• CMIE
• Left-shifted esophagus
• Narrow mediastinum
• RAMIE

• Esophageal cancer
• Minimally invasive esophagectomy
• Robot-assisted esophagectomy

• Humans
• Esophagectomy/methods
• Esophageal Neoplasms/surgery
• Esophageal Neoplasms/pathology
• Robotic Surgical Procedures/methods
• Male
• Female
• Middle Aged
• Prospective Studies
• Registries
• Aged
• Minimally Invasive Surgical Procedures/methods
• Follow-Up Studies
• Prognosis
• Postoperative Complications/epidemiology

• Esophageal carcinoma
• Esophageal perforation
• Treatment outcome

• Humans
• Esophageal Neoplasms/surgery
• Esophageal Neoplasms/complications
• Esophageal Perforation/surgery
• Esophageal Perforation/etiology
• Esophagoscopy
• Esophagectomy
• Prognosis

• esophageal cancer
• invasive minimally esophagectomy
• mid-term outcomes
• robotic-assisted
• video-assisted

• Digestive organ surgery
• Learning curve
• Robotic surgery
• da Vinci™ surgical system
• hinotori™ surgical system

• Humans
• Robotic Surgical Procedures/instrumentation
• Robotic Surgical Procedures/methods
• Retrospective Studies
• Male
• Female
• Middle Aged
• Aged
• Operative Time
• Gastrectomy/methods
• Gastrectomy/instrumentation
• Digestive System Surgical Procedures/methods
• Digestive System Surgical Procedures/instrumentation
• Learning Curve
• Pancreatectomy/methods
• Pancreatectomy/instrumentation
• Esophagectomy/methods
• Esophagectomy/instrumentation
• Adult

• Robotic
• minimally invasive surgery
• robot-assisted

• Humans
• Robotic Surgical Procedures/methods
• Laparoscopy/methods

• Long-term outcomes
• RAMIE
• RLNI
• Short-term outcomes

• esophageal cancer
• esophagectomy
• neoadjuvant chemoradiotherapy tumor positive resection margins

• gastrointestinal system
• minimally invasive surgery
• robotic surgery

• United States
• Humans
• Robotic Surgical Procedures
• Robotics
• Digestive System Surgical Procedures
• Stomach
• Rectum

• Boehmeria
• Esophageal Neoplasms/surgery
• Esophagectomy/methods
• Humans
• Minimally Invasive Surgical Procedures/methods
• Registries
• Robotic Surgical Procedures/methods
• Robotics
• Treatment Outcome

• McKeown
• esophagectomy
• meta-analysis
• minimally invasive
• oesophageal cancer
• robot-assisted

• NCCN
• esophageal cancer
• esophagectomy
• lymphadenectomy
• minimally invasive

Although the introduction of minimally invasive surgical techniques has improved surgical outcomes in recent decades, esophagectomy for esophageal cancer is still associated with severe complications and a high mortality rate. Robot-assisted surgery is already established in certain fields and robot-assisted esophagectomy may be a possible alternative to the standard minimally invasive esophagectomy. The goal of this study was to investigate whether robot assistance in esophagectomy can improve patient outcome while maintaining good oncological control.

Data of all patients who underwent minimally invasive esophagectomy between January 2018 and November 2021 at University Hospital Mannheim was collected retrospectively. Patients were divided into two cohorts according to operative technique (standard minimally invasive (MIE) vs. robot-assisted esophagectomy (RAMIE), and their outcomes compared. In a separate analysis, patients were propensity score matched according to age, gender and histological diagnosis, leading to 20 matching pairs.

95 patients were included in this study. Of those, 71 patients underwent robot-assisted esophagectomy and 24 patients underwent standard minimally invasive esophagectomy. Robot-assisted esophagectomy showed a lower incidence of general postoperative complications (52.1% vs. 79.2%, p=0.0198), surgical complications (42.3% vs. 75.0%, p=0.0055), a lower rate of anastomotic leakage (21.1% vs. 50.0%, p=0.0067), a lower Comprehensive Complication Index (median of 20.9 vs. 38.6, p=0.0065) as well as a shorter duration of hospital stay (median of 15 vs. 26 days, p=0.0012) and stay in the intensive care unit (median of 4 vs. 7 days, p=0.028) than standard minimally invasive surgery. After additionally matching RAMIE and MIE patients according to age, gender and diagnosis, we found significant improvement in the RAMIE group compared to the MIE group regarding the Comprehensive Complication Index (median of 20.9 vs. 38.6, p=0.0276), anastomotic leakage (20% vs. 55%, p=0.0484) and severe toxicity during neoadjuvant treatment (0 patients vs. 9 patients, p=0.005).

