Application of robot minimally invasive Ivor Lewis esophagectomy

cited this article: Zhang Yajie, Han Yu, Jie Jie, Li HechengApplication of robot minimally invasive Ivor Lewis radical esophagectomyChina's thoracic and cardiovascular surgery clinical journal, 2018, 25 (9): 735-741doi: 10.7507/1007-4848.201804080China is one of the highest incidence rate of esophageal cancer in the worldAt present, surgery is the most important means to treat esophageal cancer, and it is also the basis of multi-disciplinary comprehensive treatment [2]Traditional open surgery has a large trauma, high incidence of perioperative complications and long postoperative recovery time [3]In recent years, endoscopic minimally invasive resection of esophageal cancer has been gradually applied in clinical practiceCompared with the traditional open surgery, endoscopic esophagectomy has advantages in reducing surgical trauma, reducing postoperative pain and complications, and shortening the length of stay [4]However, the operation of endoscopic esophagectomy is relatively complex and the learning curve is long [5], especially for the two incision intrathoracic anastomosis (Ivor Lewis), which is the most widely used method in China, The limitations of endoscopic surgery, such as two-dimensional field of vision, long straight rigid instruments, and the need for the master knife to rely on assistant to control the lens, make it difficult to perform intrathoracic gastroesophageal anastomosis and mediastinal lymph node dissection [6]< br / > < br / > as a new generation of minimally invasive surgery system, Leonardo da Vinci robot system has three-dimensional surgical field with 10-15 times magnification, seven free motion simulation wrists and a tremor filtering system that can improve the accuracy of surgeryIn 2003, robots were first used in the surgical treatment of esophageal cancer [7]At present, there are only a few reports of robot assisted radical esophagectomy at home and abroad [8-9]Since May 2015, our department has carried out the robot assisted Ivor Lewis operationNow we summarize the operation method and effect< br / > < br / > 1 data and methods < br / > < br / > 1.1 clinical data and grouping < br / > < br / > retrospective analysis of the clinical data of patients who had undergone radical resection of esophageal cancer assisted by Da Vinci robot in Ruijin Hospital Affiliated to Shanghai Jiaotong University Medical College from May 2015 to April 2018Inclusion criteria: (1) all patients were diagnosed as middle and lower esophageal cancer by gastroscopy and pathological examination before operation; (2) preoperative clinical stage evaluation of the scope of focus surgical operation can be completely removed, CT3 ~ 4 and / or N + patients received new adjuvant treatment with the informed consent of patients and their families; (3) all patients and their families were informed of the characteristics and costs of the robot surgery program before operation and agreed to accept the operationExclusion criteria: (1) preoperative examination and evaluation of patients with high-risk surgery risk or intolerable surgery; (2) patients with previous history of subtotal gastrectomy and right chest surgery due to benign and malignant gastric lesions; (3) preoperative examination and exclusion of cervical lymph node metastasisAccording to the above inclusion and exclusion criteria, 70 patients were included in the study, including 54 males and 16 females, with an average age of (62.0 ± 7.6) yearsThere were 29 middle thoracic esophageal tumors and 41 lower thoracic tumorsTwo patients with ct3n2 agreed to receive neoadjuvant radiotherapy and chemotherapy, and then evaluated the tumor stage again, and finally received surgery40 patients were anastomosed with gastroesophageal intrathoracic stapler, 30 patients were anastomosed with gastroesophageal double-layer manualSee Table 1 for clinical data of patients< br / >The operation was performed by abdominal and chest operation< br / >The abdominal incision was made by the five hole method (Figure 1a)An pneumoperitoneum needle was placed 2 cm from the lower edge of the umbilicus to establish an artificial pneumoperitoneum, and 12 mm trocar was placed as the observation hole after maintaining to 12-15 mm Hg; 8 mm trocar was placed 2 cm below the left and right anterior axillary costal arch under the 30 degree lens as the operation hole of 1 and 3 mechanical arms respectively, and 8 mm trocar was placed 1 cm above the umbilicus hole of the right middle clavicle as the operation hole of 2 mechanical