Robot-Assisted Thoracolaparoscopic Esophagectomy: The Netherlands
For locally advanced esophageal cancer, radical surgical resection is the mainstay of treatment. Lymph node metastases occur along the entire tract of the esophagus in an early stage. Optimal treatment involves neo-adjuvant chemoradiotherapy followed by a two field thoraco-abdominal en bloc esophagectomy with an extensive mediastinal and truncal lymph node dissection.
Techniques for minimally invasive esophagectomy have been introduced to reduce surgical trauma and morbidity of traditional open esophagectomy. However, conventional endoscopic surgery is limited by 2-dimensional vision, reduced dexterity and limited degrees of freedom. Robotic systems were developed to overcome such limitations, enabling the surgeon to perform complex minimally invasive surgical procedures. Advantages include reduced blood loss and fast postoperative recovery.
This chapter describes the indications and preoperative considerations for robot-assisted thoracolaparoscopic esophagectomy. Furthermore, anesthesiological management is discussed, addressing important intraoperative issues such as single lung ventilation and fluid management.
The three-stage operative procedure is described in detail. The thoracoscopic phase is performed using the robotic DaVinci Si system (Intuitive Surgical Inc., Sunnyvale CA, USA). The laparoscopic phase is performed with conventional laparoscopy. A gastric conduit is created extracorporally and a cervical esophagogastric anastomosis is formed.
Additionally, the clinical care of patients after esophagectomy is discussed with a specific focus on anastomotic leakage and chylous leakage.
KeywordsEsophagectomy Thoracoscopy Single lung ventilation Laparoscopy Gastric conduit Lymph node dissection Thoracic duct Anastomotic leakage Chylous leakage
- 10.Omloo JM, Lagarde SM, Hulscher JB, Reitsma JB, Fockens P, van Dekken H, ten Kate FJ, Obertop H, Tilanus HW, van Lanschot JJ. Extended transthoracic resection compared with limited transhiatal resection for adenocarcinoma of the mid/distal esophagus: five-year survival of a randomized clinical trial. Ann Surg. 2007;246:992–1000.CrossRefGoogle Scholar
- 22.Wittekind C, Greene FL, Hutter RVP, Klimpfinger M, Sobin LH. TNM atlas. Illustrated guide to the TNM/pTNM classification of malignant tumors. 2004.Google Scholar
- 26.American Society of Anesthesiologists. Standards for basic anestheticmonitoring. http://www.asahq.org/For-Healthcare-Professionals/Standards-Guidelines-and-Statements.aspx. Accessed July 2011.
- 27.Sato N, Koeda K, Ikeda K, Kimura Y, Aoki K, Iwaya T, Akiyama Y, Ishida K, Saito K, Endo S. Randomized study of the benefits of preoperative corticosteroid administration on the postoperative morbidity and cytokine response in patients undergoing surgery for esophageal cancer. Ann Surg. 2002;236:184–90.CrossRefGoogle Scholar
- 32.Chandrashekar MV, Irving M, Wayman J, Raimes SA, Linsley A. Immediate extubation and epidural analgesia allow safe management in a high-dependency unit after two-stage oesophagectomy. Results of eight years of experience in a specialized upper gastrointestinal unit in a district general hospital. Br J Anaesth. 2003;90:474–9.CrossRefGoogle Scholar
- 34.Ajani J, Bekaii-Saab T, D’Amico TA, Fuchs C, Gibson MK, Goldberg M, Hayman JA, Ilson DH, Javle M, Kelley S, Kurtz RC, Locker GY, Meropol NJ, Minsky BD, Orringer MB, Osarogiagbon RU, Posey JA, Roth J, Sasson AR, Swisher SG, Wood DE, Yen Y. Esophageal cancer clinical practice guidelines. J Natl Compr Canc Netw. 2006;4:328–47.CrossRefGoogle Scholar