Abstract
Background
The use of robot-assisted minimally invasive esophagectomy (RAMIE) in the prone position for esophageal cancer has been currently increasing worldwide. In future, as surgical-assisted robots become more widespread, it is estimated that only two methods of transthoracic approach will remain: RAMIE and open thoracotomy for thoracic esophageal cancer. RAMIE in the left lateral decubitus position (RAMIE-LLDP) has the same field of view as open thoracotomy, is safe in emergency situations, and provides education on open thoracotomy.
Methods
Between September 2020 and April 2024, RAMIE-LLDP was performed in 64 consecutive patients with esophageal cancer. RAMIE-LLDP was performed with the operating table rotated and tilted 45° to the ventral side under artificial pneumothorax. The hand-control setting of the surgical-assist robot system was reversed left to right when the Patient Cart was rolled from the same direction as the RAMIE in the prone position.
Results
The mean total surgery and console times during the thoracic procedure were 254-min overall and 225 min in the last 24 cases and 195-min overall and 178- min in the last 24 cases, respectively. The mean amount of blood loss was 203.4 g overall and 28.3 g in the last 24 cases. Postoperative recurrent laryngeal nerve palsy with Clavien–Dindo classification (CD) was ≥ 2 in six patients (9.4%). Postoperative pneumonia with CD ≥ 2 was observed in 11 patients (17.2%). Conversion to open thoracotomy was observed in three patients (4.7%). In all three patients, an immediate conversion to thoracotomy without patients’ position change was actually possible and no serious complications were noted. No mortality occurred within 30 days postoperatively.
Conclusion
RAMIE-LLDP which facilitates emergency thoracotomy has perioperative results comparable to those of conventional thoracoscopic esophagectomy and is educational for open surgery. RAMIE-LLDP is the safest and most optimal surgery for esophageal cancer.
Keywords: Left lateral decubitus position, Robot-assisted minimally invasive esophagectomy, Thoracoscopic esophagectomy, Esophageal cancer
In thoracic surgery, the surgeon stands on the patient’s dorsal side during right open thoracotomy for right lung cancer. Similarly, for esophageal cancer, the standard procedure was a right thoracotomy with the surgeon standing dorsal to the patient and the right-hand forceps parallel to the trachea and recurrent laryngeal nerve in the superior mediastinum. However, since Cuschieri et al. reported thoracoscopic surgery for esophageal cancer in 1992 [1], thoracoscopic surgery for esophageal cancer has gradually been performed worldwide. Since 1995, we have also introduced thoracoscopic surgery for esophageal cancer in the left lateral decubitus position to ensure safety for emergency thoracotomy and have reported the results [2–5]. In 2006, Palanivelu et al. reported thoracoscopic surgery for esophageal cancer with an artificial pneumothorax in the prone position [6], and minimally invasive esophagectomy (MIE) for esophageal cancer in the prone position has become popular worldwide. Subsequently, a randomized controlled trial of open thoracotomy versus MIE for esophageal cancer was conducted, and the results of MIE were reported to be comparable to those of open surgery in terms of long-term outcomes with fewer postoperative complications [7, 8]. The development of surgical-assisted robots has been underway since around 1990, and surgical-assisted robots became available in the USA in 2003. The first case of robot-assisted MIE (RAMIE) for esophageal cancer was reported in 2004 [9] and a series of RAMIE cases in the prone position using a surgical-assist robot was reported in 2006 [10]. The use of RAMIE in the prone position for treating esophageal cancer has been increasing worldwide. In Japan, it has been rapidly increasing since it was included in the insurance coverage in 2018. However, when emergency open thoracotomy is necessary for RAMIE in the prone position because of an accidental injury, RAMIE requires extra time to roll out the Patient Cart during emergency thoracotomy, which is longer and riskier than conventional MIE. This is even more pronounced in the case of major vessel injuries in the thoracic cavity. In future, as surgical-assisted robots become more widespread, it is estimated that only two methods of the transthoracic approach will remain: RAMIE and open thoracotomy for thoracic esophageal cancer. RAMIE in the left lateral decubitus position (RAMIE-LLDP), which has the same field of view as open thoracotomy, is safe for emergencies, provides education on open thoracotomy, and is easier to perform. However, as far as we searched PubMed in April 2024 using the keywords “robot-assisted minimally invasive esophagectomy” and “left lateral decubitus position,” we did not find any relevant reports. We report the details and results of the RAMIE-LLDP.
