Contribution of robotics to minimally invasive esophagectomy

Technical details for a robot-assisted hand-sewn esophago-gastric anastomosis during minimally invasive Ivor Lewis esophagectomy

Background

Minimally invasive Ivor Lewis esophagectomy (MIILE) provides better outcomes than open techniques, particularly in terms of post-operative recovery and pulmonary complications. However, in addition to requiring advanced technical skills, thoracoscopic access makes it hard to perform esophagogastric anastomosis safely, and the reported rates of anastomotic leak vary from 5 to 16%. Several minimally invasive esophago-gastric anastomotic techniques have been described, but to date strong evidence to support one technique over the others is still lacking. We herein report the technical details and preliminary results of a new robot-assisted hand-sewn esophago-gastric anastomosis technique.

Methods

From January 2018 to December 2020, 12 cases of laparoscopic/thoracoscopic Ivor Lewis esophagectomy with robot-assisted hand-sewn esophago-gastric anastomosis were performed. The gastric conduit was prepared and tailored taking care of vascularization with a complete resection of the gastric fundus. The anastomosis consisted of a robot-assisted, hand-sewn four layers of absorbable monofilament running barbed suture (V-lock). The posterior outer layer incorporated the gastric and esophageal staple lines.

Results

The post-operative course was uneventful in nine cases. Two patients developed chyloperitoneum, one patient a Sars-Cov-2 infection, and one patient a late anastomotic stricture. In all cases, there were no anastomotic leaks or delayed gastric conduit emptying. The median post-operative stay was 13 days (min 7, max 37 days); the longest in-hospital stay was recorded in patients who developed chyloperitoneum.

Conclusion

Despite the small series, we believe that our technique looks to be promising, safe, and reproducible. Some key points may be useful to guarantee a low complications rate after MIILE, particularly regarding anastomotic leaks and delayed emptying: the resection of the gastric fundus, the use of robot assistance, the incorporation of the staple lines in the posterior aspect of the anastomosis, and the use of barbed suture. Further cases are needed to validate the preliminary, but very encouraging, results.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00464-021-08715-4.

Robotic resection for esophageal cancer

Background

In the surgical treatment of esophageal cancer, complete tumor resection is the most important factor and determines long-term survival. With an increase in robotic expertise in other fields of surgery, robotic-assisted minimally invasive esophagectomy (RAMIE) was born. Currently, there is a lack of convincing data on the extent of expected benefits (perioperative and oncologic outcomes and/or quality of life). Some evidence exists that patients’ overall quality of life and physical function improves, with less fatigue and pain 3 months after surgery. We aimed to review the available literature regarding robotic esophagectomy, compare perioperative, oncologic, and quality of life outcomes with open and minimally invasive approaches, and give a brief overview of our standardized four-arm RAMIE technique and explore future directions.

Methods

A Medline (PubMed) search was conducted including the following key words: esophagectomy, minimally invasive esophagectomy, robotic esophagectomy, Ivor Lewis and McKeown. We present the history, different techniques used, outcomes, and the standardization of robotic esophagectomy.

Results

Robotic esophagectomy offers a steeper learning curve with fewer complications but comparable oncological results compared to conventional minimally invasive esophagectomy.

Conclusions

Available studies suggest that RAMIE is associated with benefits regarding length of stay, clinical outcomes, and quality of life—if patients are treated in an experienced center with a standardized technique for robotic esophagectomy—making it a potentially beneficial tool in the treatment of esophageal cancer. However, center-wide standardization and prospective data collection will be a necessity to prove superiority of robotic esophagectomy.

Intrathoracic side-to-side esophagogastrostomy with a linear stapler and barbed suture in robot-assisted Ivor Lewis esophagectomy

Background

The side‐to‐side anastomosis was considered a promising approach to create an intrathoracic esophagogastrostomy in the minimally invasive esophagectomy, with advantages over the side‐to‐end anastomosis with aspects of no need for additional mini‐thoracotomy and lower occurrence of stenosis. The hand‐sewing anterior aspect of the anastomosis is technically challenging in the thoracoscopic Ivor Lewis esophagectomy. Here we introduced our initial experience to facilitate this approach by using the surgical robot and barbed suture.

Methods

A retrospective study of all patients underwent robot‐assisted Ivor Lewis esophagectomy with side‐to‐side esophagogastrostomy from February 2016 to September 2018 was performed. The technical details are described in this paper.

