closed using a robotic large mega needle drive from Arm 3 and interrupted 3-0 polydioxanone suture (PDS). The nasogastric tube is inserted under direct vision before completing this anterior inner layer. The anterior portion of the anastomosis is reinforced by placing several interrupted 3-0 silk Lembert sutures.

CONCLUSION

There have been significant improvements made in the surgical resection of esophageal cancer from the highly morbid open esophagectomy. Various robotic instrument tips include forceps, scissors, electrocautery tools, scalpels, and other surgical tools that are familiar to the surgeon from open surgery and conventional minimally invasive surgery. They are offered in a variety of diameters and may be selected and used interchangeably during a surgery. Though, selective use of instruments is important to keep robotic costs down. With each new instrument introduced in the robot, addition charges are made. In addition, the same setup of instruments can be used for both the abdomen and the thorax. The instruments can be kept sterile while repositioning of the patient occurs. The application of robotic technology in esophagectomy has proven to increase accuracy in dissection secondary to improved visualization and improved flexibility through articulation of instruments compared with conventional minimally invasive techniques.