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Robotic-assisted minimally invasive esophagectomy (RAMIE) is emerging as an alternative to minimally invasive esophagectomy (MIE).
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Early retrospective reports suggest RAMIE Ivor Lewis is feasible, with short-term outcomes equivalent to those of open surgery or standard MIE.
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Potential pitfalls and complications, in particular during airway dissection and anastomotic creation, are avoidable and should be recognized.
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Prospective trials investigating safety, outcomes, and quality-of-life profiles for
Robotic-Assisted Minimally Invasive Esophagectomy: The Ivor Lewis Approach
Section snippets
Key points
Introduction: nature of the problem
In patients with benign or malignant disease requiring esophagectomy, minimally invasive approaches to resection have become increasingly used, with a growing body of data documenting excellent outcomes in these patients.1, 2, 3 At least 1 randomized prospective study has cited decreased pulmonary complications and improved perioperative outcomes with minimally invasive esophagectomy (MIE) in comparison with open resection.4
Although robotic approaches to these operations have been described,
Preoperative Planning
All patients presenting with an endoscopy-confirmed and biopsy-confirmed diagnosis of esophageal carcinoma undergo rigorous preoperative evaluation to assess comorbidities and fitness for surgery. Staging is performed by means of computed tomography scanning of the chest, abdomen, and pelvis; endoscopic ultrasonography; and fluorodeoxyglucose-18 positron emission tomography scanning. Patients with early-stage lesions confined to the mucosa (T1a or less) are referred for diagnostic endoscopic
Step 1: Initial Hiatal Dissection
Initial dissection is begun by opening the lesser sac and dissecting free the esophageal hiatus (Video 1). If a replaced left hepatic artery is encountered, it is clipped temporarily; the left liver lobe is assessed after a period of time and is often sacrificed if no vascular compromise to the liver is identified. For lower esophageal tumors, portions of the right or left crus may be dissected free and removed with the esophagus if cause for suspicion of tumor involvement is identified.
Step 6: En Bloc Esophageal Mobilization
Using the 5-mm atraumatic robotic grasper, the lower lobe of the lung is retracted superior-laterally, and the inferior ligament is divided to the level of the inferior pulmonary vein (Video 6). The initial en bloc dissection is begun along the pericardium adjacent to the inferior vena cava. A combination of gentle blunt and sharp dissection readily allows the surgeon to completely mobilize the esophageal hiatus down to the contralateral pleura. Dissection is continued superiorly by first
Clinical results in the literature
Experience with RAMIE is in its infancy. Although growing, the literature pertaining to RAMIE remains sparse and is limited to case reports and early institutional case series. These reports are summarized in Table 1. The vast majority of series detail a modified McKeown (3-hole) or transhiatal approach6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22 lymph node retrieval was 20 (range, 3–38).
Cerfolio and colleagues23 reported the first series of cases with an intrathoracic
Summary
RAMIE Ivor Lewis is a technically demanding, but feasible approach to esophageal resection. It requires stringent patient selection and a multidisciplinary effort. Additional outcome data and further studies to evaluate differences between RAMIE and standard MIE including, but not limited to perioperative outcomes, cost implications and long-term oncologic outcomes in esophageal cancer must be undertaken. Although care must be taken during the learning phase of these operations to avoid known
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Cited by (44)
Comparison of robotic-assisted minimally invasive esophagectomy versus minimally invasive esophagectomy: A propensity-matched study from a single high-volume institution
2023, Journal of Thoracic and Cardiovascular SurgeryTwo-Year Quality of Life Outcomes After Robotic-Assisted Minimally Invasive and Open Esophagectomy
2021, Annals of Thoracic SurgeryCitation Excerpt :Written informed consent was obtained from all enrolled patients. The surgical approach (RAMIE vs OE) was determined by the surgeon to whom each patient presented, with 2 of 8 surgeons performing RAMIE3 exclusively and all others performing OE only. Ivor Lewis was the predominant type of esophagectomy in both the robotic group (2 of 64) and the open group (103 of 106).
Implementation of robot-assisted Ivor Lewis procedure: Robotic hand-sewn, linear or circular technique?
2020, American Journal of SurgeryCitation Excerpt :Potscher et al. reinforced the reconstruction by oversewing (3-0 V-loc) the anastomosis in a circular fashion. A detailed publication reporting the intracorporal introduction of the anvil was provided by Sarkaria.16,24 Throughout the procedure the bedside assistant played a pivotal role as he or she was responsible for introducing and maneuvering the circular stapler.
Totally robotic ivor-Lewis esophagectomy with intrathoracic robot-sewn anastomosis for cardio-esophageal cancer with the da VINCI XI
2019, Surgical OncologyCitation Excerpt :Indocyanine green dye was administrated to assess gastric conduit perfusion before/after anastomosis. Intrathoracic end-to-end esophagogastric anastomosis was created [1]. Postoperative recovery was uneventful.
Early Quality of Life Outcomes After Robotic-Assisted Minimally Invasive and Open Esophagectomy
2019, Annals of Thoracic SurgeryCitation Excerpt :In a multicenter, randomized controlled trial, Biere and colleagues6 identified significantly lower pulmonary morbidity in MIE (n = 59) than OE (n = 56) patients, with otherwise comparable rates of major morbidity and mortality. Early reports on RAMIE mirror these findings.9,10,26 As presented in Table 2, secondary outcome endpoints from the current study support these previous findings, with no significant differences identified in mortality or overall morbidity at 30 and 90 days.
Does the Approach Matter? Comparing Survival in Robotic, Minimally Invasive, and Open Esophagectomies
2019, Annals of Thoracic Surgery
Disclosures: The authors have no disclosures.