Having done super speciality M.Ch Surgical Oncology from Kidwai memorial Institute of Oncology, Bangalore we were all exposed to Esophageal cancer surgery more than many institutes in India. Teachers like Dr. Prabhakaran, Dr. Chandra Sekhar , Dr. Vijay Kumar, Dr. Krishna Murthy, Dr. K.V..Virendra Kumar sirs used to do fantastic job of trans hiatal Esophagectomy. I studied 256 cases there and found that the technique evolved over a decade, refined with better technique and guidelines. The mortality dropped from 30% to 5% after few years. And so also morbidity. I used to assist at least 3 cases a week and was always thinking how to decrease death rate and reduce post operative complications. And used to thing any other way of doing it.
Background:
Cancer of esophagus is one of deadliest cancers with a dismal 5 year survival rate of 25-30%. Radical esophagectomy with lymphadenectomy is the cornerstone of the multimodality treatment with curative intent. Worldwide transthoracic esophagectomy is the preferred procedure which allows en-bloc resection of tumour. Thorcoscopic approach reduces the morbidity and mortality associated with open procedure. Robotic approach for esophagus resection is appealing but still under investigational stage.
We adopted to VATS or actually total thoracosopically . There were not many teachers and I used to watch websurg and refined my technique slowly. We avoided putting hand in chest and operating or avoided opening chest after we started thoracoscopically. This happened 15 years ago in Yashoda Hospital, Secunderabad when I joined there initially.
My passion of Robotic technology and especially doing an Esophagectomy took me to KIMS Hospital where first early robot EA’s launched10 years ago. Even before I was trained in the handling of robotic instruments I did my first robotic Esophagectomy with extrapolation of our well established steps of the procedure. There were no videos those days ,our knowledge of selecting proper case, prep work up (learnt from Kidwai), gentle handling of tissue and Esophagus like in thoracoscopy helped us in completing these 176 procedures on the whole.
GAJA’S TECHNIQUE OF ROBOTIC ESOPHAGECTOMY consists of 10 steps done sequentially and carefully
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 video POSTED IN YOUTUBE CHANNEL demonstrates technique of esophagectomy and clearance of recurrent laryngeal nodes, subcarinal and parabronchial nodes along with lower periesophageal group. The abdominal part is done in supine with dissection of coeliac, left gastric, hepatic and splenic nodes with preparation of gastric conduit with staplers. The end to end esophago-gastric anastomosis is performed with mobilized stapled gastric conduit and cervical esophagus in single layer .The patient is discharged on 6th postoperative day and oral intake was started on 10th postoperative day.
We have been performing robotically assisted radical esophageal mobilization for operable carcinoma esophagus since 10 years.
In our experience the magnified 3 D image of the robot coupled with dexterity of instruments helps us to dissect critical areas like recurrent laryngeal nodes specially on the opposite side and splenic nodes with extreme accuracy and comfort. Approach to Aorto-pulmonary window and subcarinal region was also safe and easier with robotic approach.
And as our experience grew we have demonstrated our technique in called and every workshop of ours which me, Dr.Kiran Mai and Dr. Kaveri Shaw introduced MIOS- Minimally Invasiv Onco Surgery workshop. MIOS was a great success done whether we were in KIMS or Yashoda.
Also becoming INTUITIVE PROCTER for robotic procedure helped me in going to great institutes like TATA, Mumbai, AIIMS, SGPGI,JIPMER, Yenopaya, APollo, Fortis etc.
After a decade of robotic surgery experience and three decades of surgical practice I realised that every case I’d different and we need to personalise the treatment and explain clearly to patients. Esophagectomy does have complications and we need to be realistic in our approach and be honest with patient. Sometimes in spite of best of the efforts we do have problems pos op as they are very high end surgeries. But I really feel Robotic Esophagectomy has changed my thinking and definitely helps patient in terms of lesser complications, better dissection, better lymph node yield and faster return to work.
excellent work Dr Jagdeesh you are a role model