Robot-assisted Thoracoscopic Esophagectomy Research Articles

A case of refractory chylothorax due to an unenclosed esophageal hiatus after subtotal esophagectomy treated with lipiodol lymphangiography

BackgroundChylothorax, a rare but serious complication following esophagectomy, can lead to dehydration, malnutrition, and even mortality. Surgical intervention is considered when conservative treatment is ineffective; however, in some refractory cases, the cause of chylothorax remains unclear. We report a case of refractory chylothorax caused by abdominal chyle leakage into the pleural space via an unenclosed esophageal hiatus.Case presentationA 66-year-old man was diagnosed with advanced esophageal squamous cell carcinoma. The patient underwent robot-assisted thoracoscopic subtotal esophagectomy in the prone position with retrosternal gastric tube reconstruction following neoadjuvant chemotherapy. The thoracic duct was ligated and resected because of tumor invasion. Chylothorax and chylous ascites were observed 2 weeks after surgery but did not improve despite conservative management with medications and drainage. Lymphoscintigraphy through the inguinal lymph node showed tracer accumulation in the fluid in both the abdominal and pleural spaces. Lipiodol lymphangiography revealed abdominal lymphoid leakage, but no leakage was detected from the thoracic duct or mediastinum. We considered that the chylothorax was caused by chylous ascites flowing into the pleural space via an unenclosed esophageal hiatus, and we performed surgical intervention. Laparotomy revealed abdominal chyle leakage and a fistula at the esophageal hiatus with the inflow of ascites into the thoracic cavity. Lipiodol lymphangiography was additionally performed for treating abdominal lymphorrhea after surgery, and resulted in the improvement of the chylothorax and ascites. The patient was discharged with no recurrence of chylothorax or chylous ascites.ConclusionsRefractory chylothorax can occur due to chylous ascites flowing into the pleural space via an unenclosed esophageal hiatus. When the site of chylothorax leakage is unclear, the possibility of inflowing chylous ascites via the unenclosed esophageal hiatus should be explored. Esophageal hiatus closure and lipiodol lymphangiography could be effective in treating refractory chylothorax of unknown cause after esophagectomy.

Subtotal esophagectomy and concurrent reconstruction with free jejunal flap for primary esophageal cancer after pancreatoduodenectomy.

Pancreatoduodenectomy and subtotal esophagectomy are widely considered the most invasive and difficult surgical procedures in gastrointestinal surgery. Subtotal esophagectomy after pancreatoduodenectomy is expected to be extremely difficult due to complicated anatomical changes, and selecting an appropriate intestinal reconstruction method will also be a difficult task. Therefore, perhaps because the method is considered impossible, there have been few reports of subtotal esophagectomy after pancreatoduodenectomy. A 73-year-old man with a history of pancreatoduodenectomy was diagnosed with superficial thoracic esophageal squamous cell carcinoma. Definitive chemoradiation therapy was recommended at another hospital; however, he visited our department to undergo surgery. We performed the robot-assisted thoracoscopic subtotal esophagectomy. There were some difficulties with the reconstruction: the gastric tube could not be used, the reconstruction was long, and the organs reconstructed in the previous surgery had to be preserved. However, the concurrent reconstruction was achieved with the help of a free jejunal flap and vascular reconstruction. All reconstructions from the previous surgery, including the remnant stomach, were preserved via regional abdominal lymph node dissection. After reconstruction, intravenous indocyanine green showed that circulation in the reconstructed intestines was preserved. On postoperative day 1, no recurrent nerve paralysis was observed during laryngoscopy. The patient could start oral intake smoothly 2weeks after surgery and did not exhibit any postoperative complications related to the reconstruction. The patient was transferred to another hospital on postoperative day 21. Owing to the free jejunal flap interposition method, we safely performed one stage subtotal esophagectomy and concurrent reconstruction, preservation of the remnant stomach, and pancreaticobiliary reconstruction in patients with a history of pancreatoduodenectomy. We believe that this method is acceptable and useful for patients undergoing complicated reconstruction.

