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World Journal of Surgery

, Volume 36, Issue 7, pp 1608–1616 | Cite as

Robot-assisted Thoracoscopic Lymphadenectomy Along the Left Recurrent Laryngeal Nerve for Esophageal Squamous Cell Carcinoma in the Prone Position: Technical Report and Short-term Outcomes

  • Koichi SudaEmail author
  • Yoshinori Ishida
  • Yuichiro Kawamura
  • Kazuki Inaba
  • Seiichiro Kanaya
  • Satoshi Teramukai
  • Seiji Satoh
  • Ichiro Uyama
Article

Abstract

Background

Meticulous mediastinal lymphadenectomy frequently induces recurrent laryngeal nerve palsy (RLNP). Surgical robots with impressive dexterity and precise dissection skills have been developed to help surgeons perform operations. The objective of this study was to determine the impact on short-term outcomes of robot-assisted thoracoscopic radical esophagectomy performed on patients in the prone position for the treatment of esophageal squamous cell carcinoma, including its impact on RLNP.

Methods

A single-institution nonrandomized prospective study was performed. The patients (n = 36) with resectable esophageal squamous cell carcinoma were divided into two groups: patients who agreed to robot-assisted thoracoscopic esophagectomy with total mediastinal lymphadenectomy performed in the prone position (n = 16, robot-assisted group) without insurance reimbursement, and those who agreed to undergo the same operation without robot assistance but with health insurance coverage (n = 20, control group). These patients were observed for 30 days following surgery to assess short-term surgical outcomes, including the incidence of vocal cord palsy, hoarseness, and aspiration.

Results

Robot assistance significantly reduced the incidence of vocal cord palsy (p = 0.018) and hoarseness (p = 0.015) and the time on the ventilator (p = 0.025). There was no in-hospital mortality in either group. There were no significant differences between the two groups with respect to patient background, except for the use of preoperative therapy (robot-assisted group <control, p = 0.003). There were no significant differences in estimated blood loss, operating time, number of dissected lymph nodes, completeness of resection, or the incidence of the other complications, except for anastomotic leakage (p = 0.038).

Conclusion

Robot-assisted thoracoscopic esophagectomy with total mediastinal lymphadenectomy is feasible and safe. This method shows promise in preventing RLNP.

Keywords

Esophageal Squamous Cell Carcinoma Recurrent Laryngeal Nerve Vocal Cord Palsy Recurrent Laryngeal Nerve Palsy Gastric Conduit 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.

Notes

Acknowledgments

The authors express special thanks to Professor Masaki Kitajima for his wonderful supervision of this project. The authors are indebted to Ms. Sheena Tam and Dr. Yuexin Li of the University of British Columbia, and Ms. Susan Holland and Mr. Victor Chen for their review of this manuscript.

Disclosures

This work was not supported by any grants or funding. No author has commercial association or financial involvement that might pose a conflict of interest.

Supplementary material

Video clip 1 The pulmonary branches of the vagus nerves were preserved and esophagocardial branches were divided in the thoracic phase (MPG 10054 kb)

Video clip 2 Robot-assisted thoracoscopic lymphadenectomy along the left RLN with the patient in the prone position. First, the trachea was rolled back carefully and firmly to the right and ventrally. Then, the tissue, including the left RLN and lymph nodes, was dissected sharply just along the trachea and the left bronchus. The posterior aspect was dissected on a vascular sheath covering the aortic arch and the left subclavicular artery. Finally, the left RLN was sharply isolated from the explored tissue and the infra-aortic arch nodes on the face of the pulmonary artery trunk, and the left paratracheal nodes were completely dissected. RLN, recurrent laryngeal nerve (MPG 8470 kb)

Video clip 3 Thoracoscopic lymphadenectomy, without robot assistance, along the left RLN with the patient in the prone position. All the procedures were essentially the same as those performed in the robot-assisted group, but the tremor of the operating surgeon and the camera could be seen. The trachea was rolled back and to the right only with the assistant surgeon’s grasper, which had no articulation (MPG 8292 kb)

Video clip 4 Placement of a long plastic bag between neck and abdomen through the posterior mediastinum (MPG 7940 kb)

