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measurement of quality of life metrics has been absent from almost all studies with one exception [105] , the
ROBOT trial. Ultimately, this information including complication rates and oncologic outcomes can help
patients make educated decisions.

Future innovations
Clearly there is a trend towards decreasing the invasiveness of esophageal resections. As surgeons’
minimally invasive skills improve, it is clear that surgical choices will steer away from hybrid procedures
to either completely minimally invasive or fully robotic techniques. Additionally, technology will allow
for surgeons to improve upon the most difficult portions of the procedure, advancing the overall flow
of the operation. For example, the mediastinal lymph node dissection is often suboptimal in transhiatal
esophagectomies given lack of direct visualization in the upper mediastinum. The need for a cervical
incision in transhiatal and McKeown esophagectomies can be morbid and increasingly prone to surgical
site infections given that the rest of the procedure can be performed with minimally invasive or robotic
fashion. In Japan, use of non-thoracic radical esophagectomy via the transcervical and transhiatal
approaches with mediastinoscopic devices has attempted to address these problems resulting in feasible
surgical outcomes [106-109] . This technique has been found to be especially helpful with squamous cell
carcinoma of the esophagus, the most common histology of esophageal cancer in Japan and Asia, and often
involving extensive mediastinal spread that can occur at an early age [107] . Additionally, esophagectomy with
mediastinal lymph node dissection, including the area along the recurrent laryngeal nerves, has become
the gold standard for radical surgical resection, however the view achieved with standard cervical incisions
has been limited [107] . The introduction of other novel minimally invasive techniques for the lymph node
dissection, such as the use of single port or robotic surgical devices, has expanded the options available to
achieve improved dissection and, ultimately, better oncologic outcomes [107] . There is no doubt that surgeons
will continue to optimize all parts of the esophagectomy operation to maximally streamline aspects of the
case in a minimally invasive fashion.

CONCLUSION
Today, surgical treatment strategies involving the use of open, thoracoscopic, laparoscopic, and robotic
[27]
techniques are routinely used to resect and reconstruct the esophagus . However, the need to decrease
the morbidity and mortality of open and hybrid surgical treatment for esophageal cancer has driven
the trend towards completely minimally invasive techniques for resection, and, more recently, robotic
assistance to perform esophagectomy. Robotic-assisted esophagectomy represents the newest innovation
in MIE with its own unique benefits and challenges; notably, the need for specific teaching programs and
proctored learning, both of which are mandatory. However, as more studies are completed which confirm
the lower incidence of major complications, and similar overall and disease-free survival compared to open
approaches, the use of robotic techniques to perform esophagectomy will likely become more common and
work alongside other proven techniques to deliver efficient oncologic care in the least invasive fashion.

DECLARATIONS
Authors’ contributions
Made substantial contributions to conception and design of the study and performed data analysis and
interpretation: Hasson RM, Fay KA, Phillips JD, Millington TM, Finley DJ
Performed data acquisition, as well as provided administrative, technical, and material support: Hasson
RM, Fay KA, Phillips JD

Availability of data and materials
Not applicable.