All patients are done under general anesthesia with endotracheal intubation. A 8 mm single lumen endotracheal tube is utilized through which a right-sided bronchial blocker is placed. This blocker is used for the thoracic portion of the procedure, after which it is simply removed and the remainder of the case is done with double lung ventilation. Esophagogastroscopy is performed by the surgeon to confirm location of the tumor and clear the esophagus and stomach of any retained contents. It is important to avoid excessive insufflation of the stomach, which would hinder the abdominal exposure and may affect mucosal integrity. A nasogastric tube is then passed and connected to low intermittent wall suction to keep the stomach decompressed. There is no need for placement of an epidural catheter as most patients can be easily managed with routine parenteral non-opioids. Early extubation is strongly recommended.

The patient is then placed in the left lateral position with slight flexion and slight anterior tilting. A total of four ports are placed (Fig. 4.2).

The first is a 12 mm port at the seventh intercostal space (ICS), just anterior to the anterior axillary line. A 5 or 10 mm thoracoscope is placed and after ensuring intrathoracic placement of the port, carbon dioxide insufflation of the pleural space is administered to a maximum pressure of 10 mmHg. The standard thoracoscope is then utilized to assist in proper placement of the other three ports. A 8.5 mm port is placed for the robotic camera at the sixth ICS, mid-axillary line. It is important to avoid placing this port too far posteriorly. Ideally this port will be at the mid-point of the thoracic esophagus, about 2 in. below the azygous vein arch. Following this an 8 mm port is placed in the third ICS, mid-axillary line for the right arm and am 8 mm port is placed in the ninth intercostal space at the mid-axillary line also (this one can be slightly more posterior). Before placing the latter three ports, it is helpful to pass a needle percutaneously at the proposed sites and using the thoracoscope to confirm adequacy of location. The standard guideline of ensuring at least a hand’s breadth between ports is important to avoid arm-collision.

For the thoracic dissection, the right arm (#1) will alternate using the robotic harmonic scalpel and the bipolar Maryland dissector while the left arm (#2) will use mainly the Caudier forceps for retraction. The assistant at the bedside will assist in providing suction and in passing the stapler. The lung is retracted anteriorly and the inferior pulmonary ligament is divided. The mediastinal pleura are then divided longitudinally both anterior and posterior to the esophagus up to the level of the azygous vein arch. The vein is then dissected free and divided using the endo-GIA stapler with a vascular load. Above the divided vein, it is important not to divide the pleura and to let it remain as a “tent” to overlie the eventual conduit. This may help wall off any cervical anastomotic leakage from the chest. The esophagus is then dissected circumferentially to include all the lymphatics and fatty tissue in-between the azygous vein, aorta and pericardium. The harmonic scalpel is helpful in dividing the aortic esophageal branches. This dissection must include a complete mediastinal nodal dissection. Stations 7, 8 and 9 are left on the esophagus, while stations 2 and 4 are removed separately. After completing the dissection of the thoracic esophagus in its entirety, a penrose drain is placed to encircle it at both the thoracic inlet and outlet of the esophagus. These drains help in identifying the esophagus in the next stages of the operation. A flexible 19 F drain is then placed along the posterior esophageal gutter. This drain may be secured to the pleura with an absorbable suture to avoid its dislodgement with ventilation. The instruments are then removed and the robot is undocked.

The patient is then positioned supine and a foam roll is placed under the left shoulder as well as under the left flank. A 4 cm incision is made along the inferior anterior border of the left sternocleidomastoid muscle. A careful circumferential dissection of the cervical esophagus is then made with care to avoid injuring the left recurrent laryngeal nerve. This dissection is carried down to the level of the Penrose drain, which was previously placed at the thoracic inlet. This drain is then partially delivered through the wound (Fig. 4.3).

Following this, standard laparoscopic technique is used to establish a pneumoperitoneum. The authors prefer a Verres needle through the umbilicus. We then proceed to place a 12 mm port just above the umbilicus and again use a laparoscope to aid in correct placement of the robotic ports using a percutaneous needle before committing to the location of the port. Four other ports are placed. An 8.5 mm port for the camera at the left paramedian line, about 1 in. above the level of the umbilicus and below the lowest point of the greater curve of the stomach. Two 8 mm ports are placed in the left flank (#3) and the left midclavicular line (#2), at about the same horizontal level. A 13 mm port (#1) is placed at the right midclavicular line, about 7 cm below the costal margin. The preferred approach for liver retraction is used. The author places a flexible retractor through a 5 mm port in the right flank, which is secured to the table with a self-retainer.