Page 72 - Read Online

Peek et al. Mini-invasive Surg 2024;8:11 https://dx.doi.org/10.20517/2574-1225.2024.47 Page 3 of 9

preoperative, perioperative, and postoperative phases. This includes analyzing motion and timing for
simulated training, establishing standardized grading systems, precisely placing surgical clips, interpreting
and processing images, delineating anatomical structures, detecting surgical instruments, and, in due
course, enabling surgical systems to adapt to dynamic conditions, mitigating physiological movements, and
augmenting surgical precision . Furthermore, personalized medicine and targeted therapies offer new
[18]
avenues for optimizing treatment strategies and improving survival rates for esophageal cancer patients. As
esophageal cancers undergo thorough genomic profiling, agents such as ramucirumab, trastuzumab, and
pembrolizumab are already used for treating esophageal carcinomas, reflecting this shift towards tailored
treatment approaches .
[19]

DISCUSSION AND METHODS
Our institution prefers the transhiatal approach, necessitating comprehensive knowledge of preoperative
patient readiness, pertinent surgical anatomy, and perioperative alterations. This is also largely because we
are located in the United States, where the histologic subtype adenocarcinoma is most prevalent. In 2012,
our facility conducted its inaugural robotic transhiatal esophagectomy (THE). Subsequently, our facility
transitioned the entire esophagectomy program from laparoscopic to RAMIE. This strategic shift aimed to
expand the pool of candidates eligible for minimally invasive surgery, capitalizing on the advantages offered
by the robotic platform. RAMIE has proven to be both safe and efficacious regarding oncological outcomes,
although proficiency in this approach requires overcoming a learning curve inherent to any novel surgical
[18]
technology. Mastery entails enhancements in operative time, blood loss, and lymph node retrieval .
Moreover, a recent comprehensive analysis conducted by our cohort using the National Surgical Quality
Improvement Program (NSQIP) database has underscored the safety and efficacy of the robotic approach in
THE. The findings reveal not only the safety of this approach but also its superiority in terms of oncologic
outcomes, as evidenced by a median survival exceeding 95 months . The following discussion will outline
[20]
our preferred institution’s approach to performing a robotic-assisted THE.

Robotic THE is undertaken using the following steps:
1. Patient preparation for THE
2. Operation set up and robotic instrumentation for THE
3. The THE operation set up
(1) Resection
1) Kocher maneuver
2) Crural and gastric dissection
3) Pyloromyotomy
4) Division of the left gastric vessels and lymphadenectomy
5) Mediastinal dissection and neck dissection
(2) Reconstruction
1) Creation of gastric conduit and gastric pull-up
2) Neck anastomosis and closure
3) Closure of esophageal hiatus
4) Postoperative patient management

Patient preparation for THE
The optimal treatment for esophageal cancer depends on the stage of the disease and typically involves a
combination of treatment modalities. All patients in our institution undergo staging with computed
tomography (CT), magnetic resonance imaging (MRI), endoscopic ultrasound/fine needle aspiration (EUS/
FNA), and positron emission tomography (PET)/CT. Neoadjuvant therapy has been shown to improve