Left recurrent nerve lymph node dissection in robotic esophagectomy for esophageal cancer without esophageal traction

BackgroundBecause the robotic arm is located on the dorsal side of the patient, when the esophagus is pulled dorsally for the left recurrent nerve lymph node (LRLN) dissection, the robotic arm interferes with the surgical field. This made it difficult to prepare for the left recurrent lymph node dissection. We developed LRLN dissection in robotic surgery with natural space creation by physiological organ movement and evaluated the short-term results.MethodsIn this retrospective study, we analyzed 102 cases of robot-assisted thoracoscopic subtotal esophagectomy (RATE) among radical subtotal esophagectomies performed between December 2018 and December 2022 using medical records. LRLN dissection is preceded by a dissection of the esophagus from the trachea. Leaving the esophagus on the vertebral side and away from the trachea resulted in a physiological elevation of the esophagus, providing space between the trachea and esophagus.ResultsThe thoracic surgery time in RATE was 181 (115–394) min. The number of LRLNs dissected was 4 (1–14). Six patients (6%) had a postoperative recurrence in the mediastinal lymph nodes. Seven patients (7%) had grade ≥ 1 left recurrent nerve palsy.ConclusionsLRLN dissection with RATE using natural space creation was performed safely with a sufficient number of dissected lymph nodes and little left recurrent nerve palsy.

432. A CASE OF ADVANCED ESOPHAGEAL CARCINOSARCOMA DIAGNOSED LATE DUE TO SEVERE STENOSIS AFTER CHEMORADIOTHERAPY

Abstract Radiochemotherapy (CRT) is one of the curative treatment options next to surgery in the treatment of esophageal squamous cell carcinoma. However, CRT may cause esophageal stenosis or obstruction during the healing process. Therefore, in such cases, follow up of early recurrence detection becomes an issue for those patients. We report a case of severe stenosis after CRT, in which recurrence could not detected until advanced cancer developed on the anal side of stenosis. The case is a 73-year-old male. He was diagnosed with upper thoracic esophageal cancer (T4N2M0StageIVa) and had undergone radical chemoradiotherapy 5 years ago. The treatment effect achieved a complete response, but the primary tumor site caused severe esophageal stenosis. Therefore, biannual CT follow up had been done instead of endoscopic follow up. During follow-up, CT revealed a new neoplastic lesion in the lower thoracic esophagus, and endoscopy inserted through a gastrostomy revealed a bulky tumor on the anorectal side of the stenotic lesion. Biopsy revealed carcinosarcoma and robot-assisted thoracoscopic esophagectomy was performed. Malignant neoplasms can be developed not only the same site of primary tumor after CRT. Especially in case of carcinosarcoma, detection would be delayed because of rapid growing. But when the severe esophageal stenosis occurred after CRT, the examination of anal side become difficult. Therefore, it is necessary to observe by frequent CT or PET examination, or endoscopy from gastrostomy for early detection of recurrence or newly malignant neoplasm.

457. STANDARDIZATION AND SHORT-TERM RESULTS OF ROBOT-ASSISTED THORACOSCOPIC ESOPHAGECTOMY

Abstract Surgical cases of robot-assisted thoracoscopic esophagectomy (RAMIE) is increasing because of the advantages of robotic system. We introduced RAMIE in 2019 and standardized the surgical procedure. The usefulness of RAMIE was examined by classifying surgical cases into early and late periods and comparing the surgical results. Fifty-four patients who underwent RAMIE were enrolled in the study. All patients underwent D2 or higher lymph node (LN) dissection, gastric tube reconstruction, and R0 surgery. The patients were divided into two groups, 26 cases in the first half up to December 2020 and 28 cases in the second half after January 2021. The patient background, surgical technique, and short-term results were compared. The tumor staging was based on the UICC 8th version. Thoracic surgery time was 274 minutes, the chest bleeding volume was 30 mL, and the postoperative hospital stay was 19 days (median). In the late stage, patients with clinical thoracic LN metastasis (p = 0.01) and advanced stage (p = 0.006) were higher than those in the early period. There were significantly more cases of thoracic duct resection and D3 dissection in the late period (p = 0.02, p = 0.009). No differences in postoperative complications and intra-hospital death was observed, however the postoperative hospital stay was significantly shortened in the late period (p = 0.001). Thorough mediastinal LN dissection by RAMIE could be safely performed by standardizing and improving the surgical procedures. RAMIE has several issues such as higher cost associated with equipment and longer operative time, but it is possible to perform precise procedures with solo surgery, and it is expected that cost reduction effects will be expected in terms of the number of participants in surgery and the length of hospital stay after surgery.