Materials and methods
Patients
This study investigated 64 consecutive patients with esophageal cancer who underwent RAMIE-LLDP at Osaka Metropolitan University Hospital between September 2020 and April 2024. All patients had esophageal cancer that was preoperatively diagnosed as amenable to radical resection preoperatively. Even if cervical lymph node metastasis was present, radical resection with additional cervical lymphadenectomy was deemed feasible. Patients with preoperative regional lymph node metastasis are generally treated with neoadjuvant chemotherapy. Patients were treated 2–3 times before surgery with either docetaxel (70/m2 day1) + cisplatin (70/m2 day1) + 5-fluorouracil (700/m2 day1–5) or cisplatin (80/m2 day1) + 5-fluorouracil (800/m2 day1–5) [11]. Patients with residual or recurrent lesions that were deemed resectable after chemoradiotherapy, at the patient’s request, underwent RAMIE-LLDP.
RAMIE-LLDP procedure
The patient was intubated with a left-sided double-lumen tube or a blocker-equipped single-lumen tube and maintained under anesthesia during the thoracic procedure with left unilateral ventilation. Using an operating table that could be rotated 20° to the left or right, the patient was placed in the left lateral decubitus position and inclined approximately 25° to the ventral side. Each time, the operating table was rotated 20° to the patient’s dorsal side to ensure emergency transition to open thoracotomy. Thoracic surgery was performed in a position in which the operating table was rotated from flat to the patient’s ventral side by 20° and finally, the patient was inclined to the ventral side by 45° (Fig. 1). Similar to conventional thoracoscopic surgery, the lung was collapsed with a 5–10-mmHg artificial pneumothorax and RAMIE-LLDP was performed.
Fig. 1.
A Patient is placed in the left lateral decubitus position and inclined approximately 25° to the ventral side. B Each time, the operating table is rotated 20° to the patient’s dorsal side to ensure that emergency transition to open thoracotomy is possible. C The operating table is rotated from flat to the patient’s ventral side by 20° and finally, the patient is inclined to the ventral side by 45°
The Da Vinci Xi surgical system™ (Intuitive Surgical Inc., Sunnyvale, CA, USA) was used in all patients. All RAMIE-LLDPs were performed by a single surgeon. For the initial 20 patients, the Patient Cart was rolled from the cranioventral side of the patient to provide free space on the patient’s dorsal side to allow for immediate emergency open thoracotomy. The port was placed between the 3rd, 5th, 7th, and 9th intercostal spaces on a line connecting the 3rd intercostal-midaxillary line and the 9th intercostal-inferior angle of scapula line (Fig. 2A). If the robot arm interference with the right upper arm of the patient was anticipated in a short-stature patient, the port was placed in the 4th, 6th, 8th, and 10th intercostal spaces along the same line. The surgeon’s left hand, camera scope, surgeon’s right hand, and forceps for maintaining the surgical field were assigned to the ports in that order from the head side. The assistant surgeon was positioned dorsal to the patient and the assistant port was placed on the 6th intercostal-the medial edge of the scapular line. Since the surgical field for the surgeon and assistant was reversed as in open thoracotomy, the assistant monitor was prepared on the patient’s ventral side and inverted to allow for eye-hand coordination. We confirmed that maximally lowering the Patient Clearance in the dry laboratory can amplify the range of forceps motion to the patient’s dorsal side by approximately 27° and that the robot arms reach well into the posterior mediastinum. For the initial 20 patients, we performed the RAMIE-LLDP by rolling in the Patient Cart from the opposite side of the RAMIE in the prone position. The Patient Clearance was lowered maximally to obtain the range of forceps motion on the patient’s dorsal side (Fig. 3). After the initial 20 patients, the Patient Cart was rolled from the craniodorsal side of the patient to perform RAMIE-LLDP with the hand-control setting of the Da Vinci Xi system reversed from left to right side (Fig. 4) and the direction of the camera changed. The port position remained the same; however, the assistant surgeons were positioned on opposite the ventral side of the patient due to assist in the development of the surgical field to the ventral side. To maintain eye-hand coordination, the assistant monitor was positioned on the patient's dorsal side. The assistant port was placed on the midclaviclar-5th intercostal line and an additional assistant port was placed on the midclaviclar-7th intercostal line after the case of conversion to open thoracotomy (Fig. 2B).
