First experience with robot-assisted thoracoscopic esophagolymphadenectomy for esophageal cancer

Intraoperative Endoscopic Botox Injection During Total Esophagectomy Prevents the Need for Pyloromyotomy or Dilatation

BACKGROUND

Esophagectomy may lead to impairment in gastric emptying unless pyloric drainage is performed. Pyloric drainage may be technically challenging during minimally invasive esophagectomy and can add morbidity. We sought to determine the effectiveness of intraoperative endoscopic injection of botulinum toxin into the pylorus during robotic-assisted esophagectomy as an alternative to surgical pyloric drainage.

MATERIALS AND METHODS

We performed a retrospective analysis of patients with adenocarcinoma and squamous cell carcinoma of the distal esophagus or gastroesophageal junction who underwent robotic-assisted transhiatal esophagectomy (RATE) without any surgical pyloric drainage. Patients with and without intraoperative endoscopic injection of 200 units of botulinum toxin in 10 cc of saline (BOTOX group) were compared to those that did not receive any pyloric drainage (noBOTOX group). Main outcome measure was the incidence of postoperative pyloric stenosis; secondary outcomes included operative and oncologic parameters, length of stay (LOS), morbidity, and mortality.

RESULTS

From November 2006 to August 2014, 41 patients (6 females) with a mean age of 65 years underwent RATE without surgical drainage of the pylorus. There were 14 patients in the BOTOX group and 27 patients in the noBOTOX group. Mean operative time was not different between the comparison groups. There was one conversion to open surgery in the BOTOX group. No pyloric dysfunction occurred in the BOTOX group postoperatively, and eight stenoses in the noBOTOX group (30%) required endoscopic therapy (P < .05). There were no differences in incidence of anastomotic strictures or anastomotic leaks. One patient in group noBOTOX required pyloroplasty 3 months after esophagectomy. There was one death in the noBOTOX group postoperatively (30-day mortality 2.4%). Mean LOS was 9.6 days, and BOTOX patients were discharged earlier (7.4 versus 10.7, P < .05).

CONCLUSION

Intraoperative endoscopic injection of botulinum toxin into the pylorus during RATE is feasible, safe, and effective and can prevent the need for pyloromyotomy.

Great Vessel Injury in Thoracic Surgery

The potential for intraoperative bleeding is inherent to the practice of thoracic surgery due to the presence of multiple vital vascular structures, complex anatomy, and constant cardiorespiratory motion. Careful and detailed preoperative evaluation and planning, comprehensive review of imaging studies, and a thorough knowledge of the operative procedure, anatomic relationships, and potential complications are of the highest importance in prevention and avoidance of bleeding complications. Preparation with a clear crisis management plan ensures an effective and expedited response when intraoperative bleeding occurs.

Laparoscopic and robot-assisted laparoscopic digestive surgery: Present and future directions

Laparoscopic surgery is applied today worldwide to most digestive procedures. In some of them, such as cholecystectomy, Nissen's fundoplication or obesity surgery, laparoscopy has become the standard in practice. In others, such as colon or gastric resection, the laparoscopic approach is frequently used and its usefulness is unquestionable. More complex procedures, such as esophageal, liver or pancreatic resections are, however, more infrequently performed, due to the high grade of skill necessary. As a result, there is less clinical evidence to support its implementation. In the recent years, robot-assisted laparoscopic surgery has been increasingly applied, again with little evidence for comparison with the conventional laparoscopic approach. This review will focus on the complex digestive procedures as well as those whose use in standard practice could be more controversial. Also novel robot-assisted procedures will be updated.

Robot-assisted minimally invasive esophagectomy for esophageal cancer: A systematic review

This paper describes the technique of robot-assisted minimally invasive esophagectomy. (RAMIE) Also, a systematic literature search was performed. Safety and feasibility of RAMIE was demonstrated in all reports. Short term oncologic results show radical resection rates of 77-100% and 18-43 lymph nodes harvested. RAMIE offers great visualization of the mediastinum and enables meticulous dissection in the mediastinum from diaphragm to thoracic inlet.

Oncologic Long-Term Results of Robot-Assisted Minimally Invasive Thoraco-Laparoscopic Esophagectomy with Two-Field Lymphadenectomy for Esophageal Cancer

BACKGROUND

Open transthoracic esophagectomy is the worldwide gold standard in the treatment of resectable esophageal cancer. Robot-assisted minimally invasive thoraco-laparoscopic esophagectomy (RAMIE) for esophageal cancer may be associated with reduced blood loss, shorter intensive care unit (ICU) stay, and less cardiopulmonary morbidity; however, long-term oncologic results have not been reported to date.

METHODS

Between June 2007 and September 2011, a total of 108 patients with potentially resectable esophageal cancer underwent RAMIE at the University Medical Centre Utrecht, with curative intent. All data were recorded prospectively.

