Robot-assisted thoracoscopic excision of a giant leiomyoma of the upper esophagus: A technical report

Robot-assisted thoracoscopic excision of a giant leiomyoma of the upper esophagus: A technical report | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Help Center Sign In Submit a Preprint Cite Share Download PDF Case Report Robot-assisted thoracoscopic excision of a giant leiomyoma of the upper esophagus: A technical report Wenqiang Wu, Zhigang Wang This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-3792525/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background: Esophageal leiomyoma is a relatively rare disease that can occur in any part of the esophagus. In the past, open thoracic surgery or video-assisted thoracoscopic surgery (VATS) were commonly used to remove esophageal leiomyomas. Case presentation: A 21-year-old male patient presented with progressive dysphagia for more than 3 years. Esophageal radiography showed a narrowed chest esophageal lumen. Esophagoscopy revealed a large tumor located 24 cm-31 cm from the incisor teeth. Robot-assisted esophageal tumor removal was performed under general anesthesia.On the third day after surgery, the patient resumed a fully liquid diet. A follow-up upper gastrointestinal contrast radiography after surgery showed no esophageal perforation, and the contrast agent passed through the esophagus smoothly. Conclusions: In this patient, the esophageal mass was large and located at the upper and middle esophagus; it was deep and had a complex anatomical structure. Robotic surgery, however, results in less trauma and precise manipulation than open surgery and is a more suitable surgical approach for deep and complex tumors in the chest cavity. esophageal leiomyoma robot-assisted surgery surgical technique Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Figure 6 Figure 7 Figure 8 Background Esophageal leiomyomas are relatively rare and can grow anywhere in the esophagus. Sixty percent of cases occur in the distal third of the esophagus, 30% in the middle third, and 10% in the proximal esophagus [ 1 ] . Patients often present with dysphagia as the main complaint, without specific clinical manifestations. Preoperative endoscopic localization and needle aspiration biopsy can confirm the diagnosis, mainly to distinguish it from esophageal stromal tumors. There are significant differences in the expression of SMA, desmin, CD117, and CD34 between the two subtypes, with positive expression of SMA and desmin in leiomyomas and positive expression of CD117 and CD34 in stromal tumors [ 2 ] . After diagnostic puncture, the esophageal mucosa layer is damaged, increasing the risk of mucosal perforation and postoperative esophageal fistula during surgical tumor debulking. Therefore, preoperative endoscopic aspiration biopsy is not recommended [ 3 ] . Esophagoscopic resection is suitable for removing tumors originating from the esophageal mucosal muscle layer and with a pedicle and a small diameter [ 3 ] . Previously, open thoracotomy or VATS was commonly used for the removal of esophageal leiomyomas. Open thoracotomy is associated with greater trauma, more intraoperative bleeding, slower postoperative recovery, and a longer hospital stay than VATS [ 4 ] . VATS imaging is two-dimensional, with a maximum field of view that can be magnified up to three times, and the activity of the operating instruments is limited. Robotic-assisted thoracoscopic surgery (RATS) provides three-dimensional imaging, allowing the field of view to be magnified by 6–10 times, with even greater freedom of robotic arm operation, which can be rotated 540 degrees [ 5 ] . Second, VATS is performed by hand through the lever principle, and subtle movements in the body cavity can be magnified. In terms of endoscopic stability, the RATS is more stable. In addition, traditional thoracoscopy uses the lever principle to pinch on the ribs, repeatedly rubbing and squeezing the intercostal nerves, significantly