Robot-Assisted Transcervical Esophagectomy for Thoracic Esophageal Carcinoma

Abstract

Surgical approaches for thoracic esophageal cancer have evolved from invasive open procedures to minimally invasive techniques such as thoracoscopic and robot-assisted surgery. While robotic surgery offers improved precision and visualization, it still relies on single-lung ventilation and may not significantly reduce postoperative complications. Recently, transcervical esophagectomy (TCE) using a mediastinoscope has emerged as a promising alternative, enabling esophageal resection and lymphadenectomy via the neck without thoracic incisions. However, challenges such as recurrent laryngeal nerve palsy and limited reproducibility persist. Robot-assisted TCE addresses these issues by improving precision and reducing interference in the narrow mediastinum. Early studies, including the authors’ pilot work, have shown encouraging results. Despite its potential, comprehensive data on the short-term outcomes and safety of this technique remain limited. This study aims to introduce robot-assisted TCE for patients with thoracic esophageal carcinoma and compare its clinical benefits with those of transthoracic robot-assisted esophagectomy, thereby clarifying its role in the evolving field of esophageal cancer surgery.

Introduction

Over the past several decades, surgical treatment for thoracic esophageal cancer has undergone a profound transformation from extensive, invasive thoracotomy to refined, minimally invasive approaches. Until the 1990s, open surgery involving wide thoracic incisions was the gold standard; however, this often resulted in serious postoperative respiratory complications due to extensive trauma and limited intraoperative visualization.

The introduction and broad adoption of thoracoscopic surgery marked a major advancement, offering reduced surgical stress, faster recovery, and a more patient-friendly alternative. Building on this foundation, robot-assisted thoracoscopic esophagectomy further elevated surgical precision through 3-dimensional imaging and exceptional dexterity. Nevertheless, the necessity for single-lung ventilation and continued reliance on traditional techniques have limited its potential to reduce complications further.

A new frontier is now emerging: mediastinoscopic surgery, specifically transcervical esophagectomy (TCE) [1]. Although conceptualized decades ago, TCE has recently regained attention due to its capacity to facilitate both esophageal resection and lymphadenectomy without the need for thoracotomy or single-lung ventilation. The author’s group previously introduced a bilateral cervical approach, which enables superior mediastinal access through a genuinely minimally invasive route.

Studies have reported promising short-term outcomes with TCE, including fewer respiratory complications and reduced surgical burden. However, challenges remain, notably the risk of recurrent laryngeal nerve palsy due to the restricted anatomical space and limitations of conventional instruments. Furthermore, the reproducibility of the technique remains limited, lacking a standardized procedural approach.

Robot-assisted TCE represents a promising advancement in this field. Robotic systems offer articulated instruments and enhanced control, which are especially advantageous within the confined mediastinum. Compared to traditional mediastinoscopy, robotic TCE minimizes collateral tissue interference and improves nerve safety [2]. The author’s initial experiences with robotic TCE have confirmed its technical feasibility and safety, suggesting its potential as a next-generation surgical solution [2,3].

As robotic TCE gains momentum, the need for robust clinical evidence becomes increasingly urgent. While scattered reports have demonstrated its feasibility, comprehensive evaluations of its safety and short-term outcomes in well- defined patient populations remain scarce [2,3]. In this study, the author outlines specific robotic TCE surgical techniques and presents typical mediastinal views obtainable using these methods. The aim is to highlight the characteristics of robotic TCE and demonstrate the actual exposure of mediastinal anatomical landmarks. In summary, robot-assisted TCE is poised to redefine esophageal cancer surgery. Combining oncologic efficacy, technical precision, and reduced invasiveness, it may soon become a cornerstone of thoracic esophagectomy.

Technique

Robotic transcervical procedure

Neck port placement

Robot-assisted TCE was consistently performed with patients in the supine position, employing a bilateral cervical approach with the da Vinci Xi platform (Intuitive Surgical Inc.). Technical details of the cervical setup have been described previously [2].

In brief, a 3.5-cm skin incision was made along the natural fold at the medial border of the sternocleidomastoid muscle. The arrangement of robotic ports for robot-assisted TCE has been outlined in previous studies [3]. A single-site access port was utilized, through which 3 robotic instruments were introduced.

The cervical phase typically was initiated on the right side. An example of the right-sided robotic approach is shown in Fig. 1A. Dissection of the dorsal and ventral portions of the esophagus was performed using a vessel sealer, while meticulous dissection around the recurrent laryngeal nerve was executed with monopolar scissors.

