Compared with open techniques, minimally invasive approaches to esophageal surgery result in shorter hospital stays,1 lower morbidity and mortality rates,1–3 improved quality-of-life scores,4,5 and earlier return to normal activities,1 while maintaining equivalent functional outcomes for benign disease1,6 and oncologic outcomes for esophageal cancer.7–9 These advantages may allow surgeons to offer esophageal surgery to patients previously considered borderline operative candidates or medically inoperable. However, there are limitations to traditional thoracoscopic and laparoscopic techniques, including 2-D imaging and fixed rigid instrumentation. Robot-assisted esophageal surgery circumvents these limitations by providing a 3-D, tenfold-magnified, high-definition, stable, controlled view along with fine-wristed instrumentation. The latter provides superior dexterity and scaled movement, eliminating tremors when working at greater distances from the trocar. Given these and other benefits, robotic platforms have the potential to place significantly greater control of the operation in the hands of the surgeon and to enhance the overall quality of minimally invasive esophageal surgery.
This chapter reviews the indications and outcomes of robot-assisted esophageal surgery for benign conditions and esophageal cancer. A thorough description of the operative techniques for all robotic esophageal operations is beyond the scope of this chapter. Rather, we use Ivor Lewis robot-assisted minimally invasive esophagectomy (RAMIE) to highlight the potential applications and advantages of a robotic surgical system for laparoscopic and thoracoscopic approaches to esophageal surgery. The laparoscopic and thoracoscopic port placement for an Ivor Lewis RAMIE can be readily adapted to other operations.
ROBOT-ASSISTED MINIMALLY INVASIVE ESOPHAGECTOMY
Beginning with the work of Theodore Billroth in the late nineteenth century, the history of esophageal resection and reconstruction techniques for esophageal carcinoma has been “the tale of men repeatedly losing to a stronger adversary yet persisting in an unequal struggle until the nature of the problem became apparent and the war was won.”10 For more than 100 years, pioneering surgeons such as Franz Torek (first transthoracic esophagectomy in 1913),11 S.F. Marshall (first transthoracic resection and primary esophagogastrostomy in 1938),12 and Ivor Lewis13 have wrestled with arduous adversaries, including perioperative morbidity and mortality, less than optimal functional results of esophageal replacement, and disease-specific survival. In undertaking these battles, the technique of esophagectomy evolved from the initial extra-anatomic reconstruction of Dr. Torek’s technique to the completely minimally invasive techniques pioneered by Dr. James Luketich at the University of Pittsburgh Medical Center.14
Esophagectomy, often part of a multimodal strategy, is a critical component in the treatment of esophageal cancer. Despite decades of refinements, complication rates after esophagectomy continue to approach 30% to 60%15 and mortality rates can exceed 20% in low-volume centers.16,17 In high-volume experienced centers, mortality rates of 5%15,16 to as low as 1%18 have been reported, suggesting the importance of the dedication of the institution to excellence in esophageal surgery and ...