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Na et al. Mini-invasive Surg 2024;8:31 https://dx.doi.org/10.20517/2574-1225.2024.10 Page 9 of 12

Following dissection up to the level of the thyroid gland, we proceed to remove the cervical paraesophageal
lymphatic tissues. The nerve and thyroid gland become visible, and most lymphatic tissues below the
thyroid gland are removed. As mentioned earlier, deep dissection to the anterior side of the trachea is
performed due to the presence of lymphatic tissues in this region.

In terms of radicality, left-side dissection is more extensive than the right side, increasing the likelihood of
nerve palsy. We refrain from fully skeletonizing the left RLN, preserving the posterior side tissue to protect
vascular structures and maintain the structural integrity of the nerve. After completing the LN dissection
along the left-side RLN, the entire course of the nerve and the tissue below the thyroid gland, between the
trachea and esophagus, is visible. The upper cervical area reveals a substantial, hollow space post-LN
dissection, with all nerves clearly visualized [Figure 4B].

For a more detailed understanding of the LN dissection along RLN, you can see videos in these links. (Right
side: https://www.youtube.com/watch?v=8hmRQJjt6JU. Left side: https://www.youtube.com/watch?v=
AAc1Urv0de4).

OUR CENTER’S EXPERIENCE
We published our early series of RE in 2016, comparing RE and VATS esophagectomy in terms of LN
numbers across different LN stations . This paper represents our initial experience, encompassing
[24]
approximately 70 cases of robotic surgery. Notably, the total number of harvested LNs along both RLN
tracts in this study was only 7. Despite the modest number, we observed a significant difference, leading us
to report a higher count of dissected LNs in RE compared to VATS esophagectomy in the total number of
dissected LNs (37.3 ± 17.1 vs. 28.7 ± 11.8; P = 0.003) and the number of LNs dissected from the upper
mediastinum (10.7 ± 9.7 vs. 6.3 ± 9.3; P = 0.032). Five-year overall survival was not different between the two
groups (69% in RE and 59% in VATS esophagectomy; P = 0.737).

After accumulating more cases in robotic surgery, we conducted a comprehensive analysis, reporting the
[37]
long-term outcomes in a recent publication . Our study included 178 patients who underwent robotic
surgery, representing an expansion from our previous work. After propensity score matching between the
RE group and open esophagectomy (OE) group, each group had 136 patients. At this juncture, the number
of LNs around both RLNs had increased to 10, a notable augmentation from the earlier count of 7. Each
side of recurrent laryngeal LN was dissected more in RE than in OE [Table 4]. The heightened emphasis on
recurrent laryngeal LN dissection in RE led to a significant reduction in LN recurrence compared to OE (RE
84.1% vs. OE 62.7%, P = 0.03). Moreover, the robotic surgery group demonstrated a noteworthy decrease in
major complications (RE 8.1% vs. OE 20.0%, P < 0.01), a primary contributor to non-cancer-related deaths
post-esophagectomy.

CONCLUSION
The LN dissection along RLN is a crucial step in esophageal surgery, especially in SqCC. Robotic assistance
is a useful tool for LN dissection along RLN. Increased harvesting yield and prevention of vocal cord palsy
are expected. However, a multi-center randomized clinical trial on this issue is necessary. Although the
effect of radical LN dissection on long-term survival is unclear, decreasing loco-regional recurrence and
potentially improving long-term survival is expected.