Robotic Assisted Transhiatal Esophageal Epiphrenic Diverticulectomy Technique Compared To Other Diverticulectomy Techniques
Nidhi Desai, John Waters, Tanya Pothini, Scott Reznik, Steve Ring, Michael Jessen, Sravanya Gavini, Howard Weiner, Kemp Kernstine.
UT Southwestern Medical Center, Dallas, TX, USA.
Background: Historically, epiphrenic esophageal diverticula (EED) have been resected through left thoracotomy. We designed a robotic transhiatal (RTED) technique that minimizes perturbation of the esophageal hiatus, avoids transthoracic access and blind passage of dilators, and resects the diverticulum. We compared short- and long-term outcomes of this technique to other techniques at our institution and the literature. Methods: From 2005 to 2022, we performed a retrospective review of a prospectively managed database of EED patients. The 4-arm robotic approach requires 7 laparoscopic ports for a diverticulectomy and a 180-degree Heller myotomy that is extended 4 cm onto the stomach along with a Dor fundoplication. Demographic, clinical, and perioperative outcomes are delineated. We performed a systematic review of the literature. We compared RTED to other approaches at our institution and in the literature. Results: 15 patients underwent robotic diverticulectomy, 11 RTED and 4 transthoracic. For the RTED patients, average age 59 y (22 to 75 y), 36% males, average BMI of 27. 100% with dysphagia, 9% with weight loss (> 5% of their body weight) and 9% with evidence of chronic aspiration. The mean operative time was 294 minutes and estimated blood loss was 60 ml. Average size of the resected diverticulum by barium esophogram was 4.7 cm (2.3 to 6.6 cm). The median length-of-stay (LOS) was 5 days. There were no clinical leaks. 1 (9%) patient developed intra-operative bilateral pneumothoraces. 1 (9%) patient developed post-operative bilateral pulmonary embolism and right pleural effusion. 1 (9%) patient reported occasional dysphagia which resolved with dilation. Patient who presented with weight loss achieved stabilization. There were no recurrences, no 30-day readmissions, and no mortality. The mean Likert postoperative pain level on days 1, 2, and 3 were 6, 4, and 3, respectively and the 24-hr morphine equivalents were 336, 97, and 41 grams, respectively. The average cost of care was $36,699. Table 1 compares the clinical details and outcomes between this group, other techniques at our institution, and the literature. Conclusions: The RTED appears safe and efficient. Compared with alternative techniques at our institution and in the literature, the procedure takes longer to perform, but there is benefit in a shorter LOS and reduced complication rate. It restores normal anatomy while preserving key elements of the normal swallowing function. 
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