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Page 2 of 11 Kikuchi et al. Mini-invasive Surg 2024;8:8 https://dx.doi.org/10.20517/2574-1225.2023.88

INTRODUCTION
Esophageal cancer is one of the leading causes of cancer-related deaths worldwide . In the Asia-Pacific
[1]
region, including Japan, the vast majority of esophageal cancers are squamous cell carcinomas (SCC)
located in the thoracic esophagus. The incidence of esophagogastric junction (EGJ) cancer has increased in
[2]
recent years, with most of them being adenocarcinomas (ADCs) . Esophagectomy with two- or three-field
lymphadenectomy plays a major role in treating resectable thoracic esophageal and EGJ cancers . However,
[3]
esophagectomy is a highly invasive procedure that can lead to severe postoperative morbidities including
pulmonary complications. Therefore, minimally-invasive esophagectomy (MIE) with a thoracoscopic and/
or laparoscopic approach has been developed and widely performed worldwide and reportedly contributed
[3-5]
to decreasing pulmonary complications . Recently, robot-assisted MIE (RAMIE) has made rapid progress
and has become widespread in its use in Japan since its insurance approval in 2018 . At our institute, we
[3,6]
implemented RAMIE in the semi-prone position using the da Vinci Xi system (Intuitive Surgical Inc.,
Sunnyvale, CA, USA) in October 2018 and improved and standardized surgical procedures to perform
curative, precise, and safe mediastinal lymphadenectomy and minimize postoperative complications.

In this technical note, we present standardized surgical techniques and short-term outcomes of RAMIE in
the semi-prone position for esophageal and EGJ cancers.

SURGICAL PROCEDURES
We performed RAMIE with two- or three-field lymphadenectomy in 91 patients with resectable thoracic
esophageal or EGJ cancers between October 2018 and March 2023. All RAMIEs were performed under
general anesthesia using a single-lumen endotracheal tube, and selective intubation was performed to block
the right lung. Following thoracic RAMIE, laparoscopic or open abdominal and cervical procedures were
performed. Bilateral cervical lymphadenectomy was performed for advanced and superficial SCC located in
the middle or upper thoracic esophagus, except for patients with high surgical risk and those registered in a
clinical trial [the Japan Clinical Oncology Group (JCOG) 2013] and assigned for esophagectomy without
prophylactic supraclavicular node dissection. The gastric conduit was mainly used for reconstruction in the
one-stage surgery, and the right colon was used in the second-stage surgery for patients with concomitant
gastric cancer or a history of gastrectomy. The posterior mediastinal route was mainly used for
reconstruction with the gastric conduit. The retrosternal or subcutaneous route was selected in some cases
because of their advanced tumor stage or poor general condition. The subcutaneous route was used for
reconstruction with the right colon. The cervical esophagus and gastric conduit or terminal ileum were
anastomosed using hand-suturing techniques. A feeding jejunostomy or gastrostomy was routinely
performed following reconstruction.

Patient position
Patients were originally placed on the operating table in a semi-prone position, with the right side of the
upper body slightly elevated on a bolster [Figure 1A]. Since June 2021, we have changed the patient
placement to a hybrid position by combining the left lateral decubitus and prone positions, which have been
[7]
used for conventional MIE at our institute . The patients were placed in the left semi-prone position, and
the operating table was rotated to simulate the left lateral decubitus position for open thoracotomy in an
emergency. They were moved to the semi-prone position by rotating the operating table, and then a slight
head-up position was made for RAMIE [Figure 1B]. Compared with the original semi-prone position, the
modified semi-prone position created a larger space between the anterior chest and the operating table
(yellow arrows, Figure 1A and B) and a slightly longer distance between the right arm and the fourth port
(blue arrows, Figure 1A and B), which increased the working space of the assistant surgeon outside the
patient and reduced the collision of the robotic fourth arm with the patient’s right arm.