RESULTS

Median duration of the surgical procedure was 381 min (range 264-636). Pulmonary complications were most common and were observed in 36 patients (33 %). Median ICU stay was 1 day, and median overall postoperative hospital stay was 16 days. In-hospital mortality was 5 %. The majority of patients (78 %) presented with T3 and T4 disease, and 68 % of patients had nodal-positive disease (cN1-3). In 65 % of patients, neoadjuvant treatment (chemotherapy 57 %, chemoradiotherapy 7 %, radiotherapy 1 %) was administered, and in 103 (95 %) patients, a radical resection (R0) was achieved. The median number of lymph nodes was 26, median follow-up was 58 months, 5-year overall survival was 42 %, median disease-free survival was 21 months, and median overall survival was 29 months. Tumor recurrence occurred in 51 patients and was locoregional only in 6 (6 %) patients, systemic only in 31 (30 %) patients, and combined in 14 (14 %) patients.

CONCLUSION

RAMIE was shown to be oncologically effective, with a high percentage of R0 radical resections and adequate lymphadenectomy. RAMIE provided good local control with a low percentage of local recurrence at long-term follow up.

Robotic transthoracic esophagectomy

BACKGROUND

We 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.

METHODS

A 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.

RESULTS

The 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.

CONCLUSIONS

We 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.

Surgical treatments for esophageal cancers

The following, from the 12th OESO World Conference: Cancers of the Esophagus, includes commentaries on the role of the nurse in preparation of esophageal resection (ER); the management of patients who develop high-grade dysplasia after having undergone Nissen fundoplication; the trajectory of care for the patient with esophageal cancer; the influence of the site of tumor in the choice of treatment; the best location for esophagogastrostomy; management of chylous leak after esophagectomy; the optimal approach to manage thoracic esophageal leak after esophagectomy; the choice for operational approach in surgery of cardioesophageal crossing; the advantages of robot esophagectomy; the place of open esophagectomy; the advantages of esophagectomy compared to definitive chemoradiotherapy; the pathologist report in the resected specimen; the best way to manage patients with unsuspected positive microscopic margin after ER; enhanced recovery after surgery for ER: expedited care protocols; and long-term quality of life in patients following esophagectomy.

[Initial results of robotic esophagectomy for esophageal cancer]

INTRODUCTION

There is scant experience with robot-assisted esophagectomy in cases of esophageal and gastro-esophageal junction cancer. Our aim is to report our current experience.

PATIENTS AND METHODS

Observational cohort study of the first 32 patients who underwent minimally invasive esophagectomy for esophageal cancer from September 2011 to June 2014. The gastric tube was created laparoscopically. In the thoracic field, a robot-assisted thoracoscopic approach was performed in the prone position with intrathoracic robotic hand-sewn anastomosis. Patient and tumour characteristics, surgical technique, short-term outcomes (morbidity and mortality) and oncological results (radicality and number of removed nodes) were evaluated.

RESULTS

Thirty-two patients, with a mean age of 58 years (34-74) were treated by a totally minimally invasive esophagectomy: robotic laparoscopy and thoracoscopy (11 McKeown and 21 Ivor-Lewis). Twenty-nine received neoadjuvant chemoradiotherapy. There were no conversions to open surgery. Console time was 218minutes (190-285). Blood loss was 170ml (40-255). One patient died from cardiac disease. Nine patients had a major complication (Dindo-Clavien grade II or higher). There was no case of respiratory complication or recurrent laryngeal nerve palsy. Five patients had intrathoracic fistula, 4 radiological and one clinical. Three had chylothorax, 2 cervical fistula and one gastric tube necrosis. The median hospital stay was 12 days (8-50). All the resections were R0 and the median of removed lymph nodes was 16 (2-23).

CONCLUSIONS

Our results suggest that minimally invasive esophagectomy with robot-assisted thoracoscopy is safe and achieves oncological standards.

European Association of Endoscopic Surgeons (EAES) consensus statement on the use of robotics in general surgery

Following an extensive literature search and a consensus conference with subject matter experts the following conclusions can be drawn: 1. Robotic surgery is still at its infancy, and there is a great potential in sophisticated electromechanical systems to perform complex surgical tasks when these systems evolve. 2. To date, in the vast majority of clinical settings, there is little or no advantage in using robotic systems in general surgery in terms of clinical outcome. Dedicated parameters should be addressed, and high quality research should focus on quality of care instead of routine parameters, where a clear advantage is not to be expected. 3. Preliminary data demonstrates that robotic system have a clinical benefit in performing complex procedures in confined spaces, especially in those that are located in unfavorable anatomical locations. 4. There is a severe lack of high quality data on robotic surgery, and there is a great need for rigorously controlled, unbiased clinical trials. These trials should be urged to address the cost-effectiveness issues as well. 5. Specific areas of research should include complex hepatobiliary surgery, surgery for gastric and esophageal cancer, revisional surgery in bariatric and upper GI surgery, surgery for large adrenal masses, and rectal surgery. All these fields show some potential for a true benefit of using current robotic systems. 6. Robotic surgery requires a specific set of skills, and needs to be trained using a dedicated, structured training program that addresses the specific knowledge, safety issues and skills essential to perform this type of surgery safely and with good outcomes. It is the responsibility of the corresponding professional organizations, not the industry, to define the training and credentialing of robotic basic skills and specific procedures. 7. Due to the special economic environment in which robotic surgery is currently employed special care should be taken in the decision making process when deciding on the purchase, use and training of robotic systems in general surgery. 8. Professional organizations in the sub-specialties of general surgery should review these statements and issue detailed, specialty-specific guidelines on the use of specific robotic surgery procedures in addition to outlining the advanced robotic surgery training required to safely perform such procedures.

