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Hasson et al. Mini-invasive Surg 2020;4:46 I http://dx.doi.org/10.20517/2574-1225.2020.10 Page 9 of 16

(67.5%) [27,41] . Regarding lymph node dissection, the mean ± SD was 18.5 ± 8.7, and the 30-day mortality was
2.5%. Interestingly, the authors reported using biologic mesh to reinforce the hiatus to address the issue of
postoperative diaphragmatic hernias, a step rarely performed today [27,41] . Others have also reported similar
[88]
outcomes [84-87] . More recently, Wecowski et al. prospectively reported their experience in incorporating
a robotic platform for transhiatal esophagectomy. Operative duration was 334 (364 ± 108.8) min, and
length of stay was 8 days. Morbidity rates were also fairly high and included respiratory failure requiring
[88]
intubation (20%), pneumonia (4%), surgical site infection (11%), renal insufficiency (2%), and UTI (2%) .
One patient died within 30 days secondary to cardiac arrest. The conversion rate was 9%, however none
were converted in the last 25 operations and blood loss also decreased over time from an initial average of
[88]
200 cc .
[89]
Kernstine et al. were the first to describe their completely robotic McKeown esophagectomy and
three-field lymphadenectomy experience. Their series included 14 patients, of whom eight underwent a
completely robotic operation [27,89] . The anastomotic leak rate was 7%, stricture rate 14%, and average blood
loss was 275 mL. Notably, the mean operating duration was 11.1 (660 min) ± 1.1 h [27,89] . More recently,
[69]
Sarkaria et al. described total robotic esophagectomy experience in 2012. In their cohort of 21 patients,
4 underwent McKeown esophagectomy and 17 underwent RAILE. The median operating time was 556
min and the conversion rate to an open procedure was 24%. The average blood loss was 307 mL while
the mortality rate was 5%. The anastomotic leak rate was clinically significant at 14%, and two patients
[69]
developed a gastrobronchial fistula secondary to a leak . Others have more recently reported their
outcomes and use of various techniques with similar results [71,90,91] .

Outcome comparisons of open, minimally invasive and robotic-assisted esophagectomy
Although review of independent outcomes in robotic surgery is important, comparing open esophagectomy
to minimally invasive approaches will help determine equality and/or superiority to current techniques. In
[92]
looking at open versus minimally invasive procedures, Naffouje et al. reported their results following a
propensity score-matched analysis using the NSQIP database evaluating participants who underwent OE
or MIE. One hundred sixty-one OTTE patients were matched with patients 1:1 who underwent minimally
invasive transthoracic esophagectomy. Higher completion rates of abdominal and mediastinal lymph node
dissections were appreciated in the OTTE subgroup (26.7% vs. 3.1% and 38.5% vs. 16.1%, respectively;
[92]
P < 0.001), and the mean operative times were also shorter (329 min vs. 414 min; P < 0.001) . Conversely,
higher rates of wound complications were appreciated in the OTTE population (7.5% vs. 1.9%), the median
hospitalization was longer (10 days vs. 8 days), more patients required discharge to a facility (18.0% vs.
8.1%), and the need for postoperative blood transfusion trended towards significance (13.0% vs. 6.8%;
P = 0.092). They concluded the OTTE cohort demonstrated higher complication rates (46.0% vs. 33.5%;
P = 0.028); however, there was no difference in the rates of negative margins, anastomotic leak, need for
[92]
reoperation, readmission, or mortality . The results were uniformly comparable when they evaluated
laparoscopic vs. robotic approaches, with the exception of higher rates of procured lymph nodes when
completed laparoscopically and higher rates of mediastinal lymph node procurement when using the
[92]
robotic approach .

[93]
Zhang et al. most recently compared minimally invasive to robotic esophagectomy. They included 66
matched pairs also using propensity score-matched cohorts, finding operative time in the RAILE group to
be significantly longer than that in the thoracoscopic-assisted Ivor Lewis (TAIL) group (302.0 ± 62.9 min
[93]
vs. 274.7 ± 38.0 min, P = 0.004) . There was no significant difference in the rates of overall complications
(28.8% vs. 24.2%, P = 0.554), blood loss {200.0 mL [interquartile range (IQR) 100.0-262.5 mL] vs.
200.0 mL (IQR 150.0-245.0 mL), P = 0.100}, length of stay [9.0 days (IQR 8.0-12.3 days) vs. 9.0 days (IQR 8.0-
11.3 days), P = 0.517], and total number of dissected lymph nodes (19.2 ± 9.2 vs. 19.3 ± 9.5, P = 0.955).
There were two conversions in the RAILE group, and there were no 30-day readmissions.