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INTRODUCTION

First described in 160 AD by Galen, the esophagus has proved to be a challenging organ to understand and manipulate. Its complex physiology and treacherous location in the posterior mediastinum precluded surgical manipulation until the 20th century. The first thoracic esophageal resection was described by Torek in 1915.1 He illustrated a resection of the midesophagus with an extra-anatomic reconstruction. Although he described only one survivor, this event heralded the beginning of esophageal surgery. For the remainder of the 21st century and into the next, surgeons endeavored to improve the technique and outcomes of this thoracic operation.

In the more modern era, numerous approaches have been introduced, making esophagectomy relatively commonplace—albeit still a challenging operation and, in many instances, with significant morbidity and mortality. Orringer and Sloan2 popularized a transhiatal approach to esophageal resection and a gastric tube reconstruction. McKeown3 described a three-field approach requiring a thoracotomy to perform the majority of the esophageal dissection, followed by a laparotomy for the gastric mobilization and, finally, a cervical incision for anastomosis. In 1944, Ivor Lewis described a two-stage esophagectomy that included a laparotomy followed by a right-sided thoracotomy with a gastroesophageal anastomosis. Variations in approaches and reconstructions have provided today’s surgeons with a large armament of techniques and fodder for debate over the ideal approach.

Open surgical procedures remain the standard of care for esophageal resections in many medical centers. However, the morbidity and mortality associated with open procedures and the diseases for which they are required still reveal the need for further improvement. For example, a 10-year review of the esophagectomy experience within the U.S. Department of Veterans Affairs hospital system revealed a morbidity of 50% and a mortality of 10%.4 Birkmeyer et al.,5 in an analysis of a national Medicare database, revealed that the mortality rates from esophagectomy in the United States ranged from 8% in high-volume centers to 23% in low-volume centers. These data and advances in surgical technology have led many centers to move toward a minimally invasive approach.

BEGINNINGS OF MINIMALLY INVASIVE ESOPHAGECTOMY

The advent of laparoscopy and thoracoscopy in the 1980s opened the door to the possibility of a minimally invasive approach to esophageal surgery. Initial experience with laparoscopic Nissen fundoplications formed the basis of the early surgical experience of the esophagus, followed by laparoscopic and thoracoscopic staging of lymph nodes. Collard et al.6 were the first to describe a thoracoscopic technique for esophageal dissection. Shortly afterward, DePaula et al. described a laparoscopic esophagectomy for achalasia.7 Swanstrom reported on a case series of nine patients using a totally laparoscopic approach.8 In a review by Law and Wong of early minimally invasive approaches to esophagectomy, it was immediately clear that many of these approaches were hybrid operations showing no particular advantage.9 In 1996, the first minimally invasive esophagectomy (MIE) performed at the University of Pittsburgh (J.L.) utilized ...

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