Robot-Assisted Oesophagectomy: Recommendations Towards a Standardised Ivor Lewis Procedure

Toward an interoperable, intraoperative situation recognition system via process modeling, execution, and control using the standards BPMN and CMMN

PURPOSE

For the modeling, execution, and control of complex, non-standardized intraoperative processes, a modeling language is needed that reflects the variability of interventions. As the established Business Process Model and Notation (BPMN) reaches its limits in terms of flexibility, the Case Management Model and Notation (CMMN) was considered as it addresses weakly structured processes.

METHODS

To analyze the suitability of the modeling languages, BPMN and CMMN models of a Robot-Assisted Minimally Invasive Esophagectomy and Cochlea Implantation were derived and integrated into a situation recognition workflow. Test cases were used to contrast the differences and compare the advantages and disadvantages of the models concerning modeling, execution, and control. Furthermore, the impact on transferability was investigated.

RESULTS

Compared to BPMN, CMMN allows flexibility for modeling intraoperative processes while remaining understandable. Although more effort and process knowledge are needed for execution and control within a situation recognition system, CMMN enables better transferability of the models and therefore the system. Concluding, CMMN should be chosen as a supplement to BPMN for flexible process parts that can only be covered insufficiently by BPMN, or otherwise as a replacement for the entire process.

CONCLUSION

CMMN offers the flexibility for variable, weakly structured process parts, and is thus suitable for surgical interventions. A combination of both notations could allow optimal use of their advantages and support the transferability of the situation recognition system.

[Robotic esophageal surgery]

Robot-assisted minimally invasive esophagectomy (RAMIE) is increasingly becoming established as a standard procedure in surgical centers for esophagectomy in cases of cancer. To date, RAMIE has been shown to have fewer postoperative complications and at least equivalent oncological outcomes compared with open resection. Compared with classical minimally invasive resection, there seem to be fewer cases of postoperative pneumonia after RAMIE. In addition, a higher number of harvested lymph nodes could lead to better oncological long-term outcomes. The learning curve for this complex surgical procedure is relatively shallow but can be greatly reduced at high-volume centers through special training and proctoring programs. Robotic surgical approaches have also been described for other esophageal diseases; however, no clear superiority compared to laparoscopic surgery has so far been shown.

Robot-assisted Ivor Lewis Esophagectomy (RAILE): A review of surgical techniques and clinical outcomes

In the past 20 years, robotic system has gradually found a place in esophagectomy which is a demanding procedure in the deep and narrow thoracic cavity containing crucial functional structures. Ivor Lewis esophagectomy (ILE) is a mainstream surgery type for esophagectomy and is widely accepted for its capability in lymphadenectomy and relatively mitigated trauma. As a minimally invasive technique, robot-assisted Ivor Lewis esophagectomy (RAILE) has been frequently compared with the video-assisted procedure and the traditional open procedure. However, high-quality evidence elucidating the advantages and drawbacks of RAILE is still lacking. In this article, we will review the surgical techniques, both short and long-term outcomes, the learning curve, and explicate the current progress and clinical efficacy of RAILE.

C-Reactive Protein as Predictor for Infectious Complications after Robotic and Open Esophagectomies

