Our next speaker is Blair Marshall,

who is going to show us

all the tips for avoiding me when

asked about leaks.

Thank you, Gail.

I have no disclosures related to

this talk,

so I'm just going to highlight

some technical aspects of the

esophageal anastomosis and how

I do it, how I set it up and

go over some Perles pitfalls and

lessons learned for the

technique that I use to do minimally

invasive esophagectomy and also

robotic.

So for poor placement, I do a little

bit differently than the Pittsburgh

group. But and the reason

is because when

I do my dissection, instead of like

a parasite

with your hernia coming across from

the right side of the patient to the

left, like that beautiful view

that gal showed you of the Karara,

I will flip the stomach up

once I've taken the short gastrique

and come at it that way.

And in bulky disease, it just helps

me a little bit more.

And I use four or five

millimeter sports and 12.

I use a five millimeter, 30 degree

camera.

If I do it robotically, I put my

points in the same place,

but I will add a 12 millimeter

utility for it.

And the reason I do this is so I can

stick a sponge in and

tamponade and I'll show you a little

bit of that.

And so the resident can help.

I still use 205 millimeter

grasshoppers. Mostly I use a

thoracic grasshoppers because

actually they fall off the stomach.

So I know I'm not going to hurt it,

unlike using some of the other types

of thoracic grasshoppers

for the robot.

So I do a modified candy

cane technique, but because of the

posterior node or fat tissue,

I will then make an accessory staple

line here because I don't disconnect

the conduit.

I'm a little more scared that

I will force it.

And this way it's been more stable

for me, so I leave it intact.

And that way we have

the stress on the staple line that's

going to get resected anyway.

So this is I do like Gayle does

and come right down on the gastric

wall. And the reason is

so that typically I usually

run into some bleeding, then I'm

going to have to over.

So and rather than doing that,

if I've dissected all that off,

I don't have as much bleeding of my

staple line.

You really want to stretch out your

conduit? I put this in so, you know,

not to to divide it there

when it's all redundant like that.

And one thing I've come to

appreciate is that the post

here, gastric wall may be a little

more redundant that the anterior

gastric wall. And so you really want

to make sure you stretch it out on

both sides and that sometimes

you think you have a force and mere

conduit, but you actually have more

posterior wall.

And so your conduit might be larger

than you think.

I don't put a sock in the measure,

but the grasper is on the robot

a four centimeters and I have the

measurement of the stapler.

And so I use that back and forth

to measure the width

of my conduit.

We articulate in the abdomen,

typically on the instruments,

and you can see there's a Penrhos

around the hiatus there

and I like to put that in and

then I'll show you.

After I've done a lot of the media

of deception through the hiatus,

I'll stick the Penrhos up into the

chest and then put

typically one to three, four by

eight, depending on

how much extensive dissection I've

done to tamponade everything

while you're closing the abdomen and

you're flipping the patient.

And so this is only going to show

double. And then

you could tie the Penrhos, which I

do as well. And it's easier to do

with the robot, but it's also we're

training residents and they need to

learn how to all use all these

instruments and devices.

And so

sometimes we use that this is

packing the mediastinum

and that way it's very dry when you

get to the chest.

So when I go to the chest, I don't

put the patient in a perfect lateral

decubitus.

I actually rotate them so

that the posture actually line is

more towards the ceiling.

And the reason I do this is so that

the lung is held by gravity.

And so you never need to waste a

grasper retracting the lung out

of your view.

I also used

to, as the operative surgeon,

be posterior to the patient.

But now both me and the

resident are anterior and that

allows a number of things.

One, that you can do the dissection

and hand off the dissection back and

forth easily with your resident when

they're struggling and that you're

both viewing the same viewpoint.

So no one's working backwards on the

camera.

I use four or five millimeter

ports and then the posterior one

is converted to an Alexis wound

retractor where the specimen removal

and the E.A. stapler.

If I do it robotically, I will put

my third arm a little higher,

and that's so you have full span

of the chest for your dissection

and we only have the PSI.

So that's

why I do it that way.

And then the assistant surgeon will

move over and I'll go the console.

This is the Orbital Anvil EPA.

It is a trans oral

anvil, which means it's attached

to an engine tube, which you pull

through your staple line or if you

do a purse string.

So because I staple off the

esophagus, this works very well

for me and is quite fast.

And I don't have to rely on my

ability to sew a purse, string

placements done by the anesthesia or

the resident the featherbed.

So when I do the time out, I

communicate and tell

them, are you familiar with this

technique? If you're not, I have a

video that's posted in

our department for them

that they can click on because it's

a long operation.

