Abstract
Introduction:
Esophageal leiomyomas are the most common benign tumors of esophagus, although rare. 1,2 Treatment of esophageal leiomyomas depends on tumor size, location, patient condition, and surgeon experience. For tumors ≤5 cm, transthoracic enucleation is the treatment of choice. 3 –5 For tumors ≥8–10 cm, termed “giant leiomyomas,” enucleation may still be performed although with an associated higher incidence of both dysphagia after closure of the esophageal muscle defect and reflux if the lower esophageal sphincter is involved. 5 –8 We present a patient with a giant leiomyoma who underwent robotic laparoscopic enucleation.
Case Details:
The patient is a 56-year-old female with a body mass index of 32 kg/m2 who presents with 6 months of intermittent chest and epigastric pain and associated dysphagia. Her comorbidities included diabetes, hypertension, and gastroesophageal reflux disease. Esophagogastroduodenoscopy demonstrates external compression of distal esophagus without other intraluminal findings. A subsequent chest computed tomography scan reveals an 8-cm lobular soft tissue mass circumferentially involving the lower esophagus. Endoscopic ultrasound shows a multilobulated hypoechoic mass measuring 8 × 6.2 cm involving 75% of the esophageal circumference. Three distinct lobules were noted as were internal calcifications. Fine-needle aspiration biopsies showed leiomyoma with benign features.
Surgical Technique:
The patient was positioned supine with both arms extended laterally. The operating table was positioned in steep reverse Trendelenburg and right lateral decubitus. We used four 8 mm robotic trocars, one accessory 11 mm trocar, and a subxyphoid 5 mm skin incision for a Nathanson liver retractor. Upon access to the peritoneum, the gastrohepatic ligament was divided as was the phrenoesophageal membrane. The esophagus was circumferentially dissected from the hiatus. The gastric fundus was mobilized by dividing the short gastric vessels and retrogastric adhesions. The esophagus was enlooped with a Penrose drain to facilitate atraumatic esophageal retraction for further mobilization and mediastinal dissection. The tumor mass was observed and carefully dissected from the esophageal wall and other mediastinal attachments. Once the tumor was fully mobilized from the esophagus, the muscular defect in the esophagus was closed and a contralateral esophageal myotomy was performed. Cruroplasty was performed in a standard manner. Finally, a 270-degree posterior fundoplication was created. The tumor was removed from the abdominal cavity using a nylon-reinforced endobag through a dilated left lateral port site.
Results:
Our operative time was 132 minutes and the estimated blood loss was 5 mL. The patient was hospitalized overnight and discharged to home on postoperative day 1, on a full liquid diet. She was advanced to a soft diet at 1 week. The patient presented to the outpatient clinic at 2 weeks and 3 months for routine follow-up, and was noted to be doing very well without dysphagia or symptoms of gastroesophageal reflux.
Discussion:
Our operative technique demonstrates several advantages of the laparoscopic approach for enucleating distal esophageal leiomyomas, even when large. This approach allows direct access to both sides of the esophagus, facilitating the performance of a contralateral myotomy to lower risk of postoperative dysphagia after closure of the esophageal wall muscular defect. Similarly, creation of an antireflux fundoplication is readily performed to minimize risk for postoperative gastroesophageal reflux. In addition, the transabdominal approach for enucleating distal esophageal leiomyoma is more familiar to minimally invasive surgeons and allows a less morbid treatment option to thoracic surgery or esophageal resection.
Conclusion:
Robotic laparoscopic enucleation of lower esophageal leiomyomas is feasible and safe, even for large tumors. This approach also allows the benefit of concurrent myotomy and antireflux surgery. This technique should be preferred to the usual transthoracic approach when laparoscopic expertise is available.
No competing financial interests exist.
Runtime of video: 9 mins 20 secs
