Iatrogenic intramural esophageal dissection secondary to insertion of nasogastric tubes and the transorally inserted anvil during robot-assisted total gastrectomy

A 37-year-old female patient (height, 161.5 cm; weight, 49.5 kg) was scheduled to undergo robot-assisted total gastrectomy for early gastric cancer. Her past medical history and physical examination were unremarkable. In the operation room, the patient was induced with 2.0-3.0 vol% sevoflurane after receiving 110 mg of propofol by intravenous injection. Tracheal intubation using a 7.0 mm internal diameter endotracheal tube was performed without difficulty 3 minutes after the patient received 10 mg of cisatracurium by intravenous injection. A 16 French silicone nasogastric tube (Levin tube, Yushin Medical, Bucheon, Korea) was inserted through the left nostril with some difficulty. The nasogastric tube was passed to 55 cm and was noted to drain a small amount of turbid fluid. Twenty minutes after induction of anesthesia, a skin incision was made. The duodenum was resected, the esophagus was clamped and stomach was removed. One and a half hours later, the nasogastric tube was removed. The surgeon made a request to insert the OrVil TM transorally and said that the anvil head should be passed as the convex surface of the anvil head is directed at the posterior wall of the esophagus. At first, the OrVil

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