Fig. 2.
A For the initial 20 cases, the Patient Cart is rolled in from the cranioventral side of the patient. To maintain eye-hand coordination, the assistant monitor is positioned on the patient’s ventral side. B After the initial 20 cases, the Patient Cart is rolled in from the craniodorsal side of the patient. To maintain eye-hand coordination, the assistant monitor is positioned on the patient’s dorsal side
Fig. 3.
For the initial 20 cases, we performed RAMIE-LLDP with rolling in the Patient Cart from the opposite side of RAMIE in the prone position. The Patient Clearance (white arrow) maximally lowered in order to obtain the range of forceps motion to the patient’s dorsal side by approximately 27°
Fig. 4.
After the initial 20 cases, the patient cart is rolled in from the dorsal side of the patient to perform RAMIE-LLDP with the hand-control setting of Da Vinci Xi system reversed from left to right side (A, B)
Intraoperative neural monitoring (IONM) was performed in only eight patients using the NIM response® system 3.0 (Medtronic Inc. Jacksonville, FL, USA).
Statistical analysis
All statistical analyses were performed using Statistical Package for the Social Sciences version 27 (IBM, Armonk, NY, USA). The frequencies of the categorical variables were compared using Pearson’s chi-square test, whereas continuous variables were compared using the Mann–Whitney U test. A p-value of < 0.05 denoted statistical significance.
Results
Patient characteristics are summarized in Table 1. The median patient age was 72 (41–87) years and this study included 75% men. The median body mass index was 20.7 (16.2–28.9). The tumors were mainly located in the upper thoracic esophagus in 10 patients (15.6%), the middle thoracic esophagus in 24 patients (37.5%), the lower thoracic esophagus in 26 patients (40.6%), and the abdominal esophagus in four patients (6.3%). The histologic types of the tumors were squamous cell carcinoma in 53 patients (82.8%), adenocarcinoma in eight patients (12.5%), neuroendocrine carcinoma in two patients (3.1%), basaloid squamous cell carcinoma in one patient (1.6%), and gastrointestinal stromal tumor in one patient (1.6%). Neoadjuvant treatment was absent in 18 (28.1%) patients, chemotherapy in 43 (67.2%) patients, and chemoradiotherapy in five (7.8%) patients. In the cTNM and pTNM Stages (Union for International Cancer Control 8th edition), seven (10.9%) and four (6.3%) patients were Stage IVB, respectively, since patients with supraclavicular lymph node metastasis were included. Intraoperative neural monitoring was performed to avoid recurrent laryngeal nerve palsy in only eight patients (12.5%). The intubation tube used during anesthesia was a single-lumen tube with a blocker in 13 patients (20.3%) and a double-lumen tube for the left lung in 51 patients (79.7%). The Patient Cart was rolled from the patient’s ventral side in the initial 20 patients (31.2%) and from the patient’s dorsal side in 44 patients (68.8%).
Table 1.
