Introduction
Leiomyomas are the commonest benign tumours arising in the oesophagus. They occur because of the hyperproliferation of smooth muscle cells of the muscular layer and are common in the muscular layer of middle and lower third of the oesophagus. They are usually slow-growing and are usually detected incidentally or may present with dysphagia, pain in the chest or upper abdomen, cough or dyspnoea. Complete excision is the surgery of choice, usually achieved by open thoracotomy . Video-assisted thoracoscopic surgery (VATS) is a minimally invasive alternative , but the two-dimensional (2D) vision as well as the limited range of movement of laprascopic instruments make dissection and suturing difficult . With the advent of Robotic- assisted surgery which offers the advantages of exceptional dexterity and a 3-dimensional stereoscopic vision ,this complex surgery especially preservation of mucosal integrity becomes relatively easier. We present a patient who presented with a large mid esophageal leiomyoma for whom we performed a robotic- assisted thoracoscopic (RATS) excision of oesophageal leiomyoma.
A 53-year-old woman presented to us with dysphagia and mild odynophagia due to a mid-esophageal leiomyoma. We present the preoperative workup with imaging , ports placed, equipment required, surgical, and postoperative follow up.
Patient Details :
A 53-year-old woman presented to us with dysphagia and mild odynophagia to solids progressively worsening over 1 year. Apart from an associated chronic back pain she had no other associated medical condition. otherwise . A CT scan of the chest showed a m dilated upper esophagus and an eccentric lobulated uniformly dense soft-tissue, mass posteriorly placed mid esophageal at the level of the azygos vein and retro carinal region. A contrast study showed a lobulated mid-esophageal mass with extrinsic compression of the esophageal leading to luminal narrowing. An upper GI endoscopy revealed a submucosal hypoechoic lobulated mass involving over 180 degrees of the mid esophageal circumference in the posterior aspect with a linear extent of 6 cm, which seemed consistent with a diagnosis of leiomyoma.
Position, port placement, equipment used, and exposure:
We used the semi-prone position , which is advantageous over lateral decubitus. We have a clearer view of oesophageal bed and posterior mediastinum with gravity-aiding clearance of blood from the surgical field. There is also along with no need for lung retraction because the lung and the hilum move away from the field due to gravity and pneumothorax. From our experience with thoracoscopic esophagectomies in full prone position visualisation of the oesophagus is better in semi-prone position because the vertebral bulge becomes less prominent owing to more anterior placement of the camera port.Semi-prone position also allows for a more anterior placement of ports in a location where the rib spaces are wider, leading to less torque at entry points and less trauma to the neurovascular bundle at points of entry.
The patient was positioned semi prone carefully padding all pressure points. We used a total of 4-ports , 3 robotic and one asssistant port for this operation. The port positioning was similar to arrangement that we use for an esophagectomy. We used a 30- degree camera. The robotic ports were 8-mm , and 1 port was 12 mm for clips and suction as well as to hold and retract the esophagus. The left hand port (arm 1) had a fenestrated bipolar grasper. The right hand port(arm 3) has a hot shears (monopolar scissors ) . Arm 2 was used for the camera. The 12-mm assistant port was used for clipping the azygos vein, suction adn retraction of the lung as well as holding and retracting the esophagus. The robotic instruments which we used were are the fenestrated bipolar grasper for the initial dissection, the hot shears for the dissection , a needle driver for suturing . A12-mm specimen- retrieval bag was also introduced through the 12 mm assistant port.
Esophageal dissection and myotomy
The esophagus was exposed by dividing the mediastinal pleura
then circumferentially mobilising and releasing the esophagus.
The azygos vein was dissected circumferentially and then clipped and divided. The esophagus was exposed adequately to expose the entire leiomyoma.
After exposing sufficient length of the esophagus the next step was to expose the leiomyoma itself by rotating the esophagus and then dividing the muscle over the mass. The robotic monopolar scissor was used with short bursts of energy to separate the leiomyoma all around and then peel it away from the muscle carefully avoiding opening up the mucosa of the esophagus.
The outer longitudinal muscle layer was peeled off the leiomyoma, exposing it all around. The leiomyoma was completely freed from the esophagus and placed in the right hemithorax.
Myotomy Closure
Next we closed the myotomy after a careful inspection to rule out any mucosal injuries. The myotomy was closed using 3-0 vicryl suture which was locked at the end of the myotomy. The specimen was then placed in a bag and retrieved via the 12-mm port. An intercostal nerve block was given, a drain placed, the lung was reinflated, and incisions were closed in layers.
Postoperative Course
The postoperative course was unremarkable. She was started on fluids on post op day 2 and advanced to a regular diet as tolerated, and the chest drain was removed .She was discharged on postoperative day 4.Sutures were removed on a routine post operative visit on day 14 ,by when her symptoms had completely resolved, and all incisions had healed well . The final pathological report revealed a 6-cm x 4-cm x 3-cm benign leiomyoma.
Discussion
Excision of esophageal leiomyoma is the preffered treatment in symptomatic patients. Both open and minimally invasive approaches are safe and effective. Robotic trans thoracic excicion of leiomyomas have been previously reported, but not well described. In this case presentation, we describe the continuity of treatment of the patient.
Video-assisted thoracoscopic surgery is the commonest minimally invasive approach used, but is not universally used as it is limited by difficulties associated with it like 2-dimensional vision and straight instrument motion that are challenging and risk disrupting mucosal integrity, especially in leiomyoma involving the upper and middle esophagus . The robotic approach, due to its endowristing offers the advantages of versatility of movement, 3D vision, and efficiency within delicate and confined spaces that are inevitably awkward with traditional VATS. The ergonomic comfort to the surgeon is also something that cannot be underscored especially in patients with a large body habitus. Several studies are now demonstrating the safety and non inferiority of outcomewith s robotic enucleation versus open and VATS approaches.
To conclude this case describes the operative technique and the advantages the robotic approach can offer for a leiomyoma of the esophagus . The 3D vision , magnification and the endo wristed instrumentation are very useful for a safe and delicate dissection in this situation.
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Dr. Sujay Susikar
Senior Consultant Surgical Oncologist and Robotic Surgeon
Kauvery Hospital, Chennai.
Dr. Kishore Kumar Reddy K
Consultant
Kauvery Hospital, Chennai