Attaining Proficiency in Robotic-Assisted Minimally Invasive Esophagectomy While Maximizing Safety during Procedure Development

Sarkaria, Inderpal S.; Rizk, Nabil P.; Grosser, Rachel; Goldman, Debra A.; Finley, David J.; Ghanie, Amanda; Sima, Camelia S.; Bains, Manjit S.; Adusumilli, Prasad S.; Rusch, Valerie W.; Jones, David R.

doi:10.1097/imi.0000000000000297

Cited by 62 publications

(48 citation statements)

References 15 publications

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“…This commentary's senior author's (I.S.S.) own extensive experience with the RAMIE Ivor Lewis approach at both Memorial Sloan Kettering Cancer Center and the University of Pittsburgh Medical Center supports this hypothesis (8,12). In a collective experience of 125 cases, there was 1 operative mortality at 90 days, median lymph node counts were greater than 25, significant anastomotic leak occurred in 4-6% of patients, and complete resection was achieved in over 90% of patients.…”

Section: Meticulous Attention To Clear Identification Of Vital Anatomymentioning

confidence: 53%

“…When they do occur, surgeons must use quick and sound judgement in determining whether these events can be managed minimally invasively, or require urgent conversion to open operations (10). During attainment of the learning curve, estimated at 35-50 cases for experienced esophageal surgeons, strong consideration should be given to conversion for technically challenging portions of the case as experience is gained (7,8).…”

Section: Meticulous Attention To Clear Identification Of Vital Anatomymentioning

confidence: 99%

“…While still limited in number, larger series of RAMIE are demonstrating feasibility, safety, and equivalence in early oncologic outcomes compared to other Ivor Lewis approaches (7,8). Putative advantages of the robotic approach include the advanced magnified stereo-optics, stabile and central visualization of the operative field, articulated instrumentation, and ability of the surgeon to self-assist.…”

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confidence: 99%

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Robotic assisted minimally invasive esophagectomy for esophageal cancer: a Comment on the Ruijin hospital experience

Pennywell

Sarkaria

2017

J. Thorac. Dis.

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Zhang et al. have described their technical approach to a total laparoscopic and thoracoscopic robotic assisted minimally invasive esophagectomy (RAMIE) via an Ivor Lewis approach for an early stage, distal, esophageal squamous cell carcinoma (1). The authors have offered a nicely detailed written, graphical, and pictorial description of port placement, positioning, and technical execution of the abdominal and thoracic portions of the operation using a three robotic-arm approach for both phases. The thoracic portion of the operation utilizes a semi-prone approach, and the intra-thoracic anastomosis is created using an end to end anastomotic (EEA) stapler. The authors depict several technical aspects including intra-corporeal creation of the gastric conduit, ligation of the thoracic duct, as well as dissection of lymph nodes along both recurrent laryngeal nerves. The patient did well with no immediate post-operative complications, and was discharged on post-operative day 8.The current report is representative of a growing number of institutional series of Ivor Lewis RAMIE for esophageal cancer (2-4). Non-robotic minimally invasive esophagectomy (MIE) has largely been established as an approach with decreased pulmonary and wound complications, and equivalent oncologic outcomes compared to open operations (5,6).While still limited in number, larger series of RAMIE are demonstrating feasibility, safety, and equivalence in early oncologic outcomes compared to other Ivor Lewis approaches (7,8). Putative advantages of the robotic approach include the advanced magnified stereo-optics, stabile and central visualization of the operative field, articulated instrumentation, and ability of the surgeon to self-assist. These advantages can be distilled into a single overarching principle: the surgeon simply gains far more control over the conduct of the operation. Intuitively, this suggests the ability to greatly increase operative efficiency with experienced users of current robotic platforms. These technologies may also potentially allow wider adoption of minimally invasive approaches by surgeons less experienced in standard minimally invasive techniques. However, this hypothesis, often assumed, is yet to be substantiated by evidence based studies.Several cautions and potential pitfalls regarding the RAMIE approach should be considered, especially when instituting new programs. Esophagectomy remains a complex operation, with operative principles and surgeon expertise that remain paramount to gaining acceptable outcomes, regardless of the approach. It is imperative for new programs early in the learning curve for overall RAMIE and/or robotic skill sets to be aware of these challenges, and to avoid recapitulating known and avoidable complications of these operations. First and foremost is the potential for airway injury and subsequent formation of enteric-airway fistula formation. This complication, far more common in minimally invasive operations (RAMIE or MIE), is almost always technical in nature. By and large, these devast...