Robot-assisted surgery can significantly improve outcomes for patients with esophageal cancer. It may lead to a shorter hospital stay as well as lower rates of complications, including anastomotic leakage.

• Hector Stiftung

• Ivor Lewis
• RAMIE
• esophageal cancer
• esophagectomy
• robotic surgery

• da Vinci surgery
• esophagectomy
• learning curve

Robot-assisted minimally invasive esophagectomy (RAMIE) shows promising results regarding postoperative complications in patients with esophageal cancer. To date, no data are available regarding postoperative analgesic consumption. The aim of this work is to evaluate analgesic consumption after esophagectomy.

A total of 274 Ivor Lewis esophageal resections performed sequentially from January 2012 to December 2020 were evaluated. RAMIE cases (n = 51) were compared with the hybrid technique (laparoscopic abdominal phase followed by open thoracotomy, n = 59) and open abdominothoracic esophagectomy (OTE) (n = 164). Data were collected retrospectively. The primary endpoint was the overall postoperative morphine consumption, which represents a reliable indirect measurement of pain. Pain levels recorded on the first, third, and fifth postoperative days were assessed as secondary endpoints.

A total of 274 patients were included. The postoperative opioid consumption rate for patients who underwent RAMIE (quartiles: 0.14, 0.23, 0.36 mg morphine milligram equivalents (MME)/kg body weight (bw)/day) was significantly lower than in the open group (0.19, 0.33, 0.58 mg MME/kg bw/day, p = 0.016). The overall postoperative opioid consumption for patients who underwent RAMIE was significantly lower (2.45, 3.63, 7.20 mg MME/kg bw/day; morphine milligram equivalents per kilogram body weight) compared with the open (4.85, 8.59, 14.63 MME/kg bw/day, p < 0.0001) and hybrid (4.13, 6.84, 11.36 MME/kg bw/day, p = 0.008) groups. Patients who underwent RAMIE reported lower pain scores compared with the open group on the fifth postoperative day, both at rest (p = 0.004) and while performing activities (p < 0.001).

This study shows that patients who underwent RAMIE experienced similar postoperative pain while requiring significantly lower amounts of opioids compared with patients who underwent open and hybrid surgery. Further studies are required to verify the results.

The field of thoracic surgery is a rapidly developing field due to exciting developments in technology and oncologic treatments as well as continuous innovation in surgical technique. Although the population of Finland is relatively small, general thoracic surgery is represented at a high level in five centralized university centers, Helsinki University Hospital, Tampere University Hospital, Turku University Hospital, Kuopio University Hospital and Oulu University Hospital. Thus, high case volume and good results are achieved in these centers. Here, we describe a short history, current state and future prospects of the field of cardiothoracic surgery in Finland, with a focus on general thoracic surgery and the perspective of Helsinki University Hospital. From the field’s birth in Finland, marked by the first lobectomy, in the late 1930’s, it has grown and adapted more and more modern techniques such as totally minimally invasive esophagectomy and robotic lung cancer surgery. Nowadays, most of general thoracic surgery in Helsinki University Hospital is either minimally invasive or robotic and open surgery is the exception to the norm. Helsinki University Hospital has a strong presence in the European general thoracic surgery community and aims to do so in the future by investing on training & education, research and surgical innovation.

• Finland
• Thoracic surgery

Flexible endoscopy has an important part in the diagnosis and treatment of postoperative complications after oncologically intended esophagectomy. Endoscopy offers the possibility of effective therapy with minimal invasiveness at the same time, and the use of endoscopic therapy procedures can avoid re-operations. In this review we present the advantages of endoscopic treatment opportunities during the last 20 years regarding patients’ treatment after esophageal cancer resection. According to prevalence and clinical relevance, four relevant postoperative complications were identified and their endoscopic treatment procedures discussed. All endoscopic therapy procedures for anastomotic bleeding, anastomotic insufficiencies, anastomotic stenosis and postoperative delayed gastric emptying are presented, including innovative developments.