Robotic-assisted minimally invasive esophagectomy: the Ivor Lewis approach

Robotic-assisted minimally invasive esophagectomy (RAMIE) is emerging as a potential alternative approach to standard minimally invasive esophagectomy (MIE). However, early reports vary widely in operative approach, method, and reporting of outcomes, including operative complications. A formal, prospective academic program to evaluate RAMIE was initiated at the authors' institution, with the primary goal of maximizing patient safety during the introduction of new technology into the operating room. The standardized RAMIE Ivor Lewis approach developed through this program is described in detail. The available literature is reviewed, with early reports suggesting outcomes similar to those of MIE and standard open esophagectomy.

Initial results of robot-assisted Ivor-Lewis oesophagectomy with intrathoracic hand-sewn anastomosis in the prone position

BACKGROUND

There is scanty experience concerning robot-assisted Ivor-Lewis oesophagectomy, so every new experience is helpful.

METHODS

We describe the techniques and short-term results of Ivor-Lewis oesophagectomy using a laparoscopic approach and robot-assisted thoracoscopy, and an observational study of prospective surveillance of the first 14 patients treated for oesophageal cancer. A gastric tube was created laparoscopically. Oesophagectomy was performed through a robot-assisted thoracoscopy followed by hand-sewn intrathoracic anastomosis.

RESULTS

There were no conversion cases. Mortality was zero. Six patients had a major complication. There were no cases of respiratory complication or recurrent laryngeal nerve palsy. Three patients had a radiological fistula (21.4%), successfully treated by endoscopic stenting, and one (7.1%) had an anastomosis leak needing reoperation. There were two cases of chylothorax (14.3%).

CONCLUSIONS

Our initial results suggest that the reported technique is safe and satisfies the oncological principles. It provides the advantages of minimally invasive surgery by overcoming some limitations of conventional thoracoscopy.

Robot-assisted gastrectomy and oesophagectomy for cancer

BACKGROUND

Robot-assisted surgery is a technically feasible alternative to open and laparoscopic surgery, which is being more frequently used in general surgery. We undertook this review to investigate whether robotic assistance provides a significant benefit for oesophagogastric cancer surgery.

METHODS

Electronic databases were searched for original English-language publications for robotic-assisted gastrectomy and oesophagectomy between January 1990 and October 2013.

RESULTS

Sixty-one publications were included. Thirty-five included gastrectomy, 31 included oesophagectomy and five included both operations. Several publications suggest that robot-assisted subtotal gastrectomy can be as safe and effective as an open or laparoscopic procedure, with equal outcomes with regard to the number of lymph nodes resected, overall morbidity and perioperative mortality, and length of hospital stay. Robotic assistance is associated with longer operation times but also with less blood loss in some reports. A significant benefit for robotic assistance has not been shown for the more extensive operations of oesophagectomy or total gastrectomy with D2-lymphadenectomy. There are very few oncologic data regarding local recurrence or long-term survival for any of the robotic operations.

CONCLUSIONS

No significant differences in morbidity, mortality or number of lymph node harvested have been shown between robot-assisted and laparoscopic gastrectomy or oesophagectomy. Robotic surgery, with its relatively short learning curve, may facilitate reproducible minimally invasive surgery in this field but operation times are reportedly longer and cost differences remain unclear. Randomized trials with oncologic outcomes and cost comparisons are needed.

Minimally invasive surgery for oesophageal cancer

Worldwide an increasing part of oncologic oesophagectomies is performed in a minimally invasive way. Over the past decades multiple reports have addressed the perioperative outcomes and oncologic safety of minimally invasive oesophageal surgery. Although many of these (retrospective) case-control studies identified minimally invasive oesophagectomy as a safe alternative to open techniques, the clear benefit remained subject to debate. Recently, this controversy has partially resolved due to the results of the first randomized controlled trial that compared both techniques. In this trial short-term benefits of minimally invasive oesophagectomy were demonstrated in terms of lower incidence of pulmonary infections, shorter hospital stay and better postoperative quality of life. However, the current lack of long-term data on recurrence rate and overall survival precludes a comprehensive comparison of minimally invasive and open oesophagectomy. Proclaiming minimally invasive oesophagectomy as the standard of care for patients with resectable oesophageal cancer would therefore be a premature decision.

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

BACKGROUND

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.

METHODS

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).

RESULTS

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.

CONCLUSIONS

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.

Defining the learning curve for robotic-assisted esophagogastrectomy

INTRODUCTION

The expansion of robotic-assisted surgery is occurring quickly, though little is generally known about the "learning curve" for the technology with utilization for complex esophageal procedures. The purpose of this study is to define the learning curve for robotic-assisted esophagogastrectomy with respect to operative time, conversion rates, and patient safety.

METHODS

We have prospectively followed all patients undergoing robotic-assisted esophagogastrectomy and compared operations performed at our institutions by a single surgeon in successive cohorts of 10 patients. Our measures of proficiency included: operative times, conversion rates, and complications. Statistical analyses were undertaken utilizing Spearman regression analysis and Mann-Whitney U test. Significance was accepted with 95 % confidence.

