Minimally Invasive and Robotic Esophagectomy

Abstract

<jats:p> 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. </jats:p>

Minimally invasive McKeown esophagectomy with two-field lymph node dissection and manual cervical esophagogastric anastomosis

“…Three-field lymphadenectomy for esophagectomy is still controversial. For para-RLN lymph node negative cases, cervical lymph node dissection can be omitted (4). In our center, there is an ongoing clinical trial for this scenario.…”

“…Since McKeown first described his esophagectomy in 1978 (1), this three-field surgery has been widely applied in clinical practice, and particularly gained momentum when the "minimally invasive era" began in the early 1990s (2). This procedure is now the mainstream esophagectomy pattern for esophageal cancer [over 90% of total procedures (3)] because (I) it can achieve en bloc resection of both thoracic and gastric lymph nodes, and (II) the cervical anastomotic leaks can be opened and drained very conveniently (4). However, the entirety of the McKeown esophagectomy procedure is still challenging for some surgeons due to its long surgical duration (~480 minutes), complicated surgical steps, and relatively high anastomotic leak rate (5).…”

Robotic esophagectomy: the evolution of open esophagectomy to current techniques and a review of the literature

“…In 1993, Collard et al [25] sophisticated the technique, and, in 1995, DePaula et al [26] was the first to perform a completely laparoscopic THE. Today, many different versions of MIE are performed [27] employing several combinations of approach using laparoscopic and thoracoscopic techniques [ Table 1, Items 1-9].…”

“…Indications for minimally-invasive esophageal resection approaches are similar to those for open esophagectomy and include esophageal cancer, failure of endoscopic ablation and/or resection for high grade dysplasia secondary to Barrett's esophagitis, stricturing of the esophagus, and the sequelae of achalasia and Chagas disease known as "burned out esophagus" [27] . Relative contraindications to its use are known extensive pleural or abdominal adhesions, with absolute contraindications involving the inability to use single-lung ventilation because of previous resection or poor lung function.…”

“…This is then followed by a thoracic phase where the specimen is resected and anastomosis completed. Advantages include good oncologic "en bloc" lymph node dissections of the stomach and thoracic esophagus, decreased incidence of anastomotic leak, and decreased injury of the recurrent laryngeal nerve [27] . Disadvantages include contamination of the chest, which can lead to longer hospital stays, decreased quality of life if anastomotic leak occurs, and increased pulmonary morbidity secondary to the need for single-lung ventilation [27] .…”