increasing postoperative incision pain. RATS reduces friction and injury through trocar protection, resulting in less postoperative pain [6]. In terms of operation time, robotic surgery has a similar operation time to traditional video-assisted thoracoscopic surgery [ 6 ] . Case Presentation 1. General information A 21-year-old male patient presented with progressive dysphagia for more than 3 years. He was thin, and his chest and abdomen were enhanced on CT (Fig. 1). The upper and middle esophageal masses showed pushing changes to the trachea and azygos vein, and the corresponding esophageal lumen was significantly narrowed. Esophageal radiography (Fig. 2) showed a narrowed chest esophageal lumen. Preoperative esophagoscopy (Fig. 3) revealed a large tumor located 24 cm-31 cm from the incisor teeth, with a smooth surface, narrow lumen, and normal mucosa. The surrounding anatomy was complex, and it was recommended that the patient undergo robot-assisted surgery to exclude surgical contraindications. After intubation with a double-lumen endotracheal tube and one-lung ventilation, robot-assisted esophageal tumor removal was performed under general anesthesia. 2. Surgical Method 2.1 Patient position: The patient assumed a left lateral position with a 45-degree anterior tilt. Four robotic arms were used for the operation (Fig. 4). The assistant port is located at the seventh intercostal space along the anterior axillary line (Fig. 4A). 2.2 After entering the chest, the lungs collapse and are pushed forward. The mediastinal pleura of the upper and middle esophagus significantly bulges, with a medium texture. The esophageal lumen above the mass was significantly dilated (Fig. 5A). 2.3 Opening of the mediastinal pleura, ligation and dissection of the azygos vein (Fig. 5B), and exposure of the esophageal muscle layer (Fig. 5C) 2.4 Upon opening the esophageal muscle layer, the mass was found to have clear boundaries, a tough texture, and a size of approximately 96 mm×67 mm×33 mm. The patient exhibited limited mobility and had not invaded the esophageal serosal layer (Fig. 6D). 2.5 Blunt and sharp dissection were used to completely remove the mass along its surface (Fig. 6E), with no injury to the esophageal mucosa (Fig. 7F). 2.6 Suturing of the esophageal muscle layer with silk thread (Fig. 7G) and suturing of the mediastinal pleura with 3 − 0 vicryl thread (Fig. 7H). 3. Results No postoperative complications occurred. Postoperative parenteral nutrition support was provided, and anal exhaust was recovered on the second day after surgery. On the third day after surgery, the patient resumed a fully liquid diet. A follow-up X-ray chest film showed good lung expansion and no pleural effusion or pneumothorax. Upper gastrointestinal contrast radiography on the fifth day after surgery showed no esophageal perforation, and the contrast agent passed through the esophagus smoothly (Fig. 10A). The patient was discharged on the sixth day after surgery. Pathological examination revealed an esophageal leiomyoma with a size of 9 cm × 6.8 cm × 3.5 cm. Immunohistochemistry revealed vimentin (focal+), SMA (+), Dog-1 (-), S-100 (focal +), CD117 (-), desmin (+), CD34 (vascular endothelial +), and Ki67 (approximately 1%). Upper gastrointestinal contrast radiography on the eleventh day after surgery showed no esophageal perforation, and the contrast agent passed through the esophagus smoothly (Fig. 10B). Discussion and Conclusions The robotic arms provide flexible, high-degree-of-freedom, and stable operation and are even superior to direct manual operation when performing local operations. The advantages of this approach are especially pronounced for tissue separation and vascular dissection. In this patient, the esophageal mass was large and located at the upper and middle esophagus; it was deep and had a complex anatomical structure. Traditional open thoracotomy can cause significant damage, while VATS is highly difficult and prone to damaging the