Robotic esophagectomy with total mediastinal lymphadenectomy using four robotic arms alone in esophageal and esophagogas
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ORIGINAL ARTICLE
Robotic esophagectomy with total mediastinal lymphadenectomy using four robotic arms alone in esophageal and esophagogastric cancer (RETML‑4): a prospective feasibility study Hiroyuki Daiko1,2 · Junya Oguma1 · Hisashi Fujiwara2 · Koshiro Ishiyama1 · Daisuke Kurita1 · Kazuma Sato2 · Takeo Fujita2 Received: 11 August 2020 / Accepted: 30 September 2020 © The Japan Esophageal Society 2020
Abstract Background Robotic-assisted esophagectomy is still in the implementation phase. Robotic surgical systems refine visualization via robotically-enhanced surgical anatomy (RESA), and the stable articulated robotic arms provide precise movements. This prospective feasibility study was conducted to evaluate robotic esophagectomy with total mediastinal lymphadenectomy using four robotic arms exclusively (RETML-4). Methods The inclusion criterion was clinical stage I–IIIB esophageal cancer with stable general condition. Patients were positioned hemi-prone with single-lung ventilation, and the operation table was tilted until the patient was prone. The first, second, third, and fourth robotic ports were inserted into the ninth intercostal space (ICS) on the angulus inferior scapulae line, seventh ICS on the posterior axillary line, and the fifth and third ICS on the mid-axillary line, respectively. RETML-4 was performed by precise sharp dissection in wide stable operation fields, with countertraction created by a tip-up fenestrated grasper with gauze. Esophagectomy was performed separately for the middle to lower, and upper esophagus. After mobilizing the middle to lower esophagus and performing lymph node dissection, the upper esophagus was mobilized, with bilateral lymph node dissection along the recurrent laryngeal nerves. The assistant surgeon was involved only during removing gauze and collecting harvested lymph nodes in the thorax. Results RETML-4 was performed in all ten patients enrolled in 2018. The median postoperative hospital stay was 15 days, and the complication rate was 60%. Nine cases achieved R0 resection. Recurrence occurred in two cases. Conclusions RETML-4 is feasible, and may facilitate minimally invasive esophagectomy by providing precise instrument movements and RESA. Keywords Esophagectomy · Robotic surgical procedures · Minimally invasive surgery · Esophageal cancer
Introduction Minimally invasive esophagectomy (MIE) provides early postoperative recovery for the patient because of the minimal chest wall trauma, and magnified anatomy (microanatomy) for the surgeon. Additionally, a robotic three-dimensional endoscope with a steady robotic arm magnifies the * Hiroyuki Daiko [email protected] 1
Esophageal Surgery Division, National Cancer Center Hospital, 5‑1‑1 Tsukiji, Chuo‑Ku, Tokyo 104‑0045, Japan
Esophageal Surgery Division, National Cancer Center Hospital East, Chiba, Japan
2
microanatomy, providing robotically-enhanced surgical anatomy (RESA). RESA enables oncological complete radical and organ function-preserved surgery [1]. However, robotic-assisted MIE (RAMIE) is still
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