First experience with robot-assisted thoracoscopic esophagolymphadenectomy for esophageal cancer

The effect of azygos vein preservation on mediastinal lymph node harvesting in thoracic esophagolymphadenectomy

The standard surgical procedure for esophageal cancer is transthoracic esophagectomy with en bloc resection of the azygos vein, thoracic duct and mediastinal lymph nodes. To reduce morbidity of esophago-lymphadenectomy, minimally invasive techniques are increasingly being applied. In (robot-assisted) thoracoscopic esophagolymphadenectomy, the azygos vein is generally left in place, as the scopic ligation of the numerous intercostal veins is technically difficult and time-consuming. This could affect the extent of mediastinal lymph node dissection. Therefore, in this study, the effect of azygos vein preservation during thoracic esophagectomy on mediastinal lymph node harvesting was assessed. In 15 human cadavers, a right-sided thoracotomy was performed, followed by esophagectomy with mediastinal lymph node dissection after ligation of the azygos arch (representing the situation in robot-assisted thoracoscopic esophagolymphadenectomy). Subsequently, the remaining azygos vein with surrounding tissue was resected. The number of lymph nodes in both specimens was determined. A mean of 17.3 (95% Poisson CI 15.3-19.6) lymph nodes was dissected en bloc with the esophagus, and 0.67 (95% Poisson CI 0.32-1.23) around the separately resected azygos vein. The additional azygos vein resection did not add to the number of lymph nodes dissected in 60% (9/15) of cadavers. In conclusion, the extent of mediastinal lymph node dissection was not substantially affected by leaving the azygos vein in situ . Time-sparing azygos vein preservation in (robot-assisted) thoracoscopic esophagolymphadenectomy may therefore be considered justified.

Video-assisted esophagectomy for esophageal cancer

Video-assisted surgery for esophageal cancer is an advanced surgical technique. It has been developed on the basis of the concept of minimally invasive surgery. Given that there are several options regarding the operative procedures for thoracic esophageal cancer, several laparoscopic approaches have been proposed. The first video-assisted thoracoscopic esophagectomy through a right thoracoscopic approach and the first transhiatal esophagectomy were reported in the early 1990s. A mediastinoscope-assisted esophagectomy has also been reported as a substitute for a blunt dissection of the esophagus. Moreover, a video-assisted Ivor-Lewis esophagectomy by right thoracotomy with intrathoracic anastomosis has also been performed. Furthermore, laparoscopic gastric mobilization and gastroplasty are also widely accepted substitutions for open laparotomy. This article reviews the literature on the laparoscopic approaches for esophageal cancer.

Robot-assisted thoracoscopic esophagectomy for a giant upper esophageal leiomyoma

This is the first report of a thoracoscopic esophagectomy for a giant leiomyoma of the upper esophagus aided by a robotic system. A 37-year-old man presented with progressive dysphagia and nocturnal aspiration. Endoscopic ultrasound and CT scan of the chest revealed an upper esophageal tumor of 9 x 4 cm arising from the muscularis mucosae. A fine needle aspiration showed clustering of mesenchymal cells, confirming the diagnosis of a stromal cell tumor. A mesenchymal malignancy was suspected because the tumor was located in the upper esophagus and was arising from the muscularis mucosae, both uncommon for a leiomyoma. Moreover, tumor size, an indicator of potential malignancy if >3 cm, was 9 cm. Therefore, an esophagectomy was performed thoracoscopically with the formation of a gastric conduit via laparotomy and a hand-sewn end-to-side cervical anastomosis. The thoracoscopic phase was performed with support of the da Vincitrade mark robotic system, which allowed for an excellent 3-dimensional view and a precise dissection of the esophagus along the vital mediastinal structures. The duration of the thoracoscopic part was 115 min and that of the total procedure was 270 min. Blood loss during the thoracoscopic phase was 50 mL; total blood loss was 200 mL. The patient was ventilated for 1 day; his total intensive care stay was 2 days. He left the hospital in good condition on the 11th postoperative day. Histopathological examination combined with immunohistochemistry revealed a leiomyoma of 9.0 x 5.0 x 2.5 cm. After 3 years of follow-up, the patient is in good health.