esophagus, surrounding nerves and blood vessels. Robotic surgery, however, results in less trauma and precise manipulation than open surgery and is a more suitable surgical approach for deep and complex tumors in the chest cavity. The surgical approach and treatment philosophy presented in this case report offer valuable insights for reference. Abbreviations VATS video-assisted thoracoscopic surgery RATS robotic-assisted thoracoscopic surgery Declarations Ethics approval and consent to participate: This article has been authorized by the patient and his family, who have signed a consent form. All authors have read and approved all versions of the manuscript, its content, and its submission to Journal of Cardiothoracic Surgery. Funding: Not applicable Authors' contributions: Zhigang Wang were surgeons who make surgical plans. Wenqiang Wu collected and collated all the information.Wenqiang Wu prepared figures and tables. Zhigang Wang revised the manuscript. All authors read and approved the final manuscript. Acknowledgements: We also wish to express our special gratitude to our colleagues in the thoracic surgery department and operating room for their support and assistance. Availability of data and materials Data supporting the results reported in the article can be found in the medical record database of the affiliated hospital of Guangdong Medical University References Mutrie CJ, Donahue DM, Wain JC, Wright CD, Gaissert HA, Grillo HC, Mathisen DJ, Allan JS. Esophageal leiomyoma: a 40-year experience. Ann Thorac Surg. 2005;79(4):1122-5. 10.1016/j.athoracsur.2004.08.029 . PMID: 15797036. Xu GQ, Zhang BL, Li YM, Chen LH, Ji F, Chen WX, Cai SP. Diagnostic value of endoscopic ultrasonography for gastrointestinal leiomyoma. World J Gastroenterol. 2003;9(9):2088–91. 10.3748/wjg.v9.i9.2088 . PMID: 12970912; PMCID: PMC4656680. Zheng RH, Feng MX, Ge D, Hou YY. [Diagnosis and treatment of esophageal leiomyoma]. Zhonghua Wei Chang Wai Ke Za Zhi. 2005;8(1):26–8. Chinese. PMID: 16148993. Shen C, Li J, Che G. Video-Assisted Thoracic Surgery vs. Thoracotomy for the Treatment in Patients With Esophageal Leiomyoma: A Systematic Review and Meta-Analysis. Front Surg. 2022;8:809253. 10.3389/fsurg.2021.809253 . PMID: 35087862; PMCID: PMC8786717. Veronesi G, Novellis P, Voulaz E, Alloisio M. Robot-assisted surgery for lung cancer: State of the art and perspectives. Lung Cancer. 2016;101:28–34. 10.1016/j.lungcan.2016.09.004 . Epub 2016 Sep 7. PMID: 27794405. Catelli C, Corzani R, Zanfrini E, Franchi F, Ghisalberti M, Ligabue T, Meniconi F, Monaci N, Galgano A, Mathieu F, Addamo E, Sarnicola N, Fabiano A, Paladini P, Luzzi L. RoboticAssisted (RATS) versus Video-Assisted (VATS) lobectomy: A monocentric prospective randomized trial. Eur J Surg Oncol. 2023;49(12):107256. 10.1016/j.ejso.2023.107256 . Epub 2023 Oct 31. PMID: 37925829. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-3792525","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Case Report","associatedPublications":[],"authors":[{"id":263268308,"identity":"0ef68b6d-0793-4f99-ba29-108c219e7a97","order_by":0,"name":"Wenqiang Wu","email":"","orcid":"","institution":"Affiliated Hospital of Guangdong Medical University","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Wenqiang","middleName":"","lastName":"Wu","suffix":""},{"id":263268309,"identity":"22afe1cb-d3cd-4660-b39a-566c2f6ce1b3","order_by":1,"name":"Zhigang Wang","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAx0lEQVRIiWNgGAWjYBACfvn3Dw58qKiRY2NvIFKLZEMO48MZZ44Z8/EcIFKLwYEcZmPeNubEeRIJRNty9pgEbxubMZvk4403GGpsoglq4WfsS5OQOCcjxyadVmzBcCwtt4GgLc0MZhIGZUBbpHPMJBgbDhPWYnAMqCWBjTmxTfIMsVrO8BgbHAB6v02Ch0gtkjPYEh82AAOZjQfolwRi/MIvwXzg8B9gVMq3H95440ONDWEtKI4kOmqQtJCqYxSMglEwCkYGAAAWQT1WTv7ulAAAAABJRU5ErkJggg==","orcid":"","institution":"Affiliated Hospital of Guangdong Medical University","correspondingAuthor":true,"submittingAuthor":false,"prefix":"","firstName":"Zhigang","middleName":"","lastName":"Wang","suffix":""}],"badges":[],"createdAt":"2023-12-22 