RESULTS

Fifty-two patients (41 male: 11 female) of mean age 66.2 ± 8.8 years underwent robotic-assisted esophagogastrectomies for malignant esophageal disease. Neoadjuvant chemoradiation was administered to 30 (61 %) patients. A significant reduction in operative times (p <0.005) following completion of 20 procedures was identified (514 ± 106 vs. 397 ± 71.9). No conversions to open thoracotomy were required. Complication rates were low and not significantly different between any 10-patient cohort; however, no complications occurred in the final 10-patient cohort. There were no in-hospital mortalities.

CONCLUSIONS

For surgeons proficient in performing minimally-invasive esophagogastrectomies, the learning curve for a robotic-assisted procedure appears to begin near proficiency after 20 cases. Operative complications and conversions were infrequent and unchanged across successive 10-patient cohorts.

Initial experience from a large referral center with robotic-assisted Ivor Lewis esophagogastrectomy for oncologic purposes

BACKGROUND

We report our initial experience of patients undergoing robotic-assisted Ivor Lewis esophagogastrectomy (RAIL) for oncologic purposes at a large-referral center.

METHODS

A retrospective review of all consecutive patients undergoing RAIL from 2010-2011 was performed. Basic demographics were recorded. Oncologic variables recorded included: tumor type, location, postoperative tumor margins, and nodal harvest. Immediate 30-day postoperative complications also were analyzed.

RESULTS

Fifty patients underwent RAIL with median age of 66 (range 42-82) years. The mean body mass index was 28.6 ± 0.7 kg/m(2); 54% and the majority had an American Society of Anesthesiologists classification of 3. The mean and median number of lymph nodes retrieved during surgery was 20 ± 1.4 and 18.5 respectively. R0 resections were achieved in all patients. Postoperative complications occurred in 14 (28%) patients, including atrial fibrillation in 5 (10%), pneumonia in 5 (10%), anastomotic leak in 1 (2%), conduit staple line leak in 1 (2%), and chyle leak in 2 (4%). The median ICU stay and length of hospitalization (LOH) were 2 and 9 days respectively. Total mean operating time calculated from time of skin incision to wound closure was 445 ± 85 minutes; however, operative times decreased over time. Similarly, there was a trend toward lower complications after the first 29 cases but this did not reach statistical significance. There were no in-hospital mortalities.

CONCLUSIONS

We demonstrated that RAIL for esophageal cancer can be performed safely and may be associated with fewer complications after a learning curve, shorter ICU stay, and LOH.

Oesophageal cancer--an overview

Oesophageal carcinoma is one of the most virulent malignant diseases and a major cause of cancer-related deaths worldwide. Diagnosis and accuracy of pretreatment staging have substantially improved throughout the past three decades. Therapy is challenging and the optimal approach is still debated. Oesophagectomy is considered to be the procedure of choice in patients with operable oesophageal cancer. Endoscopic measures and limited surgical procedures provide an alternative in patients with early carcinomas confined to the oesophageal mucosa. Chemotherapy and radiotherapy or concurrent chemoradiotherapy are also frequently applied, either as definitive treatment or as neoadjuvant therapy within multimodal approaches. The question of whether multimodal treatment offers improved results has been the focus of many studies since the 1990s. Although results are discordant and even some meta-analyses remain inconclusive, it is now widely accepted that multimodal therapy leads to a modest survival benefit. The role of minimally invasive oesophagectomy is not yet defined. Endoscopic stent insertion, radiotherapy and other palliative measures provide relief of tumour-related symptoms in advanced, unresectable tumour stages.

Robotic-assisted enucleation of a large lower esophageal leiomyoma and review of literature

Leiomyoma is the most common benign esophageal neoplasm. Different invasive surgical approaches have been described for management of such lesions. The literature is reviewed and a robotic assisted left thoracoscopic enucleation with the patient in the right side position is described. A 40-year-old male patient, otherwise healthy, found to have a lower midiastinal mass on screening X-ray, is described. Physical examination and blood tests were within normal limits. Diagnostic work-up included: computerized tomography (CT) scanning of the chest and midiastinum that revealed a 40 × 30 mm mass of the distal esophagus, an upper gastrointestinal endoscopy showed a lower protruding esophageal submucosal mass with intact mucosa, a filling defect was apparent on esophagography. Endoscopic ultrasonography (EUS) showed the same findings, biopsies were taken and leimyoma was diagnosed. Under general anesthesia with a double-lumen endotracheal tube, the patient was positioned on his right side. A 30 robotic scope was introduced in the left 7th intercostal space on the posterior axillary line. Two 8-mm robotic trocars were inserted in the left 5th and 9th intercostals spaces on the same line. Operative field was clearly exposed and an additional 5-mm ethicon trocar was inserted. The inferior pulmonary ligament was released, the parietal pleural space opened, proximal and distal control was achieved using Penrose. The muscular layer of the lower esophagus was opened by coagulation hook, the lesion was enucleated without mucosal penetration. Intraoperative endoscopy permitted localization of the lesion and ensured mucosal integrity. The muscular layer was not closed and the chest drain was left. Total operative time was 200 min and blood loss was less than 20 mL. A Gastrograffin swallow on the first post-operative day showed good esophageal clearance and absence of leak, the patient was allowed a liquid diet. He was discharged on the third post-operative day in a good general condition, benign pathology was confirmed.

