J Robotic Surg (2013) 7:325–332 DOI 10.1007/s11701-012-0391-y
ORIGINAL ARTICLE
Contribution of robotics to minimally invasive esophagectomy Ismael Diez Del Val • Carlos Loureiro Gonzalez • Santiago Larburu Etxaniz • Julen Barrenetxea Asua • Saioa Leturio Fernandez • Sandra Ruiz Carballo • Eider Etxebarria Beitia • Patricia Perez de Villarreal • Lorena Hierro-Olabarria Jose Esteban Bilbao Axpe • Jaime Jesus Mendez Martin
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Received: 20 October 2012 / Accepted: 27 December 2012 / Published online: 24 January 2013 Ó Springer-Verlag London 2013
Abstract Robot-assisted surgery has the advantages of a three-dimensional view, versatility of instruments and better ergonomics. It allows fine dissection and difficult anastomoses in deep fields. Based on our experience, we try to define what are the main contributions of robotics to minimally invasive esophagectomy. From December 2009 to July 2012, we performed 24 minimally invasive esophagectomies (9 transhiatal, 5 Ivor-Lewis and 10 three-field), 16 of them robotically (8, 5 and 3, respectively). Eighteen patients (18/24 = 75 %) received neoadjuvant therapy. Nine patients (9/24 = 37.5 %) had symptomatic complications: 4 anastomotic leaks treated conservatively, one staple failure of the gastric plasty needing reoperation, one biliary peritonitis secondary to a gangrenous cholecystitis, one intrathoracic gastric migration after the only nonresectable case, one chylothorax and one patient with major cardiopulmonary complications. The median number of lymph nodes harvested was 12 ± 7. Median length of stay was 14 ± 13.5 days. Thirty-day mortality was nil. Complications were not related
I. Diez Del Val (&) C. Loureiro Gonzalez J. Barrenetxea Asua J. E. Bilbao Axpe Esophago-gastric Surgery and Robotic Unit, Service of General and Digestive Surgery, Basurto University Hospital, Avenida Montevideo, 18, 48013 Bilbao, Spain e-mail:
[email protected] S. Larburu Etxaniz Esophago-gastric Surgery Unit, Service of General and Digestive Surgery, Donostia University Hospital, Paseo Dr Begiristain, 115, 20080 san sebastian, Spain S. Leturio Fernandez S. Ruiz Carballo E. Etxebarria Beitia P. Perez de Villarreal L. Hierro-Olabarria J. J. Mendez Martin Service of General and Digestive Surgery, Basurto University Hospital, Avenida Montevideo, 18, 48013 Bilbao, Spain
to the robot itself but to the complexity of both the technique and the patient. Although we found no advantages for the use of robotics during threefield minimally invasive esophagectomy, robotic mediastinal dissection during transhiatal esophagectomy can be performed safely under direct vision. Moreover, hand-sewn robotic-assisted technique in the prone position is promising and maybe the simplest way to carry out thoracic anastomosis during Ivor-Lewis esophagectomy Keywords Esophagus Robotic surgery Minimally invasive esophagectomy Ivor-Lewis Esophagectomy Transhiatal esophagectomy
Introduction Minimally invasive esophagectomy (MIE) is increasingly being used for surgical management of esophageal cancer, with the aim of reducing morbidity and mortality while preserving oncologic quality of the resection. Large series have reported a low incidence of respiratory complications and mortality, whereas the medium-term, stage-specific survival seems to be similar to open esophagectomy [1]. Nevertheless, unlike other minimally invasive procedures, it has not become widespread, because it is still considered one of the most complex gastrointestinal surgical operations [2]. Robot-assisted surgery has the potential to accelerate the learning curve of MIE because of increased magnification with three-dimensional view, articulation of instruments, improved dexterity, and better ergonomics. It is specially designed for fine dissection or difficult anastomoses in fields presenting challenging access, like the mediastinum [3, 4]. Although the surgical approach (transthoracic, transhiatal, three-field esophagectomy) is typically based on surgeon and institutional preference, there has been a trend in
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recent years to change from a cervical to an intrathoracic anastomosis, due both to epidemiological (dramatic increase in the incidence of lower-third esophageal adenocarcinoma) and surgical factors, such as better exposure, the potential for an improved rate of complete resection and lower rates of anastomotic and recurrent laryngeal nerve complications [1, 5]. Several ways have been developed to perform this difficult anastomosis during thoracoscopy [6–9]. The objective of this article is to present our experience and details of our technique with what we consider the simplest way to perform an intrathoracic anastomosis during a minimally invasive Ivor-Lewis esophagectomy: robotic hand-sewn anastomosis in the prone position. This technique fits perfectly the description of an innovation in Stage 2a of the IDEAL framework for describing evaluations of surgical interventions [10]. We have therefore reported our prospective study using the format suggested for this stage in the IDEAL recommendations [11].