Patient characteristics (n = 64)
| Age (years), mean, median (range) | 69.3, 72 (41–87) |
|---|---|
| Male, n (%) | 48 (75.0) |
| BMI, median (range) | 20.7(16.2–28.9) |
| Tumor location | |
| Ut / Mt / Lt / Ae, n (%) | 10 (15.6) / 24 (37.5) / 26 (40.6) / 4 (6.3) |
| Histologic findings | |
| SCC / Adeno / NEC / Basaloid / GIST, n (%) | 53 (82.8) / 8 (12.5) / 2 (3.1) / 1 (1.6) / 1 (1.6) |
| Neoadjuvant therapy | |
| None / Chemotherapy / Chemoradiotherapy, n (%) | 18 (28.1) / 43 (67.2) / 5 (7.8) |
| cTNM Stage (UICC 8th) | |
| 1 / II / III / IVA / IVB, n (%) | 11 (17.2) / 13 (20.3) / 31 (48.4) / 2 (3.1) / 7 (10.9) |
| pTNM Stage (UICC 8th) | |
| 0 / IA / IB / IIA / IIB / IIIA / IIIB / IVA / IVB, n (%) | 2 (3.1) / 3 (4.7) / 14 (21.9) / 6 (9.4) / 15 (23.4) / 3 (4.7) / 12 (18.9) / 5 (7.8) / 4 (6.3) |
| Lymphadenectomy | |
| None / Two fields / Three fields, n (%) | 2 (3.1) / 41 (64.1) / 21 (32.8) |
| Anastomosis site | |
| Cervical / Intrathoracic, n (%) | 63 (98.4) / 1 (1.6) |
| Reconstructed organ | |
| Stomach / Jejunum / ileo-colon, n (%) | 56 (87.5) / 0 (0) / 8 (12.5) |
| Two-stage operation, n (%) | 5 (7.8) |
| Intraoperative neural monitoring | |
| Yes / No, n (%) | 8 (12.5) / 54 (87.5) |
| Intubation tube for anesthesia | |
| Single lumen / Double lumen, n (%) | 13 (20.3) / 51 (79.7) |
| Roll in the direction of the patient cart, n (%) | |
| Ventral / Dorsal | 20 (31.2) / 44 (68.8) |
BMI body mass index, Ut upper thoracic esophagus, Mt middle thoracic esophagus, Lt lower thoracic esophagus, Ae abdominal esophagus, SCC squamous cell carcinoma, Adeno adenocarcinoma, NEC neuroendocrine carcinoma, Basaloid basaloid squamous cell carcinoma, GIST gastrointestinal stromal tumor, UICC 8th Union for International Cancer Control 8th edition
The surgical outcomes and postoperative complications are summarized in Table 2. The mean total surgery time during the thoracic procedure was 254.2 min overall, 340.1 min in the initial 20 patients, 283.8 min in the next 20 patients, and 224.6 min in the next 24 patients. Console time during the thoracic procedure averaged 194.7-min overall, 279.3 min in the initial 20 patients, 213.9 min in the next 20 patients, excluding the three patients with conversion to thoracotomy, and 177.9 min in the next 24 patients. Both the total surgery and console times during the thoracic procedure tended to shorten, but there was no significant difference among the three groups. The mean amount of blood loss during the thoracic procedure was 203.4-g overall, 76.7 g in the initial 20 patients, 378.5 g in the next 20 patients, and 28.3 g in the next 24 patients, significantly higher in the middle 20 patients. In one patient, the surgical-assisted robot system froze during the operation; however, it was restored after approximately 10 min by restarting the Da Vinci Xi system, and the surgery was performed without any problems. The median postoperative lengths of intensive care unit stay and hospital stay were 2 days (1–14 days) and 21 days (9–93 days), respectively. The median number of retrieved mediastinal lymph nodes was 22 (3–58). Postoperative complications of Clavien–Dindo classification [12] (CD) ≥ 2 were observed in 32 patients (50.0%) overall. Postoperative recurrent laryngeal nerve palsy with CD ≥ 1 was present in 14 patients (21.9%) and CD ≥ 2 in six patients (9.4%). Postoperative recurrent laryngeal nerve palsy was observed in one of eight patients (12.5%) who underwent IONM and in 13 of 54 patients (23.2%) who did not undergo IONM, with no significant difference. Postoperative pneumonia with CD ≥ 2 was observed in 11 patients (17.2%), anastomotic leakage with CD ≥ 2 in nine patients (14.1%), Chylothorax with CD ≥ 2 in one patient (1.6%), and no pulmonary thrombosis. Surgical site infections were observed in 14 patients (21.9%), including those with anastomotic leakage. Conversion to open thoracotomy was observed in three patients (4.7%), one with injury to the base of the left bronchial artery, one with azygos vein injury, and one with nocturnal ventilatory disturbance due to tracheal compression. The median time from the decision to converting to open surgery to open thoracotomy completion was 4.6 min (3.7–12.2 min). Conversion to thoracotomy occurred in only one of 51 patients with double-lumen tube placement, but it was significantly more common in two of 13 patients with a single-lumen tube with a blocker (p < 0.01). There were three patients (4.7%) of unscheduled reoperation within 30 days. One patient underwent thoracoscopic hemostasis for bleeding in the right thoracic cavity on the fourth postoperative day, one patient underwent laparotomy for a jejunostomy trouble, and one patient underwent laparotomy for anastomotic leakage of the colonojejunostomy during ileocecal reconstruction. There was no mortality within 30 days after surgery, but one patient died within 90 days after surgery.
Table 2.
Surgical outcomes and postoperative complications
| Total (n = 64) | Initial 20 cases (n = 20) | 20 cases after the initial 20 cases (n = 20) | 24 cases after the initial 40 cases (n = 24) | |
|---|---|---|---|---|
| Total time during thoracic procedure (min), mean ± SD | 254.2 ± 41.9 | 340.1 ± 70.3 | 283.8 ± 63.9 | 224.6 ± 44.3 |
| 251.5 ± 61.2 | ||||
| Console time during thoracic procedure (min), mean ± SD | 194.7 ± 23.7 | 279.3 ± 65.4 | 211.5 ± 42.8 | 177.9 ± 40.0 |
| 193.2 ± 43.2 | ||||
| Amount of blood loss during thoracic procedure (g), mean ± SD | 203.4 ± 247.6 | 76.7 ± 124.2 | 378.5 ± 945.4* | 28.3 ± 26.4 |
| 187.5 ± 653.0 | ||||
| Trouble of robot surgical system, n (%) | 1 (1.6) | 1 (1.6) | 0 (0) | 0 (0) |
| Postoperative length of ICU stay (days), median (range) | 2 (1–14) | 2 (1–2) | 2 (2–14) | 2 (2–2) |
| Postoperative length of hospital stay (days), median (range) | 21 (9–93) | 22 (16–59) | 19 (9–93) | 20 (14–40) |
| Number of retrieved mediastinal lymph nodes, median (range) | 22 (3–58) | 22 (10–40) | 20 (6–58) | 18 (6–39) |
| Overall postoperative complications (CD ≥ 2), n (%) | 32 (50.0) | 10 (50.0) | 11 (55.0) | 11 (45.8) |
| Recurrent laryngeal nerve paralysis | ||||
| CD ≥ 1 / CD ≥ 2, n (%) | 14 (21.9) / 6 (9.4) | 4 (20.0) / 2 (10.0) | 4 (20.0) / 3 (15.0) | 6 (25.0) / 1 (4.2) |
