Refinement of minimally invasive esophagectomy techniques after 15 years of experience

Advances in the Surgical Management of Esophageal Cancer

Radical esophagectomy with two or three-field lymphadenectomy remains the mainstay of curative treatment for localized esophageal cancer, often in combination with systemic chemotherapy and/or radiotherapy. In this article, we describe notable advances in the surgical management of esophageal cancer over the past decade that have led to an improvement in both surgical and oncologic outcomes. In addition, we discuss new approaches to surgical management currently under investigation that have the potential to offer further benefits to appropriately selected patients. These incremental breakthroughs primarily include advances in endoscopic and minimally invasive techniques, perioperative management protocols, as well as the application of local therapies, including surgery, to oligometastatic disease.

A refined procedure for esophageal resection using a full minimally invasive approach

Objective

Newer minimally invasive approaches to esophagectomy have brought substantial benefits to esophageal-cancer patients and continue to improve. We report here our experience with a streamlined procedure as part of a comprehensive perioperative-care program that provides additional advances in the continued evolution of this procedure.

Methods

All patients with primary esophageal cancer referred for resection to the Oakland Medical Center of the Kaiser-Permanente Northern California health plan who underwent this approach between January 2013 and August 2018 were included. Operative and clinical outcome variables were extracted from the electronic medical record, operating-room files, and manual chart review.

Results

142 patients underwent the new procedure and care program; 121 (85.2%) were men with mean age of 64.5 years. 127 (89.4%) were adenocarcinoma; 117 (82.4%) were clinical stage III or IVA. 115 (81.0%) required no jejunostomy. Median hospital length-of-stay was 3 days and 8 (5.6%) patients required admission to the intensive care unit. Postoperative complications occurred in 22 (15.5%) patients within 30 days of the procedure. There were no inpatient deaths; one patient (0.7%) died within 30 days following discharge and three additional deaths (2.1%) occurred through 90 days of follow-up.

Conclusions

This approach resulted in excellent clinical outcomes, including short hospital stays with limited need for the intensive care unit, few perioperative complications, and relatively few patients requiring feeding tubes on discharge. This comprehensive approach to esophagectomy is feasible and provides another clinically meaningful advance in the progress of minimally invasive esophagectomy. Further development and dissemination of this method is warranted.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13019-022-01765-2.

Minimally Invasive Versus open AbdominoThoracic Esophagectomy for esophageal carcinoma (MIVATE) - study protocol for a randomized controlled trial DRKS00016773

BACKGROUND

The only curative treatment for most esophageal cancers is radical esophagectomy. Minimally invasive esophagectomy (MIE) aims to reduce postoperative morbidity, but is not yet widely established. Linear stapled anastomosis is a promising technique for MIE because it is quite feasible even without robotic assistance. The aim of the present study is to compare total MIE with linear stapled anastomosis to open esophagectomy (OE) with circular stapled anastomosis with special regard to postoperative morbidity in an expertise-based randomized controlled trial (RCT).

METHODS/DESIGN

This superiority RCT compares MIE with linear stapled anastomosis (intervention) to OE with circular stapled anastomosis (control) for Ivor-Lewis esophagectomy. It was initiated in February 2019, and recruitment is expected to last for 3 years. For inclusion, patients must be 18 years of age or more with a resectable primary malignancy in the distal esophagus. Participants with tumor localizations above the azygos vein, metastasis, or infiltration into adjacent tissue will be excluded. In an expertise-based approach, the allocated treatment will only be carried out by the single most experienced surgeon of the surgical center for each respective technique. The sample size was calculated with 20 participants per group for the primary endpoint postoperative morbidity according to comprehensive complication index (CCI) within 30 postoperative days. Secondary endpoints include anastomotic insufficiency, pulmonary complications, other intra- and postoperative outcome parameters such as estimated blood loss, operative time, length of stay, short-term oncologic endpoints, adherence to a standardized fast-track protocol, postoperative pain, and postoperative recovery (QoR-15). Quality of life (SF-36, CAT EORTC QLQ-C30, CAT EORTC QLQ-OES18) and oncological outcomes are evaluated with 60 months follow-up.