14:29:13","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-3792525/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-3792525/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":49073146,"identity":"fdbacf01-eaf9-4d8b-9724-0a31605225ed","added_by":"auto","created_at":"2024-01-02 17:28:10","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":347428,"visible":true,"origin":"","legend":"\u003cp\u003ePreoperative Esophagography (A): The esophageal lumen is narrowed at the level of T3-T7 vertebrae, involving a length of approximately 10cm; Chest CT: Axial view (B), Sagittal view (C), Coronal view (D), The esophageal leiomyoma is located in the upper middle esophagus (approximately T1-T6 vertebral levels), measuring 96mm x 67mm x 33mm in size, pressing against the trachea and azygos vein.\u003c/p\u003e","description":"","filename":"Fig1.png","url":"https://assets-eu.researchsquare.com/files/rs-3792525/v1/77c4a7fd1ebef3f4e5205a5d.png"},{"id":49072751,"identity":"e7e0985b-46d9-4d37-a3db-61b5daeae465","added_by":"auto","created_at":"2024-01-02 17:20:10","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":333193,"visible":true,"origin":"","legend":"\u003cp\u003eEsophageal Endoscopy: A large mass is seen 24cm-31cm from the mouth, with a smooth surface, narrow lumen, and normal mucosa.\u003c/p\u003e","description":"","filename":"Fig2.png","url":"https://assets-eu.researchsquare.com/files/rs-3792525/v1/e9538330902f59d195b81d9f.png"},{"id":49072755,"identity":"dc88ebe2-e237-4ef2-a9f3-a169314b56af","added_by":"auto","created_at":"2024-01-02 17:20:11","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":758786,"visible":true,"origin":"","legend":"\u003cp\u003eSelection of surgical approach: With the esophageal tumor as the center, number 1 is the assisting robotic arm operation hole, number 2 is the laparoscope hole, and numbers 3 and 4 are the main robotic arm operation holes.\u003c/p\u003e","description":"","filename":"Fig3.png","url":"https://assets-eu.researchsquare.com/files/rs-3792525/v1/7230cba5a030d4ea8d0fab0d.png"},{"id":49072753,"identity":"0948fe6f-21fd-46e4-b9a6-6b90524fa415","added_by":"auto","created_at":"2024-01-02 17:20:11","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":559842,"visible":true,"origin":"","legend":"\u003cp\u003eSelection of surgical approach: With the esophageal tumor as the center, number 1 is the assisting robotic arm operation hole, number 2 is the laparoscope hole, and numbers 3 and 4 are the main robotic arm operation holes.\u003c/p\u003e","description":"","filename":"Fig4.png","url":"https://assets-eu.researchsquare.com/files/rs-3792525/v1/8f3d602554386cd350e3ce69.png"},{"id":49072749,"identity":"ac86dd7b-58ae-4a5e-8ce0-5620e1094857","added_by":"auto","created_at":"2024-01-02 17:20:10","extension":"png","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":654767,"visible":true,"origin":"","legend":"\u003cp\u003eOpening the esophageal muscle layer (D); Dissecting the esophageal mass (E)\u003c/p\u003e","description":"","filename":"Fig5.png","url":"https://assets-eu.researchsquare.com/files/rs-3792525/v1/988fae1d70bde3be080b9802.png"},{"id":49073147,"identity":"46bb6808-5061-45a2-a612-6caf36bcb562","added_by":"auto","created_at":"2024-01-02 17:28:11","extension":"png","order_by":6,"title":"Figure 6","display":"","copyAsset":false,"role":"figure","size":708689,"visible":true,"origin":"","legend":"\u003cp\u003eInspecting the esophageal mucosa for damage (F), suturing the esophageal muscular layer (G) and the mediastinal pleura (H).