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Section: Meticulous Attention To Clear Identification Of Vital Anatomymentioning

confidence: 53%

Section: Meticulous Attention To Clear Identification Of Vital Anatomymentioning

confidence: 99%

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confidence: 99%

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Robotic assisted minimally invasive esophagectomy for esophageal cancer: a Comment on the Ruijin hospital experience

Pennywell

Sarkaria

2017

J. Thorac. Dis.

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“…The quality of the initial institutional experience has been greatly aided by the extensive previous experience and expertise of the two senior authors of this publication (IS Sarkaria and JD Luketich). The previously published experience by one of the senior authors (IS Sarkaria) at Memorial Sloan Kettering Cancer Center reported excellent outcomes in 100 patients undergoing RAMIE with an anastomotic leak rate of 6%, 0% 30-day mortality, and a 90-day mortality rate of 1% (12). The robotic platform offers many potential advantages to this specific operation.…”

Section: Discussionmentioning

confidence: 99%

Technique of robotic assisted minimally invasive esophagectomy (RAMIE)

et al. 2017

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Minimally invasive esophagectomy (MIE) has gained popularity over the last two decades as an oncologically sound alternative to open esophagectomy. Robotic assisted minimally invasive esophagectomy (RAMIE) has been developed at few highly-specialized centers, and overall experience with this technique remains limited. Herein, we describe our overall approach to this operation and specific technical issues.

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“…Robotic console time with this innovative procedure was reported to be significantly reduced after the initial six patients 22. A significant reduction in total operative time was identified after the initial 20 or 30 cases 27, 28…”

Section: Learning Curvementioning

confidence: 92%

Robotic surgery for esophageal cancer: Merits and demerits

Seto

Mori

Aikou

2017

Annals of Gastroent Surgery

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Since the introduction of robotic systems in esophageal surgery in 2000, the number of robotic esophagectomies has been gradually increasing worldwide, although robot‐assisted surgery is not yet regarded as standard treatment for esophageal cancer, because of its high cost and the paucity of high‐level evidence. In 2016, more than 1800 cases were operated with robot assistance. Early results with small series demonstrated feasibility and safety in both robotic transhiatal (THE) and transthoracic esophagectomies (TTE). Some studies report that the learning curve is approximately 20 cases. Following the initial series, operative results of robotic TTE have shown a tendency to improve, and oncological long‐term results are reported to be effective and acceptable: R0 resection approaches 95%, and locoregional recurrence is rare. Several recent studies have demonstrated advantages of robotic esophagectomy in lymphadenectomy compared with the thoracoscopic approach. Such technical innovations as three‐dimensional view, articulated instruments with seven degrees of movement, tremor filter etc. have the potential to outperform any conventional procedures. With the aim of preventing postoperative pulmonary complications without diminishing lymphadenectomy performance, a nontransthoracic radical esophagectomy procedure combining a video‐assisted cervical approach for the upper mediastinum and a robot‐assisted transhiatal approach for the middle and lower mediastinum, transmediastinal esophagectomy, was developed; its short‐term outcomes are promising.Thus, the merits or demerits of robotic surgery in this field remain quite difficult to assess. However, in the near future, the merits will definitely outweigh the demerits because the esophagus is an ideal organ for a robotic approach.

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Attaining Proficiency in Robotic-Assisted Minimally Invasive Esophagectomy While Maximizing Safety during Procedure Development

Cited by 62 publications

References 15 publications

Robotic assisted minimally invasive esophagectomy for esophageal cancer: a Comment on the Ruijin hospital experience

Robotic assisted minimally invasive esophagectomy for esophageal cancer: a Comment on the Ruijin hospital experience

Technique of robotic assisted minimally invasive esophagectomy (RAMIE)

Robotic surgery for esophageal cancer: Merits and demerits

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