DISCUSSION

MIVATE is the first RCT to compare OE with circular stapled anastomosis to total MIE with linear stapled anastomosis exclusively for intrathoracic anastomosis. The expertise-based approach limits bias due to heterogeneity of surgical expertise. The use of a dedicated fast-track protocol in both OE and MIE will shed light on the role of the access strategy alone in this setting. The findings of this study will serve to define which approach has the best perioperative outcome for patients requiring esophagectomy.

TRIAL REGISTRATION

German Clinical Trials Register DRKS00016773 . Registered on 18 February 2019.

Ivor-Lewis oesophagectomy: A standardized operative technique in 11 steps

SYNOPSIS

Standardization of robotic oesophagectomy can benefit both patients and surgeons by decreasing complications, shortening the learning curve and improving surgical training.

BACKGROUND

Thoraco-abdominal oesophagectomy with lymphadenectomy is the cornerstone of curative therapy for oesophageal carcinoma. To reduce post-operative morbidity, minimally invasive technology has become increasingly established. Conventional thoraco-laparoscopic procedures, however, are limited by their technical feasibility. These limitations can be overcome using robot-assisted technology.

METHODS

Robotic Ivor-Lewis oesophageal resection has gradually been implemented in our clinic from 2013. We have performed over 250 robot-assisted minimally invasive oesophagectomies and more than 2000 robotic procedures overall. This experience allowed us to establish a standardized operative technique.

RESULTS

We identified 11 operative steps as key elements for oesophageal resection, which should help implementation of this technique and allow surgeons to approach this complex procedure with greater confidence.

CONCLUSION

Standardization is fundamental to the establishment of a new surgical technique and is a key element in the learning curve of Ivor-Lewis oesophageal resection. Standardization can lead to better reproducibility of results, and thus to improved quality.

Robotic-assisted single-incision gastric mobilization for minimally invasive oesophagectomy for oesophageal cancer: preliminary results

OBJECTIVES

With the gradual acceptance of robotic-assisted surgery to treat oesophageal cancer and the application of a single-port approach in several abdominal procedures, we adopted a single-port technique in robotic-assisted minimally invasive oesophagectomy during the abdominal phase for gastric mobilization and abdominal lymph node dissection.

METHODS

Robotic-assisted oesophagectomy and mediastinal lymph node dissection in the chest were followed by robotic-assisted gastric mobilization and conduit creation with abdominal lymph node dissection, which were performed via a periumbilicus single incision. The oesophagogastrostomy was accomplished either in the chest (Ivor Lewis procedure) or neck (McKeown procedure) depending on the status of the proximal resection margin.

RESULTS

The procedure was successfully performed on 11 patients with oesophageal cancer from January 2017 to December 2018 in our institute. No surgical or in-hospital deaths occurred, though we had one case each of anastomotic leakage, pneumonia and hiatal hernia (9%).

CONCLUSIONS

Robotic single-incision gastric mobilization for minimally invasive oesophagectomy for treating oesophageal cancer seems feasible. Its value in terms of perioperative outcome and long-term survival results awaits future evaluation.

Clinical characteristics and surgical treatment of esophageal cancer spinal metastasis - A single center 10-year retrospective study

OBJECTIVE

Our research aims to discuss the clinical characteristics, treatment methods, and prognostic characteristics of patients with esophageal cancer spinal metastasis. It is one of the largest clinical studies on the disease to date. The purpose is to improve clinicians' understanding of the clinical features and prognosis of esophageal spine metastases and share our experience in dealing with this entity.

METHODS

Six patients with spinal metastasis due to esophageal cancer who had received surgical treatment at the bone tumor center of Peking Union Medical College Hospital from January 2010 to January 2020 were selected. The clinical data, surgical records, imaging examinations, pathological reports, and immunohistochemical results of all patients were reviewed by the team. In the study, we applied two surgical treatments, namely open surgery and percutaneous vertebroplasty. Radiotherapy, chemotherapy, and targeted therapy were used as adjuvant treatments. Retrospective analysis of the patient's basic clinical data were analyzed.

RESULTS

All six patients with metastatic spinal esophageal cancer (MSEC) were male with an average age of 58.0 ± 5.3 years. The average duration between the esophageal cancer resection and diagnosis of spinal metastases was 24.8 (2-72) months. Of the six patients, four had spinal metastases located in the thoracic spine and two had metastases located in the lumbar spine. We referred to the revised Tokuhashi score and Tomita score to recommend individualized surgical treatment plans for patients, and fully respected the patients' wishes. All six patients underwent surgical treatment, a total of six operations, including four percutaneous vertebroplasty and two open surgery. After the operations, the symptoms of the patients improved significantly. During the follow-up, all six patients died of the disease with the average time from spinal surgery to death being 8.8 ± 3.7 months.