Patients, methods and surgical technique Following our experience with three-field minimally invasive esophagectomy, the introduction of robot-assisted esophagogastric surgery in September 2009 allowed us to perform totally robotic transhiatal esophagectomy and the robotic minimally invasive Ivor-Lewis procedure with hand-sewn intrathoracic anastomosis. We present a longitudinal descriptive study focusing on technical details and immediate outcomes. From December 2009 to July 2012, we proposed a total esophagectomy to 24 patients in our Unit. There were 20 men and 4 women with a median age of 60.5 ± 16 years. Pathology showed 12 adenocarcinomas, 11 squamous-cell carcinomas and one peptic stenosis. Seventeen patients received preoperative chemoradiotherapy, one followed the MAGIC-scheme with perioperative chemotherapy and six had no adjuvant therapy: one due to benign disease, 1 for early cancer and 4 others because of medical conditions. A combined thoracoscopic and laparoscopic approach is used in most patients, although a robotic transhiatal esophagectomy may be indicated in early tumors or in selected patients with poor pulmonary function. Three-field MIE for middle-third tumors is pragmatically performed with or without robotic assistance, depending on its availability. Epidural analgesia is routinely used. A single-lumen Univent-type endotracheal tube is inserted in case a thoracoscopic access is planified. Hemodynamic parameters, such as central venous pressure, heart rate and arterial pressure are monitored, as well as airway pressure and lung compliance.
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The procedure starts by laparoscopy in tumors located at the distal third of the esophagus or EGJ, whereas thoracoscopy is the initial step of the operation for middle-third lesions. During robotic transhiatal esophagectomy, three 8-mm robotic trocars are used, one of them for liver and pericardial retraction, plus two 12-mm conventional ports for camera and assistance. First of all, we explore the abdominal cavity to rule out any possible metastases, and we dissect the distal esophagus until the proximal part of the tumor, to be sure about its resectability. A Penrose drain is passed around GEJ for traction, progressing under direct vision up to above the carina (Fig. 1). At the level of the inferior pulmonary veins, the 30° camera is changed to a 0° one, to improve anterior dissection. Branches from the aorta are sealed with harmonic or bipolar cautery. Eventual openings of the pleurae are managed by decreasing abdominal pressure to 10 mmHg. Once the mediastinal dissection has been completed, we convert to traditional laparoscopy. After changing the lefthand robotic trocar by a 12-mm conventional one to facilitate stapling, we divide the gastrocolic omentum taking care to preserve the right gastroepiploic arcade. The left gastric artery and vein are clipped or stapled (white cartridge) and a Heineke-Mikulicz pyloroplasty is routinely performed. A narrow gastric tube is then constructed by dividing the stomach from the incisura angularis with a 3.5-mm stapler (blue load). The proximal portion of the tube is then attached to the specimen, and passed through the posterior mediastinum up to the left cervical incision. The abdominal phase of the minimally invasive IvorLewis procedure fits the previous description. Patients are placed in steep reverse Trendelenburg position for traditional laparoscopy using five ports in a V-shape fashion, with the surgeon between the legs. Once the gastric tube has been constructed and fixed to the surgical specimen, it is passed through the opened right pleura up into the chest and the hiatus is then closed, and a Jackson-Pratt suction drain left in place. Although we have used the robot for this phase of the operation, we find no clear advantages, mainly because of the need of excessive visceral manipulation and the fact that several mechanical or electrical devices still have to be applied by the assistant, such as staplers, clips or sealing instruments. Other than the mediastinal progression, the main advantages of the robotic approach are seen during the thoracoscopic phase of the Ivor-Lewis technique. The patient is changed to the prone position, the right lung collapsed and four trochars introduced: one 12-mm camera port at the scapula tip to hold the camera, two 8-mm robotic ports two intercostal spaces proximal and distally, posterior in relation to the camera to create a triangle to make dissection easier, and a fourth 12-mm supplementary port for assistance (Fig. 2).
