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Robotic Esophagectomy for Cancer: Early Results and Lessons Learned

https://doi.org/10.1053/j.semtcvs.2015.10.006Get rights and content

Minimally invasive esophagectomy with intrathoracic dissection and anastomosis is increasingly performed. Our objectives are to report our operative technique, early results and lessons learned. This is a retrospective review of 85 consecutive patients who were scheduled for minimally invasive Ivor Lewis esophagectomy (laparoscopic or robotic abdominal and robotic chest) for esophageal cancer. Between 4/2011 and 3/2015, 85 (74 men, median age: 63) patients underwent robotic Ivor Lewis esophageal resection. In all, 64 patients (75%) had preoperative chemoradiotherapy, 99% had esophageal cancer, and 99% had an R0 resection. There were no abdominal or thoracic conversions for bleeding. There was 1 abdominal conversion for the inability to completely staple the gastric conduit. The mean operative time was 6 hours, median blood loss was 35 ml (no intraoperative transfusions), median number of resected lymph nodes was 22, and median length of stay was 8 days. Conduit complications (anastomotic leak or conduit ischemia) occurred in 6 patients. The 30 and 90-day mortality were 3/85 (3.5%) and 9/85 (10.6%), respectively. Initial poor results led to protocol changes via root cause analysis: longer rehabilitation before surgery, liver biopsy in patients with history of suspected cirrhosis, and refinements to conduit preparation and anastomotic technique. Robotic Ivor Lewis esophagectomy for cancer provides an R0 resection with excellent lymph node resection. Our preferred port placement and operative techniques are described. Disappointingly high thoracic conduit problems and 30 and 90-day mortality led to lessons learned and implementation of change which are shared.

Introduction

The use of minimally invasive esophagectomy (MIE) and hybrid esophagectomy has increased recently. The term “minimally invasive” refers to performing both the thoracic and the abdominal phases of the operation with laparoscopic, thoracoscopic, or robotic assistance. Hybrid esophagectomy combines minimally invasive with neck approach and open approaches (eg, laparoscopy and thoracotomy, laparotomy, and video-assisted thoracoscopic surgery). Recent studies have demonstrated that MIE may be associated with decreased blood loss, chest tube duration, length of stay, and respiratory complications and possibly reduced cost vs open esophagectomy.1, 2, 3, 4, 5 Previous reports on robotic-assisted Ivor Lewis esophagectomies, have demonstrated feasibility, with perioperative outcomes similar to MIE.6, 7, 8 Our objective in this study is to report our series and some of the lessons we have learned during the experience.

Section snippets

Methods

This is a retrospective cohort study of prospectively collected data evaluating a consecutive series of patients who underwent thoracic robotic minimally invasive Ivor Lewis esophagectomy. All patients with a planned Ivor Lewis esophagectomy with a robotic thoracic approach and laparoscopic or robotic abdominal approach were included in the study. Patients with mid or distal esophageal lesions were candidates for Ivor Lewis esophagectomy. Preoperative evaluation included endoscopic ultrasound,

Laparoscopic Phase With Gastric Conduit Creation

The placement of ports for the laparoscopic phase of the operation is shown in Figure 2A. The camera port is located 15 cm inferior to the xiphoid process and 3 cm to the left of midline. The liver retractor may be positioned via a subxiphoid port (grasper or Nathanson retractor) as depicted or a right subcostal port using a Mediflex (Islandia, NY) Positractor with a Lapro-Flex self-forming retractor. A tongue of omentum is preserved during conduit creation order to cover the anastomosis and

Results

Between 4/2011 and 3/2015, 92 patients underwent consecutive robotic esophagectomy. The first 7 patients had their abdominal phase of the operation performed via laparotomy and were excluded from this study. The remaining 85 consecutive patients (74 men, 87%) underwent a MIE. Their preoperative characteristics are shown in Table 1. Mean operating time, defined as the time between first skin incision and closure of last skin incision and including repositioning and docking or undocking of the

Discussion

Reported series of robotic esophagectomies are shown in Table 3. Our series compares favorably in terms of operative time, intraoperative blood loss, and conversion rate. Our series was similar to prior robotic series in terms of anastomotic or conduit complication rate (7.1%), lymph nodes dissected (median: 22), R0 resection rate (99%), median postoperative length of stay (8 days), rate of pneumonia (7.1%), atrial fibrillation (7.1%), and overall major morbidity. When compared to other

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    Disclosures: Robert J. Cerfolio: proctor for Intuitive Surgical, consultant for Ethicon and Community Health Systems.

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