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Robotic McKeown Esophagectomy using Double-Bipolar Method

Authors
Hemaavathi Mani1, Said Mohamed Said Bani Araba2, Jun Liang Teh2, Asim Shabbir2, Jimmy Bok-Yan So2, Guowei Kim3,4

Affiliations

  1. General Surgery, National University Hospital, Singapore
  2. Upper Gastrointestinal Surgery, National University Hospital, Singapore
  3. Upper Gastrointestinal Surgery, Gleneagles Hospital, Singapore
  4. Upper Gastrointestinal Surgery, Mount Elizabeth Novena Hospital, Singapore

Background
First described in 2011 by Professor Ichiro Uyama, the double-bipolar technique has been recognised to enhance precise dissection with efficient haemostasis, and minimise thermal spread to adjacent structures in confined spaces with limited range of movement for instruments. In this case, this double-bipolar method was utilised for a robotic McKeown esophagectomy with Maryland and fenestrated bipolar forceps in the right and left hands respectively. The patient, a 51-year-old Chinese gentleman from Singapore, had a previous stage 4A sclerosing B cell mediastinal lymphoma in complete remission after chemotherapy, autologous stem cell transplant and radiotherapy.

Methods
After presenting with dysphagia with solid food for 3 weeks, the patient underwent further endoscopic and radiologic evaluation that revealed a clinical stage II/III squamous cell carcinoma of the upper oesophagus with no other distal metastases. After discussion at the multidisciplinary tumour board, the patient completed 3 cycles of neoadjuvant docetaxel, cisplatin, and 5-fluorouracil chemotherapy. Imaging done post-chemotherapy revealed a partial response, and the patient underwent a McKeown esophagectomy using the da Vinci Xi robotic platform.

Results & Discussion
In a semi-prone 45o left lateral position, thoracic dissection of the oesophagus was performed robotically with en bloc lymphadenectomy, followed by the proximal transection of the oesophagus at the apex of the thorax with nerve testing to ensure the preservation of the bilateral recurrent laryngeal nerves. Patient was then switched to a French position for the laparoscopic abdominal mobilisation and creation of the gastric conduit. Indo-cyanin green was employed to ensure perfusion of the conduit before being brought into the neck via a retrosternal tunnel. Linear functional end-to-end cervical anastomosis was performed, followed by a creation of a feeding jejunostomy. Post-operatively, patient recovered well and was discharged home on POD12.

Conclusion
The versatility and pinpoint accuracy of the double-bipolar method enables it to be a viable dissection technique in a McKeown esophagectomy.

Keywords
McKeown Esophagectomy, Robotic, Double-Bipolar Method