Background: Esophageal cancer (EC) is the sixth-leading cause of cancer-related deaths in the world. Esophagectomy is the most effective treatment for patients without invasion of adjacent organs or distant metastasis. Complications and relevant problems may occur in the early post-operative course or in a delayed fashion. Here, innovative endoscopic techniques for the treatment of postsurgical problems were developed during the past 20 years. Methods: Endoscopic treatment strategies for the following postoperative complications are presented: anastomotic bleeding, anastomotic insufficiency, delayed gastric passage and anastomotic stenosis. Based on a literature review covering the last two decades, therapeutic procedures are presented and analyzed. Results: Addressing the four complications mentioned, clipping, stenting, injection therapy, dilatation, and negative pressure therapy are successfully utilized as endoscopic treatment techniques today. Conclusion: Endoscopic treatment plays a major role in both early-postoperative and long-term aftercare. During the past 20 years, essential therapeutic measures have been established. A continuous development of these techniques in the field of endoscopy can be expected.

• endoscopic complication management
• esophageal cancer
• postsurgical complication

Esophageal submucosal tumors (SMTs) are rare heterogenous clinical entities. The surgical resection can be performed in different surgical approaches. However, the robotic surgical strategy is poorly documented in the treatment of SMTs. We present our series of operated esophageal SMTs approached via robotic-assisted surgery. Six patients with symptomatic esophageal submucosal tumors underwent robotic surgery within a 3-year period. The performed procedures were robotic-assisted enucleation, robotic esophagectomy (RAMIE) and reverse hybrid robotic esophagectomy. Patients’ clinical data, intra/postoperative outcomes, and histopathological features were retrieved from the institution’s prospective database. Five of six patients were scheduled for upfront surgery: four underwent robotic enucleation (three leiomyoma and one suspected GIST) and one underwent reverse hybrid robotic esophagectomy (suspected GIST). One patient, diagnosed with GIST, was treated with neoadjuvant Imatinib therapy, before undergoing a RAMIE. No major intra-operative complications were recorded. Median length of stay was 7 days (6–50), with a longer post-operative course in patients who underwent esophagectomy. Clavien–Dindo > 3a complications occurred in two patients, aspiration pneumonia and delayed gastric emptying. The final histopathological and immuno-histochemical diagnosis were leiomyoma, well-differentiated GIST, low-grade fibromyxoid sarcoma and Schwannoma. Robotic-assisted surgery seems to be a promising option for surgical treatment strategies of benign or borderline esophageal submucosal tumors.

• Esophageal submucosal tumor
• Robotic enucleation
• Robotic-assisted minimally invasive esophagectomy
• SMTs

Robotic surgery continues to grow in thoracic surgery, and currently plays an evolving role in esophagectomy. Robotic assisted minimally invasive esophagectomy (RAMIE) has continued to expand, with many institutions adapting the technique. As the overall experience continues to grow, new data is emerging in its support. We present our approach to this operation.

• Esophagectomy
• esophageal cancer
• minimally invasive
• robotic

To investigate the applications of robot-assisted surgery and its effect on surgical outcomes in orthopaedic trauma patients.

A search was performed in PubMed and Embase for articles in English, Dutch, German, or French, without restrictions on follow-up times, study size, or year of publication.

Studies were included if they investigated patients undergoing robot-assisted fracture fixation surgery for orthopaedic trauma.

Outcomes studied were operating time, fluoroscopy time/frequency, complications, functional outcomes, intraoperative blood loss, fracture healing, and screw placement accuracy. Critical appraisal was done by using the Methodological Index for Non-Randomized Studies.

Narrative review.

A total of 3832 hits were identified with the search and 8 studies were included with a combined total of 437 included patients, 3 retrospective cohort studies, 2 prospective cohort studies, 1 cohort study not otherwise specified, 1 case series, and 1 randomized controlled trial. Four studies investigated pelvic ring fractures, 3 studies investigated femur fractures, and 1 study investigated scaphoid fractures. Seven investigated percutaneous screw fixation and 1 studied intramedullary nail fixation. One robotic system was used across all studies, the TiRobot, and all procedures were performed in China. The limited evidence suggests that that robot-assisted orthopaedic trauma surgery may reduce operating time, use of fluoroscopy, intraoperative blood loss, and improve screw placement accuracy, but the overall quality of evidence was low with a high risk of bias. Robot-assisted fracture fixation does not appear to lead to better functional outcomes for the patient.