Introduction: The value of C-reactive protein (CRP) as a predictor of anastomotic leakage (AL) after esophagectomy has been addressed by numerous studies. Despite its increasing application, robotic esophagectomy (RAMIE) has not been considered separately yet in this context. We, therefore, aimed to evaluate the predictive value of CRP in RAMIE. Material and Methods: Patients undergoing RAMIE or completely open esophagectomy (OE) at our University Center were included. Clinical data, CRP- and Procalcitonin (PCT)-values were retrieved from a prospectively maintained database and evaluated for their predictive value for subsequent postoperative infectious complications (PIC) (AL, gastric conduit leakage or necrosis, pneumonia, empyema). Results: Three hundred and five patients (RAMIE: 160, OE: 145) were analyzed. PIC were noted in 91 patients on postoperative day (POD) 10 and 123 patients on POD 30, respectively. Median POD of diagnosis of PIC was POD 8. Post-operative CRP-values in the robotic-group peaked one and two days later, respectively, and converged from POD 5 onward compared to the open-group. In the group with PIC, CRP-levels in the robotic-group were initially lower and started to differ significantly from POD 3 onward. In the open-group, increases were already noticed from POD 3 on. Procalcitonin levels did not differ. Best Receiver operating curve (ROC)-results were on POD 4, highest negative predictive values at POD 5 (RAMIE) and POD 4 (OE) with cut-off values of 70 mg/L and 88.3 mg/L, respectively. Conclusion: Post-operative CRP is a good negative predictor for PIC, after both RAMIE and OE. After RAMIE, CRP peaks later with a lower cut-off value.

Circular vs. linear stapling after minimally invasive and robotic-assisted esophagectomy: a pooled analysis

Purpose

Current data states that most likely there are differences in postoperative complications regarding linear and circular stapling in open esophagectomy. This, however, has not yet been summarized and overviewed for minimally invasive esophagectomy, which is being performed increasingly.

Methods

A pooled analysis was conducted, including 4 publications comparing linear and circular stapling techniques in minimally invasive esophagectomy (MIE) and robotic-assisted minimally invasive esophagectomy (RAMIE). Primary endpoints were anastomotic leakage, pulmonary complications, and mean hospital stay.

Results

Summarizing the 4 chosen publications, no difference in anastomotic insufficiency could be displayed (p = 0.34). Similar results were produced for postoperative pulmonary complications. Comparing circular stapling (CS) to linear stapling (LS) did not show a trend towards a favorable technique (p = 0.82). Some studies did not take learning curves into account. Postoperative anastomotic stricture was not specified to an extent that made a summary of the publications possible.

Conclusions

In conclusion, data is not sufficient to provide a differentiated recommendation towards mechanical stapling techniques for individual patients undergoing MIE and RAMIE. Therefore, further RCTs are necessary for the identification of potential differences between LS and CS. At this point in research, we therefore suggest evading towards choosing a single anastomotic technique for each center. Momentarily, enduring the learning curve of the surgeon has the greatest evidence in reducing postoperative complication rates.

Robotic-assisted minimally invasive esophagectomy (RAMIE) for esophageal cancer training curriculum-a worldwide Delphi consensus study

BACKGROUND

Structured training protocols can safely improve skills prior initiating complex surgical procedures such as robotic-assisted minimally invasive esophagectomy (RAMIE). As no consensus on a training curriculum for RAMIE has been established so far it is our aim to define a protocol for RAMIE with the Delphi consensus methodology.

METHODS

Fourteen worldwide RAMIE experts were defined and were enrolled in this Delphi consensus project. An expert panel was created and three Delphi rounds were performed starting December 2019. Items required for RAMIE included, but were not limited to, virtual reality simulation, wet-lab training, proctoring, and continued monitoring and education. After rating performed by the experts, consensus was defined when a Cronbach alpha of ≥0.80 was reached. If ≥80% of the committee reached a consensus an item was seen as fundamental.

RESULTS

All Delphi rounds were completed by 12-14 (86-100%) participants. After three rounds analyzing our 49-item questionnaire, 40 items reached consensus for a training curriculum of RAMIE.

CONCLUSION

The core principles for RAMIE training were defined. This curriculum may lead to a wider adoption of RAMIE and a reduction in time to reach proficiency.

Robotic-assisted minimally invasive Ivor Lewis esophagectomy within the prospective multicenter German da Vinci Xi registry trial

Abstract

Purpose

Robotic-assisted minimally invasive esophagectomy (RAMIE) has become one standard approach for the operative treatment of esophageal tumors at specialized centers. Here, we report the results of a prospective multicenter registry for standardized RAMIE.

