The Orvil end-to-side anastomosis for Ivor-Lewis minimally invasive esophagectomy: technique, considerations, and challenges

Novel modification of the end-to-end anastomosis (EEA) circular stapler anvil for transoral passage significantly bypassed the technical challenges of intracorporal anvil placement for minimally invasive upper gastrointestinal anastomoses. Since commercialization of this concept as the Orvil (Covidien, Minneapolis, MN, USA), circular double-stapled techniques have been utilized for reconstruction following Ivor-Lewis minimally invasive esophagectomy (MIE). Despite its relative simplicity and popularity, the anastomosis has received critique for the issue of overlapping staple lines, which may increase rates of leak and stricture. Although these concerns have validity, their impact can be greatly reduced with strong consideration of procedural nuances. Meticulous care is needed to reduce microvascular trauma, maintain proper alignment, and eliminate tension. Overall construction of a successful anastomosis is a dynamic process which is dependent on a combination of numerous patient and technical factors. Based on the most recent literature, rates of both clinically significant leak and stricture are approximately 4% for the Orvil double-stapled esophagogastric anastomosis. Here we present our own technique and highlight the technical challenges which must be considered for successful creation of the Orvil EEA double-stapled anastomosis during Ivor-Lewis MIE. With proper understanding of technical aspects, experience, and practice refinement, the anastomosis adds an effective and convenient reconstructive option to the esophageal surgeon's repertoire. © 2022 Journal of Innovation Management. All rights reserved.