CONCLUSIONS

In general, patients with esophageal cancer spine metastases have a poor prognosis, and the average survival time of these patients often does not exceed 12 months. The combination of surgical treatment and postoperative adjuvant therapy can control symptoms effectively and improve the patient's quality of life.

Techniques of uniportal video-assisted thoracic surgery-esophageal and mediastinal indications

Uniportal approach for esophagus and mediastinum is gaining popularity. While a transthoracic approach is applied for esophagus frequently from the 5th or 6th intercostal space on the posterior axillary line, approach to anterior mediastinum is variable with access through right/left chest, cervical and subxiphoid regions. The results of uniportal approach for esophagus and mediastinum are comparable with multiport video-assisted thoracic surgery (VATS) and open approach in terms of bleeding, oncologic adequacy and operation times. Indications are similar with open and multiportal VATS cases, however large mediastinal tumors (>5 cm) and T3-4 esophageal cancers can be challenging in the beginning in terms of oncologic adequacy of the operations. Uniportal approach for esophagus and mediastinum is utilized more frequently and initial reports show that it is feasible and its applicability and advantages will become apparent in the coming years.

Minimally Invasive and Robotic Esophagectomy: A Review

Great advances have been made in the surgical management of esophageal disease since the first description of esophageal resection in 1913. We are in the era of minimally invasive esophagectomy. The current three main approaches to an esophagectomy are the Ivor Lewis technique, McKeown technique, and the transhiatal approach to esophagectomy. These operations were associated with a high morbidity and mortality. The recent advances in minimally invasive surgical techniques have greatly improved the outcomes of these surgical procedures. This article reviews the literature and describes the various techniques available for performing minimally invasive esophagectomy and robot-assisted esophagectomies, the history behind the development of these techniques, the variations, and the contemporary outcomes after such procedures.

Benchmark values for transthoracic esophagectomy are not set as the defined "best possible"-a validation study

Background

Recently, benchmark values for low-comorbidity patients at high-volume centers were set to define "best achievable results" for transthoracic minimally invasive esophagectomy (MIE). We aimed to validate suggested benchmark values by comparing them to outcomes at a medium-volume center in Finland.

Methods

All MIEs (n=82) performed at Central Finland Central Hospital between September 2012 and November 2017 including 75 totally MIE and 7 hybrid procedures. The aim of the study was to compare the results to previously suggested benchmark parameters for postoperative morbidity measured with the Clavien-Dindo classification and comprehensive complication index. Target benchmark parameters were ≤55.7% for any complications, ≤30.8% for major complications (Clavien-Dindo ≥3a), ≤40.8% for 30-day and ≤42.8% for 90-day comprehensive complication index, ≤20% for anastomosis leak, ≤31.6% for pulmonary complications, ≤1.0% for 30-day mortality and ≤4.6% for 90-day mortality.

Results

Compared with benchmark patients, our patients were older (median 68 vs. 58 years), with more comorbidities. All parameters measuring complications showed better results in our study than benchmark values. Median intensive care unit stay of 1 (IQR, 1-1) and hospital stay of 9 (IQR, 9-12) days were also shorter. At least 1 complication developed in 45.1%, and 6.1% faced major morbidity. Median (IQR) comprehensive complication index for both 30 and 90 days was 0 (IQR, 0-20.9 days). Anastomosis leak and pulmonary complications were observed in 3.7% and 22.0%, respectively. The 30- and 90-day mortality was 1.2% (1/82).

Conclusions

Benchmark values assessing postoperative morbidity after MIE do not represent the defined "best achievable" results after completed learning curves.