| IONM (+) / IONM (-), n (%) | 1 (12.5) / 13 (23.2) | 0 (0) / 3 (18.8) | 0 (0) / 4 (21.1) | 1 (25.0) / 5 (25.0) |
| Pneumonia (CD ≥ 2), n (%) | 11 (17.2) | 2 (10.0) | 5 (25.0) | 4 (16.7) |
| Anastomotic leakage (CD ≥ 2), n (%) | 9 (14.1) | 4 (20.0) | 4 (20.0) | 1 (4.2) |
| Chylothorax (CD ≥ 2), n (%) | 1 (1.6) | 0 (0) | 1 (1.6) | 0 (0) |
| Pulmonary thrombosis (CD ≥ 2), n (%) | 0 (0) | 0 (0) | 0 (0) | 0 (0) |
| SSI (CD ≥ 2), n (%) | 14 (21.9) | 5 (25.0) | 6 (30.0) | 3 (12.5) |
| Conversion to thoracotomy, n (%) | 3 (4.7) | 0 (0) | 3 (15) | 0 (0) |
| Single lumen / Double lumen, n (%) | 2 (25.0) / 1 (8.3)** | 0 (0) / 0 (0) | 2 (25.0) / 1 (8.3)** | 0 (0) / 0 (0) |
| Unscheduled reoperation within 30 days, n (%) | 3 (4.7) | 1 (5.0) | 2 (10.0) | 0 (0) |
| Mortality within 30 days, n (%) | 0 (0) | 0 (0) | 0 (0) | 0 (0) |
| Mortality within 90 days, n (%) | 1 (1.6) | 0 (0) | 1 (5.0) | 0 (0) |
SD standard deviation, ICU intensive care unit, CD Clavien–Dindo classification, IONM intraoperative neural monitoring, SSI surgical site infection
*Amount of blood loss during thoracic procedure was significantly greater in the middle 20 cases than in the early 20 cases and in the last 24 cases (p < 0.01)
**Conversion to thoracotomy was significantly more common in cases with a single-lumen tube than in cases with a double-lumen tube (p < 0.01)
Discussion
Esophageal cancer is the seventh leading cause of cancer and the sixth cause of cancer-related death worldwide [13]. Surgery remains the mainstay of treatment for resectable advanced esophageal cancer without distant metastasis in the 2020s [14]. The most important aspect of surgery is safety, and it is crucial that intraoperative accidents do not lead to serious postoperative complications. The thoracic cavity contains organs so important that they are surrounded by an armor called the thoracic cage, and the esophagus is adjacent to important organs such as the aorta, pulmonary artery, pulmonary vein, trachea, and bronchus. Therefore, endoscopic esophageal cancer surgery should facilitate emergency thoracotomy. To ensure safety, we have always performed thoracoscopic esophagectomy for esophageal cancer in the left lateral decubitus position. However, in the conventional thoracoscopic esophagectomy in the left lateral decubitus position, the assistant’s skill greatly affects the development of the surgical field, including lung compression. Conventional thoracoscopic esophagectomy in the prone position, where gravity facilitates lung compression, has come to dominate. With the development of surgical-assisted robots, thoracoscopic esophagectomy can now be performed from the patient's dorsal side with the patient tilted ventrally at a 45° position in the semi-lateral decubitus position to facilitate lung compression by gravity. In the left semi-lateral decubitus position, the surgeon needs to stand on the back of the patient, which is impossible for humans because of the strain on the lower back from bending forward. However, the surgical-assist robot makes this approach possible.