They have ample time to review

how to place that

Ambuhl and it's pretty

straightforward for us.

But my partner has had

them put the energy to portion

through the nose. And once you start

pulling out the esophagus, you find

out that the Ambles can't go through

the nose. It's somewhat upsetting

for the surgeon or they try

to put the stapler angle in first,

which is very counterintuitive.

But you can't anticipate

the errors that can be invented, you

know.

So communication's very important

here and there are some strategies

to help you place it.

It gets hung up on the perform

sinus. So there's a what we call

the laryngeal shake, where you pull

up on the larynx and shake it back

and forth so you can slide it down.

You also want that soft side

on the posterior wall and lube

it up very well.

The other thing that you do is it

gets hung up at the aortic arch in

the endotracheal tube balloon.

And so you sometimes need to just

deflate your cuff transiently

to pull it through and down.

So it goes very smoothly and it can

be very quick.

So this is just pulling up the

conduit.

And so you can see the stabilize

oriented properly

and then I just rely on tactile

feedback, I don't use any stitches

to tell me where everything is

and I haven't used the accessory

state line in this patient.

But this is the hook.

Scissors are perfectly sized to

transact the staple line here.

And then you'll see the tip of that

energy to.

And then that just now gets pulled

through that police report that I've

converted to and Alexis wound

retractor.

There's a five millimeter and

holder, and then you just

pull that out and

then I will pull my conduit up

and then so to silk sutures on

either side before

I transect the staple line and that

so I have something to pull, you

know, the sock over the foot

technique to get your E.A.

into your conduit.

And you can see there's a grasper

there that I'm using that's a

pediatric

laparoscopic grasper that's about

three millimeters in thickness

and 23 millimeters in

length so that you're not using your

laparoscopic instruments at the

patient's chest in your arms are up

here.

Once the pin goes through, you want

to make sure you see that orange

band and then fire your

stapler.

Gently rocket to extract

it.

And then resect the the rest

of the.

Open gastronomy,

so this

orrible ambles associated with a

highly great and I tried

to figure it out, so I tried a

number of things for many years and

others have experienced the same

leak rate and it's only two rows

of staples on your anastomosis.

And so I started wrapping all my

anastomosis with Omentum, and

that didn't change our leak rate.

So I spied everything and that

didn't change our leak rate.

But then I noticed when I was

scoping them that they seemed to

leak on the left side all the time.

And this is esophageal peristalsis

that we don't think about usually

because we don't see it.

We see it in the small ball all the

time. But that led me to the

concern that maybe there's tension

that I don't think about.

And so this is how we do our

anastomosis.

Right. And everybody talks about

wanting to put your pin through

between points and point B, because

those are it's a well vascularized

area. And so you're not going to

have ischemia.

But the problem is that when you

take that conduit up into the chest

and you start rotating it over once

your pin is there, that you've

actually falsely created an

increased area of tension

at point B, which is on the

left side.

And so once you

do your anastomosis, everything

looks perfectly sized in the chest.

But we haven't thought about when

the patient wakes up and starts

swallowing.

And so it led me to think that

it was that two rows

of staple line was not enough

to take care

of any tension that might be coming

from esophageal peristalsis.

And so then I started

circumferential over sewing

my staple lines and we saw a drastic

reduction in the incidence of

esophageal leaks.

But you can see this poster

interrupted suture overlying

the membranous portion of the

airway.

It's technically a pretty tricky

type of suture, and it's trickier

even to teach residents who don't

have as much experience as we

do. And so in order to facilitate

this is why I started doing some

robotic esophagectomy, because it

just facilitated at the end of a

very long operation how to

technically over so circumferential

the staple line.

And so this is the minimally

invasive technique, but this is the

robotic technique.

Another little trick I use is that

you can sometimes get this

mettlesome mediastinal

oozing that interferes with your

visualization.

And so because you have that Alexis

wound retractor open, I

will just take a pediatric

endotracheal tube and line it

up in the mediastinum and just keep

it on suction so it's continually

suction suctioning and I don't have

to stop to improve my visibility.

And so these backhanded angled

sutures are facilitated by

the use of a robot.

And this will come sometimes I run

it sometimes for robotically

I run it, but when I do it at the

bedside, I interrupted.

So am I in robotic arm?

There are challenging procedures,

meticulous attention to technical

aspects are critical, and in our

experience over sewing, the

anastomosis seems to significantly

improve the leak rate with the Orvil

E.A. in our hands.

Thank you.