Novel surgical technique of robot-assisted thoracoscopic esophagectomy in the lateral decubitus position

We performed robot-assisted thoracoscopic esophagectomy in lateral decubitus position (LDP) with camera rotation and manual hand control assignment to reproduce the visualization and manipulation of open esophagectomy or thoracoscopic esophagectomy in LDP. Four robotic ports and two 12 mm assistant ports were placed. The camera image for the operator was vertically and horizontally inverted by camera rotation to create an operative view similar to that achieved under open thoracotomy. We used a forward-oblique viewing endoscope with a 30° down-facing orientation. The mediastinal view was obtained by single lung ventilation, artificial pneumothorax by carbon dioxide insufflation, and trachea retraction by the assistant. The right and left hands were assigned to any combination of two out of the three arms depending on the situation. The remaining arm was used as an assistant to create an adequate surgical view. The robotic platform is useful to manage aortic injury by direct suturing.

Robot-assisted thoracoscopic esophagectomy for gastrointestinal stromal tumor of the esophagus: A case report

IntroductionA gastrointestinal stromal tumor (GIST) often arises in the stomach and small intestine, while esophageal GIST is rare. The first-choice treatment is surgical resection, but there is no standard technique. Herein, we describe our experience in the treatment of esophageal GIST and discuss the usefulness of robotic esophagectomy.Presentation of caseThe patient was a 60-year-old woman, who was diagnosed with a 30 mm GIST in the middle thoracic esophagus. We underwent robot-assisted thoracoscopic esophagectomy in the prone position. The duration of the thoracoscopic part was 69 min and the total operation time was 319 min. Total blood loss was 135 ml. The patient's postoperative course was uneventful after surgery and the patient was discharged home in good condition on the 18th postoperative day.DiscussionThe prognosis of esophageal GIST was less favorable compared with gastric GIST, and due to the anatomical peculiarities of the esophagus, which surgical procedure should be performed is still under debate. Robotic surgery has several technological advantages as it provides a three-dimensional view, ten times magnification, tremor control, and ambidexterity. Therefore, Robotic-assisted minimally invasive esophagectomy (RAMIE) allows achieving for safe R0 resection of esophageal GIST.ConclusionRAMIE may be useful for esophageal GIST because it facilitates safe and minimally invasive surgery in a limited space of the thoracic cavity.

Lower local recurrence rate after robot-assisted thoracoscopic esophagectomy than conventional thoracoscopic surgery for esophageal cancer

The oncological advantages of robot-assisted thoracoscopic esophagectomy (RATE) over conventional thoracoscopic esophagectomy (TE) for thoracic esophageal cancer have yet to be verified. In this study, we retrospectively analyzed clinical data to compare the incidences of recurrence within the surgical field after RATE and TE as an indicator of local oncological control. Among 121 consecutive patients with thoracic esophageal or esophagogastric junction cancers for which thoracoscopic surgery was indicated, 51 were treated with RATE while 70 received TE. The number of lymph nodes dissected from the mediastinum, duration of the thoracic portion of the surgery, and morbidity due to postoperative complications did not differ between the two groups. However, the rate of overall local recurrence within the surgical field was significantly (P = 0.039) higher in the TE (9%) than the RATE (0%) group. Lymph node recurrence within the surgical field occurred in left recurrent nerve, left tracheobronchial, left main bronchus and thoracic paraaortic lymph nodes, which were all difficult to approach to dissect. The other two local failures occurred around the anastomotic site. This study indicates that using RATE enabled the incidence of recurrence within the surgical field to be reduced, though there were some limitations.