\u003c/p\u003e","description":"","filename":"Fig6.png","url":"https://assets-eu.researchsquare.com/files/rs-3792525/v1/a2e15106ad1e57636ff0f0e3.png"},{"id":49072756,"identity":"edb32167-850c-486a-b911-7c915263d7cc","added_by":"auto","created_at":"2024-01-02 17:20:11","extension":"png","order_by":7,"title":"Figure 7","display":"","copyAsset":false,"role":"figure","size":538542,"visible":true,"origin":"","legend":"\u003cp\u003eEsophageal Tumor: A piece of tissue with a volume of 9cm x 6.8cm x 3.5cm, with gray-white appearance and medium texture (A). H\u0026amp;E staining at 100x magnification (B) and 400x magnification (C), consistent with a diagnosis of smooth muscle tumor based on immunohistochemical staining results. Immunohistochemical staining showed Vimentin (focal +), SMA (+), Dog-1 (-), S-100 (focal +), CD117 (-), Desmin (+), CD34 (vascular endothelial cells +), Ki67 (approximately 1%).\u003c/p\u003e","description":"","filename":"Fig7.png","url":"https://assets-eu.researchsquare.com/files/rs-3792525/v1/9e51a35ec4b3e9d5a2a1eeaa.png"},{"id":49072752,"identity":"4a91004d-93db-472d-9d9b-952098404f3c","added_by":"auto","created_at":"2024-01-02 17:20:10","extension":"png","order_by":8,"title":"Figure 8","display":"","copyAsset":false,"role":"figure","size":308208,"visible":true,"origin":"","legend":"\u003cp\u003eOn the fifth day after surgery (A) and on the eleventh day after surgery (B), the contrast medium passed through the esophagus smoothly without any signs of extravasation.\u003c/p\u003e","description":"","filename":"Fig8.png","url":"https://assets-eu.researchsquare.com/files/rs-3792525/v1/211883ec86a4da2ee9146152.png"},{"id":50090769,"identity":"eb60c175-2135-4d69-af9f-4e34f23fa3eb","added_by":"auto","created_at":"2024-01-24 11:37:49","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":6529130,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-3792525/v1/fb8e6091-1023-4d8e-9bf9-506b375c18eb.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Robot-assisted thoracoscopic excision of a giant leiomyoma of the upper esophagus: A technical report","fulltext":[{"header":"Background","content":"\u003cp\u003eEsophageal leiomyomas are relatively rare and can grow anywhere in the esophagus. Sixty percent of cases occur in the distal third of the esophagus, 30% in the middle third, and 10% in the proximal esophagus \u003csup\u003e[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]\u003c/sup\u003e. Patients often present with dysphagia as the main complaint, without specific clinical manifestations. Preoperative endoscopic localization and needle aspiration biopsy can confirm the diagnosis, mainly to distinguish it from esophageal stromal tumors. There are significant differences in the expression of SMA, desmin, CD117, and CD34 between the two subtypes, with positive expression of SMA and desmin in leiomyomas and positive expression of CD117 and CD34 in stromal tumors \u003csup\u003e[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]\u003c/sup\u003e. After diagnostic puncture, the esophageal mucosa layer is damaged, increasing the risk of mucosal perforation and postoperative esophageal fistula during surgical tumor debulking. Therefore, preoperative endoscopic aspiration biopsy is not recommended \u003csup\u003e[\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]\u003c/sup\u003e. Esophagoscopic resection is suitable for removing tumors originating from the esophageal mucosal muscle layer and with a pedicle and a small diameter \u003csup\u003e[\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003ePreviously, open thoracotomy or VATS was commonly used for the removal of esophageal leiomyomas. Open thoracotomy is associated with greater trauma, more intraoperative bleeding, slower postoperative recovery, and a longer hospital stay than VATS \u003csup\u003e[\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eVATS imaging is two-dimensional, with a maximum field of view that can be magnified up to three times, and the activity of the operating instruments is limited. Robotic-assisted thoracoscopic surgery (RATS) provides three-dimensional imaging, allowing the field of view to be magnified by 6\u0026ndash;10 times, with even greater freedom of robotic arm operation, which can be rotated 540 degrees \u003csup\u003e[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]\u003c/sup\u003e. Second, VATS is performed by hand