Taro Oshikiri1, Gosuke Takiguchi2, Naoki Urakawa2, Hiroshi Hasegawa2, Masashi Yamamoto2, Shingo Kanaji2, Kimihiro Yamashita2, Takeru Matsuda3, Tetsu Nakamura2, Satoshi Suzuki4, Yoshihiro Kakeji2. 1. Division of Gastrointestinal Surgery, Department of Surgery, Graduate School of Medicine, Kobe University, Kobe, Hyogo, Japan. oshikiri@med.kobe-u.ac.jp. 2. Division of Gastrointestinal Surgery, Department of Surgery, Graduate School of Medicine, Kobe University, Kobe, Hyogo, Japan. 3. Division of Minimally Invasive Surgery, Department of Surgery, Graduate School of Medicine, Kobe University, Kobe, Japan. 4. Division of Community Medicine and Medical Network, Department of Social Community Medicine and Health Science, Graduate School of Medicine, Kobe University, Kobe, Japan.
Abstract
BACKGROUND: Given the worldwide popularization of conventional minimally invasive esophagectomy (C-MIE), robot-assisted MIE (RAMIE) can be expected to provide a finer procedure. However, controversy remains regarding whether RAMIE is superior to C-MIE in preventing recurrent laryngeal nerve (RLN) palsy. Considering the shallow learning curve for RAMIE, a novel procedure for lymphadenectomy along the RLN during RAMIE is needed. METHODS: Based on a logical and simple understanding of the left upper mediastinum anatomy, the authors developed a novel "modified bascule method" for RAMIE that could simplify lymphadenectomy along the left RLN and prevent it from being touched and stretched. Between 2018 and 2020, 46 patients with esophageal carcinoma underwent RAMIE using this method at Kobe University. RESULTS: The modified bascule method was used to perform RAMIE for 29 men and 17 women with a median age of 67 years (range, 49-82 years). The median thoracoscopic procedure time was 438 min (range, 344-625 min), and the median console time was 351 min (range 273-518 min). The study harvested a median of 24 (range, 8-34) lymph nodes from the thoracic portion and 4 (range, 0-10) lymph nodes from along the left RLN. The mortality rate was 0%. Postoperative left RLN palsy classified as Clavien-Dindo (C-D) grade 1 or higher was observed for 9 patients (19%), whereas grade 2 or higher was not seen (0%). Pneumonia and anastomotic leakage rates higher than C-D grade 2 were respectively 13% and 19%. CONCLUSIONS: The novel modified bascule method for RAMIE can promote feasible lymphadenectomy along the left RLN even when performed during the learning period.
BACKGROUND: Given the worldwide popularization of conventional minimally invasive esophagectomy (C-MIE), robot-assisted MIE (RAMIE) can be expected to provide a finer procedure. However, controversy remains regarding whether RAMIE is superior to C-MIE in preventing recurrent laryngeal nerve (RLN) palsy. Considering the shallow learning curve for RAMIE, a novel procedure for lymphadenectomy along the RLN during RAMIE is needed. METHODS: Based on a logical and simple understanding of the left upper mediastinum anatomy, the authors developed a novel "modified bascule method" for RAMIE that could simplify lymphadenectomy along the left RLN and prevent it from being touched and stretched. Between 2018 and 2020, 46 patients with esophageal carcinoma underwent RAMIE using this method at Kobe University. RESULTS: The modified bascule method was used to perform RAMIE for 29 men and 17 women with a median age of 67 years (range, 49-82 years). The median thoracoscopic procedure time was 438 min (range, 344-625 min), and the median console time was 351 min (range 273-518 min). The study harvested a median of 24 (range, 8-34) lymph nodes from the thoracic portion and 4 (range, 0-10) lymph nodes from along the left RLN. The mortality rate was 0%. Postoperative left RLN palsy classified as Clavien-Dindo (C-D) grade 1 or higher was observed for 9 patients (19%), whereas grade 2 or higher was not seen (0%). Pneumonia and anastomotic leakage rates higher than C-D grade 2 were respectively 13% and 19%. CONCLUSIONS: The novel modified bascule method for RAMIE can promote feasible lymphadenectomy along the left RLN even when performed during the learning period.
Authors: B Feike Kingma; Peter P Grimminger; Pieter C van der Sluis; Marc J van Det; Ewout A Kouwenhoven; Yin-Kai Chao; Chun-Yi Tsai; Hans F Fuchs; Christiane J Bruns; Inderpal S Sarkaria; James D Luketich; Jan W Haveman; Boudewijn van Etten; Philip W Chiu; Shannon M Chan; Philippe Rouanet; Anne Mourregot; Jens-Peter Hölzen; Rubens A Sallum; Ivan Cecconello; Jan-Hendrik Egberts; Frank Benedix; Mark I van Berge Henegouwen; Suzanne S Gisbertz; Daniel Perez; Kristina Jansen; Michal Hubka; Donald E Low; Matthias Biebl; Johann Pratschke; Paul Turner; Kish Pursnani; Asif Chaudry; Myles Smith; Elena Mazza; Paolo Strignano; Jelle P Ruurda; Richard van Hillegersberg Journal: Ann Surg Date: 2020-11-09 Impact factor: 13.787