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Fig. 2 Position of the trocars and robotic arms (scapula in dotted line)
Fig. 1 Robotic thanshiatal esophagectomy. a The aorta represents the posterior plan of the dissection, b the pericardium and inferior pulmonary veins at the anterior plan, c the carina is clearly identified
After division of the azygos vein with a 2.0-mm linear stapler (grey cartridge), the esophagus is mobilized up to the level of 2–4 cm above the carina, including all surrounding nodes between the aorta, pericardium and contralateral mediastinal pleura, taking care to seal any aortoesophageal vessels or lymphatic branches and respecting the membranous tracheal wall.
Once the esophagus has been freed, it is sectioned above the azygos vein, the surgical specimen left aside and the gastric tube placed with the staple line towards the camera, in order to choose the right place for the incision for anastomosis between the esophageal stump and the great curvature, avoiding a redundant sigmoid gastric plasty. Two reference stitches are placed, a posterior-running and continuous or interrupted anterior sutures easily fashioned between the opening in the stomach tube and the end of the esophagus thanks to the versatility provided by the Da Vinci system to the needle holder. A barbed suture may be of help in order to avoid losing tension inappropriately from the continuous suture. The redundant gastric tube tissue is stapled and removed (Fig. 3). Extraction of the esophagogastric specimen and the resected tip of the gastric tube are performed through a small thoracotomy created by enlarging the incision made for the left arm of the robot (Fig. 4). The last five patients with a cervical anastomosis had a tube esophagostomy in order to improve comfort, protect the suture and reduce pulmonary complications [12].
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Fig. 3 Details of the intrathoracic hand-sewn anastomosis, a the esophagus is sectioned above the azygos vein, b the ideal level for the anastomosis at the greater curvature, c opening the gastric plasty,
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d posterior continuous suture, e posterior thread finished, f the nasogastric probe is advanced before ending the anterior continuous suture, g stapling of the tube remnant, h completed anastomosis
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Fig. 4 External view of scars before discharge. The left arm of the robot has been enlarged to extract the surgical specimen
A barium swallow is performed between the fourth and seventh postoperative day to rule out any possible pulmonary complications or anastomotic leaks (Fig. 5). Oral intake is then resumed and drains removed.
Results A total of 23 esophagectomies were performed in this period, because one patient was considered unresectable due to preoperatively undetected peritoneal carcinomatosis. Eight transhiatal esophagectomies were carried out, 6 of them by robotic approach. In one patient needing a coloplasty for a previous gastrectomy the operation started by the open technique. One patient was converted to an open procedure due to a bulky EGJ tumor. Four patients had a minimally invasive Ivor-Lewis esophagectomy with a robotic-assisted intrathoracic handsewn anastomosis in the prone position. In another patient, the thorax could not be entered to place trocars due to a calcified pachypleuritis and extensive pleural adhesions and a thoracotomy had to be carried out. For tumors located at the middle third of the esophagus, 10 three-field MIEs were performed, three of them by robotic assistance, depending on the availability of the robot.The complete series is summarized in Table 1. Four patients had to be converted to an open procedure: one to laparotomy, already described, and 3 others to
Fig. 5 Barium swallow on 7th postoperative day
thoracotomy, 2 of them due to pleural adhesions and one case to control a hemorrhage coming from a direct aortic vessel. Nine patients (9/24 = 37.5 %) had symptomatic complications: 4 anastomotic leaks (3 cervical, 1 thoracic) treated nonoperatively, one staple failure of the gastric plasty needing reoperation, one biliary peritonitis secondary to a gangrenous cholecystitis, one intrathoracic gastric migration after a diagnostic laparoscopy [13], one persistent chylous fistula that was controlled by surgical ligation of the thoracic duct and one patient with major cardiopulmonary complications. Thirty-day mortality was nil, although 2 patients died 45 and 57 days after the operation, as a consequence of complications. After robotic Ivor-Lewis esophagectomy with handsewn anastomosis, one leak was observed. It was managed conservatively, maintaining the pleural drain for 4 weeks. The stent placed endoscopically did not contribute to healing because of distal migration and had to be removed. Median length of stay was 14 ± 13.5 days. The mean number of lymph nodes harvested was 12 ± 7, probably biased by neoadjuvant therapy. Four patients (25 %) had complete pathologic response after chemoradiation (Mandard tumor regression grade 1).