Uniportal video-assisted thoracic surgery for esophageal cancer

Classical video-assisted thoracic surgery (VATS) approach to esophageal cancer uses four incisions. The rationale is to facilitate movement of the instruments and the esophagus and also suturing during placement of a purse-string suture for an intrathoracic anastomosis. Uniportal VATS (U-VATS) is challenge for surgeons, as you have to do an esophageal mobilization and anastomosis from a single 3-5 cm incision. The incision is placed either at the 5th or 6th intercostal space close to the posterior axillary line. Esophagus is mobilized en bloc with the subcarinal and periesophageal lymph nodes. The crucial parts are inclusion of subcarinal lymph node in the specimen, mobilization of the specimen from the left main bronchus and esophagogastric anastomosis. Esophagus is encircled with a thick penrose drain and retracted anterior and posteriorly during this dissection. Once the esophagus is completely mobilized, if an intrathoracic anastomosis is to be performed, gastric conduit is pulled inside the chest in correct orientation. A linear completely stapled side to side anastomosis is performed. A thick tissue endoscopic stapler is used for posterior and anterior wall. A single chest drain is placed and incision is closed. There are several intrathoracic anastomotic techniques. All of these techniques can be applied through a uniportal approach. Side to side completely stapled anastomosis is safe, fast and easy to perform. There is a single report on esophagectomy comparing uniportal and multiportal VATS approaches in esophageal cancer which showed comparable results in terms of duration of surgery, amount of bleeding, lymph node yield and leak rates. U-VATS for esophageal cancer is emerging as a new approach and the technique is feasible and certainly future studies will show if it is reproducible and provides a clinical advantage for the patient.

Fully robotic da Vinci Ivor-Lewis esophagectomy in four-arm technique-problems and solutions

The aim of this technical note is a step-by-step description of a fully robotic abdominothoracic esophagectomy with an intrathoracic esophagogastrostomy. We report on our technique and short-term results of 75 patients undergoing an Ivor-Lewis esophagectomy using a fully robotic 4-arm approach in the abdominal and thoracic phase with a hand-sewn intrathoracic anastomosis. There are several important steps and differences to consider compared to the conventional minimal invasive approach (patient's positioning, anaesthesiological set up, port placement, gastric conduit pull up, technique of esophagostrostomy). Mean operative time was 392 minutes (240-610) with a 94% R0 resection status. Conversion to open procedure occurred in 2 (2.6%) in the abdominal, and 14 (18.2%) in the thoracic phase. Main reasons for conversion were problems during the lifting of the gastric conduit and difficulties in the construction of the esophagogastrostomy. The rate dropped during the last 20 patients (1/20 (10%). Our results suggest that the reported technique is safe and feasible. It satisfies the oncological principles and provides the advantages of robotic assisted minimal invasive surgery.

Implementation of minimally invasive esophagectomy in a tertiary referral center for esophageal cancer

BACKGROUND

Esophagectomy remains the gold standard in the curative intent treatment of resectable esophageal cancer. However, this procedure is complex and associated with high risk of complications. In an effort to reduce the postoperative morbidity associated with open esophagectomy various minimally invasive techniques have been introduced and developed during the recent years. The aim of the current study was to present our 4.5-year experience of the gradual implementation of various minimally invasive esophagectomy (MIE) techniques in our tertiary referral center.

METHODS

From May 2012 a transitional period from conventional open esophagectomy to MIE was initiated. This period was preceded by fellowships and visits to expert centers abroad. Thereafter, a gradual implementation and refinement of the new techniques followed. Technique related data were collected prospectively.

RESULTS

Between January 1^st 2011 and December 31^st 2016 a total of 249 patients underwent an esophagectomy in our unit. Seventy-six cases were performed through a conventional open esophagectomy and 173 by some type of MIE. An increasing utilization of MIE over this time period was seen and finally reached 100% of treatment intentions, during the last 2 years. Ten cases (5.7%) where converted to open approach. A decrease in leak rate, operating time, peroperative bleeding and hospital stay as well as an increasing number of harvested lymph nodes was observed during the implementation period.

CONCLUSIONS

The transition from conventional open esophagectomy to MIE was successful at our center. The implementation was overall safe with good postoperative outcomes, although changes in results required technical modifications over time.

A standardized comparison of peri-operative complications after minimally invasive esophagectomy: Ivor Lewis versus McKeown

BACKGROUND

While our institutional approach to esophageal resection for cancer has traditionally favored a minimally invasive (MI) 3-hole, McKeown esophagectomy (MIE 3-hole) during the last five years several factors has determined a shift in our practice with an increasing number of minimally invasive Ivor Lewis (MIE IL) resections being performed. We compared peri-operative outcomes of the two procedures, hypothesizing that MIE IL would be less morbid in the peri-operative setting compared to MIE 3-hole.

