Esophagectomy has been the mainstay of curative treatment for esophageal cancer and it is the standard of care for patients with locally advanced esophageal cancer. Intrathoracic anastomosis is one of the most challenging steps of this procedure. Methods: In this paper, we evaluated a prospective cohort of 27 patients with distal esophageal lesions that were offered minimally invasive Ivor Lewis minimally esophagectomy with a totally hand sewn anastomosis. We introduce the first use of an

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... lated needle holder for thoracoscopic suturing in the same technique. Results: Mean time for anastomosis was 60 min (40-120 min). Anastomotic leakage occurred in 4 patients (14.8%). These included 1 patient (3.7%) with a type I, 2 patients (7.4%) with a type II anastomotic leak and one patient with a type III leak (2.7%). Two patients (7.4%) had type III necrosis of the conduit. Conservative management with endovac and stents was completed in 3 patients. Reoperation was required in two cases (7.4%). The mean length of stay was 9 days (7-28 days). One serious complication involving death occurred (3.7%). Five patients (18.5%) experienced dysphagia that turned out in anastomotic strictures and required endoscopic dilatation. Conclusions: Thoracoscopic hand sewn anastomosis is feasible and reproducible and has an acceptable leak and stricture rate even within the learning curve. Flexible articulated instruments are a promising tool for minimally invasive surgery in restricted space.