Rebuilding the Pathway: Robotic-Assisted Retrosternal Esophageal Reconstruction

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In this video, the authors present their robotic-assisted technique for esophageal reconstruction in the substernal position. The patient was a 66-year-old female with a history of dysphagia, who was admitted with shortness of breath and hemoptysis following an esophagogastroduodenoscopy (EGD) performed at an outside hospital. Imaging revealed a midthoracic esophageal obstruction, a large mediastinal fluid collection, and a confirmed esophageal perforation on esophagram. 
 
Due to her malnourished and septic state, she underwent esophageal resection with bipolar exclusion and the creation of a cervical esophagostomy. Pathology confirmed T3 squamous cell carcinoma, and she was referred for adjuvant chemoradiotherapy. Following multidisciplinary tumor board recommendations, her definitive reconstruction was deferred until optimization of her nutritional status and recovery, which occurred five months post-initial surgery. 
 
The reconstruction began with diagnostic laparoscopy, which confirmed no metastatic disease. Gastric mobilization and a Kocher maneuver were performed. The substernal dissection created a tunnel for the gastric conduit, which was fashioned using robotic staplers, and perfusion was confirmed with ICG. A jejunostomy tube was placed for postoperative nutrition. 
 
In the left neck, the esophagostomy site was mobilized, and an esophagogastric anastomosis was performed using a modified Orringer technique. The anastomosis was confirmed intraoperatively with endoscopy and a water test, which demonstrated no leak. 
Postoperatively, the patient was extubated immediately and initiated on jejunostomy feeds on postoperative day one. A barium swallow and esophagram on postoperative day five confirmed an intact anastomosis. She was discharged on postoperative day seven. She has remained disease-free 18 months post-reconstruction and continues to tolerate an oral diet. 
 
This case highlights the feasibility and safety of robotic-assisted substernal esophageal reconstruction in a complex oncologic and surgical patient, demonstrating excellent functional and oncologic outcomes. 

References

1. Petrov RV, Bakhos CT, Abbas AE. Robotic substernal esophageal bypass and reconstruction with gastric conduit-frequently overlooked minimally invasive option. J Vis Surg. 2019 May;5:47. doi: 10.21037/jovs.2019.04.02. Epub 2019 May 7. PMID: 31157161; PMCID: PMC6538941.

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