arms; 1 cm above the umbilicus hole of the left middle clavicle as the operation hole of 1 12 mm trocar was placed in cm level as an auxiliary operation holeThe robot operating arm enters from the head side and is connected directly above the operating tableThe 1 arm is connected with the ultrasonic knife, the 2 arm is connected with the bipolar electrocoagulation forceps, and the 3 arm is connected with the cadiere forcepsThe assistant stands between the two legs of the patient to assist the operation, through the auxiliary hole to pull, clamp, attract and operate the linear cutterIn abdominal operation, firstly, the liver was suspended by purse string and Hem-O-lock V type, the lesser omentum was opened, the lesser omentum was excised along the ligaments of the liver and stomach until the right side of the cardia, the stomach was lifted to the upper left, the lymph nodes were completely cleaned along the common hepatic artery, the left gastric artery and the splenic artery, and the left gastric artery was severed by the double clamp of Hem-O-lock or the intracavitary cutter Free the back wall and fundus of the stomach, expose the spleen and deal with the short gastric vessels Open the greater omentum 2 cm away from the gastroepiploic vascular arch, cut the gastrocolic ligament and the left gastroepiploic vessels to the head side until the treated short gastric vessels meet, and continue to dissociate to the left side of the cardia, open the feet of the diaphragm on both sides, free the lower part of the esophagus, and connect with the right chest After the stomach was completely free, the tubular stomach was made from the side of the lesser curvature of the stomach to the bottom of the stomach The width of the tubular stomach was about 4 cm The remnant of esophagus and cardia were fixed with sutures The lower esophageal gauze was fixed and sent into the right chest Jejunostomy was performed 30 cm from the troostal ligament < br / > The chest incision was made by six hole method (Fig 1b): 12 mm trocar was placed in the 5th intercostal space of the right axillary front to establish the artificial pneumothorax and maintain 8 mm Hg 8 mm trocar was placed in the 3rd intercostal axillary front, the 7th intercostal posterior axillary line and the 8th intercostal scapular line as the No 1, No 2 and No 3 mechanical arm operation holes respectively 12 mm trocar was placed in the 6th and No 8 intercostal axillary front lines as the auxiliary operation holes The mechanical arm enters from the back side, the 1 arm is connected with the electric hook or Maryland pliers, and the 2 arm, 3 arm and auxiliary hole connection device are similar to the abdominal operation An assistant stands on the patient's ventral side to assist the operation Open the upper mediastinum pleura and clean the lymph nodes and fatty tissue beside the right recurrent laryngeal nerve The arcus azygos was dissected and closed with a cutting occluder Free the esophagus downward, and clean the lymph nodes in the inferior carina, bilateral parabronchi and paraesophagus Connect with the abdomen, pull the gauze strip to suspend the esophagus, clean the lymph nodes beside the left recurrent laryngeal nerve, and fully free the esophagus to the chest top According to different anastomosis methods, digestive tract reconstruction can be divided into stapler and manual anastomosis Anastomotic method of stapler (Fig 2): the proximal esophagus was cut off at 5 cm from the upper edge of the tumor The 7th intercostal accessory hole was enlarged to 3 cm, and the incision protective sheath was placed The specimen was taken out and the tumor margin was examined by frozen pathology during operation The stapler base was placed in the proximal part of the esophagus, and the bag suture fixed base was made with the help of the mechanical arm Lift up the tubular stomach and open it from the front wall, place the tubular anastomat from the auxiliary hole, place it from the front wall of the tubular stomach and lead it out through the back wall, and match the anastomat and the pin seat under the cooperation of the assistant and the mechanical arm, anastomose the proximal esophagus with the posterior wall of the stomach, cut the closure device in a straight line to close the tubular stomach stump Manual anastomosis mode (Figure 3): robot assisted double-layer manual anastomosis of esophagus and stomach is adopted First, the proximal esophagus was cut and closed at 5 cm of the upper edge of the tumor with a linear cutting and closing device, and the specimen was removed 