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 Table of Contents  
Year : 2020  |  Volume : 4  |  Issue : 3  |  Page : 87-91

Robotic esophageal mobilization: A new norm in the future?

Department of Surgical Oncology, Yenepoya Medical College, Mangalore, Karnataka, India

Date of Submission21-Jul-2020
Date of Decision11-Aug-2020
Date of Acceptance26-Aug-2020
Date of Web Publication26-Nov-2020

Correspondence Address:
K C Jalaluddin Akbar
Department of Surgical Oncology, Yenepoya Medical College, Mangalore, Karnataka
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/oji.oji_33_20

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Background: Esophageal cancer is one of the common cancer with high mortality. Radical resections offer the best survival. However, traditional radical resection involves thoracotomy, resulting in pulmonary complications. Video-assisted thoracoscopic surgery has overcome this but requires a long learning curve and limitations in certain areas. Robotic-assisted thoracic mobilization has shown promising results. Here, we are sharing initial experience of robotic esophageal mobilization. Aim: The aim of the study is to assess the feasibility, safety, and learning curve of performing robotic esophageal mobilization among patients with esophageal cancers. Materials and Methods: Retrospective review of medical records was conducted for 33 cases who underwent robotic esophageal mobilization in our institute from August 2016 to August 2019. Results: The study population comprised 24 men and 9 women. The mean age of presentation was 55.3 years. Mean operative time was 204 min, and mean thoracic mobilization time was 108 min. The mean lymph node retrieval was 16.6. The postoperative surgical complications were less such as pulmonary complication, i.e., pneumonia in three patients and recurrent nerve palsy, anastomotic leak, and surgical site infection in 1 patient each. There was no procedure-related mortality. Conclusion: Robotic-assisted esophageal mobilization can be safely done without compromising the oncological safety with less postoperative pulmonary complications.

Keywords: Esophageal cancer, robotic esophagectomy, robotic surgery

How to cite this article:
Shetty R, Akbar K C, Rao H T, Vijayakumar M, Reddy R J. Robotic esophageal mobilization: A new norm in the future?. Oncol J India 2020;4:87-91

How to cite this URL:
Shetty R, Akbar K C, Rao H T, Vijayakumar M, Reddy R J. Robotic esophageal mobilization: A new norm in the future?. Oncol J India [serial online] 2020 [cited 2021 Dec 5];4:87-91. Available from: https://www.ojionline.org/text.asp?2020/4/3/87/301580

  Introduction Top

Esophageal cancer is the seventh most common cancer worldwide. The overall 5-year survival rate remains poor despite the improvement in treatment modality.[1] Surgery is the primary modality of treatment for esophageal cancer.[2] Surgical options include transthoracic esophagectomy or transhiatal esophagectomy; radical resection offers the best survival but is associated with significant morbidity.[3] Transhiatal has lower complications but concerns about the limited lymphadenectomy. Minimal invasive procedures such as thoracoscopic procedures done either by video-assisted thoracoscopic surgery (VATS) or robotic assisted have decreased pulmonary complications and improved patient outcomes.[4],[5] In view of this robotic-assisted surgeries in particular are gaining popularity and steadily increasing everywhere.[6] Here, we are sharing our initial experiences.

  Materials and Methods Top

The present study was a retrospective review of our initial experience of 3 years of robotic-assisted esophageal surgery conducted at a tertiary care cancer center from August 2016 to August 2019. In our institution, annually around 30–35 new esophageal cancers get registered. Usually, 15–20 esophagectomies were done per year.

Robotic esophagectomy was done using DaVinci Si Surgical System. Three surgeons are trained as console surgeons, who were doing regular esophagectomies previously either by thoracotomy or VATS for esophageal mobilization.

