What are the steps of a robotic McKeown esophagectomy in an adult patient with resectable distal or mid‑esophageal cancer who is medically fit for minimally invasive surgery?

Robotic McKeown Esophagectomy Operative Steps

The robotic McKeown esophagectomy is performed in three distinct phases: thoracic esophageal mobilization with two-field lymphadenectomy using the robotic system, laparoscopic abdominal gastric mobilization, and cervical esophagogastric anastomosis. 1, 2

Phase 1: Thoracic Phase (Robotic-Assisted Right Thoracoscopy)

Patient Positioning and Port Placement:

• Position the patient in left lateral decubitus position for right thoracoscopic approach 1, 3
• Place robotic ports in the right chest to access the thoracic esophagus 4, 3
• Utilize the Da Vinci robotic system for enhanced surgical dissection with additional degrees of freedom and 3D visualization 2

Thoracic Dissection:

• Mobilize the thoracic esophagus completely using robotic instruments 1, 2
• Perform two-field lymphadenectomy including mediastinal and upper abdominal lymph nodes 1, 2
• Dissect the esophagus from surrounding structures with improved precision from robotic ergonomics 2
• Divide the azygos vein to facilitate complete mobilization 3
• Preserve the recurrent laryngeal nerves during dissection (though injury remains a recognized complication) 4

Phase 2: Abdominal Phase (Laparoscopic)

Gastric Conduit Creation:

• Perform laparoscopic abdominal mobilization of the stomach 5, 1, 2
• Create a gastric tube conduit for esophageal reconstruction, which is the preferred conduit 5
• Perform abdominal lymph node dissection to achieve at least 15 lymph nodes for adequate oncologic staging 5, 6
• Preserve the right gastric and right gastroepiploic arteries to maintain conduit perfusion 3
• Divide the left gastric artery and short gastric vessels 3
• Create a pyloroplasty or pyloromyotomy to facilitate gastric emptying 3

Phase 3: Cervical Phase (Open)

Cervical Anastomosis:

• Make a left cervical incision to access the cervical esophagus 5, 1, 3
• Mobilize the cervical esophagus and divide it at the appropriate level 3
• Pull the gastric conduit through the posterior mediastinum into the neck 3
• Create a hand-sewn cervical esophagogastric anastomosis 2, 3
• Place a feeding jejunostomy tube during the abdominal phase for postoperative nutrition 5

Key Technical Advantages

The McKeown approach offers specific benefits over the Ivor Lewis technique:

• Suitable for proximal and mid-esophageal tumors requiring adequate proximal margins 7, 1
• Allows three-field lymph node dissection for comprehensive oncologic resection 1, 3
• Avoids the morbidity of intrathoracic anastomotic leak, as cervical leaks are generally better tolerated 1, 4

Expected Operative Parameters

• Mean operative time approximately 500 minutes (8+ hours) 2
• Mean blood loss approximately 350 mL 2
• Mean hospital stay 13 days 2
• Conversion to open procedure may be necessary in approximately 7% of cases 6

Critical Pitfalls to Avoid

Anastomotic complications remain significant:

• Cervical anastomotic leak occurs in approximately 15% of cases but is typically managed conservatively 4, 2
• Recurrent laryngeal nerve injury continues to occur despite careful dissection 4

Lymph node dissection requirements:

• Remove at least 15 lymph nodes for adequate staging in patients without neoadjuvant therapy 5, 6
• Similar lymph node resection is recommended after preoperative chemoradiation, though optimal number is unknown 5

Patient selection considerations:

• This procedure should only be performed in high-volume esophageal centers by experienced surgeons 5, 8
• Robotic approach requires surgeons with specific expertise in robotic techniques 2
• Patients must be medically fit to tolerate this extensive three-phase operation 8