Level of evidence: III

• fracture fixation
• orthopaedic trauma
• robot-assisted
• systematic review
• trauma surgery

• Minimally invasive surgery
• Oesophageal surgery
• Survival analysis
• Thoracoscopy

• esophageal cancer
• long-term outcomes
• minimally invasive esophagectomy
• propensity score-matched
• robotic surgery

A gastrointestinal stromal tumor (GIST) often arises in the stomach and small intestine, while esophageal GIST is rare. The first-choice treatment is surgical resection, but there is no standard technique. Herein, we describe our experience in the treatment of esophageal GIST and discuss the usefulness of robotic esophagectomy.

The patient was a 60-year-old woman, who was diagnosed with a 30 mm GIST in the middle thoracic esophagus. We underwent robot-assisted thoracoscopic esophagectomy in the prone position. The duration of the thoracoscopic part was 69 min and the total operation time was 319 min. Total blood loss was 135 ml. The patient's postoperative course was uneventful after surgery and the patient was discharged home in good condition on the 18th postoperative day.

The prognosis of esophageal GIST was less favorable compared with gastric GIST, and due to the anatomical peculiarities of the esophagus, which surgical procedure should be performed is still under debate. Robotic surgery has several technological advantages as it provides a three-dimensional view, ten times magnification, tremor control, and ambidexterity. Therefore, Robotic-assisted minimally invasive esophagectomy (RAMIE) allows achieving for safe R0 resection of esophageal GIST.

RAMIE may be useful for esophageal GIST because it facilitates safe and minimally invasive surgery in a limited space of the thoracic cavity.

•

There is no standard technique due to the anatomical peculiarities of the esophagus.

• Esophageal gastrointestinal stromal tumor
• Esophagectomy
• Minimally invasive
• Robotic surgery

• Hybrid
• Minimally invasive
• Oesophageal cancer
• Oesophagectomy
• Robotic

• Esophageal cancer
• Esophagectomy
• Ivor Lewis
• Robotic
• Survival

Thoracolaparoscopic esophagectomy (TLE) for carcinoma esophagus has better short-term outcomes compared to open esophagectomy. The precise role of robot-assisted laparoscopic esophagectomy (RALE) is still evolving. Single center retrospective analysis of TLE and RALE performed for carcinoma esophagus between January 2015 and September 2018. Propensity score matching was done between the groups for age, gender, BMI, ASA grade, tumor location, neoadjuvant therapy, the extent of surgical resection (Ivor Lewis or McKeown’s), histopathological type (squamous cell carcinoma or adenocarcinoma), clinical T and N stages. The primary outcome parameter was lymph node yield. Secondary outcome parameters were resection margin status, duration of surgery, blood loss, conversion to open procedure, length of hospital stay, length of ICU stay, complications, 90-day mortality and cost. There were 90 patients in TLE and 25 patients in RALE group. After propensity matching, there were 22 patients in each group. The lymph node yield was similar in both the groups (23.95 ± 8.23 vs 22.73 ± 11.63; p = 0.688). There were no conversions or positive resection margins in either group. RALE was associated with longer operating duration (513.18 ± 91.23 min vs 444.77 ± 64.91 min; p = 0.006) and higher cost ($5271.75 ± 456.46 vs $4243.01 ± 474.64; p < 0.001) than TLE. Both were comparable in terms of blood loss (138.86 ± 31.20 ml vs 133.18 ± 34.80 ml; p = 0.572), Clavien-Dindo grade IIIa and above complications (13.64% vs 9.09%; p = 0.634), hospital stay (12.18 ± 6.35 days vs 12.73 ± 7.83 days; p = 0.801), ICU stay (4.91 ± 5.22 days vs 4.77 ± 4.81 days; p = 0.929) and mortality (0 vs 4.55%; p = 0.235). RALE is comparable to TLE in terms of short-term oncological and perioperative outcomes except for longer operating duration when performed for carcinoma esophagus. RALE is costlier than TLE.

