Robotic-assisted minimally invasive esophagectomy

Abstract

The optimal surgical approach for advanced benign and local malignant esophageal disease remains largely debatable. Esophagectomy is technically demanding and can result in significant morbidity, as well as mortality. Efforts to reduce associated morbidity have sparked the adoption of minimally invasive techniques, particularly robotic assisted approaches. Robotic surgery has been widely adopted by many thoracic surgeons over the past two decades and adds several technical advancements that circumvent the inherent limitations of conventional open or minimally invasive approaches. Robotic-assisted minimally invasive esophagectomy (RAMIE) has been considered safe, while reducing morbidity (blood loss, surgical-site and respiratory infections), and providing acceptable oncological outcomes. Key concepts of the RAMIE approach include appropriate abdominal and thoracoscopic port placements to optimize bedside assistance, gastric mobilization, pyloroplasty, gastric tube construction, esophageal mobilization, optimal lymphadenectomy, and creation of the esophagogastric anastomosis. Proficiency in the robotic approach can be achieved through a proctored curriculum, and earlier pathways to proficiency have been shown in surgeons with previous foregut experience. Overall, early studies vary in methodology and peri-operative outcomes, but few prospective trials are ongoing and long-term data remain limited. The focus of our manuscript is to highlight the existing literature on outcome differences between RAMIE and non-robotic approaches, and to discuss our peri-operative and intra-operative approach in patients undergoing RAMIE at a high-volume center.