Ann Thorac Surg 2008;85:S757-S759. doi:10.1016/j.athoracsur.2007.11.046
© 2008 The Society of Thoracic Surgeons
Supplement: The Minimally Invasive Thoracic Surgery Summit
Robotic Esophagectomy: Is It an Advance and What is the Future?
Thomas J. Watson, MD*
Division of Thoracic and Foregut Surgery, Department of Surgery, University of Rochester School of Medicine and Dentistry, Rochester, New York
* Address correspondence to Dr Watson, Division of Thoracic and Foregut Surgery, Department of Surgery, University of Rochester School of Medicine and Dentistry, 601 Elmwood Ave, Box Surgery, Rochester, NY 14642 (Email: thomas_watson{at}urmc.rochester.edu).
Presented at the Minimally Invasive Thoracic Surgery Summit, New York, NY, June 8–9, 2007.
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Introduction
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Surgical robotics have been increasingly used in the past several years to assist in a variety of operations. Some applications, such as in prostatectomy, have been widely adopted and have largely supplanted the alternative minimally invasive or open techniques. The use of surgical robots in other procedures, although apparently safe and feasible, has not been as common. Robotic-assisted esophagectomy is one such procedure.
Although a limited number of case reports and small case series have demonstrated the feasibility of robotic esophagectomy, no large series of patients undergoing such operations has been reported to date. Data regarding successful completion rates for the procedure, operative times, lengths of stay, intraoperative complications, morbidity, mortality, and costs are limited. In addition, no data have been reported on medium- or long-term results regarding cure rates for esophageal cancer or functional outcomes. This report reviews the available literature about robotic esophagectomy and highlights issues pertinent to the eventual adoption or rejection of the technology for this specific indication. In this article, robotic esophagectomy refers specifically to esophagectomy completed with the assistance of the da Vinci Surgical System (Intuitive Surgical Inc, Sunnyvale, CA).
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Potential Advantages of Robotic Esophagectomy
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Relative to traditional minimally invasive surgical procedures using standard instrumentation and visualization, robotic-assisted surgery possesses several potential advantages. The da Vinci Surgical System allows increased magnification with three-dimensional imaging. Current systems are available in high definition, although similar systems are penetrating the market for standard laparoscopy and thoracoscopy. The robotic arms allow improved dexterity and articulation relative to standard, rigid, minimally invasive instrumentation. Seven degrees of motion are afforded by the robotic system:- 1 in/out,
- 2 rotation,
- 3 pitch at wrist,
- 4 yaw at wrist,
- 5 pitch at fulcrum,
- 6 yaw at fulcrum, and
- 7 grip strength.
In addition, the robotic arms allow for improved motion stability with tremor filtration and motion scaling, potentially aiding fine movements.
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Potential Disadvantages of Robotic Esophagectomy
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Compared with traditional minimally invasive surgery, robotic-assisted surgery has a number of identifiable disadvantages. At least early in the operative team’s experience, set up time is prolonged. In addition, the team requires specialized training, making interchangeability of staff an issue. Instrumentation is limited at present and is likely to remain so for the foreseeable future. The initial fixed cost of the equipment is high, and the cost of the disposable instruments is typically higher than for other minimally invasive devices. Maintenance costs are a real concern, as is storage, given the bulk of the equipment.
The nature of robotic surgery is that the surgeon is separated from the patient and is positioned outside of the sterile operative field; therefore, it is mandatory that a trained assistant is within the sterile field and ready to assist in the event of an emergency, such as acute hemorrhage. The da Vinci machine lacks tactile feedback, perhaps limiting its effectiveness in a procedure where touch is an important component. Finally, because of the nature by which the surgeon works alone at a console, learning procedures and training others can be a challenge.
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Reported Experiences
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Initial Case Reports
The first robotic-assisted esophagectomy was reported in 2003 [1]. The patient had a T1 N0 M0 adenocarcinoma on the final pathologic examination of the resected specimen. Most of the abdominal portion of the procedure was completed using standard laparoscopic instrumentation and techniques without robotic assistance. The distal esophagus was resected using the transhiatal route with the da Vinci robot. No deliberate mediastinal lymphadenectomy was reported. Foregut continuity was reestablished by a gastric pull-up with cervical esophagogastrostomy. A gastric drainage procedure was not added, although a feeding jejunostomy tube was placed. Estimated operative blood loss was 50 mL. The total operative time was 246 minutes, with the robotic-assisted dissection occupying 52 minutes. The authors concluded that the procedure was best restricted to patients with early-stage disease. An alternative viewpoint, however, is that a more aggressive lymphadenectomy is desirable in such a situation, especially if the tumor has infiltrated the submucosa and the potential for lymph node metastasis is significant.
The first combined transthoracic and transabdominal robotic-assisted esophagectomy with cervical esophagogastric anastomosis was reported in 2004 [2]. The patient was judged preoperatively to have a T3 N0 esophageal adenocarcinoma by computed tomography (CT), positron emission tomography (PET), and endoscopic ultrasonography (EUS) and was given neoadjuvant combined chemoradiation (40 Gy of radiation therapy.)
The operation was performed in two stages under one period of general anesthesia. The patient was initially placed in the left lateral–to–nearly prone position and single-lung ventilation was established to the left lung. The thoracic portion of the procedure was performed through 5 puncture wounds in the right chest. The intrathoracic esophagus, periesophageal and paratracheal lymph nodes, and thoracic duct were resected.