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Table 1 Patients and surgical techniques Surgical technique
Intention-to-treat Total
Thanshiatal esophagectomy
9
Open 1
Unresectable
Robotic
Minimally invasive
8
Resected Open
1
Postoperative complications
Robotic
1
Minimally invasive
6
Conversions 1
1 gastric migrationb 1 cervical leak 1 stapler failureb 1 biliary peritonitisb
Ivor-Lewis
5
5
Three-field esophagectomy
10
3
Total
24
4 7
3
5
1
1 thoracic leak
2a
1 chylothoraxb 2 cervical leaks 1 cardiopulmonary
a
1
16
7
1
1
One forced conversion due to acute bleeding from a direct branch of the aorta.
Discussion Minimally invasive and open esophagectomy are comparable in terms of postoperative outcomes and survival [14], with potential improvements in surgical morbidity, transfusion rate, hospital stay, recovery of gastrointestinal function and respiratory complications favoring MIE [2, 15–19]. Comparing hand-sewn versus stapled anastomoses, leak rates are similar in several published randomized controlled trials [9, 20–22]. Although the circular-stapled method significantly reduces operative time, it seems to increase the risk of anastomotic stricture [22]. In the metaanalyses by Urschel [20] and Honda [22], the circular stapler appeared to increase operative mortality, although the authors cannot adequately explain this result. Indications and approach during minimally invasive esophagectomy have been evolving over time. Approaches used at present depend on cancer stage, tumour location, body habitus and pulmonary function [23, 24]. From early cancers to more advanced disease, the initial transhiatal procedure has opened the door to thoracoscopy, mainly for oncological reasons. Thoracoscopic mobilisation of the esophagus is currently the preferred technique for most surgeons to achieve long-term locoregional control of the disease [25]. Cervical anastomoses have been the rule for MIE. Nevertheless, although easier to treat, the incidence of cervical anastomotic leaks, between 10 and 20 % in most series, is significantly higher compared with intrathoracic anastomosis [26], that is now favored by several authors with large experience [5, 27]. Due to its degree of complexity, intrathoracic anastomoses were usually either avoided or performed by an open approach. Several manoeuvers have been designed for this
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13 b
5
4 (3 elective)
9/24
Patients needing reoperation
critical step during minimally invasive surgery: transoral or transthoracic placement of the anvil [8], introduction of the circular stapler through a small thoracotomy or retrieval of the gastric tube out of the thorax to reintroduce it with the stapler into the cavity [28], or even adding a supplementary thoracotomy to the procedure to secure the proximal esophagus. Few cases have been published to date with a thoracoscopic hand-sewn anastomosis in the prone position [29, 30]. During the last few years, some experience has been acquired with robotic-assisted esophagectomy [31–35]. The systematic review published by Clark [34], with 9 short series and 130 patients, shows no differences in outcomes compared with conventional minimally invasive techniques: there was an anastomotic leak rate of 18 % and pulmonary complications occurred in 25 % of patients. Probably, robotics holds the most utility when the procedure requires fine motions in a limited space. The main limitations of the robot come from the loss of tactile sensation that can lead to inadvertent ripping of the tissue when an important visceral manipulation is needed. Equipment size and weight with difficulties for changing the port location or the operating room table during surgery, the cost of the device and prolonged operative times may jeopardize the potential benefits of the system as well [36]. For operations performed over a wide area and not requiring delicate movements, the disadvantages of robotics may outweigh any potential advantages [37]. That may be why three-field minimally invasive esophagectomy is mainly performed with standard laparoscopic/thoracoscopic visualization and instrumentation, rather than robotic-assisted. This is not the case for transhiatal MIE, in which the length of robotic instruments and their versatility allow the
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mediastinal dissection to be performed completely under direct vision. Concerning intrathoracic anastomosis, the technique we have described in this report seems to be the simplest for a safe anastomosis. The angulation given to the needle holder by the robotic system makes it feasible to perform a onelayer continuous or interrupted suture without any major concern or technical difficulty. A small thoracotomy is only needed at the end of the procedure to extract the surgical specimen. We consider this technique a promising way to reduce anastomotic leaks after esophagectomy and one of the main contributions of robotics to esophageal surgery. Acknowledgments We have to thank Dr. Peter McCulloch, from the center for evidence-based medicine (Oxford, UK), for his critical review of the manuscript. Conflict of interest
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13.
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16.
None. 17.
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