J Robotic Surg
DOI 10.1007/s11701-016-0668-7
CASE REPORT
The robotic approach for enucleation of a giant esophageal lipoma
Cheng-Hung How1,2 • Jang-Ming Lee2
Received: 21 August 2016 / Accepted: 5 December 2016
Ó Springer-Verlag London 2016
Abstract An 87-year-old man, who had been experiencing
progressive dysphagia and slight chest discomfort for
12 months, presented for an esophagram with a diagnosis
of achalasia. A giant esophageal lipoma (14.5- 9 4.5-
9 3.5-cm) that caused symptomatic dysphagia and a dila-
ted esophagus was revealed by computed tomography and
endoscopic esophageal ultrasound. For such a huge eso-
phageal lipoma in a geriatric patient, we successfully
enucleated the mediastinal lesion via a minimally invasive
approach using the da Vinci S Surgical System.
Keywords Esophageal surgery
Esophagus, benign
disease
Robotics
Introduction
Esophageal lipomas are rare, comprising 0.4% of all
digestive tract benign neoplasms [1]. Most of these tumors
are clinically silent before they are large enough to cause
symptoms, of which dysphagia due to esophageal
obstruction is the most common. Treatment options range
from observation for small tumors to surgical excision via
the thoracotomy approach for large or symptomatic tumors.
A recent case series documented the feasibility of a
& Jang-Ming Lee
ntuhlee@yahoo.com; jmlee@ntu.edu.tw
1
Division of Thoracic Surgery, Department of Surgery, Far
Eastern Memorial Hospital, New Taipei City, Taiwan
2
Division of Thoracic Surgery, Department of Surgery,
National Taiwan University Hospital and National Taiwan
University College of Medicine, 7, Chung-Shan South Road,
Taipei 10002, Taiwan
minimally invasive thoracoscopic approach [2]. We present
the case of an 87-year-old man with recent dysphagia due
to a giant esophageal lipoma, which was enucleated suc-
cessfully via a robot-assisted thoracoscopic approach.
An 87-year-old man with hypertension and a 12-month
history of progressive dysphagia and slight chest discom-
fort presented for an esophagram under the diagnosis of
achalasia. Findings were significant for an esophageal
submucosal lesion with a dilated esophagus (Fig. 1a).
Chest computed tomography (CT) revealed a 14.5- 9 4.5-
9 3.5-cm, hypoattenuating submucosal mass on the pos-
terior wall of the middle and lower esophagus, with -90 to
-110 Hounsfield units (Fig. 1b, c). The mass corresponded
to the lesion seen on the prior esophagram. Endoscopic
ultrasonography confirmed the submucosal origin of the
mass which was homogenously hyperechoic with regular
margins.
For the transthoracic approach, the patient was intu-
bated with a double-lumen endotracheal tube to allow
single-lung ventilation in the prone position. The da Vinci
S Surgical System (Intuitive Surgical, Inc, Sunnyvale,
CA, USA), which has a four-trocar access to the right
pleural cavity [the fifth intercostal space (ICS) at the mid-
axillary line for the camera port, the third and sixth ICS at
the posterior axillary line for the robotic arms, and the
seventh ICS at the mid-axillary line for the assistant port],
was used [3]. The lung was retracted anteriorly to expose
the esophagus and posterior mediastinal submucosal
tumor. Enucleation was initially performed by opening
the pleura/adventitia of the mid-esophagus, followed by a
myotomy over the tumor. The plane between the tumor,
muscularis propria, and underlying submucosa was
developed gradually using an 8-mm EndoWrist Grasper
and EndoWrist Scalpel, under a 30-degree thoracoscopic
camera. The tumor was enucleated and removed into a
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Fig. 1 a The dilated esophagus with a large filling defect from the
middle to the lower esophagus. b Non-enhanced coronal CT of the
chest revealing a submucosal, hypoattenuating lesion with dense fat in
specimen bag. The wall of the esophagus opening was
closed with a single-layer extramucosal Maxon suture.
Subsequently, a chest tube was left in place for 3 days.
