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Introduction

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The first report of minimally invasive esophagectomy (MIE) appeared in the early 1990s. Whether thoracoscopic, laparoscopic, transhiatal, or combined, MIE evolved as a result of several goals: to reduce thoracotomy-related chest wall discomfort and postoperative debility; to achieve a more frequent R0 rate and better lymphadenectomy; and to achieve superior local control compared with the MIE transhiatal esophagectomy.1,2 Robotic-assisted esophageal resection emerged onto the surgical literary scene in 2003 and 2004 with the transhiatal esophagectomy and 3-field esophagolymphadenectomy, respectively. The advantages of robotic technology that are brought to this procedure include multi-articulated instruments with 7 degrees of rotational freedom, referred to as the EndoWrist®, simulating normal wrist movements thus differentiating the robotic system from standard videoscopic techniques; and the three-dimensional (3D) imaging provided by the double optic system allowing depth perception that improves surgical precision. Subsequent case series over the last decade have accomplished many of these goals while conferring clinical advantages of minimally invasive surgery (MIS), thus paving a road for the different methods of the robotic-assisted esophagectomy.

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General Principles

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Robotic esophagectomy has been performed for high-grade dysplasia, invasive carcinoma, and severe surgically failed esophageal dysfunction. Esophageal cancer is the most common indication, although not readily accepted by the esophageal surgical community. The nihilists believe the sole benefits of MIE are a new conduit for swallowing and some staging information, and that radiation and chemotherapy are critical for long-term survival. Others believe that resection not only provides palliation, but also reduces the likelihood of local–regional recurrence and, if performed correctly, will improve survival. Collaborative efforts have found that depth of esophageal wall penetration and location of tumor are important for determining the extent of lymphadenectomy. Key factors for surgical and clinical success must follow a few general rules: (1) achieve an R0 resection; (2) provide adequate staging by performing an extensive lymphadenectomy assisted by knowledge of the tumor location, cell type, as well as information from high-resolution computed tomogram (CT), FDG-positron emission tomography, and endoscopic ultrasound; and (3) minimize local–regional recurrence, postoperative pain, and procedural-related morbidity and mortality.

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An open technique using wide resection can be compromised because of the lack of visibility inherent in a thoracotomy exposure and articulations necessary to perform a thorough lymphadenectomy. In addition, the significant torque on the chest wall required to obtain the best visibility increases the likelihood for postoperative discomfort. Aforementioned robotic advantages, we feel, solve limitations of prior approaches thus extending clinical benefits to the patient.

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Patient Selection

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The preoperative evaluation is no different for robotic surgery than for the conventional open surgical procedure. The history and physical examination are integral components in the initial phases of surgical decision making. Further workup may include CXR, CT chest/abdomen, FDG-positron emission tomography, barium swallow, upper endoscopy, bronchoscopy, endoscopic ultrasound, pulmonary function testing, and cardiopulmonary exercise testing. We do not exclude patients based on BMI, ASA ...

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