Combined thoracoscopic and laparoscopic robotic-assisted minimally invasive esophagectomy using a four-arm platform: experience, technique and cautions during early procedure development

OBJECTIVES

This study reports an early, single-institution experience of combined thoracoscopic and laparoscopic robotic-assisted minimally invasive esophagectomy (RAMIE) using a four-arm robotic platform, with special attention given to the pitfalls and complications during procedure development.

METHODS

We conducted a prospective, single-cohort, observational study of patients undergoing RAMIE at a single institution.

RESULTS

A total of 21 patients (median age, 62 years [range, 37-83 years]) underwent RAMIE with a four-arm robotic platform (17 by Ivor Lewis and 4 by McKeown). Of the patients, 17 (81%) had a complete (R0) resection, and 16 (76%) received induction treatment, the majority (14/21 [67%]) with combined chemoradiation. The median operative time was 556 min (range, 395-807 min), which decreased to 414 min (range, 405-543 min) for the last 5 cases in the series. The median estimated blood loss was 307 cm(3) (range, 200-500 cm(3)), and the median length of hospital stay was 10 days (range, 7-70 days). The median number of lymph nodes resected was 20 (range, 10-49). Five (24%) patients were converted to open procedures. Five patients (24%) had major complications. One (5%) died of complications on postoperative Day 70, and 3 (14%) had clinically significant anastomotic leaks (Grade II or greater, by Common Terminology Criteria for Adverse Events version 3.0). Three patients (14%) in this early experience developed airway fistulas.

CONCLUSIONS

While four-arm RAMIE may offer advantages over standard minimally invasive esophagectomy approaches, its adoption in a structured program, with critical evaluation of adverse events and subsequent adjustment of technique, is paramount to maximize patient safety, minimize complications and improve the conduct of operation early in the learning curve. Particular technical consideration should be given to prevention of airway complications.

Robot-assisted minimally invasive thoraco-laparoscopic esophagectomy versus open transthoracic esophagectomy for resectable esophageal cancer, a randomized controlled trial (ROBOT trial)

BACKGROUND

For esophageal cancer patients, radical esophagolymphadenectomy is the cornerstone of multimodality treatment with curative intent. Transthoracic esophagectomy is the preferred surgical approach worldwide allowing for en-bloc resection of the tumor with the surrounding lymph nodes. However, the percentage of cardiopulmonary complications associated with the transthoracic approach is high (50 to 70%).Recent studies have shown that robot-assisted minimally invasive thoraco-laparoscopic esophagectomy (RATE) is at least equivalent to the open transthoracic approach for esophageal cancer in terms of short-term oncological outcomes. RATE was accompanied with reduced blood loss, shorter ICU stay and improved lymph node retrieval compared with open esophagectomy, and the pulmonary complication rate, hospital stay and perioperative mortality were comparable. The objective is to evaluate the efficacy, risks, quality of life and cost-effectiveness of RATE as an alternative to open transthoracic esophagectomy for treatment of esophageal cancer.

METHODS/DESIGN

This is an investigator-initiated and investigator-driven monocenter randomized controlled parallel-group, superiority trial. All adult patients (age ≥ 18 and ≤ 80 years) with histologically proven, surgically resectable (cT1-4a, N0-3, M0) esophageal carcinoma of the intrathoracic esophagus and with European Clinical Oncology Group performance status 0, 1 or 2 will be assessed for eligibility and included after obtaining informed consent. Patients (n = 112) with resectable esophageal cancer are randomized in the outpatient department to either RATE (n = 56) or open three-stage transthoracic esophageal resection (n = 56). The primary outcome of this study is the percentage of overall complications (grade 2 and higher) as stated by the modified Clavien-Dindo classification of surgical complications.

DISCUSSION

This is the first randomized controlled trial designed to compare RATE with open transthoracic esophagectomy as surgical treatment for resectable esophageal cancer. If our hypothesis is proven correct, RATE will result in a lower percentage of postoperative complications, lower blood loss, and shorter hospital stay, but with at least similar oncologic outcomes and better postoperative quality of life compared with open transthoracic esophagectomy. The study started in January 2012. Follow-up will be 5 years. Short-term results will be analyzed and published after discharge of the last randomized patient.

TRIAL REGISTRATION

Dutch trial register: NTR3291 ClinicalTrial.gov: NCT01544790.

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

BACKGROUND

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.

METHODS

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.

RESULTS

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).

CONCLUSION

Robot-assisted thoracoscopic esophagectomy with total mediastinal lymphadenectomy is feasible and safe. This method shows promise in preventing RLNP.