References

  1. 1.
    Fujita H, Sueyoshi S, Tanaka T et al (2002) Three-field dissection for squamous cell carcinoma in the thoracic esophagus. Ann Thorac Cardiovasc Surg 8:328–335PubMedGoogle Scholar
  2. 2.
    Bumm R, Wong J (1994) More or less surgery for esophageal cancer: extent of lymphadenectomy for squamous cell esophageal carcinoma - How much is necessary? Dis Esophagus 7:151–155Google Scholar
  3. 3.
    Fumagalli U, Panel of Experts (1996) Resective surgery for cancer of the thoracic esophagus: results of a Consensus Conference held at the 6th World Congress of the International Society for Diseases of the Esophagus. Dis Esophagus 9(suppl):30–38Google Scholar
  4. 4.
    Gockel I, Kneist W, Keilmann A et al (2005) Recurrent laryngeal nerve paralysis (RLNP) following esophagectomy for carcinoma. Eur J Surg Oncol 31:277–281PubMedCrossRefGoogle Scholar
  5. 5.
    Gelpke H, Grieder F, Decurtins M et al (2010) Recurrent laryngeal nerve monitoring during esophagectomy and mediastinal lymph node dissection. World J Surg 34:2379–2382. doi: 10.1007/s00268-010-0692-0 PubMedCrossRefGoogle Scholar
  6. 6.
    Fujita H, Kakegawa T, Yamana H et al (1995) Mortality and morbidity rates, postoperative course, quality of life, and prognosis after extended radical lymphadenectomy for esophageal cancer. Comparison of three-field lymphadenectomy with two-field lymphadenectomy. Ann Surg 222:654–662PubMedCrossRefGoogle Scholar
  7. 7.
    Peracchia A, Ruol A, Bardini R (1992) Lymph node dissection for cancer of the thoracic esophagus: how extended should it be? Analysis of personal data and review of the literature. Dis Esophagus 5:69–78Google Scholar
  8. 8.
    Baba M, Aikou T, Yoshinaka H et al (1994) Long-term results of subtotal esophagectomy with three-field lymphadenectomy for carcinoma of the thoracic esophagus. Ann Surg 219:310–316PubMedCrossRefGoogle Scholar
  9. 9.
    Isono K, Sato H, Nakayama K (1991) Results of a nationwide study on the three-field lymph node dissection of esophageal cancer. Oncology 48:411–420PubMedCrossRefGoogle Scholar
  10. 10.
    Nishimaki T, Suzuki T, Suzuki S et al (1998) Outcomes of extended radical esophagectomy for thoracic esophageal cancer. J Am Coll Surg 186:306–312PubMedCrossRefGoogle Scholar
  11. 11.
    Nishihira T, Mori S, Hirayama K (1992) Extensive lymph node dissection for thoracic esophageal carcinoma. Dis Esophagus 5:79–89Google Scholar
  12. 12.
    Périé S, Laccourreye O, Bou-Malhab F et al (1998) Aspiration in unilateral recurrent laryngeal nerve paralysis after surgery. Am J Otolaryngol 19:18–23PubMedCrossRefGoogle Scholar
  13. 13.
    Noshiro H, Iwasaki H, Kobayashi K et al (2010) Lymphadenectomy along the left recurrent laryngeal nerve by a minimally invasive esophagectomy in the prone position for thoracic esophageal cancer. Surg Endosc 24:2965–2973PubMedCrossRefGoogle Scholar
  14. 14.
    Boone J, Schipper ME, Moojen WA et al (2009) Robot-assisted thoracoscopic oesophagectomy for cancer. Br J Surg 96:878–886PubMedCrossRefGoogle Scholar
  15. 15.
    Ruurda JP, van Vroonhoven TJ, Broeders IA (2002) Robot-assisted surgical systems: a new era in laparoscopic surgery. Ann R Coll Surg Engl 84:223–226PubMedCrossRefGoogle Scholar
  16. 16.
    Camarillo DB, Krummel TM, Salisbury JK Jr (2004) Robotic technology in surgery: past, present, and future. Am J Surg 188:2S–15SPubMedCrossRefGoogle Scholar
  17. 17.
    Ministry of Health, Labor and Welfare. Annual health, labor and welfare report 2009–2010. Available at http://www.mhlw.go.jp/english/wp/wp-hw4/02.html (accessed)
