Objectives : We report an early, single-institution experience of Robot-Assisted Minimally Invasive McKeown Esophagectomy (RAMIME) using a four-arm platform. The technique details, rationale, complications, and pitfalls during procedure development are discussed. Methods: This was a retrospective observational study. Results: Nine of the 11 patients (median age: 57 years [range: 45-83]) had a complete (R0) resection; 10 were given induction treatment combined with chemoradiation. The median operative time was 795 min (range: 635-975). The median thoracoscopic console time was 270 min (range: 135-330). The median laparoscopic console time was 160 min (range: 150-260 min). The median blood loss was 300 cm 3 (range: 100-650), and the median length of hospital stay was 18 days (range: 14-36). The median number of lymph nodes harvested was 28 (range: 9-39). No patients were converted to open procedures. Four patients had major complications; one died of liver failure on postoperative day 16; and none had clinically significant anastomotic leaks. Conclusions: RAMIME is feasible. With good understanding of the robotic concepts and a good robotic team, RAMIME is worth trying. In addition to its well-known benefits, RAMIME permits replacing one human assistant.

aided by the improved performance and evolving ergonomics of these devices. The Hydrojet dissector has proven to be of enormous benefit in open liver resection. It allows precise parenchymal dissection and clear exposure of even the smallest vessels and biliary radicles. Its adoption in open surgery has been somewhat limited, with the established technologies of CUSA, bipolar electrocautery and ultrasonic technology enjoying more widespread adoption. In laparoscopic liver surgery, few centres routinely employ the Hydrojet. Our institution routinely employs Hydrojet for live donor hepatectomy and as such we have extensive experience with the device. We have employed Hydrojet regularly for laparoscopic hepatectomy and describe herein our technique of parenchymal division during major hepatectomy, combining the benefits of the Hydrojet and the Harmonic Scalpel. We demonstrate the precise parenchymal dissection made possible by the laparoscopic Hydrojet. We propose that this technique of liver resection is safe, efficient and precise.

KEYWORDScervical esophageal cancer; double esophageal stent; esophageal stent; self-expanding metal stent; tracheoesophageal fistula Summary Treatment of tracheoesophageal (TE) fistula is always a challenge, in particular TE fistula caused by malignancy. In the past decade, the development of a self-expanding metal stent (SEMS) has made management of esophageal stenosis or perforation much easier. Nevertheless, management of a cervical esophageal lesion is still debatable. A cervical esophageal stent may compromise the upper esophageal sphincter (UES) function and is usually listed as a contraindication. Here, a 53-year-old male had cervical esophageal cancer complicated with a TE fistula. After initial management with a SEMS, the patient had temporary improvement, but later suffered a recurrent TE fistula. The TE fistula was successfully managed by the placement of a second modified SEMS just below the UES without removal of the previous SEMS. The patient tolerated the procedure well and regained proper swallowing function.

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