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Robotic esophagectomy with outermost layer-oriented dissection for esophageal cancer: technical aspects and a retrospective review of a single-institution database

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Abstract

Background

Systematic lymph node dissection in patients with gastric cancer could be sufficiently and reproducibly achieved along the outermost layer of the autonomic nerves and similar concept has been extensively used for robotic esophagectomy (RE) since 2018. This study aimed to determine the surgical and oncological safety of RE using the outermost layer-oriented approach for esophageal cancer (EC).

Methods

Sixty-six patients who underwent RE with total mediastinal lymphadenectomy for primary EC between April 2018 and December 2021 were retrospectively reviewed. All underwent the outermost layer-oriented approach with intraoperative nerve monitoring (IONM). Postoperative complications within 30 days were analyzed.

Results

Among the patients, 51 (77.3%) were male. The median age was 64 years, and the body mass index was 21.8 kg/m2. Furthermore, 58 (87.9%) patients had squamous cell carcinoma and eight (12.1%) patients had adenocarcinoma. Clinical stages I, II, and III were seen in 23 (34.8%), 23 (34.8%), and 16 (24.2%) patients, respectively. Thirty-four (51.5%) patients received preoperative treatment. No patient shifted to conventional thoracoscopic or open procedure intraoperatively. The median operative time was 716 min with 119 mL of blood loss. Additionally, 64 (97%) patients underwent R0 resection. The morbidity rates based on Clavien–Dindo grades ≥ II and ≥ IIIa were 30.3% and 10.6%, respectively, within 30 postoperative days. None died within 90 days postoperatively. Three (4.5%) patients exhibited recurrent laryngeal nerve (RLN) palsy (CD grade ≥ II). The sensitivity and specificity of IONM for RLN palsy were 50% and 98.3% at the right RLN and 33.3% and 98.0% at the left RLN, respectively.

Conclusion

RE with the outermost layer-oriented approach can provide safe short-term outcomes.

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Abbreviations

EC:

Esophageal cancer

RCTs:

Randomized controlled trials

DVSS:

Da Vinci Surgical System

RE:

Robotic esophagectomy

OL:

Outermost layer

RLN:

Recurrent laryngeal nerve

CD:

Clavien–Dindo

IONM:

Intraoperative nerve monitoring

ICS:

Intercostal space

PPV:

Positive predictive value

NPV:

Negative predictive value

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Acknowledgements

The authors would like to thank MARUZEN-YUSHODO Co., Ltd. (https://kw.maruzen.co.jp/kousei-honyaku/) for the English language editing.

Funding

This work was not supported by any grants or funding.

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Authors and Affiliations

  1. Department of Advanced Robotic and Endoscopic Surgery, Fujita Health University, Toyoake, Japan

    Masaya Nakauchi, Kazuki Inaba & Ichiro Uyama

  2. Department of Surgery, Fujita Health University, 1-98 Dengakugakubo, Kutsukake, Toyoake, Aichi, 470-1192, Japan

    Susumu Shibasaki, Kazumitsu Suzuki, Akiko Serizawa, Shingo Akimoto, Tsuyoshi Tanaka & Koichi Suda

  3. Collaborative Laboratory for Research and Development in Advanced Surgical Technology, Fujita Health University, Toyoake, Japan

    Ichiro Uyama

  4. Collaborative Laboratory for Research and Development in Advanced Surgical Intelligence, Fujita Health University, Toyoake, Japan

    Koichi Suda

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  1. Masaya Nakauchi
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Contributions

All authors have fully satisfied the ICMJE authorship criteria as detailed in the following: Study design: MN, SS, IU, and KS; Data collection: MN, SS, AS, KS, and TT; Statistical analysis and interpretation of results: MN, SS, SA, KI, and KS; Drafting of the manuscript: MN, SS, and KS; Critical revision of the manuscript for important intellectual content: IU and KS. All authors have read and approved the final manuscript and are accountable for all aspects of the work, particularly in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Corresponding author

Correspondence to Koichi Suda.

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Disclosures

Ichiro Uyama has received lecture fees from Intuitive Surgical, Inc., outside of the submitted work. Ichiro Uyama have been funded by Medicaroid, Inc. in relation to the Collaborative Laboratory for Research and Development in Advanced Surgical Technology, Fujita Health University. Koichi Suda has been funded by Sysmex, Co. in relation to the Collaborative Laboratory for Research and Development in Advanced Surgical Intelligence, Fujita Health University, and has also received advisory fees from Medicaroid, Inc., outside of the submitted work. Masaya Nakauchi, Susumu Shibasaki, Kazumitsu Suzuki, Akiko Serizawa, Shingo Akimoto, Tsuyoshi Tanaka, Kazuki Inaba, Ichiro Uyama, and Koichi Suda have no conflicts of interest or financial ties to disclose.

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Supplementary Information

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464_2023_10437_MOESM1_ESM.jpeg

Supplementary file1 (JPEG 124 KB)—Three independent dissectible layers were regarded as landmarks to mobilize the esophagus: (1) layer along the aortic adventitia (blue triangle), (2) layer along the adipose tissue surrounding the thoracic duct (yellow triangle), and (3) interpleural ligament (Morosow’s ligament) (red triangle).

464_2023_10437_MOESM2_ESM.jpeg

Supplementary file2 (JPEG 88 KB)—The dorsal aspect of the upper esophagus was mobilized on the interpleural fascia in a caudocranial direction beyond the thoracic inlet. Then, the interpleural fascia was dissected from the adipose tissue surrounding the thoracic duct along the left aspect of the upper esophagus, and the dorsolateral aspect of the left upper mediastinal periesophageal tissue was sufficiently mobilized (green area).

Supplementary file3 (MP4 273392 KB)—Surgical procedures of the outermost layer-oriented approach.

464_2023_10437_MOESM4_ESM.jpeg

Supplementary file4 (JPEG 121 KB)—Outermost layer in the concentric-structured model. The outermost layer is shown in the purple line and dividing line between station 106rec and 106pre (green arrow).

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Nakauchi, M., Shibasaki, S., Suzuki, K. et al. Robotic esophagectomy with outermost layer-oriented dissection for esophageal cancer: technical aspects and a retrospective review of a single-institution database. Surg Endosc 37, 8879–8891 (2023). https://doi.org/10.1007/s00464-023-10437-8

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