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Ackerman et al. Mini-invasive Surg 2021;5:14 https://dx.doi.org/10.20517/2574-1225.2021.02 Page 3 of 19

[18]
while an RAI of ≥ 37 had a PPV of 10.7% .

Disease specific
In addition to the aforementioned assessments, additional testing is performed selectively based on the
patient’s underlying ailment.

Malignancy
Once malignancy is confirmed by endoscopic biopsy, staging is completed with endoscopic ultrasound
(EUS), computed tomography (CT) with fluorodeoxyglucose-18 positron emission tomography (PET),
[19]
and/or staging laparoscopy with gastric extension . Upfront surgery is offered for selected patients with
node-negative clinical T1a or T1b tumors, and patients with T2 N0 disease. For patients with potentially
resectable disease that are clinically node-positive or at high-risk for node positivity (cT3-4), neoadjuvant
chemotherapy with or without radiation is performed before restaging and consideration for surgery.
Patients with local-regional disease unfit for surgery are treated with definitive chemoradiotherapy. This
approach echoes with that outlined by the American Society of Clinical Oncology in their recent
[20]
guideline .

Benign
Less commonly performed for benign indications than for malignant, esophagectomy remains a definitive
treatment for several conditions. End-stage achalasia, previously failed (often multiple) operations for
gastroesophageal reflux disease (GERD) and/or hiatal hernia, and trauma account for 84% of
[21]
esophagectomies for benign indications . Other less common indications in selected patients include
motility orders (diffuse esophageal spasm, scleroderma), strictures, benign tumors, spontaneous or
iatrogenic perforations, congenital anomalies, and caustic ingestion.

The preoperative workup is tailored to the exact benign indication. At a minimum, esophagoscopy and
fluoroscopic esophagram are required. Frequent additions include but are not limited to CT scans,
esophageal manometry, esophageal pH monitoring, endoscopic ultrasound, endobronchial ultrasound,
gastric emptying studies, and bronchoscopy.

OPERATIVE TECHNIQUE
Despite many technological advances, the principles and techniques of minimally invasive esophagectomy
at the University of Pittsburgh remain largely unchanged from Dr. Luketich’s early description in the
1990s [2,22-24] . Especially for those with prior minimally invasive esophageal surgery experience, the robotic
techniques described are largely an evolution of the traditional minimally invasive concepts rather than a
unique procedure, albeit with far more sophisticated instrumentation . Here, we describe in detail the Ivor
[25]
Lewis esophagectomy for malignant diseases and also discuss minor differences in procedures for benign
indications.

Pre-incision
Although often overlooked, the period prior to an incision should be used as an opportunity to maximize
the chances of a successful surgery. The team should review the case specifics ahead of time and outline a
clear plan for the conduct of the operation. Attention should be paid to emergency contingencies and plans
for such events should be verbalized.