Robotic Enucleation of Esophageal Leiomyoma

Summary

This manuscript describes the surgical technique for robotic enucleation of an esophageal leiomyoma, serving as a reference for similar cases.

Abstract

Esophageal leiomyoma is a rare benign tumor of the esophagus. Depending on local complications, complete resection is the treatment of choice. Minimally invasive surgical enucleation should be performed if endoscopic dissection is not possible. In this manuscript, we describe the technique for robotic enucleation of a mid-third esophageal leiomyoma. A 58-year-old patient presented with increasing dysphagia to our outpatient clinic. Endoscopy revealed a submucosal tumor at around 25 cm measured from the upper incisors. CT scan showed an esophageal tumor measuring 7 cm in diameter between the junction of the azygos vein and the tracheal bifurcation. A biopsy taken from the specimens indicated the presence of leiomyoma. After discussion in the multidisciplinary tumor board, surgical resection was recommended. The operation was performed using a robotic system with a four-arm technique. Enucleation of the tumor succeeded without damaging the esophageal mucosa and without any other intraoperative complications. The postoperative course was uneventful, and oral food intake was started on postoperative day 1. Wound healing was unremarkable. The patient was discharged after 5 days. Histological examination confirmed the diagnosis of esophageal leiomyoma. The goal of this article is to present the state-of-the-art technique for the surgical removal of an esophageal leiomyoma as an organ-sparing procedure. This approach may serve as a valuable resource for surgeons seeking to provide optimal care for their patients.

Introduction

Leiomyoma of the esophagus is a rare mesenchymal tumor and approximately 50x less common than esophageal cancer¹. Although benign in nature, tumor growth often results in local symptoms such as dysphagia². Leiomyoma is the most frequent benign tumor of the esophagus and mostly occurs in the mid and lower third of the organ; tumor location in the proximal part of the tube is rather rare³.

Diagnosis of esophageal leiomyoma is crucial. Endoscopy and endoscopic-guided ultrasound reveal intraluminal tumor growth that is restricted to the submucosal layer. Computed Tomography (CT) or Magnetic Resonance Imaging (MRI) imaging shows a homogenous intraluminal tumor appearance, characterized as a smoothly elevated and sessile lesion in the posterior mediastinum⁴. The biopsy taken during endoscopy represents the gold standard for precise diagnosis.

Treatment of esophageal leiomyoma is recommended upon diagnosis and is relevant in case of local symptoms, mainly dysphagia. Depending on the size of the lesion, endoscopic treatment should be preferred as long as it is technically feasible⁵. However, endoscopic removal of the tumor carries the risk of perforation, leading to mediastinitis, sepsis, and other critical health conditions.

Surgical resection of esophageal leiomyoma is a valid treatment option and is predominantly applied if larger tumor growth is present⁶. Surgery can be carried out by an open trans-thoracic approach or minimally invasive, such as thoracoscopically or robot assisted. In recent years, the minimally invasive approach has become increasingly adopted in clinical practice and is now routinely performed in specialized centers⁶. The limits of minimally invasive surgery might be a tumor size larger than 10 cm and a lesion location higher than 15 cm measured from the upper incisors. Compared to thoracoscopy, robot-assisted surgery reduces surgical trauma due to high, 3D-based magnification and its triangulation capabilities. Several robotic systems from different companies are used in clinical practice.

Numerous intrathoracic operations are performed safely, robot-assisted, including esophageal or lung resection^7,8. Robot-assisted enucleation of esophageal leiomyoma has been rarely described. Some individual reports can be found in the literature^9,10,11. Robotic surgery is associated with fewer intraoperative and postoperative complications, increased surgical accuracy, and earlier recovery from surgery, resulting in shorter hospital stays¹².

The aim of this article is to present a case report of a male patient with a leiomyoma in the mid-third of the esophagus. Surgical removal is carried out by robot-assisted enucleation. This provides a step-by-step tutorial beginning from robotic port placement to enucleation of the specimen and closure of the thorax. It may serve as a guide for use in further operations performed by other surgeons for patients with leiomyoma of the esophagus.

Case presentation:

We present the case of a 58-year-old male patient with a 6 month history of increasing dysphagia. Upper endoscopy shows submucosal tumor growth at 25 cm. Consequently, a CT-scan was performed, revealing a 7 cm tumor in the esophagus. Histologically, a benign leiomyoma was diagnosed. Surgery therapy was indicated.