The patient was then rotated into the supine position. The cervical esophagus was isolated and encircled through a left cervicotomy. The abdomen was explored using robotic assistance through 6 puncture wounds in the abdomen. The stomach was mobilized as for a standard transhiatal esophagectomy, and a gastric tube was prepared using multiple fires of a linear endostapler. No gastric drainage procedure was performed, although a feeding jejunostomy tube was placed. The gastric tube was sutured to the distal end of the esophageal specimen, and the specimen was delivered through the neck, bringing the gastric conduit to the cervical region via the posterior mediastinum. A cervical esophagogastric anastomosis was completed and the neck wound was drained. The time in the operating room was 11 hours, with a total surgical console time of 4 hours 20 minutes. Estimated blood loss was 900 mL.
Subsequent Case Series
Since these initial case reports, two other small series of esophagectomy using robotic assistance have been reported [3, 4]. One such series from Austria details 4 patients undergoing robotic-assisted esophagectomy [3]. The robotic-assisted thoracic portion of the procedure required a median of 173 minutes to complete. The abdominal and cervical portions of the procedures were completed in typical open fashion. Length of stay averaged 14 days. A median of 12 lymph nodes were harvested, although the report did not specify how many of these nodes were specifically dissected during the thoracic portion of the procedure compared with during the open laparotomy.
Another report from the Netherlands detailed 21 robotic-assisted esophagectomies, of which 18 were successfully completed [4]. In this series, similar to the prior report, the thoracic robotic-assisted portion of the procedure averaged 180 minutes. Also similar to the other report, the abdominal and cervical portions of the procedure were completed in an open fashion in the first 16 patients, although laparoscopy was used on the last two procedures. Length of stay averaged 18 days and nodal harvest averaged 20 nodes.
Common to these experiences has been the ability to complete the thoracic portion of the operation robotically in a high percentage of cases, the yield of a moderate number of mediastinal lymph nodes, and rates of intraoperative and postoperative complications consistent with the experience from traditional open and minimally invasive esophagectomy. Uniformly absent from these reports have been long-term follow-up data for survival rates, local control, and functional outcomes.
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Comment
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Robotic surgery has generated much excitement and interest since the da Vinci Surgical System was granted United States Food and Drug Administration approval in July 2000. For some procedures, such as prostatectomy or mitral valve surgery, robotic-assisted techniques have been extensively used and have found a niche. For other operations, such as esophagectomy, adoption of robotics has been much less enthusiastic. The reasons for this disparity likely reflect how the inherent advantages and disadvantages of robotics, compared with traditional open and minimally invasive surgery, differ for various operations. Robotics, perhaps, holds the most utility when the procedure requires fine motions in a limited space. For operations performed over a wide area and not requiring delicate movements, the disadvantages of robotics may outweigh any potential advantages.
Robotic-assisted esophagectomy is similar to minimally invasive esophagectomy (MIE) as performed with standard laparoscopic/thoracoscopic visualization and instrumentation, so comparisons between the two techniques are inevitable. Although robotic-assisted esophagectomy and MIE can be performed by using a transhiatal route or with combined transthoracic and transabdominal approaches, MIE has been much more extensively undertaken with the latter.
The largest experience to date with MIE comes from the University of Pittsburgh [5]. In their series of 222 procedures, performed mainly with combined thoracoscopy and laparoscopy with a cervical esophagogastric anastomosis, the average operative time was 7.5 hours, although it diminished to 4.5 hours after the first 20 cases. Nonemergency conversion to an open procedure was required in 7.2% of patients. Median length of stay was 7 days, with a median length of intensive care stay of 1 day. Operative mortality was 1.4%, with a 32% major and 24% minor complication rate. Although no data were provided on local control, the medium-term, stage-specific survival was similar to reports from open esophagectomy. Whether the addition of robotic assistance can improve upon these results has yet to be demonstrated.
In conclusion, the experience with robotic-assisted esophagectomy has been limited. The equipment costs, necessary training of surgeons and operating room personnel, set up time, and limited instrumentation have all been barriers to more widespread use. The fact that the surgeon is physically separated from patient and is outside of the sterile operative field raises potential safety concerns. The data on robotic-assisted esophagectomy suggest that the procedure is safe, feasible, and associated with perioperative outcomes similar to open and minimally invasive esophagectomy. No data, however, demonstrate improved outcomes in terms of operative morbidity, pain, length of stay, operative time, or total costs. For this procedure ultimately to gain widespread acceptance, identifiable benefit relative to other approaches will need to be demonstrated in order to offset inherent disadvantages and financial concerns.
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References
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- Horgan S, Berger RA, Elli EF, Espat NJ. Robotic-assisted minimally invasive transhiatal esophagectomy Am Surg 2003;69:624-626.[Medline]
- Kernstine KH, DeArmond DT, Karimi M, et al. The robotic, 2-stage, 3-field esophagolymphadenectomy J Thorac Cardiovasc Surg 2004;127:1847-1849.[Free Full Text]
- Bodner JC, Zitt M, Ott H, et al. Robotic-assisted thoracoscopic surgery (RATS) for benign and malignant esophageal tumors Ann Thorac Surg 2005;80:1202-1206.[Abstract/Free Full Text]
- van Hillegersberg R, Boone J, Draaisma WA, Broeders IA, Giezeman MJ, Borel Rinkes IH. First experience with robot-assisted thoracoscopic esophagolymphadenectomy for esophageal cancer Surg Endosc 2006;20:1435-1439.[Medline]
- Luketich JD, Alvelo-Rivera M, Buenaventura PO, et al. Minimally invasive esophagectomy: outcomes in 222 patients Ann Surg 2003;238:486-495.[Medline]
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Introduction
Potential Advantages of Robotic...