METHODS

Our institution's IRB-approved esophageal database was queried to identify all patients who underwent totally MI esophagectomy (MIE IL vs. MIE 3-hole) from June 2011 to May 2016. Patient demographics, preoperative and peri-operative data, as well as post-operative complications were compared between the two groups. Post-operative complications were analyzed using the Clavien-Dindo classification system.

RESULTS

There were 110 patients who underwent totally MI esophagectomy (MIE IL n = 49 [45%], MIE 3-hole n = 61 [55%]). The majority of patients were men (n = 91, 83%) with a median age of 62.5 (range 31-83). Preoperative risk stratifiers such as ECOG score, ASA, and Charlson Comorbidity Index were not significantly different between groups. Anastomotic leak rate was 2.0% in the MIE IL group compared to 6.6% in the MIE 3-hole group (p = 0.379). The rate of serious (Clavien-Dindo 3, 4, or 5) post-operative complications was significantly less in the MIE IL group (34.7 vs. 59.0%, p = 0.013). Serious pulmonary complications were not significantly different (16.3 vs. 26.2%, p = 0.251) between the two groups.

CONCLUSIONS

In this cohort, totally MIE IL showed significantly less severe peri-operative morbidity than MIE 3-hole, but similar rates of serious pulmonary complications and anastomotic leaks. These findings confirm the safety of minimally invasive Ivor Lewis esophagectomies for esophageal cancer when oncologically and clinically appropriate. Minimally invasive McKeown esophagectomy remains a satisfactory and appropriate option when clinically indicated.

Simple preoperative risk scale accurately predicts perioperative mortality following esophagectomy for malignancy

Surgery remains one of the major treatment options available to patients with esophageal cancer, with high mortality in certain cohorts. The aim of this study was to develop a simple preoperative risk scale based on patient factors, hospital factors, and tumor pathology to predict the risk of perioperative mortality following esophagectomy for malignancy. The Nationwide Inpatient Sample database was used to create the risk scale. Patients who underwent open or laparoscopic transhiatal and transthoracic esophageal resection were identified using International Classification of Diseases, 9th edition codes. Patients <18 years and those with peritoneal disease were excluded. Multivariate logistic regressions were used to define a predictive model of perioperative mortality and to create a simple risk scale. From 1998 to 2011, a total of 23 751 patients underwent esophagectomy. The observed overall perioperative mortality rate for this cohort was 7.7%. Minimally invasive techniques, and operations performed in higher volume centers were protective, whereas increasing age, comorbidities and diagnosis of squamous cell carcinoma were independent predictors of mortality. Based on this population, a risk scale from 0-16 was created. The calibration revealed a good agreement between the observed and risk scale-predicted probabilities. A set of sensitivity/specificity analyses was then performed to define normal (score 0-7) and high risk (score 8-16) patients for clinical practice. Mortality in patients with a score of 0-7 ranged from 1.3-7.6%, compared with 10.5-34.5% in patients with a score of 8-16. This simple preoperative risk scale may accurately predict the risk of perioperative mortality following esophagectomy for malignancy and can be used as a clinical tool for preoperative counseling.

Comparison of single- and multi-incision minimally invasive esophagectomy (MIE) for treating esophageal cancer: a propensity-matched study

OBJECTIVE

To compare the perioperative outcome of minimally invasive (MIE) esophagectomy performed with a single- or a multi-incision in treating esophageal cancer.

METHOD

Patients with esophageal cancer who underwent MIE from 2006 to 2016 were evaluated. A 3-4-cm incision was created in both the thoracoscopic and the laparoscopic phases during the single-incision MIE procedures. A propensity-matched comparison was made between the two groups of patients.

RESULTS

We analyzed a total of 48 pairs of patients with propensity-matched from the cohort of 360 patients undergoing MIE during 2006-2015. There is no statistical difference in terms of postoperative ICU and hospital stay, number of dissected lymph nodes and presence of major surgical complications (anastomotic leakage and pulmonary complications) between the two groups of patients. The pain score one week after surgery was significantly lower in the single-incision group (p < 0.05). There was no surgical mortality in the single-incision MIE group.