through the lever principle, and subtle movements in the body cavity can be magnified. In terms of endoscopic stability, the RATS is more stable. In addition, traditional thoracoscopy uses the lever principle to pinch on the ribs, repeatedly rubbing and squeezing the intercostal nerves, significantly increasing postoperative incision pain. RATS reduces friction and injury through trocar protection, resulting in less postoperative pain [6]. In terms of operation time, robotic surgery has a similar operation time to traditional video-assisted thoracoscopic surgery \u003csup\u003e[\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e "},{"header":"Case Presentation","content":"\u003cp\u003e1. General information\u003c/p\u003e\n\u003cp\u003eA 21-year-old male patient presented with progressive dysphagia for more than 3 years. He was thin, and his chest and abdomen were enhanced on CT (Fig.\u0026nbsp;1). The upper and middle esophageal masses showed pushing changes to the trachea and azygos vein, and the corresponding esophageal lumen was significantly narrowed. Esophageal radiography (Fig.\u0026nbsp;2) showed a narrowed chest esophageal lumen. Preoperative esophagoscopy (Fig.\u0026nbsp;3) revealed a large tumor located 24 cm-31 cm from the incisor teeth, with a smooth surface, narrow lumen, and normal mucosa. The surrounding anatomy was complex, and it was recommended that the patient undergo robot-assisted surgery to exclude surgical contraindications. After intubation with a double-lumen endotracheal tube and one-lung ventilation, robot-assisted esophageal tumor removal was performed under general anesthesia.\u003c/p\u003e\n\u003cp\u003e2. Surgical Method\u003c/p\u003e\n\u003cp\u003e2.1 Patient position: The patient assumed a left lateral position with a 45-degree anterior tilt. Four robotic arms were used for the operation (Fig.\u0026nbsp;4). The assistant port is located at the seventh intercostal space along the anterior axillary line (Fig.\u0026nbsp;4A).\u003c/p\u003e\n\u003cp\u003e2.2 After entering the chest, the lungs collapse and are pushed forward. The mediastinal pleura of the upper and middle esophagus significantly bulges, with a medium texture. The esophageal lumen above the mass was significantly dilated (Fig.\u0026nbsp;5A).\u003c/p\u003e\n\u003cp\u003e2.3 Opening of the mediastinal pleura, ligation and dissection of the azygos vein (Fig.\u0026nbsp;5B), and exposure of the esophageal muscle layer (Fig.\u0026nbsp;5C)\u003c/p\u003e\n\u003cp\u003e2.4 Upon opening the esophageal muscle layer, the mass was found to have clear boundaries, a tough texture, and a size of approximately 96 mm\u0026times;67 mm\u0026times;33 mm. The patient exhibited limited mobility and had not invaded the esophageal serosal layer (Fig.\u0026nbsp;6D).\u003c/p\u003e\n\u003cp\u003e2.5 Blunt and sharp dissection were used to completely remove the mass along its surface (Fig.\u0026nbsp;6E), with no injury to the esophageal mucosa (Fig.\u0026nbsp;7F).\u003c/p\u003e\n\u003cp\u003e2.6 Suturing of the esophageal muscle layer with silk thread (Fig.\u0026nbsp;7G) and suturing of the mediastinal pleura with 3\u0026thinsp;\u0026minus;\u0026thinsp;0 vicryl thread (Fig.\u0026nbsp;7H).\u003c/p\u003e\n\u003cp\u003e3. Results\u003c/p\u003e\n\u003cp\u003eNo postoperative complications occurred. Postoperative parenteral nutrition support was provided, and anal exhaust was recovered on the second day after surgery. On the third day after surgery, the patient resumed a fully liquid diet. A follow-up X-ray chest film showed good lung expansion and no pleural effusion or pneumothorax. Upper gastrointestinal contrast radiography on the fifth day after surgery showed no esophageal perforation, and the contrast agent passed through the esophagus smoothly (Fig.