ABSTRACT
Total esophagectomy for esophageal cancer is associated with high morbidity. The avoidance of a thoracic access could especially reduce the occurrence of pulmonary complications. Therefore, the combination of a high transhiatal dissection of the esophagus and a neck access with mediastinal dissection of the esophagus appears to be a possibility to reduce the pulmonary risks. However, the access to the posterior mediastinum is very limited with the conventional minimal invasive instruments. These limitations can be overcome by the use of a surgical robot.In this article, we present a novel operation technique for a complete robot-assisted (da Vinci Xi) McKeown procedure avoiding a thoracic approach and abdominal incision by using a rendezvous technique with an abdominal and cervical docking of the robot system.
Subject(s)
Esophageal Neoplasms/surgery , Esophagectomy/methods , Mediastinoscopy , Robotic Surgical Procedures , Equipment Design , Esophageal Neoplasms/pathology , Esophagectomy/adverse effects , Esophagectomy/instrumentation , Humans , Mediastinoscopy/adverse effects , Mediastinoscopy/instrumentation , Patient Positioning , Robotic Surgical Procedures/adverse effects , Robotic Surgical Procedures/instrumentation , Surgical Equipment , Treatment OutcomeABSTRACT
BACKGROUND: Difficulties in thoracic access and the risk of pulmonary complications are major problems in esophageal surgery. Transhiatal techniques have been described to avoid the thoracic approach, but their oncological radicality continues to be questioned. A combination of a cervical and transhiatal approach, however, appears promising. We describe the technique of a robot-assisted cervical esophagectomy (RACE procedure), combined with a transhiatal approach in a rendezvous technique. METHODS: The da Vinci Xi® robotic system was docked in a single port technique via a cervical approach. The upper third of the esophagus and the surrounding lymphatic tissue was dissected thoracically. Subsequently, the system was docked abdominally to allow us to completely dissect the esophagus in the rendezvous procedure. RESULTS: The patients (n = 4) suffered no trauma or injury to surrounding structures during the procedure, and sensitive structures were preserved. Almost no robot arm collision occurred, and the arms did not contact the patients' head or shoulders. No patient converted to conventional robotic-assisted transthoracic esophagectomy. Complications included anastomotic leakage (n = 1), transient palsy of the recurrent laryngeal nerve (n = 1), and pneumonia (n = 1). CONCLUSIONS: The cervical approach to esophagectomy allows comfortable preparation and facilitates transhiatal access, while the rendezvous procedure enables easy identification of the cranial dissection plane. The degrees of freedom of movement of the robotic instruments allow for precise and controlled preparation, and the latest technology minimizes the risk of robot arm collision in single-excision surgery. This combined, robot-assisted approach appears to be a promising procedure for esophagectomy.