Methods

The German da Vinci Xi registry trial included all consecutive patients who underwent RAMIE at five tertiary university centers between Oct 17, 2017, and Jun 5, 2020. RAMIE was performed according to a standard technique using an intrathoracic circular stapled esophagogastrostomy.

Results

A total of 220 patients were included. The median age was 64 years. Total minimally invasive RAMIE was accomplished in 85.9%; hybrid resection with robotic-assisted thoracic approach was accomplished in an additional 11.4%. A circular stapler size of ≥28 mm was used in 84%, and the median blood loss and operative time were 200 (IQR: 80–400) ml and 425 (IQR: 335–527) min, respectively. The rate of anastomotic leakage was 13.2% (n=29), whereas the two centers with >70 cases each had rates of 7.0% and 12.0%. Pneumonia occurred in 19.5% of patients, and the 90-day mortality was 3.6%. Cumulative sum analysis of the operative time indicated the end of the learning curve after 22 cases.

Conclusions

High-quality multicenter registry data confirm that RAMIE is a safe procedure and can be reproduced with acceptable leak rates in a multicenter setting. The learning curve is comparably low for experienced robotic surgeons.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00423-022-02520-w.

Using the da Vinci X® - System for Esophageal Surgery

Robotic esophageal surgery is becoming more widely adopted. Several publications on the feasibility, short-term outcomes and technical aspects are available. Most of these articles used either the da Vinci® SI system or in newer series the Xi System. The da Vinci® X system is generally considered less suited for multiquadrant access like in esophageal surgery, hence only limited data is available. Here we describe our initial experience with 16 Ivor-Lewis robotic assisted minimally invasive esophagectomies (RAMIE) in patients with esophageal adenocarcinoma. The da Vinci® X system was installed in our department in 2019; the robotic program comprises colorectal, pancreatic and esophageal surgery. The first two patients were operated in the presence of a proctor. An operative standard was established including fluorescence angiography (Firefly®). Technical aspects with focus on the characteristics of the da Vinci® X system, operating room setup, and short-term outcomes are discussed.

Double-Docking Technique, an Optimized Process for Intrathoracic Esophagogastrostomy in Robot-Assisted Ivor Lewis Esophagectomy

Background

Though robotic Ivor Lewis esophagectomy has been increasingly applied, intrathoracic esophagogastrostomy is still a technical barrier. In this retrospective study, we introduced a double-docking technique for intrathoracic esophagogastrostomy to optimize surgical exposure and facilitate intrathoracic anastomosis. Moreover, we compared the clinical outcomes between the double-docking technique and anastomosis with a single-docking procedure in robotic Ivor Lewis esophagectomy.

Methods

From March 2017 to September 2020, the clinical data of 68 patients who underwent robotic Ivor Lewis esophagectomy were reviewed, including 23 patients who underwent the double-docking technique (double-docking group) and 45 patients who underwent single-docking robotic esophagectomy (single-docking group). All patients were diagnosed with esophageal cancer or gastro-esophageal junction by biopsy before surgery. The technical details of the double-docking technique are described in this article.

Results

There was no difference in the patient demographics data between the two groups. The median surgical time in the double-docking group was slightly shorter than in the classic group without statistical difference (380 vs. 395 min, p = 0.368). In the double-docking group, the median blood loss was 90 mL, the median number of lymph nodes harvested was 17, and the R0 resection rates were 100% (23/23). There were no differences in the surgical outcomes between the two groups.

Conclusions

Based on our experience, the double-docking technique provides good surgical exposure when fashioning anastomosis, and such a technique does not increase the surgical time. Therefore, we believe that the double-docking technique is a safe and effective method for intrathoracic esophagogastrostomy while providing good exposure and ensuring the convenience and reliability of intrathoracic anastomosis.

