450. LINEAR STAPLED TECHNIQUE FOR ROBOTIC ASSISTED MINIMALLY INVASIVE ESOPHAGECTOMY AND GASTRECTOMY: TECHNIQUE, STEPWISE INTRODUCTION, REPRODUCIBILITY AND OUTCOMES

Background Robotic-assisted surgery (RAS) for esophagectomy and gastrectomy is gaining in popularity. Compared to open oesophagectomy and conventional minimally invasive techniques, RAS is associated with decreased rates of complications, increased harvested lymph nodes and shorter length-of-stay. However, high anastomotic leak rates (20–27%) have been seen within randomised trials and case series, with up to 50% early in some published series. We present our technique and results of the staged introduction of a linear anastomosis. Methods The technique was initially developed by a single surgeon at open surgery; then adapted to thoracoscopic surgery and finally reproduced at RAS by several surgeons across two centres. Using a prospectively maintained database we reviewed the first forty-two cases utilising a modified linear anastomosis technique for oesophageal anastomosis. Outcomes, with particular focus on the anastomosis were reviewed. We also describe in detail the technical steps involved in our technique for a side-to-side linear semi-mechanical stapled anastomosis using a tri-stapler, with a 2-layer V-lock closure of the common enterotomy, during robotic surgery (video https://www.dropbox.com/s/ljf3zmuy68qry7b/Anastomosis%20technique_Short_Sound.mp4?dl=0). Results Forty patients had a two-stage esophagectomy, one with colonic reconstruction, and two, total gastrectomy. Median age was 62 (range 47–85). 93% (39/42) were adenocarcinomas, the remainder were squamous cell carcinomas. The anastomosis was performed via an open approach in the initial 11, thoracoscopically in 4, then robotically in 27 (including the two gastrectomies). The first 20 anastomoses were performed by one surgeon, who then taught four others. Two grade I anastomotic leaks occurred (4.7%), both were treated conservatively. There was no 30-, 90-day, or in hospital mortality. Non-anastomotic complications occurred in 14/42 (33.3%) of patients, most commonly respiratory (5/42, 11.9%). Conclusion We report a reproducible technique for semi-mechanical linear stapled anastomosis and its safe introduction into esophageal and gastric resections, including RAS. Anastomotic leak rates are below the internationally reported rates, even in the early phase of its introduction in open, thoracoscopic and RAS. With good training and mentorship this may help more centres safely introduce a RAS esophago-gastric programme, improve patient outcomes and reduce length of stay.