Optimization of robot-assisted thoracoscopic esophagectomy in the lateral decubitus position.

On the introduction of robot-assisted thoracoscopic esophagectomy (RATE), we refined the robotic system application to enhance our surgical experience obtained through thoracoscopic esophagectomy (TE) in the lateral decubitus position (LDP). Herein, we evaluate our methods introduced to optimize RATE in the LDP. We performed RATE in the LDP with camera rotation and manual hand control assignment to reproduce the surgical view and manipulation of open esophagectomy. Forty patients underwent RATE between July 2018 and August 2020. After the initial 30 cases (initial RATE group), we optimized the port arrangement and robot settings in the most recent ten cases (recent RATE group). The surgical results of RATE were compared with those of 30 patients underwent TE between April 2014 and May 2019 selected by propensity score-matched analysis based on cStage (TE group). Operative duration was significantly longer in the initial RATE group than the TE group and the recent RATE group. Thoracic blood loss was significantly less in the initial RATE group than the TE group. Console time was significantly shorter in the recent RATE group than the initial RATE group. There was no surgical mortality in RATE and the surgical morbidity rate was similar in the three groups. Camera rotation and manual hand control assignment during RATE in the LDP reproduced the surgical view and manipulation of open esophagectomy and TE in the LDP. The robotic platform enabled meticulous dissection and reduced blood loss, but was initially time-consuming. Optimization of the port arrangement minimized operative duration.

Prevention of intra-thoracic recurrent laryngeal nerve injury with robot-assisted esophagectomy.

Transthoracic esophagectomy for esophageal cancer is one of the most invasive procedures in surgery for gastrointestinal cancer. Serious complications sometimes occur after esophageal cancer surgery, including recurrent laryngeal nerve injury and pneumonia. The purpose of this study was to access the possibility of robot-assisted thoracoscopic esophagectomy for esophageal cancer in terms of preventing recurrent laryngeal nerve injury. Operations in thoracic part were performed in prone position with bilateral ventilation. During dissection of the recurrent laryngeal nerve lymph nodes, thin blood vessels were coagulated with Maryland bipolar forceps in the left hand and then dissected with monopolar scissors in the right hand. Especially when dissecting left recurrent laryngeal nerve lymph nodes, the nerve was left unisolated from the vascular sheath that involves the aortic arch. Short-term outcomes including operative time, estimated blood loss, and postoperative complications including recurrent laryngeal nerve injury were accessed. From November 2018 to January 2020, 20 patients underwent robot-assisted thoracoscopic esophagectomy for esophageal cancer. Thoracic operative time was 242 min, estimated blood loss in the thoracic part was minimal, the number of dissected mediastinal lymph nodes was 19 (all median), and the incidence rates of recurrent laryngeal nerve injury and pneumonia were 10% (2 case) and 10% (2 cases), respectively. Robot-assisted thoracoscopic esophagectomy for esophageal cancer has the possibility of reducing recurrent laryngeal nerve injury even in the introductory period. Randomized controlled trials are required to confirm this advantage of the robotic surgery.

Lymph Node Evaluation in Robot-Assisted Versus Video-Assisted Thoracoscopic Esophagectomy for Esophageal Squamous Cell Carcinoma: A Propensity-Matched Analysis.

Radical lymph node dissection (LND) along the bilateral recurrent laryngeal nerve (RLN) is a surgically challenging procedure with a high rate of morbidity. Here, we assessed in a retrospective manner the adequacy of LND along the RLN performed with robot-assisted thoracoscopic esophagectomy (RATE) versus video-assisted thoracoscopic esophagectomy (VATE) in patients with esophageal squamous cell carcinoma (ESCC). This was a single-center, retrospective, propensity-matched study. ESCC patients who underwent McKeown esophagectomy and bilateral RLN LND with a minimally invasive approach were divided into two groups according to the use of robot-assisted surgery or not (RATE vs VATE, respectively). Using propensity score matching, 34 balanced matched pairs were identified. The number of dissected nodes as well as the rates of RLN palsy and perioperative complications served as the main outcome measures. No conversion to open thoracotomy occurred in either group. Intraoperative blood loss and the need of blood transfusions did not show significant intergroup differences. The mean number of dissected nodes was similar in the two study groups, the only exception being the left RLN area. Specifically, the mean number of nodes removed from this region was 5.32 in the RATE group and 3.38 in patients who received VATE (p=0.007). Notably, the RATE and VATE groups did not differ significantly with regard to rates of both RLN palsy (20.6 vs 29.4%, respectively, p=0.401) and pulmonary complications (5.9 vs 17.6%, respectively, p=0.259). Compared with VATE, RATE resulted in a higher lymph node yield along the left RLN without increasing morbidity.

