Page 31 - Read Online

Page 2 of 8 Triantafyllou et al. Mini-invasive Surg 2023;7:31 https://dx.doi.org/10.20517/2574-1225.2023.48

minimally invasive approaches, and the morbidity and mortality rates after the resection remain high even
[1]
in specialised European centres (reported as 59% morbidity and 4.5% mortality, respectively) . More
precisely, anastomotic leak has long been considered to be one of the most fearful complications, with a rate
[2]
that varies in the literature between 10% and 35% . Two main benefits of the thoracic compared to the
cervical anastomosis have been outlined regardless of the technical approach: firstly, lower rates of
anastomotic leak, hence postoperative stenosis, secondary to preventing ischemia of the gastric conduit, and
secondly, a lower risk of damage to the recurrent laryngeal nerve .
[3,4]

Laparoscopic, thoracoscopic, robot-assisted, and hybrid techniques are evolving worldwide, aiming to
minimise the surgical complications. The emergence of robot-assisted minimally invasive esophagectomy
(RAMIE) has been welcomed internationally by high-volume surgical units with enthusiasm. Refinements
of the anastomotic technique through the robotic approach, either in terms of suturing or using novel
instruments and equipment, have the rationale to decrease the operative time, enhance the view of the
surgical field, and reduce the anastomotic leak rate. To date, these rates are in favour of the intrathoracic as
opposed to the cervical anastomosis; herein, many centres have almost inclusively adopted the Ivor Lewis
[5]
technique .

Since the presentation of the first minimally invasive esophagectomy (MIE), a variety of different
anastomotic techniques have been proposed, whereas there is increasing interest in establishing standard
[6]
technical steps in the form of recommendations and recently published guidance by experts on the field .
The current trends and technical details of the robot-assisted anastomotic techniques will be discussed in
this review.

PAST
Based on multicentre randomised trials (RCTs), the emergence of MIE has shown promising perioperative
and long-term results; hence, many esophageal surgeons worldwide have incorporated the technique
[7,8]
without compromising the oncologic outcome . RCTs have shown that apart from the improved quality of
life and lower rates of cardiopulmonary complications after MIE compared to the traditional resections, the
rate of anastomotic leak was found to be similar between totally MIE and open surgery [9,10] . Another
interesting finding of those older studies was the preference for a neck anastomosis in both surgical arms
(66% for the open resections and 64% for the minimally invasive, respectively).

The contributions of pioneers around the world have led to the evolution and advances in esophageal
surgery. From the open esophagectomy to the MIE, expert teams worldwide have presented their results
and the process of the learning curve in specialised centres [11-13] . RAMIE, initially introduced two decades
ago, is another evolving approach with promising results. The first robotic esophagectomy was attempted in
2002 by Melvin et al., while the first transhiatal RAMIE was successfully performed by Dr. Horgan more
than two decades ago [14,15] . The first robotic three-stage esophagectomy was reported a few years later. Since
then, the robotic procedures in the treatment of esophageal malignancy have become popular among
several centres worldwide [Figure 1].

According to previously published studies, the comparison of the perioperative and oncological outcomes
after traditional MIE and RAMIE has resulted in encouraging findings. The ROBOT trial compared RAMIE
to open esophagectomy, indicating accelerated perioperative recovery after RAMIE and equal oncological
outcomes . Furthermore, a meta-analysis collected the results of eight case-control studies and resulted in
[16]
similar results between MIE and RAMIE . In the past, other non-randomised studies have also shown no
[17]
clearly significant superiority of RAMIE over MIE; however, a trend towards more radical lymph node