  18. 18.
    Oken MM, Creech RH, Tormey DC et al (1982) Toxicity and response criteria of the Eastern Cooperative Oncology Group. Am J Clin Oncol 5:649–655PubMedCrossRefGoogle Scholar
  19. 19.
    Suda K, Kitagawa Y, Ozawa S et al (2007) Neutrophil elastase inhibitor improves postoperative clinical courses after thoracic esophagectomy. Dis Esophagus 20:478–486PubMedCrossRefGoogle Scholar
  20. 20.
    Rice TW, Blackstone EH, Rusch VW (2010) 7th edition of the AJCC Cancer Staging Manual: esophagus and esophagogastric junction. Ann Surg Oncol 17:1721–1724PubMedCrossRefGoogle Scholar
  21. 21.
    Engstad K, Schipper PH (2009) Laryngopharyngeal dysfunction after esophagectomy. In: Jobe BA, Thomas CR, Hunter JG (eds) Esophageal cancer: principles and practice. Demos Medical Publishing, New York, pp 660–661Google Scholar
  22. 22.
    Baba M, Aikou T, Natsugoe S et al (1998) Quality of life following esophagectomy with three-field lymphadenectomy for carcinoma, focusing on its relationship to vocal cord palsy. Dis Esophagus 11:28–34PubMedGoogle Scholar
  23. 23.
    Akiyama H, Tsurumaru M, Udagawa H et al (1994) Radical lymph node dissection for cancer of the thoracic esophagus. Ann Surg 220:364–372PubMedCrossRefGoogle Scholar
  24. 24.
    Watanabe H, Kato H, Tachimori Y (2000) Significance of extended systemic lymph node dissection for thoracic esophageal carcinoma in Japan. Recent Results Cancer Res 155:123–133PubMedCrossRefGoogle Scholar
  25. 25.
    Shiozaki H, Yano M, Tsujinaka T et al (2001) Lymph node metastasis along the recurrent nerve chain is an indication for cervical lymph node dissection in thoracic esophageal cancer. Dis Esophagus 14:191–196PubMedCrossRefGoogle Scholar
  26. 26.
    Tsurumaru M, Kajiyama Y, Udagawa H et al (2001) Outcomes of extensive lymph node dissection for squamous cell carcinoma of the thoracic esophagus. Ann Thoracic Cardiovasc Surg 7:325–329Google Scholar
  27. 27.
    Nishimaki T, Suzuki T, Tanaka Y et al (1997) Evaluating the rational extent of dissection in radical esophagectomy for invasive carcinoma of the thoracic esophagus. Surg Today 27:3–8PubMedCrossRefGoogle Scholar
  28. 28.
    van Hillegersberg R, Boone J, Draaisma WA et al (2006) First experience with robot-assisted thoracoscopic esophagolymphadenectomy for esophageal cancer. Surg Endosc 20:1435–1439PubMedCrossRefGoogle Scholar
  29. 29.
    Kernstine KH, DeArmond DT, Shamoun DM et al (2007) The first series of completely robotic esophagectomies with three-field lymphadenectomy: initial experience. Surg Endosc 21:2285–2292PubMedCrossRefGoogle Scholar
  30. 30.
    Kim DJ, Hyung WJ, Lee CY et al (2010) Thoracoscopic esophagectomy for esophageal cancer: feasibility and safety of robotic assistance in the prone position. J Thorac Cardiovasc Surg 139:53–59PubMedCrossRefGoogle Scholar

Copyright information

© Société Internationale de Chirurgie 2012

Authors and Affiliations

  • Koichi Suda
    • 1
    Email author
  • Yoshinori Ishida
    • 1
  • Yuichiro Kawamura
    • 1
  • Kazuki Inaba
    • 1
  • Seiichiro Kanaya
    • 2
  • Satoshi Teramukai
    • 3
  • Seiji Satoh
    • 1
  • Ichiro Uyama
    • 1
  1. 1.Division of Upper GI, Department of SurgeryFujita Health UniversityToyoakeJapan
  2. 2.Department of GI SurgeryOsaka Red Cross HospitalTennoujiJapan
  3. 3.Translational Research CenterKyoto University HospitalSakyo-kuJapan

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