Evolution of the surgical technique of minimally invasive Ivor-Lewis esophagectomy: description according to the IDEAL framework

• Published in: Diseases of the esophagus Vol. 32; no. 3
• Main Authors: Stenstra, M H B C, van Workum, F, van den Wildenberg, F J H, Polat, F, Rosman, C
• Format: Journal Article
• Language: English
• Published: United States 01.03.2019
• Subjects: Aged; Carcinoma - surgery; Esophageal Neoplasms - surgery; Esophagectomy - education; Esophagectomy - methods; Female; Humans; Laparoscopy - education; Laparoscopy - methods; Learning Curve; Male; Middle Aged; Outcome and Process Assessment, Health Care - methods; Outcome and Process Assessment, Health Care - standards; Proof of Concept Study; Thoracoscopy - education; Thoracoscopy - methods; Treatment Outcome; Ivor–Lewis esophagectomy; IDEAL framework; minimally invasive esophagectomy; learning curve
• ISSN: 1120-8694; 1442-2050
• DOI: 10.1093/dote/doy079

Totally minimally invasive Ivor-Lewis esophagectomy (Ivor Lewis TMIE) is a technically challenging procedure and is associated with a learning curve. Refinement of surgical technique is an important part of this learning curve. However, detailed descriptions of these refinements according to the idea, development, exploration, assessment, and long-term follow-up (IDEAL) framework are lacking and this study was undertaken to fill this knowledge gap. From 2010 until 2016, all consecutive patients (n = 164) were included from the first patient undergoing Ivor Lewis TMIE. Surgical reports were analyzed and surgeons were interviewed to determine surgical refinements. These data were used to describe the transition of the surgical technique from IDEAL stage IIB to stage III. The main findings were that four refinements were made to the surgical procedure in IDEAL stage IIB: (1) At case 9, the use of the 25 mm OrVil was abandoned, exchanged for a 28 mm EEA stapler and a large omental wrap around the anastomosis was introduced; (2) at case 27, the omental wrap was reduced in volume; (3) at case 60, the omental wrap was refined to cover the full 360° of the anastomosis and (4) at case 77, the fixation of the anvil with the Endostitch was replaced by fixation with two Endoloops®. During the transition from IDEAL stage IIB to stage III, the incidence of anastomotic leakage decreased from 26.0% to 4.6% (P < 0.001) and the incidence of textbook outcome increased from 31.2% to 47.1% (P = 0.039). In conclusion, this study describes the surgical refinements that were made during the progression of Ivor Lewis TMIE from IDEAL stage IIB to IDEAL stage III. During IDEAL stage IIB, postoperative outcome improved as surgical proficiency was gained and the technique was refined.