The Oncologic Outcome of Esophageal Squamous Cell Carcinoma Patients After Robot-Assisted Thoracoscopic Esophagectomy With Total Mediastinal Lymphadenectomy

The oncologic outcome of esophageal squamous cell carcinoma (ESCC) patients after robot-assisted thoracoscopic esophagectomy (RATE) with total mediastinal lymphadenectomy (ML) has not been reported. This study was performed to determine the oncologic outcome of RATE and the effectiveness of total ML for ESCC. The 115 patients who underwent RATE without neoadjuvant therapy from 2006 to 2014 were reviewed. The efficacy index (EI) was calculated bymultiplying the incidence of metastasis by the 3-year survival rate of the patients for each node station. The majority of patients were male (92.2%), and the mean age was 63.2 ± 0.8 years. Tumor location was the upper esophagus in 12 patients (10.4%), the middle esophagus in 59 patients (51.3%), and the lower esophagus in 44 patients (38.3%). R0 resection was achieved in 110 (95.7%) patients; the mean number of dissected nodes was 49.0 ± 1.9. Operative mortalities were 4 (3.5%) cases; in the remaining 111 patients, the mean follow-up time was 32.4 ± 2.2 months. Overall survival (OS) and recurrence-free interval (RFI) at 3 years were 85.0% and 79.4%, respectively. The 3-year OS and RFI were 94.4% and 96.2% in patients with stage I disease, 86.2% and 80.1% in stage II disease, and 77.8% and 79.5% in stage IIIA disease, respectively. High EI values were determined in the bilateral recurrent laryngeal nerve (RLN) nodes in upper and middle ESCC, and in the left gastric and paracardial nodes in lower ESCC. The oncologic outcome of RATE was acceptable. Total ML, including dissection of the RLN nodes, is recommended especially in upper or middle ESCC.

Decreased Incidence of Postoperative Delirium in Robot-assisted Thoracoscopic Esophagectomy Compared With Open Transthoracic Esophagectomy.

Postoperative delirium (POD) is one of messy complications related with increased mortality and hospital costs. Patients undergoing esophagectomy are more in danger of delirium than other kinds of surgeries. We investigated the impact of robot-assisted thoracoscopic esophagectomy on the incidence of POD compared with open transthoracic esophagectomy. A retrospective review was completed for the patients who underwent esophagectomy from December 2, 2012 and April 15, 2015 (n=529). POD was assessed using Confusion Assessment Method for the Intensive Care Unit. The comparison of group differences between the robotic esophagectomy group (R group) and the open esophagectomy group (O group) was conducted with and without propensity score (PS) matching method. Univariate model was used for 247 PS-matched patients to calculate the odds ratio of potential risk factors of POD. The incidence rate of POD was significantly lower among R group patients than O group (30% vs. 42%; P=0.035) after PS matching method. The risk of POD in R group was 0.55-fold lower than that of O group. Operative time and intraoperative blood loss were also significantly lower in R group patients. In conclusion, robotic thoracoscopic esophagectomy lowers the incidence of POD 0.55-fold compared with open transthoracic esophagectomy.

Robot-Assisted Mckeown Esophagectomy is Feasible After Neoadjuvant Chemoradiation. Our Initial Experience.

