Preoperatively, patients are advised to ingest only clear liquids 2–3 days before surgery. Premedication with prophylactic anti-reflux is strongly recommended. Pneumatic compression stockings are placed routinely. In order to minimize aspiration risk during induction of anesthesia, the airway can be secured either after a rapid sequence induction with cricoid pressure or with fiberoptic bronchoscope assistance while the patient is awake. If possible, an orogastric tube (OG-Tube) is placed to fully decompress the esophagus and the stomach. The anesthesiologist is advised not to force the OG-Tube if resistance is found. In older patients with several comorbidities, a Foley catheter is set and usually removed after the surgery. Intraoperative monitoring will be guided by the American Society of Anesthesiologists (ASA) recommendations.

Once under general endotracheal anesthesia, the patient is placed in a modified lithotomy position over a “bean bag.” Its use prevents the patient from moving down the table when in steep reverse Trendelenburg is needed. The beanbag is then inflated and a 4-in. tape is used to secure the patient to the table. The legs and pressure points are cushioned appropriately. The skin of the abdomen is prepped and draped from the nipple line to the pubis. The exposure of the chest is required in the eventuality of conversion to thoracotomy. The bedside component of the robot is positioned over the patient’s left shoulder. The operating room set up is shown in Fig. 6.2.

The positioning of the trocar is the same used in every advanced esophageal procedure. The first trocar is placed through a gasless optical technique in the periumbilical area, utilizing a bladeless 12-mm trocar with an optical tip that eliminates blind entry to the abdominal cavity. This 12-mm trocar is required for the 30° robotic camera system. Its positioning left to the midline allows better visualization of the gastroesophageal junction (GEJ). Pneumoperitoneum is induced. Two 8-mm trocar ports are then placed, one each at the left and right mid-clavicular line subcostal margin. The size of these trocars is specific for the robotic system. An additional 10/12-mm trocar is placed at the left lateral abdominal wall to assist with suction and passage of sutures. A 5-mm incision is made in the subxiphoid area, and the left lobe of the liver is retracted using the Nathanson liver retractor, allowing exposure of the anterior part of the stomach and the hiatus (Fig. 6.3a, b).

With a 5-trocar technique, an additional 12-mm trocar is inserted. In this case, the third robotic arm is used for retraction and the assistant can use the fifth trocar for suction, passing of sutures or cutting. This technique is ideal when a well-trained assistant in robotic approach is not available (Fig. 6.4a, b).

Once the trocars are in place, the nursing personnel approximate the robotic surgical cart into position and the arms are attached to the three specific trocars. A Cadiere Forceps is placed in the surgeon’s left hand and in the right hand; the articulated hook cautery or the harmonic scalpel is positioned (Fig. 6.5).

The assistant surgeon is situated on the patient’s left side. During the case, the assistant is in charge of cutting, suction and retraction. Also, if needed, the assistant switches the robotic instruments for the operating surgeon. For that reason, basic training in laparoscopic surgery and robotics is essential.

The procedure starts by dividing the peritoneum overlying the left crus of the diaphragm utilizing the harmonic scalpel. The phrenoesophageal membrane is transected as well. A blunt technique is used to dissect and separate the esophagus from the left crus to minimize the risk of inadvertent injury or perforation of the esophagus. The dissection is continued in the posterior mediastinum lateral and anterior to expose the lower third of the esophagus.

Once access to the posterior mediastinum is obtained, the short gastric vessels are then carefully divided, starting at the level of the lower pole of the spleen (Fig. 6.6).

Full mobilization of the fundus is carried out, by dividing posterior adhesions to the anterior capsule of the pancreas. During this maneuver, the surgeon uses an atraumatic grasper to retract the stomach medially and the harmonic scalpel, which allows performing this part of the operation in a bloodless fashion. The left side of the esophagus is identified, by dissecting the left crus from the esophagus. Only the anterior part of the esophagus is dissected, respecting the posterior attachments of the esophagus. After that, attention is centered on the exposure of the right crus. At this time, the assistant provides traction of the stomach, meanwhile the surgeon, using an atraumatic grasper and harmonic scalpel divides the gastrohepatic ligament below the hepatic branch of the vagus nerve and extends the dissection upwards. The peritoneum overlying the anterior surface of the right crus of the diaphragm and the phrenoesophageal membrane is transected. The right crus is identified and separated from the esophagus by blunt dissection.

After passing a #44F bougie through the mouth by the anesthesia team, the removal of the fat pad is accomplished to better expose the GEJ. The placement of the bougie helps with the performance of the myotomy. The assistant retracts the GEJ caudally with the atraumatic grasper to increase the length of the intra-abdominal esophagus. It is important at this point of the dissection to identify and preserve the anterior branch of the vagus nerve (Fig. 6.7).

After its identification, the vagus nerve is dissected upwards in an extension of approximately 10 cm, divorcing it clearly from the esophageal wall and moving it to the right side. The myotomy is started out just above the GEJ on the 12 o’clock position using the articulated hook electrocautery. Methodical marking of the area is performed by scoring the esophagus with the back of the hook electrocautery for about 6–7 cm above the GEJ. The submucosal plane is reached in one point by dividing the longitudinal and circular muscle layer (Fig. 6.8).