Robot-assisted minimally invasive esophagectomy is equivalent to thoracoscopic minimally invasive esophagectomy

The use of the surgical robot has been increasing in thoracic surgery. Its three-dimensional view and instruments with surgical wrists may provide advantages over traditional thoracoscopic techniques. Our initial experience with thoracoscopic robot-assisted minimally invasive esophagectomy (RAMIE) for esophageal cancer was compared with our traditional thoracoscopic minimally invasive esophagectomy (MIE) approach for esophageal cancer. A retrospective review of a prospective database was performed. From July 2008 to October 2009, 43 patients underwent MIE resection. Patients who had benign disease and intrathoracic anastomosis were excluded. Results are presented as mean ± SD. Significance was set as P < 0.05. Eleven patients who underwent RAMIE and 26 who underwent MIE were included in the cohort. No differences in age, sex, race, body mass index, or preoperative radiotherapy or chemotherapy between the groups were observed. No significant differences in operative time, blood loss, number of resected lymph nodes, postoperative complications, days of mechanical ventilation, length of intensive care unit stay, or length of hospital stay were also observed. In this short-term study, RAMIE was found to be equivalent to thoracoscopic MIE and did not offer clear advantages.

Robot-assisted transhiatal esophagectomy: a 3-year single-center experience

Minimally invasive esophagectomy has emerged as an important procedure for disease management in esophageal cancer (EC) with clear margin status, less morbidity, and shorter hospital stays compared with open procedures. The experience with transhiatal approach robotic esophagectomy (RE) for dissection of thoracic esophagus and associated morbidity is described here. Between March 2007 and November 2010, 40 patients with resectable esophageal indications underwent transhiatal RE at the institute. Clinical data for all patients were collected prospectively. Of 40 patients undergoing RE, one patient had an extensive benign stricture, one had high-grade dysplasia, and 38 had EC. Five patients were converted from robotic to open. Median operative time and estimated blood loss were 311 minutes and 97.2 mL, respectively. Median intensive care unit stay was 1 day (range, 0-16), and median length of hospital stay was 9 days (range, 6-36). Postoperative complications frequently observed were anastomotic stricture (n= 27), recurrent laryngeal nerve paresis (n= 14), anastomotic leak (n= 10), pneumonia (n= 8), and pleural effusion (n= 18). Incidence rates of laryngeal nerve paresis (35%) and leak rate (25%) were somewhat higher in comparison with that reported in literature. However, all vocal cord injuries were temporary, and all leaks healed following opening of the cervical incision and drainage. None of the patients died in the hospital, and 30-day mortality was 2.5% (1/40). Median number of lymph nodes removed was 20 (range, 3-38). In 33 patients with known lymph node locations, median of four (range, 0-12) nodes was obtained from the mediastinum, and median of 15 (range, 1-26) was obtained from the abdomen. R0 resection was achieved in 94.7% of patients. At the end of the follow-up period, 25 patients were alive, 13 were deceased, and 2 patients were lost to follow-up. For patients with EC, median disease-free survival was 20 months (range, 3-45). Transhiatal RE, by experience, is a feasible albeit evolving oncologic operation with low hospital mortality. The benefits include minimally invasive mediastinal dissection without thoracotomy or thoracoscopy. A reasonable operative time with minimal blood loss and postoperative morbidity can be achieved, in spite of the technically demanding nature of the procedure. Broader use of this technology in a setting of high-volume comprehensive surgical programs will almost certainly reduce the complication rates. Robotic tanshiatal esophagectomy with the elimination of a thoracic approach should be considered an option for the appropriate patient population in a comprehensive esophageal program.

Robotic oncological surgery: our initial experience of 164 cases

Minimal access surgery is an accepted modality for benign surgery. Despite the advantages of laparoscopy, its acceptance in oncology is slow. Robotic surgery is an emerging field with rapid acceptance because of the 3-dimensional image, dexterity of instruments and autonomy of camera control. We report here our experience of using the Da Vinci robot for various oncological procedures. We performed 164 oncological surgeries from November 2009 to June 2011. The surgeries performed included thoracic, colorectal, hepatobiliary, gynaecological and urological system. We could complete 163 cases robotically. We share our initial experience of robotic surgery in oncology with comparison with other series.

Robot-assisted distal gastrectomy for gastric cancer: initial experience

BACKGROUND

This study evaluated the feasibility and safety of robotic surgery in gastrectomy for gastric cancer.

METHODS

Between April and October 2009, 12 patients who were diagnosed with stage I gastric cancer underwent robot-assisted distal gastrectomy (RADG) using the da Vinci System (Intuitive Surgical, Sunnyvale, CA). The clinical and pathological characteristics of the patients and surgical outcome were analyzed.

RESULTS

All procedures were completed successfully, with no laparoscopic or open conversion. The mean operating time was 253 minutes (range 170-365), and the mean blood loss was 135 mL (range 30-500). The resection margin was negative in all specimens, and a mean of 46 (range 21-115) lymph nodes was retrieved. The mean time to resume a soft diet and hospital stay was 4.6 and 6.6 days, respectively. Acute pancreatitis occurred in 1 patient and resolved with conservative management.

CONCLUSIONS

In our initial experience, RADG was feasible, enabling a fast patient recovery and good operative outcome.

Thoracoscopic resection for esophageal cancer: A review of literature

Esophageal resection remains the only curative option in high grade dysplasia of the Barrett esophagus and non metastasized esophageal cancer. In addition, it may also be an adequate treatment in selected cases of benign disease. A wide variety of minimally invasive procedures have become available in esophageal surgery. Aim of the present review article is to evaluate minimally invasive procedures for esophageal resection, especially the approach performed through right thoracoscopy.