Neoadjuvant chemoradiation has become the standard of care for esophageal cancer, especially for middle third esophageal lesions and those with squamous histology. Although more and more thoracic surgeons and surgical oncologists have now shifted to video-assisted and robot-assisted thoracoscopic esophagectomy; there is still limited experience for the use of minimal-assisted approaches in patients undergoing surgery after neoadjuvant chemoradiation. Most surgeons have concerns of feasibility, safety, and oncological outcomes as well as issues related to difficult learning curve in adopting robotic esophagectomy in patients after chemoradiation. We present our initial experience of Robot-Assisted Mckeown Esophagectomy in 27 patients after neoadjuvant chemoradiation, from May 2013 to October 2014. All patients underwent neoadjuvant chemoradiation to a dose of 50.4Gy/25Fr with concurrent weekly cisplatin, followed by reassessment with clinical examination and repeat FDG PET/CT 6weeks after completion of chemoradiation. Patients with progressive disease underwent palliative chemotherapy while patients with either partial or significant response to chemoradiation underwent Robot-Assisted Mckeown Esophagectomy with esophageal replacement by gastric conduit and esophagogastric anastomosis in the left neck. Out of 27 patients, 92.5% patients had stage cT3/T4 tumours and node-positive disease in 48.1% on imaging. Most patients were middle thoracic esophageal cancers (23/27), with squamous histology in all except for one. All patients received neoadjuvant chemoradiation and subsequently underwent Robot Assisted Mckeown Esophagectomy. The average time for robot docking, thoracic mobilization and total surgical procedure was 13.2, 108.4 and 342.7min, respectively. The procedure was well tolerated by all patients with only one case of peri-operative mortality. Average ICU stay was 6.35days (range 3-9days). R0 resection rate of 96.3% and average lymph node yield of 18 could be achieved. Pathological node negativity rate (pN0) and complete response (pCR) were 66.6 and 44.4%, respectively. In the initial cases, four patients had to be converted to open due technical reasons or intraoperative complications. The present study, with shorter operative times, similar ICU stay, overall low morbidity, and mortality and optimal oncological outcomes suggest that robot-assisted thoracic mobilization of esophagus in patients with prior chemoradiation is feasible and safe with acceptable oncological outcomes. It has a shorter learning curve and hence allows for a transthoracic minimally invasive transthoracic esophagectomy to more and more patients, otherwise unfit for conventional approach.

Robotic transthoracic esophagectomy.

BackgroundWe have initially published our experience with the robotic transthoracic esophagectomy in 32 patients from a single institute. The present paper is the extension of our experience with robotic system and to best of our knowledge this represents the largest series of robotic transthoracic esophagectomy worldwide. The objective of this study was to investigate the feasibility of the robotic transthoracic esophagectomy for esophageal cancer in a series of patients from a single institute.MethodsA retrospective review of medical records was conducted for 83 esophageal cancer patients who underwent robotic esophagectomy at our institute from December 2009 to December 2012. All patients underwent a thorough clinical examination and pre-operative investigations. All patients underwent robotic esophageal mobilization. En-bloc dissection with lymphadenectomy was performed in all cases with preservation of Azygous vein. Relevant data were gathered from medical records.ResultsThe study population comprised of 50 men and 33 women with mean age of 59.18 years. The mean operative time was 204.94 mins (range 180 to 300). The mean blood loss was 86.75 ml (range 50 to 200). The mean number of lymph node yield was 18. 36 (range 13 to 24). None of the patient required conversion. The mean ICU stay and hospital stay was 1 day (range 1 to 3) and 10.37 days (range 10 to 13), respectively. A total of 16 (19.28%) complication were reported in these patents. Commonly reported complication included dysphagia, pleural effusion and anastomotic leak. No treatment related mortality was observed. After a median follow-up period of 10 months, 66 patients (79.52%) survived with disease free stage.ConclusionsWe found robot-assisted thoracoscopic esophagectomy feasible in cases of esophageal cancer. The procedure allowed precise en-bloc dissection with lymphadenectomy in mediastinum with reduced operative time, blood loss and complications.Electronic supplementary materialThe online version of this article (doi:10.1186/s12893-015-0024-2) contains supplementary material, which is available to authorized users.

