The benefits and limitations of robotic assisted transhiatal esophagectomy for esophageal cancer

Abstract

Robotic-assisted transhiatal esophagectomy (RATE) is a minimally invasive approach to total esophagectomy with less morbidity but equivalent efficacy when compared with the traditional open approach. The robotic platform offers numerous technical advantages that assist with the esophageal dissection, which allows the procedure to be completed without entry into the thoracic cavity. The major criticism of the transhiatal approach is that it forfeits the ability of the surgeon to perform a formal lymphadenectomy, but this does not appear to affect long-term survival.

Keywords: Esophageal cancer; esophagectomy; fluorescence-guided surgery; indocyanine green (ICG); robotic-assisted transhiatal esophagectomy (RATE).

Conflict of interest statement

Conflicts of Interest: The authors have no conflicts of interest to declare.

Figures

Figure 1

Trocar position for robotic-assisted transhiatal esophagectomy (RATE). The 8 mm ports are robotic trocars that double as the working ports for the laparoscopic portion of the case. The 12 mm port is a standard trocar that is used for the camera port, and the 5 and 10 mm ports are for the assisting surgeon to provide traction and suction.

Figure 2

Representative view of the mediastinum during the robotic portion of the case. At the completion of the mediastinal dissection the esophagus (asterisk) is retracted anterolaterally and the azygous vein (solid arrow) is clearly visualized to the right and the aorta (dashed arrow) is to the left.

Figure 3

Representative image of indocyanine green (ICG) fluorescence angiography, which assesses the microperfusion of the tubularized gastric graft. The green represents blood flow and can be seen all the way to the tip of the graft (solid arrow). The dashed arrow shows the reinforced staple line.

Figure 4

Schematic of the tubularized gastric graft that is sutured to the fully dissected esophagus and proximal stomach. Care is taken throughout the procedure to avoid damage to the right gastroepiploic artery, which will serve as the blood supply to the neoesophagus. The minimally invasive surgeon observes as the graft is pulled through the hiatus with care to ensure that the graft does not become twisted or kinked and is not under tension.

Figure 5

Supplemental video of key steps selected to demonstrate the advantages of robotic assisted transhiatal esophagectomy (5). Available online: http://www.asvide.com/articles/1138