[Change of strategy to minimally invasive esophagectomy-Results at a certified center]

Hintergrund

Es gibt Hinweise, dass die roboterassistierte minimal-invasive Ösophagektomie (RAMIE) die Morbidität im Vergleich zur konventionellen Operationstechnik verringern kann.

Ziel der Arbeit

Es erfolgte eine Vergleichsanalyse eines Single-Center-Strategiewechsels des Standards von offener Ösophagektomie zu RAMIE mit perioperativer, enteraler, selektiver Darmdekontamination (SDD).

Material und Methoden

Patienten- und Morbiditätsdaten nach elektiver RAMIE entsprechend dem neuen Standardmanagement zwischen Juli 2018 und September 2020 wurden retrospektiv mit einer historischen Kontrollkohorte nach offener Ösophagektomie zwischen Januar 2014 und Juni 2018 verglichen. Es erfolgte eine 1:1-Propensity-Score-Matching(PSM)-Analyse.

Ergebnisse

Insgesamt 75 Patienten konnten nach PSM in beiden Gruppen analysiert werden. Etwa zwei Drittel der Operationen erfolgte aufgrund eines Adenokarzinoms und ein Drittel bei Plattenepithelkarzinom. Im Median wurden 22 bzw. 21 Lymphknoten reseziert. Die intrathorakale Ösophagogastrostomie erfolgte in der RAMIE-Gruppe in 97 % mit einem Zirkularstapler mit ≥28 mm Durchmesser (offen: 25 mm in 90 % der Fälle). Die Operationszeit war länger (Median 490 vs. 339 min, p < 0,001), hingegen waren der Blutverlust (Median 300 vs. 500 ml, p < 0,001), die Anastomoseninsuffizienz- (8,0 % vs. 25,3 %, p = 0,004), Wundinfektions- (4,0 % vs. 17,3 %, p = 0,008) und pulmonale Komplikationsrate (29,3 % vs. 44,0 %, p = 0,045) sowie die mediane Krankenhausverweildauer (14 vs. 20 Tage, p < 0,001) und die 90-Tage-Mortalität signifikant geringer verglichen mit der offenen Kontrollkohorte (4,0 % vs. 13,3 %, p = 0,039).

Diskussion

Ein konsequenter Wechsel des perioperativen Managements u. a. mit RAMIE und SDD kann zu einer stabilen Reduktion der Morbidität ohne Einschränkungen der onkologischen Radikalität führen.

Pretreatment-assisted robot intrathoracic layered anastomosis: our exploration in Ivor-Lewis esophagectomy

Background

Minimal invasive Ivor-Lewis esophagectomy (MIIVE) with intrathoracic esophago-gastric anastomosis (EGA) is still under exploration and the preferred technique for intrathoracic anastomosis has not been established.

Methods

We retrospectively reviewed 43 consecutive patients who underwent MIIVE using the series technique called pretreatment-assisted robot intrathoracic layered anastomosis (PRILA), performed by a single surgeon between September 2018 and December 2020. The operative outcomes were analyzed.

Results

The mean total operation time had been reduced from 446.38±54.775 minutes (range, 354-552) in the first year to 347.70±60.420 minutes (range, 249-450) later. There were no conversions to thoracotomy. All the patients achieved R0 resection. No patient suffered from anastomotic leakage. There was no 30-day mortality. The median length of postoperative stay was 10.0 days.

Conclusions

PRILA further visualizes and streamlines the process of minimal invasive intrathoracic EGA, thus ensuring the precise anastomosis. It could be considered as a feasible alternative for intrathoracic EGA in MIILE.

[New techniques and training methods for robot-assisted surgery and cost-benefit analysis of Ivor Lewis esophagectomy]

INTRODUCTION

Robotic surgery was introduced into general surgery more than 20 years ago. Shortly afterwards, Horgan performed the first robotic-assisted esophagectomy in 2003 in Chicago. The aim of this manuscript is to elucidate new developments and training methods in robotic surgery with a cost-benefit analysis for robotic-assisted Ivor Lewis esophagectomy.