3-0 barbed wire was used to sew the myometrium of the back wall of esophagus and the seromuscular layer of the back wall of stomach continuously The remnant of esophagus was cut by electric scissors, and the back wall of stomach was opened at the same time 3-0 Vicryl wire was used to sew the mucosa layer of the back wall of esophagus and the mucosa layer of the back wall of stomach intermittently to complete the double-layer anastomosis of the back wall of the anastomosis The gastric and esophageal mucosa and sarcoplasmic layer were sutured in two layers with 3-0 barbed wire The anterior wall of the double-layer anastomosis was covered with greater omentum After the thorax is flushed and hemostasis is fully completed, the mechanical arm shall be evacuated A 28 × thoracic drainage tube was placed in the thoracic cavity from the auxiliary hole, and a 10 × Jackson Pratt tube was placed beside the anastomotic hole from the trocar hole in the third arm < br / > < br / > 1.3 perioperative observation index < br / > < br / > (1) perioperative short-term clinical efficacy: operation time, intraoperative bleeding volume, conversion to thoracotomy and laparotomy rate, postoperative hospital and 30 day mortality, complication rate, postoperative hospital stay Postoperative complications include anastomotic leakage, pulmonary complications, cardiovascular complications, recurrent laryngeal nerve injury, chylothorax and incision infection (2) Oncology indexes: tumor specimen size, R0 resection rate, total lymph nodes and lymph nodes clearance of chest, abdomen and bilateral recurrent laryngeal nerve, pathological stage (using the 8th Edition uicc-ajcc esophageal cancer stage guideline [10]) < br / > results < br / > < br / > 2.1 the short-term clinical effect of perioperative period < br / > 70 patients successfully completed the robot assisted Ivor Lewis operation, the average operation time was (308.7 ± 60.6) min, and the average bleeding volume was (190.0 ± 95.1) ml A total of 2 patients were converted to open surgery (1 case of malignant atrial fibrillation and 1 case of severe adhesion) There was no death in hospital or 30 days after operation Postoperative complications occurred in 24 patients (34.3%), including anastomotic leakage in 6 cases (8.6%), pulmonary complications in 7 cases (10.0%), recurrent laryngeal nerve injury in 6 cases (8.6%), chylothorax in 1 case (1.4%), cardiovascular complications in 5 cases (7.1%), incision infection in 1 case (1.4%) The median postoperative hospital stay was 9.0 (IQR, 5.0) days, as shown in Table 2 < br / > The average size of the tumor was (3.2 ± 1.5) cm All the operations were R0 resection Two patients received neoadjuvant radiotherapy and chemotherapy before operation, one of them had complete postoperative response (PCR), the other one had ypt2n1 There were 4 cases in stage 0, 15 in stage I, 28 in stage II, 21 in stage III and 2 in stage IV The total number of lymph nodes was (19.3 ± 8.7), including (8.9 ± 6.6) in abdomen, (10.1 ± 5.6) in chest, (1.5 ± 2.2) in left recurrent laryngeal nerve, and (1.4 ± 1.6) in right recurrent laryngeal nerve (Table 3) < br / > < br / > 3 discussion < br / >, The first two kinds of operation were reported Robot assisted Ivor Lewis operation needs to perform intrathoracic gastroesophageal anastomosis and other relatively complex operations, so it is rarely carried out at present The operation of transesophageal hiatus esophagectomy is relatively easy, but there are limitations such as incomplete mediastinal lymph node clearance [17] Compared with Ivor Lewis operation, the incidence of recurrent laryngeal nerve injury and anastomotic leakage was higher in McKeown operation [18-19] Since May 2015, our department has carried out Leonardo robot assisted esophageal cancer Ivor Lewis operation on the basis of proficient completion of endoscopic esophageal cancer Ivor Lewis operation < br / > < br / > thoracoscopy combined with radical resection of esophageal cancer was used earlier, and its clinical application is relatively mature at present Noble et al [20] reported the prospective study of 53 cases of total endoscopic esophageal cancer after Ivor Lewis operation The main postoperative complications were 24.5% and anastomotic leakage 9% According to the data of our center [21], the incidence of complications and anastomotic leakage was 12.2% and 3.4% respectively in 29 cases of Ivor Lewis operation Compared with the whole endoscopic resection of esophageal cancer, robot assisted resection of esophageal cancer has not been widely used