The role of robotic assisted laparoscopy for oesophagogastric oncological resection; an appraisal of the literature

The introduction of surgical robotics to the field of surgical oncology brings with it an expectation not only of improved vision, instrumentation, and precision but also as a result, a potential for improved oncological outcomes. The current interest in the field of oesophagogastric oncology is explored in this review together with the benefits, real and potential, that robotic assistance offers surgical cancer resection as well as some of the limiting factors which may be hampering its uptake into current surgical practice. A systematic review of all the published literature up until April 2010 was examined across the field of esophageal and gastric cancer resection. A quantitative assessment of the oncological, operative, and functional outcomes was determined from each procedure. The level of evidence behind the results was determined using the Oxford Centre for Evidence-based Medicine Levels of Evidence; Therapy and Prevention. Three hundred and five cases from 19 independent studies were included for review. Nine studies explored the outcomes from robotic-assisted esophagectomy and eight, the robotic-assisted gastrectomy. Two articles included small case series of both procedures. The level of evidence was predominantly based on case series or expert opinion (Level 4 or 5) with only three unmatched or poorly matched comparative trials (Level 4) with no randomized trials evident. Improved operative outcomes and hospital stays were demonstrated with a reduction of 2 days when the robotic-assisted gastrectomy technique was employed compared with the open. No improvement in oncological outcomes could be identified with the use of the robot for either oesophageal or gastric cancer resection; however, in terms of short-term oncological outcomes, these were at least equivalent to the open approach for oesophageal cancer and early stage gastric cancer. Robotic-assisted laparoscopic surgery is a feasible technique to use to perform a safe and oncologically sound resection for oesophageal and early gastric cancer. Operative benefits appear to be encouragingly similar to the laparoscopic approach with some demonstration of improvement over the open technique despite a prolonged operative time. However, the level of evidence is suboptimal and more randomized controlled trials and long-term survival studies within a framework of measured and comparable outcomes is required.

Postoperative incidence of incarcerated hiatal hernia and its prevention after robotic transhiatal esophagectomy

BACKGROUND

Transhiatal robot-assisted total esophagectomy (RE) has gained acceptance as a minimally invasive procedure with several clinical benefits. In this report, the authors describe their experience with the incidence of incarcerated hiatal hernia after RE.

METHODS

Between March 2007 and July 2009, 36 patients underwent RE at the authors' institution. A retrospective chart review was performed, and data were abstracted including gender, age, weight at surgery, presenting symptoms, pathologic diagnosis, operative time, estimated blood loss, mortality, and postoperative complications.

RESULTS

The study cohort consisted of 28 men and 8 women undergoing RE. Their average age was 65.4±10.5 years, and their mean body weight was 86.2±24.8 kg at surgery. A review of medical records indicated that 7 (19.4%) of the 36 patients had postoperative incarcerated hiatal hernias. Two of these patients had experienced two episodes of incarceration, which required reoperation. One patient died of complications related to hernia repair. Six (85.7%) of 7 patients had a preexisting diagnosis of hiatus hernia which was significantly higher in comparison to the incidence of this complication within the group of 29 patients without post-operative hernia incarcerations (11 of 29, 37.9%; Fisher's exact p=0.04).

CONCLUSIONS

The results indicate that postoperative incarcerated hiatal hernia after RE is an infrequently reported, albeit serious, complication. A preexisting hiatal hernia may put patients at a higher risk of incarceration. According to the authors' experience, a primary closure and reinforcement with mesh sutured to the gastric wall is recommended as a preventive measure. Diligent follow-up evaluation with regular computed tomography (CT) scans investigating likelihoods for incarceration is advisable, especially for patients with preexisting hernias.

Robotic distal pancreatectomy: cost effective?

BACKGROUND

Minimally invasive techniques and even robotics in pancreaticobiliary surgery are being used increasingly. Cost-effectiveness is a practical burden associated with the introduction of surgical innovation. This study compares the costs and the outcomes of open, laparoscopic, and robotic distal pancreatectomies. We hypothesized that robotic distal pancreatectomy is cost-effective.

METHODS

Between August 2008 and August 2009, 77 distal pancreatectomies were performed at a single academic medical center. A retrospective analysis of prospectively collected data on demographics, short-term outcomes, and direct cost was performed.

RESULTS

Thirty-two open distal pancreatectomies, 28 laparoscopic distal pancreatectomies, and 17 robotic distal pancreatectomies were performed. Age, American Society of Anesthesia preoperative risk score, and specimen length were similar. Indications for laparoscopic distal pancreatectomies and robotic distal pancreatectomies included more cystic neoplasms (49%) and fewer malignancies (29%) versus open distal pancreatectomies (16% and 47%). Spleen preservation occurred in 65% robotic distal pancreatectomies versus 12% and 29% in open distal pancreatectomies and laparoscopic distal pancreatectomies (P < .05). The operative time averaged 298 minutes in robotic distal pancreatectomies versus 245 and 222 minutes in open distal pancreatectomies and laparoscopic distal pancreatectomies (P < .05). Blood loss and morbidity were similar with no mortality. The length of stay was 4 days in robotic distal pancreatectomies versus 8 and 6 in open distal pancreatectomies and laparoscopic distal pancreatectomies (P < .05). The total cost was $10,588 in robotic distal pancreatectomies versus $16,059 and $12,986 in open distal pancreatectomies and laparoscopic distal pancreatectomies.

