Thoracoscopic esophagectomy for esophageal cancer: Feasibility and safety of robotic assistance in the prone position

Objective

To assess the feasibility and safety of robot-assisted thoracoscopic esophagectomy for esophageal cancer in the prone position.

Methods

Twenty-one patients underwent robot-assisted thoracoscopic esophagectomy in the prone position by a surgical oncologist who had no prior experience with thoracoscopic esophagectomy. Hemodynamic and respiratory parameters were serially recorded to monitor changes in prone positioning.

Results

All thoracoscopic procedures were completed with a robot-assisted technique followed by cervical esophagogastrostomy. R0 resection was achieved in 20 patients (95.2%), and the number of dissected nodes was 38.0 ± 14.2. Robot console time was significantly reduced from 176.3 ± 12.3 minutes in the initial 6 patients (group 1) to 81.7 ± 16.5 minutes in the latter 15 patients (group 2) (P = .000). In group 2, there was less blood loss (P = .018), more patients could be extubated in the operating room (P = .004), and the number of dissected mediastinal nodes tended to be increased (P = .093). There was no incidence of pneumonia or 90-day mortality. Major complications included anastomotic leakage in 4 patients, vocal cord palsy in 6 patients, and intra-abdominal bleeding in 1 patient. The prone position led to an elevation of central venous pressure and mean pulmonary arterial pressure and a decrease in static lung compliance. However, cardiac index and mean arterial pressure were well maintained with the acceptable range of partial pressure of arterial oxygen and carbon dioxide.

Conclusion

Robotic assistance in the prone position is technically feasible and safe. Prone positioning was well tolerated, but preoperative risk assessment and meticulous anesthetic manipulation should be carried out.

CTSNet classification: 7, 28

Abbreviations and Acronyms: CI, cardiac index, CVP, central venous pressure, MIE, minimally invasive esophagectomy, MPAP, mean pulmonary arterial pressure, Pao₂, partial pressure of arterial oxygen, Paco₂, partial pressure of arterial carbon dioxide, pkAWP, peak airway pressure, plAWP, plateau airway pressures, ThE, thoracoscopic esophagectomy