METHODS

Systematic literature search regarding new technology and training methods for robotic surgery and cost analysis of intraoperative materials for hybrid and robotic-assisted Ivor Lewis esophagectomy.

RESULTS

Robotic-assisted esophageal surgery is complex and involves an extensive learning curve, which can be shortened with modern teaching methods. New robotic systems aim at the use of image-guided surgery and artificial intelligence. Robotic-assisted surgery of esophageal cancer is significantly more expensive that surgery without this technology.

CONCLUSION

Oncological short-term and long-term benefits need to be further evaluated to support the higher cost of robotic esophageal cancer surgery.

RAMIE: tradition drives innovation-feasibility of a robotic-assisted intra-thoracic anastomosis

Due to the difficulties in the intra-thoracic esophagogastric anastomosis creation, totally minimally invasive Ivor Lewis esophagectomy (MIE) did not encountered a large diffusion, preferring hybrid techniques or cervical anastomosis. Robot-assisted minimally invasive esophagectomy (RAMIE) has gained popularity due to an easy reproducibility of the open anastomotic technique. In this feasibility study, we described the RAMIE technique introduced in our Center, providing innovative details for a mechanical end-to-end anastomosis. With patient in prone position, esophagectomy is conducted through the meso-esophagus plan. Robotic hand-sewn purse-string is realized above Azygos vein. A 4-cm thoracotomy in the fifth intercostal space is performed by enlarging the trocar incision. The tubulization is performed to create an access pouch for the introduction of the circular stapler. After the creation of the end-to-end anastomosis, the access pouch is resected and a robotic over-sewn is realized. From January 2020 until July 2020, ten patients were enrolled. No restriction in term of age, BMI, ASA grade or previous surgery were applied. Median operative time was 700 min. R0 resection was achieved in all cases with a good lymph node harvesting. No anastomotic leak or stricture were observed. One chyle leak was treated conservatively. Median length of stay was 8 days and 90 days mortality was 0%. This study evidenced how robotic surgery allowed us to perform the same anastomosis of our open technique with good oncological results and morbidity and length of stay comparable with our previous results. Of note, longer operative time has been recorded. Further studies after the completion of the learning curve are necessary to address more definite conclusions.

Technical details of the hand-sewn and circular-stapled anastomosis in robot-assisted minimally invasive esophagectomy

The circular mechanical and hand-sewn intrathoracic anastomosis are most often used in robot-assisted minimally invasive esophagectomy (RAMIE). The aim of this study was to describe the technical details of both techniques that were pioneered in two high volume centers for RAMIE. A prospectively maintained database was used to identify patients with esophageal cancer who underwent RAMIE with intrathoracic anastomosis. The primary outcome was anastomotic leakage, which was analyzed using a moving average curve. For the hand-sewn anastomosis, video recordings were reviewed to evaluate number of sutures and distances between the anastomosis and the longitudinal staple line or gastric conduit tip. Between 2016 and 2019, a total of 68 patients with a hand-sewn anastomosis and 60 patients with a circular-stapled anastomosis were included in the study. For the hand-sewn anastomosis, the moving average curve for anastomotic leakage (including grade 1-3) started at a rate of 40% (cases 1-10) and ended at 10% (cases 59-68). For the circular-stapled anastomosis, the moving average started at 10% (cases 1-10) and ended at 20% (cases 51-60). This study showed the technical details and refinements that were applied in developing two different anastomotic techniques for RAMIE. Results markedly improved during the period of development with specific changes in technique for the hand-sewn anastomosis. The circular-stapled anastomosis showed a more stable rate of performance.