Robot-assisted thoracoscopic esophagectomy with extensive mediastinal lymphadenectomy: experience with 114 consecutive patients with intrathoracic esophageal cancer.

The study aims to report the operative outcomes of robot-assisted thoracoscopic esophagectomy (RATE) with extensive mediastinal lymphadenectomy (ML) for intrathoracic esophageal cancer. We analyzed a prospective database of 114 consecutive patients who underwent RATE with lymph node dissection along recurrent laryngeal nerve (RLN) followed by cervical esophagogastrostomy. The study included 104 men with a mean age of 63.1 ± 0.8 years. Of these, 110 (96.5%) had squamous cell carcinoma, and the location of the tumor was upper esophagus in 7 (6.1%), middle in 62 (54.4%), and lower in 45 (39.5%). Preoperative concurrent chemoradiation was performed in 15 patients (13.2%). All but one patient underwent successful RATE, and R0 resection was achieved in 111 patients (97.4%). Extended ML and total ML were performed in 24 (21.1%) and 90 (78.9%) patients, respectively. Total operation time was 419.6 ± 7.9 minutes, and robot console time was 206.6 ± 5.2 minutes. The mean number of total, mediastinal, and RLN nodes was 43.5 ± 1.4, 24.5 ± 1.0, and 9.7 ± 0.7, respectively. The most common complication was RLN palsy (30, 26.3%), followed by anastomotic leakage (17, 14.9%) and pulmonary complications (11, 9.6%). Median hospital stay was 16 days, and 90-day mortality was observed in three patients (2.5%). On multivariate analysis, preoperative concurrent chemoradiation was a risk factor for pulmonary complications (odds ratio 7.42, 95% confidence interval 1.91-28.8, P = 0.004). RATE with extensive ML could be performed safely with acceptable postoperative outcomes. Long-term survival data should be followed in the future to verify the oncological outcome of the procedure.

Feasibility of a robot-assisted thoracoscopic lymphadenectomy along the recurrent laryngeal nerves in radical esophagectomy for esophageal squamous carcinoma

Lymph node dissection along bilateral recurrent laryngeal nerves (RLNs) is an essential component of radical esophagectomy for esophageal squamous carcinoma. However, it is associated with significant morbidity and requires a great deal of skill when performed with minimally invasive surgery. Between October 2010 and July 2012, 40 consecutive patients underwent a robot-assisted thoracoscopic esophagectomy and total mediastinal lymphadenectomy. The lymph nodes along the dorsal side of the RLNs were removed in the initial 18 patients (group 1), and the RLNs were skeletonized by dissection of all the lymph nodes and surrounding fatty tissues in the following 22 patients (group 2). All but one patient underwent a successful robot-assisted, thoracoscopic esophagectomy. The mean operation time was 428.6 ± 75.0 min, and the mean robot console time was 186.7 ± 52.1 min. An average of 42.6 ± 14.1 nodes was retrieved, and the mean number of dissected nodes from the mediastinum and the RLN chains were 25.5 ± 9.6 and 9.6 ± 6.5, respectively. One mortality occurred (2.5%), and the incidences of pneumonia and RLN palsy were 12.5 and 20%, respectively. The mean robot console time was longer in group 2 (211.4 ± 49.5 min) than in group 1 (156.6 ± 38.2 min) (p < 0.001), and group 2 had higher mean numbers of dissected nodes from the mediastinum (30.3 ± 7.9 vs 19.6 ± 8.2; p < 0.001) and the RLN chains (13.5 ± 5.7 vs 4.8 ± 3.6; p < 0.001). Although RLN palsy was more common in group 2 (31.8 vs 5.6%; p = 0.054), all palsies resolved within 1 year. Robot-assisted thoracoscopic lymphadenectomy along bilateral RLNs was technically feasible and safe. Skeletonization of the RLNs yields more lymph nodes, but efforts should be made to decrease the incidence of RLN palsy.