\u0026nbsp;10A). The patient was discharged on the sixth day after surgery. Pathological examination revealed an esophageal leiomyoma with a size of 9 cm \u0026times; 6.8 cm \u0026times; 3.5 cm. Immunohistochemistry revealed vimentin (focal+), SMA (+), Dog-1 (-), S-100 (focal +), CD117 (-), desmin (+), CD34 (vascular endothelial +), and Ki67 (approximately 1%). Upper gastrointestinal contrast radiography on the eleventh day after surgery showed no esophageal perforation, and the contrast agent passed through the esophagus smoothly (Fig.\u0026nbsp;10B).\u003c/p\u003e"},{"header":"Discussion and Conclusions","content":"\u003cp\u003eThe robotic arms provide flexible, high-degree-of-freedom, and stable operation and are even superior to direct manual operation when performing local operations. The advantages of this approach are especially pronounced for tissue separation and vascular dissection.\u003c/p\u003e \u003cp\u003eIn this patient, the esophageal mass was large and located at the upper and middle esophagus; it was deep and had a complex anatomical structure. Traditional open thoracotomy can cause significant damage, while VATS is highly difficult and prone to damaging the esophagus, surrounding nerves and blood vessels. Robotic surgery, however, results in less trauma and precise manipulation than open surgery and is a more suitable surgical approach for deep and complex tumors in the chest cavity. The surgical approach and treatment philosophy presented in this case report offer valuable insights for reference.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"50%\" valign=\"top\"\u003e\n \u003cp\u003eVATS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"50%\" valign=\"top\"\u003e\n \u003cp\u003evideo-assisted thoracoscopic surgery\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"50%\" valign=\"top\"\u003e\n \u003cp\u003eRATS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"50%\" valign=\"top\"\u003e\n \u003cp\u003erobotic-assisted thoracoscopic surgery\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e"},{"header":"Declarations","content":"\u003cp\u003eEthics approval and consent to participate:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThis article has been authorized by the patient and his family, who have signed a consent form. All authors have read and approved all versions of the manuscript, its content, and its submission to Journal of Cardiothoracic Surgery.\u003c/p\u003e\n\u003cp\u003eFunding: Not applicable\u003c/p\u003e\n\u003cp\u003eAuthors\u0026apos; contributions:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eZhigang Wang were surgeons who make surgical plans. Wenqiang Wu collected and collated all the information.Wenqiang Wu prepared figures and tables. Zhigang Wang revised the manuscript. All authors read and approved the final manuscript.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAcknowledgements:\u003c/p\u003e\n\u003cp\u003eWe also wish to express our special gratitude to our colleagues in the thoracic surgery department and operating room for their support and assistance.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eData supporting the results reported in the article can be found in the medical record database of the affiliated hospital of Guangdong Medical University\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eMutrie CJ, Donahue DM, Wain JC, Wright CD, Gaissert HA, Grillo HC, Mathisen DJ, Allan JS. Esophageal leiomyoma: a 40-year experience. Ann Thorac Surg. 2005;79(4):1122-5. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.athoracsur.2004.08.029\u003c/span\u003e\u003cspan address=\"10.1016/j.athoracsur.2004.08.029\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. PMID: 15797036.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eXu GQ, Zhang BL, Li YM, Chen LH, Ji F, Chen WX, Cai SP. Diagnostic value of endoscopic ultrasonography for gastrointestinal leiomyoma. World J Gastroenterol. 2003;9(9):2088\u0026ndash;91. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.3748/wjg.v9.i9.2088\u003c/span\u003e\u003cspan address=\"10.3748/wjg.v9.i9.2088\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. PMID: 12970912; PMCID: PMC4656680.