Robotic Enucleation of Giant Esophageal Leiomyoma
The patient was scheduled for robotic enucleation of the leiomyoma.
The authors performed a 4-arm technique with a 10 mm auxiliary port.
First, the pulmonary ligament was sectioned with the Maryland bipolar
forceps in order to mobilize the lung and facilitate esophageal
visualization. Second, the mediastinal pleural was divided anteriorly to
expose the anterior aspect of the esophagus and facilitate its
mobilization. The azygous vein was dissected and divided with an
endostapler. The mediastinal pleural was also divided posteriorly. A
myotomy of the muscular layer of the esophagus was performed with
Maryland bipolar forceps in order to expose and visualize the tumor.
Lesions of the mucosa should be avoided during this maneuver.
Once
the leiomyoma was identified, the myotomy was prolonged cranially and
caudally and blunt dissection and cauterization of adhesions between the
tumor and the muscular and mucosa layers was carried out in order to
free the tumor. Several tractor sutures were placed in different points
of the tumor. Pulling these sutures, the surgeon could mobilize the
tumor and better expose points of adhesions and tension. In this
particular case, the leiomyoma was lobulated. First the lower and bigger
part of the tumor was dissected, liberated from the esophagus with
blunt dissection and cauterization with Maryland bipolar forceps in
order to avoid mucosa injuries. Once liberated from the esophagus, the
specimen was inserted into an endobag. Later, the upper and smaller part
of the tumor was removed in the same manner. After complete removal of
the tumor, the mucosa was perfectly visualized, and an air bolus was
introduced in the esophagus through the nasogastric tube in order to
check the absence of esophageal leaks. Suture of the myotomy was
performed with a 3/0 barbed V-loc suture. Barbed sutures facilitate the
closure of the myotomy by making unnecessary to knot the suture and
providing a correct tension. Finally, the nasogastric tube was removed,
and a 24 F chest tube was inserted into the pleural cavity.
References
- Choong CK, Meyers BF. Benign esophageal tumors: introduction, incidence, classification, and clinical features. Semin Thorac Cardiovasc Surg. 2003;15:3-8.
- Inderhees S, Tank J, Stein HJ, Dubecz A. [Leiomyoma of the esophagus : A further indication for robotic surgery?]. Chir Z Alle Geb Oper Medizen. 2019;90:125-130.