Results

A total of 37 patients (35 male and 2 female, median age of 62.7 years) were successfully treated with completely robot‐assisted Ivor Lewis esophagectomy. The median total surgical time was 340 minutes including 65 minutes to perform the anastomosis. Median estimated blood loss was 120 mL and the length of hospital stay was 10 days. There was no 90‐day mortality. Three patients suffered anastomotic leakage (8.1%,3/37), who were successfully treated without reoperation.

Conclusion

Our initial results imply that it is technically feasible to perform intrathoracic gastroesophageal anastomosis by taking advantage of a robotic system and knotless suturing.

Robot-assisted esophagogastric reconstruction in minimally invasive Ivor Lewis esophagectomy

Background

Although the incidence of esophagogastric junction cancer has increased considerably in recent years, the application of minimally invasive Ivor Lewis esophagectomy, especially in East Asia, is still much rarer than the McKeown approach. The reconstruction of the alimentary tract is one of the main technical challenges under traditional endoscopy. The robotic surgical system with high-resolution 3D images and multiarticulate instruments may help simplify this procedure. Here, we describe our experience in the gastric tube and esophagogastric anastomosis construction, and the initial clinical results for Ivor Lewis robot-assisted minimally invasive esophagectomy (RAMIE).

Methods

A retrospective study of all patients undergoing Ivor Lewis RAMIE with circular stapled anastomosis at a single institution from December 2016 to June 2018 was performed. Operative and postoperative outcomes were recorded.

Results

Twenty-four patients [median age, 63 years (range, 49-77 years)] underwent Ivor Lewis RAMIE during the study period with a four-arm robotic platform. Four patients (16.7%) received neoadjuvant therapy. The median estimated blood loss was 120 mL (range, 50-210 mL). The median operating time was 352.5 min (range, 259-485 min). There was no conversion to an open surgical procedure. Postoperative complications occurred in 3 (12.5%) patients. Complications included pneumonia in two patients (8.3%) and mediastinitis in 1 (4.2%). The median stay in the intensive care unit was 1 d (range, 0-8 d) and the median postoperative hospital stay was 11 d (range, 8-30 d). All patients had an R0 resection. The median number of nodes removed was 19 (range, 11-30) and the median number of positive nodes removed was 1 (range, 0-8).

Conclusions

Our initial results indicate that Ivor Lewis RAMIE may be a safe and feasible alternative to open and endoscopic Ivor Lewis esophagectomy.

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.

Early Outcomes of Robot-Assisted Versus Thoracoscopic-Assisted Ivor Lewis Esophagectomy for Esophageal Cancer: A Propensity Score-Matched Study

BACKGROUND

Both robot-assisted Ivor Lewis esophagectomy (RAILE) and conventional thoracoscopic-assisted Ivor Lewis esophagectomy (TAILE) are minimally invasive surgical techniques for the treatment of middle and distal esophageal cancer. However, no research studies comparing early outcomes between RAILE and TAILE have been reported.

METHODS

A retrospective analysis was made of 184 patients, 76 in the RAILE group and 108 in the TAILE group, who underwent minimally invasive Ivor Lewis esophagectomy between December 2014 and June 2018. Propensity score-matched analysis was performed between the two groups based on demographics, comorbidities, American Society of Anesthesiologists score, tumor location, tumor size, and pathological stage. Perioperative outcomes were compared.

RESULTS

Two conversions to thoracotomy occurred in the RAILE group. There was no 30-day in either group. Sixty-six matched pairs were identified for each group. Within the propensity score-matched cohorts, the operative time in the RAILE group was significantly longer than that in the TAILE group (302.0 ± 62.9 vs. 274.7 ± 38.0 min, P = 0.004). There was no significant difference in the blood loss [200.0 ml (interquartile range [IQR], 100.0-262.5 ml) vs. 200.0 ml (150.0-245.0 ml), P = 0.100], rates of overall complications (28.8 vs. 24.2%, P = 0.554), length of stay [9.0 days (IQR 8.0-12.3 days) vs. 9.0 days (IQR 8.0-11.3 days), P = 0.517], the number of total dissected lymph nodes (19.2 ± 9.2 vs. 19.3 ± 9.5, P = 0.955), and detailed categories of lymph nodes.

CONCLUSIONS

RAILE demonstrated comparable early outcomes compared with TAILE and should be considered as an alternative minimally invasive option for treating esophageal cancer.