Fig. 1.

Overview of port placement for bilateral cervical manipulation in robot-assisted cervical esophagectomy. (A) Photograph of port positioning, taken from the left side of the patient’s head, for the bilateral cervical approach. A GelPOINT access platform (Applied Medical Inc.) is placed in the bilateral cervical area, with the port positioned at the apex of an isosceles triangle oriented craniocaudally. (B) Photograph from the caudal side after port placement and robotic docking in the left cervical approach. Similar to the right cervical approach, the port is positioned at the apex of an isosceles triangle along the craniocaudal axis.

After completing the right cervical procedure, the robotic system was repositioned for the left-sided approach, as illustrated in Fig. 1B. Transcervical robotic dissection was conducted as previously described [2,3], enabling direct access to the tracheal bifurcation and epicardial surface, while facilitating systematic lymphadenectomy in the subcarinal region.

Transcervical mediastinal dissection

Representative surgical view of the right transcervical procedure

Figs. 2 and 3 show representative intraoperative views captured during the transcervical phase of the procedure (Supplementary Video 1). The bilateral transcervical approach typically began with right-sided cervical access. The initial dissection targeted the dorsal aspect of the esophagus and the anterior perivertebral fascia. This was followed by careful separation along the left dorsal esophageal plane until the thoracic duct was identified.

Fig. 2.

Typical surgical field and landmarks in robot-assisted cervical esophagectomy via the right cervical approach. (A) This image illustrates the initial stage of dorsal esophageal dissection via the right cervical approach. The procedure begins by detaching the fascia anterior to the vertebrae and adjacent to the right posterior aspect of the esophagus. Dissection then proceeds caudally along the natural plane of the organ sheath. (B) Dissection continues caudally along the organ sheath, now focusing on the left aspect of the esophagus while carefully preserving the thoracic duct (T-D). The descending aorta (DA) is revealed from the level of the aortic arch (AA). Notably, the lymphatic structures requiring removal are primarily located along the esophageal margin. Dissection of the dorsal esophagus continues downward to the mid-mediastinum. (C) Once dorsal esophageal dissection reaches the mid-mediastinum, attention is shifted to the lymph nodes surrounding the right recurrent laryngeal nerve (RLN-rt). These tissues enveloping the nerve are meticulously separated from both the trachea and the nerve itself. The procedure is then extended by gently peeling tissues away from the right lateral surface of the esophagus. (D) Following lymph node dissection around the RLN-rt, the surgical field is extended downward between the trachea and esophagus toward the subcarinal region. Provided the right recurrent nerve remains unaffected by instrument manipulation, the subcarinal lymph nodes are included in the dissection. Bro-rt, right bronchus; Bro-lt, left bronchus; CA, common carotid artery; Ve, vertebral column.

Fig. 3.

Typical surgical field and landmarks in robot-assisted cervical esophagectomy via the left cervical approach. (A) In the left cervical approach, dissection begins by separating the esophagus from the left side of the surrounding organ sheath. Fibrous tissues extending toward the left recurrent laryngeal nerve (RLN-lt) are carefully incised, effectively aligning and centralizing the esophagus and trachea within the surgical field. (B) The procedure then proceeds caudally, gradually exposing the left main bronchus and esophagus down to the level of the pericardium. As the left parietal pleura becomes visible, continuity is established with the dissection plane created from the right cervical side. This integration enables broader esophageal dissection from the middle to the lower mediastinum. (C) Subsequently, attention is shifted to the RLN-lt. By exposing the lateral aspect of the trachea, the surrounding connective tissues encasing the nerve are gently separated and dissected caudally. This facilitates the en bloc removal of both nerve-associated lymphatic tissue and adjacent structures with precise control. (D) The final view depicts the fully dissected region surrounding the RLN-lt. The left thyroid lobe is clearly visible on the left side of the image, and all connective tissue along the nerve—from the cervical region down into the thoracic cavity—has been meticulously removed. AA, aortic arch; CA, carotid artery; CS, cardiac sac; DA, descending aorta; Pv-inf-lf, left pulmonary vein inferior; Ve, vertebral column.

Dissection along the organ sheath and within the pneumomediastinum enabled safe exposure of the left thoracic duct while preserving its surrounding layer. Maintaining this anatomical plane, the dissection was continued caudally (Fig. 2A). As the procedure advanced downward, the descending aorta was exposed from the aortic arch, and dissection proceeded as far caudally as possible within this preserved layer.