All patients were worked up and staged appropriately. All the preoperative investigation procedure data such as routine hematological and biochemical profiles, upper gastrointestinal endoscopy with biopsy reports, chest radiograph, and contrast-enhanced computed tomography scan of thorax and abdomen were recorded in the structured pro forma. Staging was done according to the American Joint Committee on Cancer 8th edition. T1 and T2 tumors were offered surgery upfront as against T3/T4 tumors, who underwent preoperative concurrent chemoradiation. Four gastroesophageal junction tumors underwent preoperative chemotherapy. The details of operation techniques were described. Postoperative events, complications, and final histopathology reports were recorded in all cases.

For esophageal mobilization, all the patients were placed in a full prone position on an operative sandbag. Three main ports and one assistant port were used for the robotic procedure [Figure 1]. Of these three main ports, one 12 mm port was used for camera (C) and two 8 mm ports were used for the robotic arms (R1 and R2). The port used for camera was put one fingerbreadth below and posterior to the inferior angle of scapula in 5th or 6th intercostal space. Two 8 mm trocars were put under thoracoscopic vision 8–9 cm far from camera port, in the 3rd and 9th intercostal space, respectively. Assistant port (A) of 12 mm size was put between the left working port and camera port [Figure 2]. The pneumoinsufflation was created to keep the pressure at 8 mmHg. Robotic cart was stationed on the left side of the patient.
Figure 1: Port placement

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Figure 2: Robotic arms after docking

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In prone position, esophagus falls forward, which makes the dissection easier. We used bipolar forceps in the left arm and monopolar scissors in the right arm. The procedure started with the incision of visceral pleura between the esophagus and lung inferior to azygos vein [Figure 3]. More than the three-fourth of the circumference of the esophagus was mobilized from cranial to caudal direction, along with paraesophageal lymph nodes and lymphatic distal to the azygos vein. The pleura on the aortic side attached to esophagus was mobilized last. The same dissection was continued in the supra-azygos region; whenever possible azygos vein was preserved; otherwise, vein was clipped and divided.
Figure 3: Infra azygos dissection of the esophagus

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The surgical specimen included the lower middle mediastinal and subcarinal nodes. Nodal dissection along recurrent nerves and aortopulmonary window was not done.

Stomach mobilization was done robotically only in five patients. For rest 28 patients, a 10 cm incision in the midline above umbilicus was made for laparotomy. The nodes along the left gastric, splenic common hepatic vessels, and paraesophageal nodes were removed for all patients. Gastric conduit was done using stapler. Pyloric dilatation was done in all cases.

Left supraclavicular 3 cm incision was placed. Esophagus was identified, dissected from trachea and surrounding structures, carefully preserving the recurrent laryngeal nerve on both sides. Esophagus was cut at the level of thoracic inlet, and Ryle's tube was attached to the distal end. Specimen was removed from the abdomen, and the gastric conduit was brought up to the neck. Anastomosis was done with linear stapler. Anterior layer was closed with 4.0 polydioxanone. Nasogastric tube was put across the anastomosis to reach pylorus. Feeding jejunostomy was done in all the patients.

  Results Top

A total of 35 patients underwent robotic esophageal mobilization during the study period. There was no conversion to open surgery after starting of the procedure due to bleeding or any untoward incidents. However, in two cases, thoracoscopy was not possible because of lung adhesions to the pleura, which were excluded from the study. Hence, 33 patients were included as the study population for analysis. The clinical and demographic profiles were mentioned in [Table 1]. The mean age of presentation was 55.3 years. There was male predominance with the male-to-female ratio of 2.67:1. The majority of patients were lower third of esophagus as the site of cancer (58%), of squamous cell histology (85%), and diagnosed at Stage II–III (82%). Upfront surgery was performed in 70% of cases.
Table 1: Clinical and demographic profile

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The docking time and operating time expressed as a time curve were given in [Figure 4] and [Figure 5], respectively. The time taken for docking, total operative procedure, undocking, and esophageal mobilization was mentioned in [Table 2]. The average blood loss during the procedure was 110 ml. The overall average lymph node retrieved was 16.6, which was higher for upfront surgery group (20) than patients receiving prior neoadjuvant treatment (9) [Table 2]. Only one case of a middle third of esophageal cancer undergoing upfront surgery had a positive circumferential margin on the final histopathology report.
Figure 4: Docking time

