Page 65 - Read Online

Page 14 of 18 Ninomiya et al. Mini-invasive Surg 2022;6:33 https://dx.doi.org/10.20517/2574-1225.2022.12

lower mediastinum (Q,R). The robotic image is vertically and horizontally inverted by camera rotation to create a similar operative view
to open thoracotomy. The left and upper sides of the monitor image are cranial and ventral, respectively. Encircled numeral corresponds
to the port or arm number. The lymphatic tissue for dissection is encircled by a white dotted line. A: Aorta; AA: assistant arm; AV:
azygos vein; D: diaphragm; E: esophagus; LH: left hand; LMB: left main bronchus; LRLN: left recurrent laryngeal nerve; MLN: metastatic
lymph node; P: pericardium; PA: pulmonary artery; PB: pulmonary branch from vagal nerve; RH: right hand; RMB: right main bronchus;
RRLN: right recurrent laryngeal nerve; S: suction; SCA: subclavian artery; T: trachea; TR: trachea retractor; VN: vagal nerve; TG: thyroid
gland; LPV: left pulmonary vein; TD: thoracic duct.

just distal of the branching point of pulmonary branches [Figure 4L]. Subcarinal lymph nodes were
dissected to expose the pericardium and bilateral main bronchus [Figure 4M and N].

Dissection around left pulmonary hilum and lower mediastinum
To expose the left pulmonary hilum, we inserted a vessel sealer from cranial side and used it with the left
hand [Figure 4O and P]. The usage of vessel sealer from cranial side enabled smooth dissection of left side
of the mediastinum at middle and lower mediastinum [Figure 4Q]. For exhaustive dissection, we transected
the thoracic duct and exposed the aortic wall by using a vessel sealer [Figure 4R].

Postoperative outcomes
We performed RATE in LDP in 58 cases from July 2018 to May 2021. The average robot set-up time
including port placement, console time, and thoracic blood loss was 23.3 ± 7.6 min, 255 ± 64 min, and
135 ± 126 g, respectively. We experienced no conversion to thoracotomy regardless of the tumor stage. The
majority of the patients, except those with stage IV disease, could achieve curative resection [Table 1]. We
experienced a case with an accidental pull out of the esophageal branch from descending aorta during
surgery. We successfully managed this serious aortic injury by direct suturing with the robotic platform
[Figure 5].

Postoperative complications with Clavien-Dindo classification grade over 2 included 11 (19.0%)
pneumonia, 4 (6.9%) recurrent laryngeal nerve palsy, 2 (3.4%) chylothorax, 14 (24.1%) anastomotic leakage,
and 4 (6.9%) acute respiratory distress syndrome. There were no specific complications related to the use of
a robot. We experienced one surgical mortality by postoperative aortic bleeding after a non-curative
operation for advanced esophageal cancer with extensive aortic invasion.

DISCUSSION
Camera rotation and manual hand control assignment in RATE in the LDP reproduced the surgical view
and manipulation achieved in open esophagectomy and TE in the LDP. In this manuscript, we present the
actual dissection procedure for esophageal cancer. We performed RATE in LDP for safe management of
intraoperative emergency and meticulous dissection of the upper mediastinum because LDP is recognized
as the optimal position for emergency thoracotomy in patients with serious tracheobronchial or major
vessel injuries [27,28] . Wide dissection is necessary in the long mediastinum for the curative surgery in
esophageal cancer, unlike pelvic surgery for rectal and gynecological malignancies. In esophageal cancer
surgery, upper mediastinal dissection is considered as the most important procedure because of the high
incidence of metastasis around bilateral RLN, which should be manipulated gently to prevent postoperative
hoarseness and mis-swallowing . Thus, we focused on the upper mediastinal dissection in TE or RATE.
[29]
Insertion of dissection scissors by the surgeon’s right hand from the dorsal and caudal directions by TE in
[27]
LDP enabled thorough dissection, especially in the left upper mediastinal region . We can reproduce the
dissection procedure of TE in LDP to perform RATE in LDP. Furthermore, the robotic platform has the
advantage of enabling the surgeon to perform precise procedures in a deep narrow area such as the left side