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Page 4 of 9 Peek et al. Mini-invasive Surg 2024;8:11 https://dx.doi.org/10.20517/2574-1225.2024.47

long-term survival by providing locoregional disease control and by reducing the risk of long-term
[13]
recurrence . At our practice, per National Comprehensive Cancer Network (NCCN) guidelines, patients
with T1b and T2 < 2 cm disease undergo surgical resection. Those with T2 > 2 cm disease or more advanced
stages receive neoadjuvant chemoradiation followed by an operation. Generally, all patients with N1 disease
or greater, regardless of T staging, undergo neoadjuvant therapy.

Informed consent is obtained. We implement a comprehensive enhanced recovery after surgery (ERAS)
protocol to ensure thorough perioperative care. This protocol at our institution allows patients to take an
active role in their healing process. ERAS patients typically leave the hospital sooner, recover quickly, and
experience fewer side effects. The program consists of four steps: preparing the patient for an operation,
managing patients’ expectations on the day of their operation, educating them about recovery in the
hospital, and recovery at home.

The surgeon discusses the operation’s specifics with the patient and family. All possible complications, such
as difficulties with swallowing, hoarseness, bleeding, infection, pneumonia, and inability to control the
disease, are thoroughly explained and documented for the patients. All patients require cardiac and
pulmonary clearances. If a patient smokes or drinks, She/He must stop four weeks before the operation.
Incentive spirometers are provided to improve lung function, and ambulation with a physical therapist is
encouraged. A diet and exercise plan is given to patients to best prepare them for the operation, which
includes bowel preparation.

The bowel preparation regimen begins two days before the operation. Patients are asked to stop all aspirin
or blood thinners seven days prior. Five days before the operation, patients begin taking immune-boosting
protein shakes. Two days before the operation, patients start a liquid diet and take their first bottle of Citrate
of Magnesia at 4:00 p.m. On the day before the operation, the patient follows a similar regimen and takes
the second bottle of Citrate of Magnesia, ensuring that the two bottles were taken 24 h apart. The patient
must refrain from eating or drinking anything after midnight.

On the day of the operation, the patient checks in two hours before the operation to undergo a surgical site
infection (SSI) protocol. This protocol may include chlorhexidine body wipes, oral rinse, teeth brushing,
and povidone intranasal swabs. SSIs related to robotic trocar incisions are generally minor and can be
resolved with antibiotics, even if they occur after the patient is discharged from the hospital. The protocol
also emphasizes pain management during the perioperative period, and our patients receive a preoperative
epidural injection of Duramorph in the operating room, along with goal-directed fluid management.

Operation set up and robotic instrumentation for THE
Patients are positioned supine on the operating table with their arms extended. Once general anesthesia is
administered, a nasogastric tube and a Foley catheter are inserted. The patient is then prepped from bedline
to bedline. Typically, the procedure involves orienting the patient in a 15-20-degree reverse Trendelenburg
position and a 5-degree rotation to the left. The operating room setup involves two teams, with two
surgeons participating in the operation: one at the bedside and one at the robotic console. The bedside
surgeon focuses on preparing the neck dissection, while the console surgeon handles both the peritoneal
and mediastinal dissections.

The operation requires using four robotic trocars: three with eight-millimeter incisions and one with a 12-
millimeter incision for the stapler device. Additionally, a single incision multi-trocar port is employed for
laparoscopic instruments through a 2-3 cm incision, consisting of up to four different trocars. A