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZheng RH, Feng MX, Ge D, Hou YY. [Diagnosis and treatment of esophageal leiomyoma]. Zhonghua Wei Chang Wai Ke Za Zhi. 2005;8(1):26\u0026ndash;8. Chinese. PMID: 16148993.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eShen C, Li J, Che G. Video-Assisted Thoracic Surgery vs. Thoracotomy for the Treatment in Patients With Esophageal Leiomyoma: A Systematic Review and Meta-Analysis. Front Surg. 2022;8:809253. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.3389/fsurg.2021.809253\u003c/span\u003e\u003cspan address=\"10.3389/fsurg.2021.809253\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. PMID: 35087862; PMCID: PMC8786717.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eVeronesi G, Novellis P, Voulaz E, Alloisio M. Robot-assisted surgery for lung cancer: State of the art and perspectives. Lung Cancer. 2016;101:28\u0026ndash;34. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.lungcan.2016.09.004\u003c/span\u003e\u003cspan address=\"10.1016/j.lungcan.2016.09.004\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Epub 2016 Sep 7. PMID: 27794405.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCatelli C, Corzani R, Zanfrini E, Franchi F, Ghisalberti M, Ligabue T, Meniconi F, Monaci N, Galgano A, Mathieu F, Addamo E, Sarnicola N, Fabiano A, Paladini P, Luzzi L. RoboticAssisted (RATS) versus Video-Assisted (VATS) lobectomy: A monocentric prospective randomized trial. Eur J Surg Oncol. 2023;49(12):107256. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.ejso.2023.107256\u003c/span\u003e\u003cspan address=\"10.1016/j.ejso.2023.107256\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Epub 2023 Oct 31. PMID: 37925829.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"esophageal leiomyoma, robot-assisted surgery, surgical technique","lastPublishedDoi":"10.21203/rs.3.rs-3792525/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-3792525/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eBackground: Esophageal leiomyoma is a relatively rare disease that can occur in any part of the esophagus. In the past, open thoracic surgery or video-assisted thoracoscopic surgery (VATS) were commonly used to remove esophageal leiomyomas.\u003c/p\u003e\n\u003cp\u003eCase presentation: A 21-year-old male patient presented with progressive dysphagia for more than 3 years. Esophageal radiography showed a narrowed chest esophageal lumen. Esophagoscopy revealed a large tumor located 24 cm-31 cm from the incisor teeth. Robot-assisted esophageal tumor removal was performed under general anesthesia.On the third day after surgery, the patient resumed a fully liquid diet. A follow-up upper gastrointestinal contrast radiography after surgery showed no esophageal perforation, and the contrast agent passed through the esophagus smoothly.\u003c/p\u003e\n\u003cp\u003eConclusions: In this patient, the esophageal mass was large and located at the upper and middle esophagus; it was deep and had a complex anatomical structure. Robotic surgery, however, results in less trauma and precise manipulation than open surgery and is a more suitable surgical approach for deep and complex tumors in the chest cavity.\u003c/p\u003e","manuscriptTitle":"Robot-assisted thoracoscopic excision of a giant leiomyoma of the upper esophagus: A technical report","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-01-02 17:20:06","doi":"10.21203/rs.3.rs-3792525/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"084975b4-f006-458e-8e9d-657321d08cc1","owner":[],"postedDate":"January 2nd, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2024-01-24T11:29:42+00:00","versionOfRecord":[],"versionCreatedAt":"2024-01-02 17:20:06","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-3792525","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-3792525","identity":"rs-3792525","version":["v1"]},"buildId":"zQwnuV7TCBrMSSSToR1PI","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}