Long-Term, Health-Related Quality of Life after Open and Robot-Assisted Ivor-Lewis Procedures-A Propensity Score-Matched Study

Esophagectomies are among the most invasive surgical procedures that highly influence health-related quality of life (HRQoL). Recent improvements have helped to achieve longer survival. Therefore, long-term postoperative HRQoL needs to be emphasized in addition to classic criterions like morbidity and mortality. We aimed to compare short and long-term HRQoL after open transthoracic esophagectomies (OTEs) and robotic-assisted minimally invasive esophagectomies (RAMIEs) in patients suffering from esophageal adenocarcinoma. Prospectively collected HRQoL-data (from the European Organization for Research and Treatment of Cancer Core Quality of Life Questionnaire-C30 (EORTC QLQ-C30)) were correlated with clinical courses. Only patients suffering from minor postoperative complications (Clavien-Dindo Classification of < 2) after R0 Ivor-Lewis-procedures were included. Age, sex, body mass index (BMI), American Society of Anesthesiologists physical status-score (ASA-score), tumor stage, and perioperative therapy were used for propensity score matching (PSM). Twelve RAMIE and 29 OTE patients met the inclusion criteria. RAMIE patients reported significantly better emotional and social function while suffering from significantly less pain and less physical impairment four months after surgery. The long-term follow up confirmed the results. Long-term postoperative HRQoL and self-perception partly exceeded the levels of the healthy reference population. Minor operative trauma by robotic approaches resulted in significantly reduced physical impairments while improving HRQoL and self-perception, especially in the long-term. However, further long-term results are warranted to confirm this positive trend.

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.

Implementation of robot-assisted Ivor Lewis procedure: Robotic hand-sewn, linear or circular technique?

BACKGROUND

Robot-assisted surgery for esophageal cancer is increasingly applied. Despite this upsurge, the preferential technique to create a robot-assisted intrathoracic anastomosis has not been established.

DATA SOURCES

Bibliographic databases were searched to identify studies that performed a robot-assisted Ivor Lewis esophagectomy and described the technical details of the anastomotic technique. Out of 1701 articles, 16 studies were included for systematic review.

CONCLUSIONS

This review shows that all technique used to create a thoracoscopic anastomosis can be adopted to robotic surgery. Techniques can be divided into three categories: robotic hand-sewn, circular stapling or linear stapling and robotic hand-sewn closure of the stapler defect. With limited robotic experience, circular stapling might be the preferred technique, however requires a well-trained bedside assistant. The linear stapling technique or hand-sewn technique are more challenging but enable experienced robotic surgeons to perform a controlled anastomosis without bedside support.

Modular step-up approach to robot-assisted transthoracic esophagectomy-experience of a German high volume center

Background

The use of robotic technology in general surgery is rapidly increasing in Europe. Aim of this study is to evaluate the introduction of new robotic technologies in a center of excellence for upper gastrointestinal surgery.

Methods

A standardized teaching protocol of a complete OR team was performed in simulation and animal models at the Center for the Future of Surgery (San Diego CA, USA) and IRCAD (Strasbourg, France) to receive certification as console surgeons. Starting 02/2017 the daVinci Xi and Stryker ICG laparoscopy systems were introduced at our academic center (certified center of excellence for surgery of the upper gastrointestinal tract, n>300 upper gastrointestinal cases/year). After simple training procedures based on our minimally invasive expertise were performed, difficulty was increased based on a modular step up approach to finally perform robotic assisted transthoracic Ivor Lewis esophagectomy.

Results

A total of 70 patients (9 females) fulfilled inclusion criteria to our study. Robotic assisted esophagectomy was divided into six modules. Level of difficulty was increased based on our modular step up approach without quality compromises. There were no intraoperative complications and no unplanned conversions to open surgery. Two surgeons were able to sequentially train and perform a completely robotic transthoracic esophagectomy using this modular approach without a substantial learning curve. A total of ten esophagectomies per surgeon were necessary to complete all modules in one case.

Conclusions

The standardized training protocol and the University of Cologne modular step up approach allowed safe introduction of the new technology used. All cases were performed safely without operation-associated complications.