CONCLUSION

These data suggest direct hospital costs are comparable among all groups. They suggest a shorter length of stay in robotic versus laparoscopic or open approaches. Finally, spleen and vessel preservation rates may improve with a robotic approach at the expense of increased operative time. In summary, robotic distal pancreatectomy is safe and cost effective in selected cases.

Minimally invasive esophagectomy

Esophageal resection is associated with a high morbidity and mortality rate. Minimally invasive esophagectomy (MIE) might theoretically decrease this rate. We reviewed the current literature on MIE, with a focus on the available techniques, outcomes and comparison with open surgery. This review shows that the available literature on MIE is still crowded with heterogeneous studies with different techniques. There are no controlled and randomized trials, and the few retrospective comparative cohort studies are limited by small numbers of patients and biased by historical controls of open surgery. Based on the available literature, there is no evidence that MIE brings clear benefits compared to conventional esophagectomy. Increasing experience and the report of larger series might change this scenario.

Minimally invasive esophagectomy

Esophageal resection is associated with a high morbidity and mortality rate. Minimally invasive esophagectomy (MIE) might theoretically decrease this rate. We reviewed the current literature on MIE, with a focus on the available techniques, outcomes and comparison with open surgery. This review shows that the available literature on MIE is still crowded with heterogeneous studies with different techniques. There are no controlled and randomized trials, and the few retrospective comparative cohort studies are limited by small numbers of patients and biased by historical controls of open surgery. Based on the available literature, there is no evidence that MIE brings clear benefits compared to conventional esophagectomy. Increasing experience and the report of larger series might change this scenario.

An update on robotic thoracic surgery and anesthesia

PURPOSE OF REVIEW

Minimally invasive surgery involving the thoracic cavity continues to increase. With the introduction of robotic systems, particularly the da Vinci robot system more than 10 years ago, thoracic operations have been performed with some provocative results and limited, defined advantages. The present review provides an overview of common thoracic surgical procedures performed with the robotic system and discusses the anesthetic implications.

RECENT FINDINGS

The literature on this topic currently includes case reports or series of clinically prospective or retrospective observational reports with the use of robotic systems, involving the thoracic cavity (mediastinal mass resections, lobectomies, and esophagectomies); unfortunately there are very limited reports related to anesthetic implications or complications related to the use of this technology. The majority of the surgical reports involve the use of lung isolation devices for thoracic surgery, specifically the use of a double-lumen endotracheal tube (DLT); a few centers use carbon dioxide (CO2) insufflation as part of their management to achieve maximal surgical exposure while compressing the operative side of the lung away from the operative area.

SUMMARY

Anesthesiologists must be familiar with lung isolation techniques and flexible fiberoptic bronchoscopy while participating in thoracic surgical cases that require robotic systems. In addition, prevention and recognition of potential complications, such as crushing injuries or nerve damage, must be sought. Because the potential for converting to an open thoracotomy exists, all measures must be taken to manage patients accordingly if the situation arises.

Robot-assisted thoracoscopic oesophagectomy for cancer

BACKGROUND

Thoracoscopic oesophagectomy was introduced to reduce the morbidity of transthoracic oesophagectomy. The aim was to assess the short- and mid-term results of robot-assisted thoracoscopic oesophagectomy for oesophageal cancer.

METHODS

Between October 2003 and May 2007, 47 patients with resectable oesophageal cancer underwent robot-assisted thoracoscopic oesophagectomy. Clinical data were collected prospectively.

RESULTS

Conversion to thoracotomy was necessary in seven patients. Median operating time was 450 min and median blood loss 625 ml. Median postoperative ventilation time was 1 day, intensive care stay 3 days and hospital stay 18 days. Twenty-one of 47 patients had pulmonary complications. Three patients died in hospital. A median of 29 (range 8-68) lymph nodes was dissected and R0 resection was achieved in 36 patients. Twenty-three patients had stage IVa disease. After a median follow-up of 35 months, median disease-free survival was 15 (95 per cent confidence interval 12 to 18) months.

CONCLUSION

Robot-assisted thoracoscopic oesophagectomy was oncologically acceptable. Operating time, blood loss and pulmonary complications might decrease with further experience.

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

OBJECTIVE

To assess the feasibility and safety of robot-assisted thoracoscopic esophagectomy for esophageal cancer in the prone position.

METHODS

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.

RESULTS

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.

CONCLUSION

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.

Minimally invasive esophagectomy for malignant and premalignant diseases of the esophagus

Minimally invasive approaches increasingly are used to treat esophageal cancer and Barrett's esophagitis with high-grade dysplasia. The goals of a minimally invasive esophageal resection are to provide sound oncologic therapy while minimizing morbidity. This article describes the technique the authors use for laparoscopic-thoracoscopic esophagectomy. Comparison data are presented for alternative endoscopic therapy primarily used in candidates not suitable for surgery.