• Carcinoma
• Esophagectomy
• Esophagus
• Laparoscopy
• Robot
• Thoracoscopy

• lymph node dissection
• robot-assisted minimally invasive oesophagectomy
• thoraco-laparoscopic minimally invasive oesophagectomy

• Robot-assisted minimally invasive esophagectomy (RAMIE)
• meta-analysis
• short-term clinical outcomes
• video-assisted minimally invasive esophagectomy

• oesophageal GIST
• oesophageal tumours
• robotic enucleation
• robotic oesophagectomy

• Esophagectomy
• Esophagus/surgery
• Humans
• Precancerous Conditions
• Retrospective Studies
• Robotic Surgical Procedures
• Treatment Outcome

• Da vinci
• Esophagectomy
• Minimally invasive esophagectomy
• RAMIE
• Robotics

Patients  with esophageal cancer  that invades adjacent structures (cT4b) are precluded from surgery and usually treated with definitive chemoradiotherapy (dCRT). dCRT might result in sufficient downstaging to enable a radical resection, possibly improving survival. This study aimed to assess the perioperative and oncologic outcomes of a salvage robot-assisted minimally invasive esophagectomy (RAMIE) in patients with cT4b esophageal cancer after dCRT.

Between June 2012 and November 2019, patients who underwent a RAMIE with a gastric conduit reconstruction after completion of dCRT for cT4b esophageal carcinoma were identified from a prospectively maintained surgical database at the University Medical Center Utrecht.

In total, 24 patients with a histopathologically confirmed T4b adenocarcinoma or squamous cell carcinoma of the esophagus were included. The adjacent organs involved were the tracheobronchial tree (67%), aorta (21%) or both (13%). No conversions or major intraoperative complications were observed. A radical resection was achieved in 22 patients (92%), and a pathologic complete response was observed in 13 (54%) patients. Postoperative grade 2 or higher complications occurred in 20 patients (83%). The disease-free survival at 24 months was 68% for the patients in whom a radical resection was achieved.

In patients with cT4b esophageal cancer treated with dCRT followed by a salvage RAMIE, a radical resection rate of 92% was achieved, with acceptable complications and promising survival rates. These results demonstrate the feasibility of a curative surgical treatment for patients with initially irresectable esophageal cancer but underscore the importance of a proper preoperative patient selection.

• Carcinoma esophagus
• Minimally invasive esophagectomy
• Neoadjuvant chemoradiation
• Robot-assisted esophagectomy
• Video-assisted thoracoscopic esophagectomy

Due to the difficulties in the intra-thoracic esophagogastric anastomosis creation, totally minimally invasive Ivor Lewis esophagectomy (MIE) did not encountered a large diffusion, preferring hybrid techniques or cervical anastomosis. Robot-assisted minimally invasive esophagectomy (RAMIE) has gained popularity due to an easy reproducibility of the open anastomotic technique. In this feasibility study, we described the RAMIE technique introduced in our Center, providing innovative details for a mechanical end-to-end anastomosis. With patient in prone position, esophagectomy is conducted through the meso-esophagus plan. Robotic hand-sewn purse-string is realized above Azygos vein. A 4-cm thoracotomy in the fifth intercostal space is performed by enlarging the trocar incision. The tubulization is performed to create an access pouch for the introduction of the circular stapler. After the creation of the end-to-end anastomosis, the access pouch is resected and a robotic over-sewn is realized. From January 2020 until July 2020, ten patients were enrolled. No restriction in term of age, BMI, ASA grade or previous surgery were applied. Median operative time was 700 min. R0 resection was achieved in all cases with a good lymph node harvesting. No anastomotic leak or stricture were observed. One chyle leak was treated conservatively. Median length of stay was 8 days and 90 days mortality was 0%. This study evidenced how robotic surgery allowed us to perform the same anastomosis of our open technique with good oncological results and morbidity and length of stay comparable with our previous results. Of note, longer operative time has been recorded. Further studies after the completion of the learning curve are necessary to address more definite conclusions.

• Ivor lewis
• RAMIE
• Robotic surgery

• Anastomosis, Surgical
• Boehmeria
• Esophageal Neoplasms/surgery
• Esophagectomy
• Feasibility Studies
• Humans
• Reproducibility of Results
• Retrospective Studies
• Robotic Surgical Procedures

• Università degli Studi di Verona

• bedside assistant
• esophageal cancer
• minimally invasive surgery
• robotic surgery

• RAMIE
• esophagectomy
• minimally invasive surgery
• robotics

• RAMIE
• esophageal cancer
• long-term survival
• recurrence pattern

• RAMIE
• intrathoracic anastomosis
• technique

• Esophageal squamous cell carcinoma
• Lymph node dissection
• Minimally invasive esophagectomy
• Recurrent laryngeal nerve
• Robot surgery

• Ivor-Lewis procedure
• oesophagectomy
• robotic esophagectomy