Subsequently, dissection moved along the right lateral aspect of the esophagus, with careful attention to avoid breaching the thoracic cavity (Fig. 2B). Connective tissues around the recurrent laryngeal nerve—including attachments to the esophageal wall and the right side of the trachea—were then gently separated, enabling precise lymphadenectomy near the right recurrent laryngeal nerve (Fig. 2C).

Following this, the surgical field between the trachea and esophagus was developed. If the movement of surgical instruments caused minimal disruption to the surrounding nerves and the risk of recurrent nerve paralysis was considered low, additional lymph node dissection was performed around the tracheal bifurcation (Fig. 2D).

Representative surgical view of the left transcervical procedure

Following completion of the right transcervical dissection, the operation continued with the left-sided cervical approach. A representative intraoperative view of this phase is shown in Fig. 3. Dissection along the left lateral and posterior esophageal planes was conducted, smoothly integrating with the previously established layer from the right approach.

Preservation of the left recurrent laryngeal nerve was confirmed by direct visualization extending to the cervical level (Fig. 3A). Dissection then proceeded along the anterior and left walls of the esophagus, moving caudally beyond the left bronchial membrane. This facilitated exposure of the lateral left pleura and the ventral pericardium (Fig. 3B).

Subsequently, precise perineural dissection of the left recurrent laryngeal nerve was performed. Due to the direct visibility of the nerve throughout this phase, en bloc dissection of the nerve and its surrounding lymphatic tissues was feasible (Fig. 3C). Dissection was extended cranially to the vicinity of the left thyroid lobe.

Fig. 3D shows the surgical field following complete dissection of the left recurrent laryngeal nerve region, demonstrating clear anatomical delineation after en bloc resection.

Short-term postoperative outcomes

The short-term postoperative outcomes of this procedure across 50 cases were notably favorable. Remarkably, no in- hospital deaths occurred among patients who underwent robot-assisted cervical esophagectomy, and all patients were discharged without significant complications. The median postoperative hospital stay was 18 days (range, 12–91 days), underscoring the procedure’s overall safety and efficient recovery. Regarding complications, recurrent laryngeal nerve paralysis (Clavien-Dindo grade ≥1) occurred in 12.0% of cases, while postoperative pneumonia (grade ≥2) occurred in 6.0%. Anastomotic leakage was observed in 12.0% of cases (grade ≥1); however, all cases were successfully managed conservatively, without surgery, and no patients experienced gastric conduit necrosis—demonstrating the stability of the reconstructive approach. These outcomes collectively underscore the procedural reliability and clinical safety of the technique, offering promising implications for broader surgical application.

Discussion

TCE, increasingly recognized as a form of mediastinoscopic surgery, is gaining attention for its less invasive nature and clinical benefits. Unlike traditional thoracoscopic surgery, TCE avoids single-lung ventilation, reduces physiological stress, and enables simultaneous abdominal surgery due to the supine positioning of the patient. This approach is especially advantageous for patients with compromised lung function or thoracic adhesions. Robot-assisted TCE, using systems such as da Vinci, further augments surgical precision and safety, demonstrating promising short-term outcomes [2,3].

TCE is typically performed via a bilateral or left cervical approach. While the bilateral route enables more thorough lymph node dissection near the right recurrent laryngeal nerve, it also carries a higher risk of nerve injury. Conventional TCE faces limitations, particularly a high incidence (up to 50%) of recurrent nerve palsy due to the restricted mediastinal space and the use of straight forceps [1,4]. Intraoperative nerve monitoring can help reduce this risk but requires the minimal use of muscle relaxants, complicating combined cervicoabdominal procedures.

Robotic TCE mitigates many of these technical limitations, although its requirement for a large docking area often necessitates separating the abdominal and cervical phases. Despite these challenges, recent studies—including the largest of its kind—support the short-term safety and efficacy of robotic TCE [5]. While this report was limited by its single-center, retrospective design, the observed complication rates (12% nerve palsy, 6% respiratory issues) were within acceptable ranges.

In conclusion, robotic TCE represents a promising advancement in esophageal cancer surgery. Broader adoption may depend on future comparative studies evaluating both short- and long-term outcomes relative to conventional TCE and transthoracic robotic approaches.

Supplementary materials

Supplementary materials can be found via https://doi.org/10.5090/jcs.25.031. Supplementary Video 1. Video demonstration of bilateral cervical procedures in the RACE technique.

Funding Statement

Funding This research did not receive any specific funding from any agencies in the public, commercial, or not-for-profit sectors.