GAJA’S TECHNIQUE OF ROBOTIC ESOPHAGECTOMY consists of 10 steps done sequentially and carefully
Having did M.Ch from Kidwai Memorial Institute of Oncology in 1999, I was exposed to Esophageal cancer surgery. What I realised there is Kidwai stated Trans Hiatal Esophagectomy,I had analysed 256 cases and observed that Surgeons were adapting and evolving in order to reduce death rate which was 21% and came down later.
I learnt in Kidwai we Surgeons need to analyse our techniques time to time to decrease complications and death rate in Esophageal cancer, the most dreaded of all cancers. We need to ADAPT, EVOLVE and STANDARDISE the procedure.
OPEN to VATS toTOTAL THORACOSCOPIC to ROBOTIC: The immersive 3D, magnification, tremor cancellation software, 5 to 8 mm access cuts and firefly, sure-form technology of Robot made it the CHOICE OF APPROACH to ESOPAHGEAL CANCERS
FIRST was making it STANDERDISED- We avoided double lumen tube as we operate in PRONE POSITION and there was no need of it, also the posterior membrane layer of trachea will be less traumatised with single lumen ET tube.
We then focussed on the port sites, having mentored many Surgeons across India in AIIMS, Adyar, Apollo, HCG, Yenopaya, Fortis, SGPGI , we realised that the SUPRA AZYGOUS dissection was the limiting factor for many, so we used Verres needle and designed a port medial to medial border of Scapula as seen in the picture, this helped us better Superior Mediastinal dissection of Esophagus and Recurrent laryngeal Nodes.
We do posterior dissection FIRST and then ANTERIOR dissection
FOR BETTER LEFT recurrent laryngeal and Aorto Pulmonary nodes we need to clip and transect the AZYGOUS VEIN. It also helps in extraction of specimen from the neck without abdominal cut in good responders.
DETAILS: Our technique of robotic assisted radical esophagectomy with mediastinal node dissection. Patient is operated in prone position with two 8mm robotic ports and an assistant port. The right hand port is uniquely placed such that it reaches the supra-azygous area with ease. We use 30o degree camera through 12mm camera port. With the use of scissors attached to mono-polar current and a grasper attached to bipolar current entire procedure is performed. Entire esophagus is mobilized up to the hiatus in systematic manner in infra-azygous area followed by supra-azygous area. The azygous vein is ligated and divided. The total technique is demonstrated in the Youtube VIDEO LINK GIVEN ABOVE
With the advent of robotic sure form staplers the anastomotic technique became streamlined as seen in the YOUTUBE VIDEO LINK
We then published our 162 Robotic Esophagectomies by this GAJA’s Technique in 2019 and we continue to ADAPT, EVOLVE and INNOVATE time to time by being in a center with the BEST TECHNOLOGY in order to reduce complications and make ESOPAHGEAL SURGERY SAFE
And we never kept the technique to ourselves, we have mentored many Surgeons across many institutions in India with a goal of TEACH 10 AMD THEY WILL EACH TEACH ANOTHER 10 and the circle of learning continues. The map below shows the states we mentored and still continue to do so with the grace of God almighty.