CONCLUSION

Minimally invasive esophagectomy performed with a single-incision approach is feasible for treating patients with esophageal cancer, with a comparable perioperative outcome with that of multi-incision approaches. The postoperative pain one week after surgery was significantly reduced in patients undergoing single-incision MIE.

Mortality after esophagectomy is heavily impacted by center volume: retrospective analysis of the Nationwide Inpatient Sample

BACKGROUND

The effects of hospital volume on in-hospital mortality after esophageal resection are disputed in the literature. We sought to analyze treatment effects in patient subpopulations that undergo esophagectomy for cancer based on hospital volume.

METHODS

We performed a retrospective analysis of the Nationwide Inpatient Sample from 1998 to 2011. Patients who underwent open or laparoscopic transhiatal and transthoracic esophageal resection were identified using ICD-9 codes. Patients <18 years and those with peritoneal disease were excluded. Multivariate logistic regression analyses were used with mortality as the independent variable to evaluate the effect of low (<6), intermediate (6-19), and high (≥20) hospital volume of esophagectomies. These analyses were repeated in different subsets of patients to determine whether hospital volume affected mortality depending on the subpopulation evaluated. Subgroups were created depending on age, race, gender, operative approach, comorbidities, and tumor pathology.

RESULTS

A total of 23,751 patients were included. The overall perioperative mortality rate was 7.7 % (low volume: 11.4 %; intermediate volume: 8.39 %, high volume: 4.01 %), and multivariate analysis revealed that high hospital volume had a protective effect (OR 0.54, 95 % CI 0.45-0.65). On subgroup analyses for low- and intermediate-volume hospitals, mortality was uniformly elevated for the subpopulations when comparing to high-volume hospitals (p < 0.05). There was no difference in mortality between low- and medium-volume hospitals and between subgroups.

CONCLUSION

No lower mortality risk subgroup could be identified in this nationwide collective. This analysis emphasizes that perioperative mortality after esophagectomy for cancer is lower in high-volume hospitals.

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.

Laparoscopic surgery: A qualified systematic review

AIM: To review current applications of the laparoscopic surgery while highlighting the standard procedures across different fields.

METHODS: A comprehensive search was undertaken using the PubMed Advanced Search Builder. A total of 321 articles were found in this search. The following criteria had to be met for the publication to be selected: Review article, randomized controlled trials, or meta-analyses discussing the subject of laparoscopic surgery. In addition, publications were hand-searched in the Cochrane database and the high-impact journals. A total of 82 of the findings were included according to matching the inclusion criteria. Overall, 403 full-text articles were reviewed. Of these, 218 were excluded due to not matching the inclusion criteria.

RESULTS: A total of 185 relevant articles were identified matching the search criteria for an overview of the current literature on the laparoscopic surgery. Articles covered the period from the first laparoscopic application through its tremendous advancement over the last several years. Overall, the biggest advantage of the procedure has been minimizing trauma to the abdominal wall compared with open surgery. In the case of cholecystectomy, fundoplication, and adrenalectomy, the procedure has become the gold standard without being proven as a superior technique over the open surgery in randomized controlled trials. Faster recovery, reduced hospital stay, and a quicker return to normal activities are the most evident advantages of the laparoscopic surgery. Positive outcomes, efficiency, a lower rate of wound infections, and reduction in the perioperative morbidity of minimally invasive procedures have been shown in most indications.

CONCLUSION: Improvements in surgical training and developments in instruments, imaging, and surgical techniques have greatly increased safety and feasibility of the laparoscopic surgical procedures.

Single-position, minimally invasive Ivor Lewis oesophagectomy for lower thoracic oesophageal cancer

Although several surgical approaches exist for lower thoracic oesophageal cancer, standardized techniques for minimally invasive oesophageal resection and intrathoracic anastomosis have not yet been established. Thus, optimization of the approach and identification of the ideal anastomosis technique are needed. Seven consecutive patients with lower thoracic oesophageal cancer were treated using a single-position, minimally invasive surgical technique with laparoscopy and thoracoscopy. In the present article, we describe this technique in detail and discuss the outcomes of these patients. No adverse events occurred intraoperatively, no failures in the intrathoracic oesophagogastrostomy were detected and favourable short-term outcomes were obtained. Thus, the procedure described is safe and technically feasible and appears to be promising as an alternative approach for the treatment of patients with lower thoracic oesophageal cancer.