Robot‐Assisted Thoracoscopic Hybrid Esophagectomy in the Semi‐Prone Position Under Pneumothorax

We performed robot-assisted thoracoscopic hybrid esophagectomy using the da Vinci Surgical System and demonstrated the potential benefit of this minimally invasive lymphadenectomy. Between April 2010 and October 2011, four patients with intrathoracic esophageal cancer underwent hybrid esophagectomy in the semi-prone position using a 3-arm standard da Vinci and a conventional thoracoscopic maneuver. All thoracoscopic procedures were completed using a robot-assisted technique. Robot-assisted thoracoscopic esophagectomy in the semi-prone position is safe and technically feasible. A hybrid procedure that combined standard da Vinci with conventional thoracosopic maneuvers overcomes the difficulties associated with using a standard da Vinci.

Robot‐assisted Thoracoscopic Lymphadenectomy Along the Left Recurrent Laryngeal Nerve for Esophageal Squamous Cell Carcinoma in the Prone Position: Technical Report and Short‐term Outcomes

Meticulous mediastinal lymphadenectomy frequently induces recurrent laryngeal nerve palsy (RLNP). Surgical robots with impressive dexterity and precise dissection skills have been developed to help surgeons perform operations. The objective of this study was to determine the impact on short-term outcomes of robot-assisted thoracoscopic radical esophagectomy performed on patients in the prone position for the treatment of esophageal squamous cell carcinoma, including its impact on RLNP. A single-institution nonrandomized prospective study was performed. The patients (n = 36) with resectable esophageal squamous cell carcinoma were divided into two groups: patients who agreed to robot-assisted thoracoscopic esophagectomy with total mediastinal lymphadenectomy performed in the prone position (n = 16, robot-assisted group) without insurance reimbursement, and those who agreed to undergo the same operation without robot assistance but with health insurance coverage (n = 20, control group). These patients were observed for 30 days following surgery to assess short-term surgical outcomes, including the incidence of vocal cord palsy, hoarseness, and aspiration. Robot assistance significantly reduced the incidence of vocal cord palsy (p = 0.018) and hoarseness (p = 0.015) and the time on the ventilator (p = 0.025). There was no in-hospital mortality in either group. There were no significant differences between the two groups with respect to patient background, except for the use of preoperative therapy (robot-assisted group <control, p = 0.003). There were no significant differences in estimated blood loss, operating time, number of dissected lymph nodes, completeness of resection, or the incidence of the other complications, except for anastomotic leakage (p = 0.038). Robot-assisted thoracoscopic esophagectomy with total mediastinal lymphadenectomy is feasible and safe. This method shows promise in preventing RLNP.

Thoracoscopic esophagectomy for esophageal cancer: Feasibility and safety of robotic assistance in the prone position

To assess the feasibility and safety of robot-assisted thoracoscopic esophagectomy for esophageal cancer in the prone position. Twenty-one patients underwent robot-assisted thoracoscopic esophagectomy in the prone position by a surgical oncologist who had no prior experience with thoracoscopic esophagectomy. Hemodynamic and respiratory parameters were serially recorded to monitor changes in prone positioning. All thoracoscopic procedures were completed with a robot-assisted technique followed by cervical esophagogastrostomy. R0 resection was achieved in 20 patients (95.2%), and the number of dissected nodes was 38.0 + or - 14.2. Robot console time was significantly reduced from 176.3 + or - 12.3 minutes in the initial 6 patients (group 1) to 81.7 + or - 16.5 minutes in the latter 15 patients (group 2) (P = .000). In group 2, there was less blood loss (P = .018), more patients could be extubated in the operating room (P = .004), and the number of dissected mediastinal nodes tended to be increased (P = .093). There was no incidence of pneumonia or 90-day mortality. Major complications included anastomotic leakage in 4 patients, vocal cord palsy in 6 patients, and intra-abdominal bleeding in 1 patient. The prone position led to an elevation of central venous pressure and mean pulmonary arterial pressure and a decrease in static lung compliance. However, cardiac index and mean arterial pressure were well maintained with the acceptable range of partial pressure of arterial oxygen and carbon dioxide. Robotic assistance in the prone position is technically feasible and safe. Prone positioning was well tolerated, but preoperative risk assessment and meticulous anesthetic manipulation should be carried out.