The postoperative hospital stay was 9 days. At postoper-
ative day 3, the patient started a semisolid diet, gradually
recovering his normal diet. No postoperative morbidity
was documented. Seven days later, the patient underwent
a barium swallow test, which demonstrated a regular
transit. The macroscopic and microscopic evaluations,
respectively, revealed a 19.5- 9 6.9- 9 5.7-cm mass
(Fig. 2a) and diffuse mature adipose tissue without atyp-
ical stromal cell, compatible with the diagnosis of eso-
phageal lipoma (Fig. 2b).
Discussion
Approximately 70–80% of benign esophageal neoplasms
are leiomyomas, whereas lipomas are rare (0.4%). Eso-
phageal lipomas usually originate from the cervical and
Fig. 2 a The well-encapsuled, yellow, and soft giant lipoma, measuring 19.5 9 6.9 9 5.7 cm in size and 259.9 g in weight. b Diffuse mature
adipose tissue without atypical stromal cell (hematoxylin-eosin staining, original magnification 9200)
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J Robotic Surg
the esophagus (white arrow). c Non-enhanced axial CT of the chest
demonstrating the esophageal lipoma (white arrow protocol: 64-slice
CT scanner, mAs: 300, kVp: 120, 5-mm slice thickness)
upper thoracic esophagus, and are more common in men
than in women (27:13) [1].
Lipomas are radiographically characterized as intralu-
minal filling defects. Signs such as a smooth surface and
‘‘squeeze’’ sign manifested by changes in contour and
configuration as a result of peristalsis are useful for dif-
ferentiating lipomas from other benign or malignant lesions
[1]. On CT, lipomas present as homogenous lesions con-
taining dense fat. On magnetic resonance imaging, lipomas
can be identified by following fat signals from T1-weighted
hyperintensity that becomes hypointense in fat-suppressed
images. Clinical features and instrumental findings can
well suggest a benign behavior, but only a histopathologic
examination can definitely exclude potential malignancy
[4].
Most esophageal lipomas are small, solitary, and
asymptomatic, and do not require treatment. However,
lipomas greater than 2 cm in diameter tend to produce
symptoms (e.g., dysphagia or chest pain). Various man-
agement options are available, depending on the tumor size
J Robotic Surg
and location, and include excision by cervical esophago-
tomy, thoracotomy, or endoscopic approach. Surgical
excision is indicated when the tumor is symptomatic or its
biological behavior is unclear [5]. Minimally invasive
resection of benign esophageal tumors is technically safe
and associated with shorter hospital stay compared with
open approaches [4, 6].
The feasibility of resection of esophageal leiomyoma
and Zenker diverticulectomy by the transthoracic approach
using the da Vinci system has been reported by Melotti
et al. [7, 8]. Owing to the advantages of the robotic system,
including the three-dimensional (3D) camera with a mag-
nified view, hand-tremor filtration, and robotic fine motion
scaling, the surgical plane can be clearly identified and
precisely dissected. This is particularly useful to prevent
mucosal injury in cases of giant esophageal submucosal
tumors. No relevant complications such as recurrent
laryngeal nerve injury, esophageal stricture, fistula, eso-
phageal perforation, or hematoma were associated with
robotic-assisted esophageal diverticulectomy [7] and in this
study. To our knowledge, this is the first case of successful
enucleation of a giant esophageal lipoma via a minimally
invasive approach, using the da Vinci S Surgical System.
In summary, our patient had an exceptionally large
esophageal lipoma that caused symptomatic dysphagia and
a dilated esophagus, which we successfully enucleated via
a robot-assisted thoracoscopic surgery.
Acknowledgements The authors thank Dr. Hsin-I Huang and Prof.
Yung-Ming Jen, Department of Pathology, National Taiwan Univer-
sity Hospital, Taipei, Taiwan, for providing consultation about the
histopathological interpretations and images.
Compliance with ethical standards
Conflict of interest Cheng-Hung How and Jang-Ming Lee declare
that they have no conflict of interest.
Informed consent All procedures followed were in accordance with
the ethical standards of the responsible committee on human exper-
imentation (institutional and national) and with the Helsinki Decla-
ration of 1975, as revised in 2000 (5). Informed consent was obtained
from all patients for being included in the study.
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