Robotic-Assisted Minimally Invasive Esophagectomy (RAMIE)

Patient Preparation

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Multidisciplinary Evaluation

• Teams include surgery, oncology, radiology, anesthesia, nutrition, and physiotherapy.

Preoperative Optimization

• Nutritional Support: Oral supplements or feeding tubes (nasogastric or jejunostomy).
• Cardiopulmonary Assessment: ECG, echocardiogram, pulmonary function tests.
• Prehabilitation: Smoking and alcohol cessation, respiratory exercises.
• Medical Stabilization: Control of diabetes, hypertension, renal dysfunction.
• Neoadjuvant Therapy: Typically completed 4–6 weeks pre-op.

Surgical Counseling and Logistics

• Informed Consent: Discussion of benefits, risks (e.g., nerve injury, conversion to open), and recovery.
• Bowel Prep and Antibiotic Prophylaxis: As per protocol.
• DVT Prophylaxis: Anticoagulants and compression devices.
• Anesthesia Preparation: Arterial line, IV access, potential epidural catheter.

Patient Positioning

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Abdominal Phase

• Supine with reverse Trendelenburg tilt.
• Arms tucked or one abducted depending on robotic setup.

Thoracic Phase

• Left Lateral Decubitus or Prone/Semi-Prone.
• Single-lung ventilation on right lung.
• Low-pressure CO₂ insufflation to aid exposure.

Cervical Phase (McKeown RAMIE)

• Supine with shoulder roll and head turned right.

Port Placement for Robotic-Assisted Minimally Invasive Esophagectomy (RAMIE)

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Ivor Lewis RAMIE

Abdominal Phase (Patient Supine)

• Camera Port: 10–12 mm port placed supraumbilically (midline or slightly to the left).
• Robotic Arm Ports:
  • Three 8 mm ports positioned in a gentle arc across the upper abdomen:
    • Right upper quadrant
    • Left upper quadrant
    • Left lateral abdomen
• Assistant Port: 12 mm port in the right lower quadrant for suction, retraction, and stapling.
• Liver Retractor Port: 5 mm port in the right subcostal area (used as needed).

Thoracic Phase (Patient Left Lateral Decubitus)

• Camera Port: 8–12 mm port in the 7th or 8th intercostal space, midaxillary line.
• Robotic Arm Ports:
  • Three 8 mm ports in the:
    • 4th intercostal space (posterior axillary line)
    • 6th intercostal space (anterior axillary line)
    • 9th intercostal space (posterior or lateral thoracic wall)
• Assistant Port: 12 mm port in the 5th or 6th intercostal space, anterior axillary line (for suction, stapling, specimen retrieval).

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McKeown RAMIE

Thoracic Phase (Patient Left Lateral Decubitus)

• Camera Port: 8–12 mm port in the 7th or 8th intercostal space, midaxillary line.
• Robotic Arm Ports:
  • Three 8 mm ports placed in:
    • 4th intercostal space
    • 6th intercostal space
    • 9th intercostal space
  • Distributed along the posterior and anterior axillary lines.
• Assistant Port: 12 mm port in the 5th or 6th intercostal space, anterior axillary line.

Abdominal Phase (Patient Supine)

• Camera Port: 10–12 mm supraumbilical.
• Robotic Arm Ports: Three 8 mm ports across the upper abdomen.
• Assistant Port: 12 mm in the right lower quadrant.
• Liver Retractor Port: 5 mm in the right subcostal area.

Cervical Phase

• No robotic ports used.
• A small left neck incision is made for a hand-sewn cervical anastomosis.

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Transhiatal RAMIE (Less Common)

Abdominal Phase (Patient Supine)

• Camera Port: 10–12 mm supraumbilical.
• Robotic Arm Ports: Three 8 mm ports in the upper abdomen.
• Assistant Port: 12 mm in the right lower quadrant.
• Liver Retractor Port: 5 mm in the right subcostal area.

Cervical Phase

• No robotic ports used.
• Left cervical incision for esophagogastric anastomosis.

Intraoperative Steps

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I. Abdominal Phase

• Port Placement: Small robotic and assistant ports.
• Exploration: Rule out metastasis.
• Gastric Mobilization:
  • Preserve right gastroepiploic arcade.
  • Divide short gastric vessels, gastrosplenic, and gastrohepatic ligaments.
  • Ligate and divide left gastric artery/vein.
• Hiatal Dissection and Phrenoesophageal Membrane Incision.
• Pyloric Intervention (Optional): Pyloroplasty or pyloromyotomy.
• Gastric Conduit Formation: Stapled tube (2–4 cm wide) along lesser curvature.
• Abdominal Lymphadenectomy.
• Feeding Jejunostomy.

II. Thoracic Phase

• Port Placement: Several robotic ports in right chest.
• Lung Isolation and CO₂ Insufflation.
• Mediastinal Pleura Incision.
• Esophageal Mobilization: Circumferential, from diaphragm to thoracic inlet.
• Azygos Vein Division.
• Thoracic Duct Ligation.
• Mediastinal Lymphadenectomy:
  • Paraesophageal
  • Subcarinal (station 7)
  • Paratracheal (stations 2R/2L, 4R/4L)
  • RLN region
  • Inferior pulmonary ligament
  • Para-aortic
• Esophageal Transection:
  • Ivor Lewis: In chest.
  • McKeown: Completed during cervical phase.
• Anastomosis (Ivor Lewis):
  • Conduit brought into chest.
  • Anastomosis via stapled or hand-sewn techniques.
  • Reinforcement with sutures or omental wrap.
• Drainage: Chest drains placed.

III. Cervical Phase (McKeown RAMIE)

• Cervical Incision and Exposure.
• Esophagus Identification and RLN Protection.
• Conduit Delivery: Pulled through posterior mediastinum.
• Specimen Removal and Transection.
• Cervical Anastomosis: Hand-sewn or stapled.
• Drain Placement and Closure.

Possible Complications and Management

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General Complications

• Anastomotic Leak:
  • Cervical: Common but manageable conservatively.
  • Intrathoracic: More severe, may need stent, drainage, or re-operation.
• Pulmonary Complications:
  • Pneumonia, atelectasis, respiratory failure.
  • Managed with physiotherapy, antibiotics, oxygen support.
• RLN Palsy:
  • Hoarseness, aspiration risk.
  • Managed with voice therapy or vocal cord medialization.
• Cardiac Events:
  • Atrial fibrillation, arrhythmias.
  • Managed with medications, anticoagulation.
• Chyle Leak:
  • Conservative management, reoperation if persistent.
• Bleeding: May require transfusion or re-operation.
• Wound Infection: Less common; treated with antibiotics and drainage.
• Delayed Gastric Emptying: Managed with prokinetics, dietary changes.
• Anastomotic Stricture (Late): Treated with endoscopic dilation.
• Reflux and Dumping Syndrome (Late):
  • Managed with lifestyle and dietary changes.
• DVT/PE: Prophylaxis standard; anticoagulation if occurs.

Robotic-Specific Considerations

• No Tactile Feedback: Reliance on visual cues.
• Longer Operative Time During Learning Phase.
• Port-Site Complications.
• Higher Cost.
• Steep Learning Curve: Requires training and experience.

A multidisciplinary team and Enhanced Recovery After Surgery (ERAS) protocols are essential for optimal outcomes.