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Page 4 of 16 Hasson et al. Mini-invasive Surg 2020;4:46 I http://dx.doi.org/10.20517/2574-1225.2020.10

Table 1. Laparoscopic, thoracoscopic and robotic approaches to esophagectomy by
1. Hybrid laparoscopic with thoracoscopy-assisted/mini-thoracotomy 2-field IL esophagectomy
2. Hybrid transthoracic with laparotomy or hand-assisted laparoscopic 2-filed IL esophagectomy
3. Total laparoscopic and thoracoscopic 2-field IL esophagectomy
4. Hybrid laparoscopic with thoracotomy three-field McKeown esophagectomy
5. Hybrid thoracoscopic with laparotomy/hand-assisted laparoscopic three-filed McKeown esophagectomy
6. Total laparoscopic and thoracoscopic three-field McKeown esophagectomy
7. Total laparoscopic THE
8. Total laparoscopic inversion esophagectomy
9. Total laparoscopic Vagus-sparing esophagectomy
10. Combination of abdominal and thoracic phases using VATS/mini-thoracotomy/thoracotomy and laparoscopy/mini-laparotomy/hand port
or full laparotomy (so-called hybrid robotic esophagectomy)
11. Total robotic IL esophagectomy
12. Total robotic THE
13. Total robotic three-field McKeown esophagectomy

IL: Ivor Lewis; THE: transhiatal esophagectomy; VATS: video-assisted thoracoscopic surgery

approach [18,19] . Unfortunately, in practice, this procedure is performed less often, which limits its benefit to
the patient.

Minimally invasive techniques
High complication rates, longer recovery times, and the desire for a less invasive procedure is what led to
the innovation driving minimally invasive surgery. Specifically for esophagectomy, the definition of a MIE
includes varying thoracoscopic and laparoscopic approaches for esophageal resection based on the location
[22]
of the tumor, clinical stage, and patient characteristics [20,21] . In 1991, Dallemagne et al. first reported the
use of laparoscopy for a hiatal hernia repair, inspiring Cuschieri et al. [23,24] who utilized thoracoscopy for
[26]
[25]
esophagectomy in 1992. In 1993, Collard et al. sophisticated the technique, and, in 1995, DePaula et al.
was the first to perform a completely laparoscopic THE. Today, many different versions of MIE are
[27]
performed employing several combinations of approach using laparoscopic and thoracoscopic techniques
[Table 1, Items 1-9].

Indications for minimally-invasive esophageal resection approaches are similar to those for open
esophagectomy and include esophageal cancer, failure of endoscopic ablation and/or resection for high
grade dysplasia secondary to Barrett’s esophagitis, stricturing of the esophagus, and the sequelae of
[27]
achalasia and Chagas disease known as “burned out esophagus” . Relative contraindications to its use are
known extensive pleural or abdominal adhesions, with absolute contraindications involving the inability
to use single-lung ventilation because of previous resection or poor lung function. As expected, surgeon
comfort and experience have proven to be additional important factors.

Reviewing the operative steps of MIE, they are similar to robotic esophagectomy with the exception of
port placement and can help to better define the benefits of robotic approaches. In general, the benefits
have proven to be great. For minimally invasive IL esophagectomy, Levy et al. [28,29] and Luketich et al. best
[30]
described the operative steps including commencing with an abdominal phase to mobilize the stomach/
proximal duodenum and create the conduit. This is then followed by a thoracic phase where the specimen
is resected and anastomosis completed. Advantages include good oncologic “en bloc” lymph node
dissections of the stomach and thoracic esophagus, decreased incidence of anastomotic leak, and decreased
[27]
injury of the recurrent laryngeal nerve . Disadvantages include contamination of the chest, which can
lead to longer hospital stays, decreased quality of life if anastomotic leak occurs, and increased pulmonary
[27]
morbidity secondary to the need for single-lung ventilation .

[31]
Suzuki et al. best described the McKeown three-field esophagectomy using a minimally invasive
approach entailing a thoracic phase similar to a minimally invasive IL approach, an abdominal phase