The major difference between robot-assisted surgery and conventional endoscopic surgeries is the significant reduction in tactile sensation, which is close to absence. The only part of the thoracic cavity where the forceps of the surgical-assist robot, which have a severely reduced sense of touch, is stuck to the vertebra. If the disadvantages of surgical-assisted robots are well understood, we believe that surgical-assisted robots will become more widely used in future. Conventional thoracoscopic esophagectomy for cancer will be replaced by robot-assisted surgery, leaving only two methods for the transthoracic approach: open thoracotomy and robot-assisted surgery. The RAMIE-LLDP, which is safe and educational as well as open thoracotomy, was considered desirable, and we performed it. In the initial 20 patients, the Patient Cart was rolled from the cranioventral side of the patient and in the remaining 44 patients, it was rolled from the craniodorsal side of the patient as RAMIE in the prone position. Both the total surgery and console times during the thoracic procedure were longer for patients rolled from the cranioventral side of the patient, but there was no significant difference. When all 64 patients were divided into three groups: (initial 20, next 20, and last 24), there was a gradual decrease in both the total surgery and console times during the thoracic procedure, but the difference was not significant. We considered that we were examining the learning curves. The total surgery time during the thoracic procedure for the last 24 cases was 224.6 min, far from the 84.2 min of the Chinese randomized controlled trial (RCT) (RAMIE trial) [15] but approaching the 170 min of the European RCT [16]. The amount of blood loss during the thoracic procedure was 203.4 g, higher than 120 g in the European RCT. In the middle 20 patients, conversion to thoracotomy was observed in three patients (4.7%), two of which were conversion due to hemorrhage, weighing 378.5 g. However, in the most recent 24 patients, the amount of blood loss was decreased to 28.3 g, and it is expected to be the same level in future with the accumulation of more cases. Of the three patients who underwent conversion, one patient with double-lumen tube placement had injuries at the base of the left bronchial artery, one patient with a single-lumen tube placement had an injury to the azygos vein causing the non-tactile forceps to move when it was hidden behind the ventilated lung after blocker displacement, and the other patient with a single-lumen tube placement had conversion to thoracotomy due to impaired ventilation after blocker dislocation by tracheal compression. Of the three patients who underwent conversion to thoracotomy, two (25.0%) out of eight patients with a single-lumen tube were significantly more than those (one [8.3%] out of 56 patients) with a double-lumen tube, suggesting that the double-lumen tube is safe for RAMIE-LLDP. A double-lumen tube was used in all the patients after the conversion to thoracotomy. In all three patients, an immediate conversion to open thoracotomy without patient’s position change was possible and did not develop into serious complications. Hence, we advocate that RAMIE-LLDP is safe.
The frequency of postoperative complications in RAMIE-LLDP is also generally similar to that of MIE as reported in the Japanese National Clinical Database [17]. In our procedure, the left sides of the middle and lower mediastinum were manipulated in the last phase, because it was performed from the cranial side to the caudal side, and the hand-control setting of the Da Vinci Xi surgical system and the direction of the camera were sometimes reversed in the same way as RAMIE in the prone position (Fig. 5). RAMIE-LLDP does not require a change in patient’s position, but only changes in the hand-control setting and direction of the camera, which enables hybrid surgery with the superior mediastinum in the left lateral decubitus position and the middle and lower mediastinum in the prone position, making ergonomic sense for right-handed surgeons, as proposed by Kaburagi et al. [18].
Fig. 5.
A The same surgical field as in conventional open surgery can be obtained and similar operations can be performed. In the superior mediastinum, the forceps for surgeon’s right hand is parallel to the trachea and left recurrent nerve, making it easier to perform the operation. B By simply reversing the hand-control setting and changing the direction of the camera, the same surgical field as that in the prone position can be obtained and the same surgery can be performed
In conclusion, RAMIE-LLDP which facilitates emergency thoracotomy, has comparable perioperative results and is suitable for open surgery because the surgical field is similar to that of open surgery. RAMIE-LLDP is the safest and most optimal surgery for esophageal cancer.
Acknowledgements
The authors thank the staff of Intuitive Surgical Inc. for their help in developing the RAMIE-LLDPs.
Author Contributions
SL conceived and designed the study, acquired, analyzed, and interpreted the data, confirmed the authenticity of the data, and drafted the manuscript. TTa, YM, SN, HM, and TI assisted with the surgery and analyzed the data. TTo, YM, HK, TF, and MS acquired and analyzed the data. KM contributed to the conception and design of the study and critically revised the manuscript. All the authors have read and approved the final version of the manuscript.
Funding
None.
Declarations
Disclosures
Drs. Lee S, Tamura T, Miki Y, Nishi S, Miyamoto H, Ishidate T, Kasashima H, Fukuoka T, Yoshii M, Shibutani M, Toyokawa T, and Maeda K have no conflicts of interest or financial ties to disclose.
Footnotes
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