Robotic Fellow Aster Hospitals, Bangalore, Karnataka, India
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Introduction: Esophageal cancer is the eighth most common cancer in the world and the sixth most common cause of cancer death. Esophagectomy with locoregional lymphadenectomy is the standard treatment of patients with resectable esophageal neoplasm. Esophagectomy is a technically demanding operation. Robotic-assisted minimally invasive esophagectomy (RAMIE) is an alternative to standard minimally invasive esophagectomy (MIE), and has been increasingly applied to the treatment of esophageal cancer. This study aims to evaluate the safety and technical feasibility of Total Robot-Assisted Three-Stage Esophagectomy and to analyse short term oncological outcomes. MATERIALS AND
Methods: From November 2011 to November 2020, one hundred sixty-eight histologically proven (T1–4a, N+, M0) Resectable Carcinoma Esophagus patients with ECOG performance status of 0 and 1, who underwent Robot-Assisted Transthoracic and Transabdominal Three-Stage Esophagectomy. We aimed to evaluate the safety and technical feasibility of Total Robot-Assisted Three-Stage Esophagectomy. Technique and feasibility of robot assisted surgery in terms of operating time, estimated blood loss, total number of lymph nodes retrieved, postoperative ventilator support, ICU stay, hospital stay, conversion to open procedure, margin status (mucosal and circumferential), intraoperative and postoperative complications were analysed. We used ICG for identification of thoracic duct intra-operatively. Complications were classified according to Modified Clavien–Dindo classification (MCDC) of surgical complications.
Results: One hundred sixty-eight total robotic esophagectomies were performed. All the patients presented in stage III and were subjected to NACT with TPF regimen. Post NACT, a partial response of 58.8% was achieved and 17.6% patients achieved a complete response. Total docking time for initial ten cases was 67.90 ± 13.24 minutes, while for subsequent cases it was 33.20 ± 4.16 minutes similarly total operative time was 429.20 ±57.65min & 321.13 ±13.75min for initial ten cases and subsequent cases, thoracic-phase operative time for initial ten cases and subsequent cases was 96.60 ±20.33minutes and 57.04 ±9.15minutes showing the steeper learning curve in robotics which is in contrast to minimal access surgery. The average blood loss was 280.32 ± 17.52 ml. Incidence of vocal cord palsy was 4.8% while delayed gastric emptying was noted in 3.2% of population. In postoperative period two patients required ventilator support, twenty patients needed ICU stay rest were shifted directly to wards, Pneumonia was reported in 1% of patients, anastomotic leak in 2.8% of patients which was managed conservatively. With the longest follow up of 50 months, 3-year DFS and OS was 75.4% & 68% respectively.
Conclusion: Robotic-assisted esophagectomy has an advantage of total thoracic and abdominal minimally invasive surgery with very low conversion rates, short learning curve, excellent chance of good quality lymphadenectomy in supra-azygous and bilateral recurrent laryngeal nerve area option for both robotic stapler and handsewn intracorporeal anastomosis with limitations of the need for specific teaching programs and proctored learning, both of which are mandatory. Total robotic esophagectomy is technically feasible in terms of completeness of surgery, achieving adequate margins and nodal harvest with minimal pulmonary morbidities."