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Figure 5: Operating time

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Table 2: Learning curve and oncological safety

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All patients were shifted to the intensive care unit (ICU), and prophylactic ventilation was done for 12 h. All the patients were extubated on postoperative day 1. The postoperative care and complications were mentioned in [Table 3]. Six out of 33 cases had postoperative complications, of which three cases suffered from pneumonia and one case each suffered from recurrent nerve palsy, anastomotic leak, and surgical site infection. There was no leakage of chyle for any patients after surgery. All the three pneumonia cases did not require ventilator support and recovered with conservative treatment. The patient with surgical site infection recovered after conservative treatment with antibiotic administration. There was no procedure-related mortality in the study.
Table 3: Postoperative care and postoperative complications

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  Discussion Top

Minimally invasive esophagectomy is being used more and more often with an idea to reduce the morbidity of thoracotomy. Furthermore, it decreases the operative time, blood loss, postoperative complications, and hospital stay, with comparable oncologic clearance. The steep learning curve in minimally invasive surgery has been a challenge, especially in VATS.[7] However, robotic-assisted minimally invasive surgery can accelerate the learning curve with the help of magnified three-dimensional (3D) view, improved articulation of instruments, and enhanced ergonomics along with the improved dexterity. Robotic-assisted surgery in thoracic mobilization of the esophagus has many advantages. The 3D view with magnification allows precise dissection of paraesophageal tissue and clearance of lymph nodes, also vital structures are spared without inadvertent injury.[8]

The time schedule of surgery and oncological safety of our study is compared with other studies in [Table 4].[9],[10],[11],[12],[13] During the initial phase of robotic thoracic mobilization, our docking time was more. However, once the entire unit got used to the procedure, the docking time came down to 15 min. After about twenty surgeries, docking time and robotic mobilization of the esophagus were standardized. Puntambekar et al. and Somashekhar and Jaka found docking time of 9.06 and 13.76, respectively, in their studies.[10],[11] We had two types of patients, one who underwent surgery upfront and the another group who underwent surgery after chemoradiation. The overall operating time was not different in two groups. However, lymph node retrieval in two groups was different. The average lymph node retrieval in our series was 16.6, which was higher for the upfront surgery group, i.e., 20 in comparison to postneoadjuvant chemoradiotherapy treatment group, i.e., 9. The less lymph node retrieval in postchemoradiation group was expected and similar in many previous studies.[14] The overall lymph node retrieval in our series was comparable with the study done by Puntambekar et al. and Chiu et al.[10],[13] The mean operative time in our series was 204 min and was comparable with a study by Puntambekar et al., where it was 204.94 min.[10] The time taken for esophageal mobilization was 108 min (68–186). We found the mean estimated blood loss of 110 ml, which was comparable with other studies such as Puntambekar et al. and Palanivelu et al.[10],[12]
Table 4: Comparison with other series

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We have analyzed our data with respect to postoperative events, complications, oncologic safety, and learning curve. In our study, robotic esophagectomy has resulted in minimal blood loss and early removal of intercostal drainage tube (ICD) and abdominal drains. In those patients who had prior chemotherapy or chemoradiation, ICD tubes and drains had to be kept for a longer duration in comparison to upfront surgery. All the patients started oral feeding from 10th post-operative day, except two patients who started orally late because of pneumonia developed during postoperative period. Pulmonary compliance was good in almost all patients during postoperative period. Only three patients developed pulmonary complications in our series. The length of ICU stays and hospital stays were comparable with other studies.[11],[12]

With our initial experience, it is evident that robotic esophageal mobilization can be easily adapted by surgeons because of the reasonably short learning curve. It offers advantage to patients with respect to better pulmonary compliance and shorter ICU stays. Moreover, it is oncologically safe, in terms of comparable node retrieval and R0 resection.

