Robotic-Assisted Oesophageal Surgery

Abstract

Abdominothoracic oesophageal resections, also known as Ivor Lewis procedures, are complex visceral surgery procedures. In recent years, substeps have increasingly been performed using minimally invasive techniques. However, intrathoracic anastomosis is still a challenge given the instrumental and technological possibilities available to date. This article provides a detailed description of the use of the Da Vinci robotic system and our techniques in oesophageal surgery. In a prospective data collection, we analysed the robotic-assisted oesophageal surgeries performed at the University Hospital of Schleswig-Holstein, Campus Kiel, between November 2013 and November 2015. A total of 56 patients underwent robotic-assisted oesophageal surgery, with 43 patients undergoing the Ivor Lewis technique, 10 patients undergoing the McKeown procedure and 3 patients undergoing enucleation of a leiomyoma. A complete tumour resection (R0 margin) was achieved in 53 patients (93.4%); the mean number of resected lymph nodes was 23 (14-75). Forty-five (80.5%) patients received an induction therapy. Mean operative time was 412 min (120-610); mean hospital stay was 19 days (4-145). A conversion to open surgery was necessary in 19 (34.1%) cases, most notably in the thoracic part of the surgical procedure (17 patients). Forty-three patients received intrathoracic oesophagogastrostomy; 4 out of 5 patients with an initial side-to-side anastomosis developed a leakage, whereupon the technique was switched to a hand-sewn procedure (leakage in 3 out of 20 patients). Other major morbidities included leakage of the gastric conduit in 2 patients (3.6%), airway fistula in 2 patients (3.6%), mesenteric ischaemia in one patient (1.8%), and peritonitis due to a dislocated feeding tube in one other patient. Pulmonary complications occurred in 19 patients (34%). Four patients (7.1%) died of pulmonary embolism, heart attack, and septic organ failure. Robotic-assisted, minimally invasive oesophagectomy is a feasible and useful approach for oncological surgery. This technique should be implemented in a structured program with an extensive and critical evaluation of the users' own results and an exchange with other experienced work teams. This helps to avoid pitfalls and to speed up the learning curve. Further technological developments and increasing experience might lead to a more widespread use of this technique.