This operative video demonstrates a robotic Ivor Lewis esophagectomy performed for poorly differentiated small cell neuroendocrine carcinoma of the distal esophagus following neoadjuvant chemoradiation.

The patient is a 65-year-old man with a history of hypertension, chronic obstructive pulmonary disease, prior tobacco use, and alcohol exposure who presented with progressive dysphagia, post-prandial discomfort, and a 20-pound weight loss.

Upper endoscopy revealed a large ulcerating mass located 32 cm from the incisors, involving the distal esophagus and gastroesophageal junction. Biopsy demonstrated poorly differentiated small cell neuroendocrine carcinoma, microsatellite stable, with genomic alterations including NOTCH1Q475fs*156, RB1 loss, and TP53 mutation.

Staging FDG-PET/CT demonstrated a 7 cm hypermetabolic distal esophageal mass extending into the gastroesophageal junction, with a prominent perigastric lymph node but no definite evidence of distant metastatic disease.

The patient underwent multimodality therapy, including:

• Definitive chemoradiation

• Cisplatin and etoposide chemotherapy

• Radiation therapy (50.7 Gy in 27 fractions)

Restaging PET/CT demonstrated marked metabolic and radiographic response without progression of disease.

Following multidisciplinary evaluation, the patient underwent robotic staging laparoscopy followed by robotic Ivor Lewis esophagectomy.

The abdominal phase included:

• Gastric mobilization and conduit creation

• Division of the left gastric artery with lymphadenectomy

• Botulinum toxin pyloroplasty

• Creation of a 3–4 cm gastric conduit

The thoracic phase included:

• Robotic mediastinal esophageal mobilization

• Division of the azygos vein

• Paraesophageal and subcarinal lymphadenectomy

• Construction of a two-layer robotic hand-sewn intrathoracic esophagogastric anastomosis

The patient recovered well following surgery and was discharged home on postoperative day four on a full liquid diet, which was advanced to a regular diet at the first postoperative clinic visit the following week.

Final pathology demonstrated complete pathologic response to neoadjuvant therapy:

• No residual viable neuroendocrine carcinoma

• 0 of 21 lymph nodes involved with tumor

• All surgical margins negative

These findings correspond to ypT0 disease with complete treatment response.

This case illustrates the application of robotic minimally invasive esophagectomy following multimodality therapy, demonstrating advanced thoracic and upper gastrointestinal oncologic surgery.