  Conclusion Top

Robotic-assisted esophageal mobilization can be safely adopted by surgeons who regularly do esophagectomies with fewer pulmonary-related complications without compromising oncological safety. Hence, in the future, more institutions and surgeons may embrace this novel technology all over the world.


The authors would like to acknowledge the contributions by Dr. Rohan Thomas Mathew, junior consultant, Department of Surgical Oncology, in the preparation of this draft.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

World Health Organization. Globocan 2018: Estimated Cancer Incidence, Mortality and Prevalence Worldwide in 2018. Available from: http://gco.iarc.fr/today/data/factsheets/cancers/6-Oesophagus-fact-sheet.pdf. [Last accessed on 2020 Jul 10].  Back to cited text no. 1
Mariette C, Piessen G, Triboulet JP. Therapeutic strategies in oesophageal carcinoma: Role of surgery and other modalities. Lancet Oncol 2007;8:545-53.  Back to cited text no. 2
Hulscher JB, van Sandick JW, de Boer AG, Wijnhoven BP, Tijssen JG, Fockens P, et al. Extended transthoracic resection compared with limited transhiatal resection for adenocarcinoma of the esophagus. N Engl J Med 2002;347:1662-9.  Back to cited text no. 3
Kim T, Hochwald SN, Sarosi GA, Caban AM, Rossidis G, Ben-David K. Review of minimally invasive esophagectomy and current controversies. Gastroenterol Res Pract 2012;2012:683213.  Back to cited text no. 4
Lv L, Hu W, Ren Y, Wei X. Minimally invasive esophagectomy versus open esophagectomy for esophageal cancer: A meta-analysis. Onco Targets Ther 2016;9:6751-62.  Back to cited text no. 5
Puntambekar SP, Rayate N, Joshi S, Agarwal G. Robotic transthoracic esophagectomy in the prone position: Experience with 32 patients with esophageal cancer. J Thorac Cardiovasc Surg 2011;142:1283-4.  Back to cited text no. 6
Palanivelu C, Prakash A, Senthilkumar R, Senthilnathan P, Parthasarathi R, Rajan PS, et al. Minimally invasive esophagectomy: Thoracoscopic mobilization of the esophagus and mediastinal lymphadenectomy in prone position--experience of 130 patients. J Am Coll Surg 2006;203:7-16.  Back to cited text no. 7
Taurchini M, Cuttitta A. Minimally invasive and robotic esophagectomy: State of the art. J Vis Surg 2017;3:125.  Back to cited text no. 8
Jagdishwar Goud G, Bala Vikas Kumar M. Totally robotic esophagectomy: The largest series. Ann Robot Surg 2019;1:1003.  Back to cited text no. 9
Puntambekar S, Kenawadekar R, Kumar S, Joshi S, Agarwal G, Reddy S, et al. Robotic transthoracic esophagectomy. BMC Surg 2015;15:47.  Back to cited text no. 10
Somashekhar SP, Jaka RC. Total (transthoracic and transabdominal) robotic radical three-stage esophagectomy-initial Indian experience. Indian J Surg 2017;79:412-7.  Back to cited text no. 11
Palanivelu C, Dey S, Sabnis S, Gupta R, Cumar B, Kumar S, et al. Robotic-assisted minimally invasive oesophagectomy for cancer: An initial experience. J Minim Access Surg 2019;15:234-41.  Back to cited text no. 12
Chiu PW, Teoh AY, Wong VW, Yip HC, Chan SM, Wong SK, et al. Robotic-assisted minimally invasive esophagectomy for treatment of esophageal carcinoma. J Robot Surg 2017;11:193-9.  Back to cited text no. 13
Chang F, Deere H, Mahadeva U, George S. Histopathologic examination and reporting of esophageal carcinomas following preoperative neoadjuvant therapy: Practical guidelines and current issues. Am J Clin Pathol 2008;129:252-62.  Back to cited text no. 14


  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]

  [Table 1], [Table 2], [Table 3], [Table 4]


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