Protocol

The patient's treatment was performed in accordance with the principles of the Declaration of Helsinki. The operation was carried out after the patient's written consent. Additionally, the patient gave written consent to the preparation of this article.

1. Preoperative procedures

1. Perform endotracheal intubation using a double-lumen tube, ensuring single ventilation of the left lung once the operation in the right hemithorax was performed.
2. After maintenance of general anesthesia, place the patient in a left-lateral position. Ensure that the left arm is placed in a swimmer-like position during crawling.
3. Place the covers after sterile disinfection of the operating field.

2.  Port placement and Robot docking

1. Use a robotic platform with a four-arm technique: 8 mm robot ports, one 12 mm assistant port was used.
2. Place the first 8 mm robot port, 4 cm medio-cranial to the apex of the scapula, in the fourth intercostal space.
3. Controlled via thoracoscopy, place the remaining three 8 mm robot trocars in the 6th, 8th, and 10th intercostal space.
4. Place the 12 mm assistant trocar in the fourth intercostal space 10 cm medial to the initially placed 8 mm port (Figure 1). Afterwards, dock the robot. 
5. Equip arm one with forceps, arm two with bipolar forceps, arm three with a 30° camera and arm four with a monopolar cautery hook.
6. Obtain pneumoperitoneum with 8 mmHg. Use arm one to retract the lung, supported by the assistant with a gauze swab.

3. Surgery

1. Start the operation by displaying the junction of the azygos vein. Ligate the vein with plastic clips through the assistant trocar.
2. Then, mobilize the esophagus while preserving the right vagal nerve. After complete mobilization of the esophagus over a length of ~10 cm, start enucleation of the lesion.
3. Perform myotomy with the monopolar cautery hook. In case of bleeding, use the bipolar forceps.
   NOTE: A formal myotomy was not necessary for this case. We partially used the hook's energy, while other steps of the procedure worked well just by the stump displacement of the muscle fibers.
4. During enucleation, ensure that the esophageal submucosa stays intact. If needed, perform traction with arm two and the bipolar forceps, assisted through the 12 mm port with a grasper. After the leiomyoma is completely removed, place it into an endobag.
5. Close the myotomy using a running suture. Afterwards, perform intraoperative endoscopy to exclude injury of the esophageal mucosa. During endoscopy, place and fix a nasogastric tube.

4. Postsurgical steps

1. Undock the robot and retrieve the specimen through the 12 mm incision. To do so, enlarge the incision to 3 cm. Ensure that the ribs were carefully spread, initially using a small Roux hook. Insert a wound protector if needed.
2. Remove the specimen and send it out for histological examination (Figure 2D-F).
3. Insert and fix a 16 Charrière chest drain. After removing the wound protector, close the thorax. Before tying the knots, ventilate the right lung, and visually check for sufficient reinflation.
4. Close the subcutaneous tissue with 3-0 polyfil suture. Close the skin with 3-0 monofil suture material.
5. Administer 2% ropivacaine injection to ensure sufficient analgesia.

Results

After the operation, the patient was supervised in the recovery area and transferred to an intensive care unit for one night. The next day, the nasogastric tube was removed, and drinking was allowed. Oral food uptake increased continuously throughout the day. Laboratory test readings stayed within a normal postoperative range: white blood cell (WBC) count was 7,300/µL, and C-reactive protein (CRP) level was 25.6 mg/L. Wound healing was unremarkable. The patient was discharged on the fifth postoperative day. One week afte...

Discussion

The best strategy for the treatment of esophageal leiomyoma is always based on multidisciplinary discussion. Successful endoscopic submucosal tunnel dissection for resection of submucosal esophageal tumors has been described before¹³. Hence, the best therapy also depends on the local capacities and availabilities. Large leiomyomas can be safely treated by surgery. The preferred technique for enucleating the tumor is robot-assisted. The advantages of this approach compared to thoracoscopy outweigh ...

Materials

List of materials used in this article

Name	Company	Catalog Number	Comments
Alexis wound protector	Applied Medical	C8702
Dafilon suture	B. Braun	C0932213
DaVinci Xi	Intuitive	IS4001-01
Endobag	Homeport	SL-A1
Hem-o-lok clip	Teleflex	544204
PDS cord	Ethicon	ZX2026
Stratafix suture	Ethicon	SXMP1B425
Vicryl suture	Ethicon	VP2401