Surgical anatomy of the upper esophagus related to robot-assisted cervical esophagectomy.

Robot-assisted cervical esophagectomy (RACE) enables radical surgery for tumors of the middle and upper esophagus, avoiding a transthoracic approach. However, the cervical access, narrow working space, and complex topographic anatomy make this procedure particularly demanding. Our study offers a stepwise description of appropriate dissection planes and anatomical landmarks to facilitate RACE. Macroscopic dissections were performed on formaldehyde-fixed body donors (three females, three males), according to the surgical steps during RACE. The topographic anatomy and surgically relevant structures related to the cervical access route to the esophagus were described and illustrated, along with the complete mobilization of the cervical and upper thoracic segment. The carotid sheath, intercarotid fascia, and visceral fascia were identified as helpful landmarks, used as optimal dissection planes to approach the cervical esophagus and preserve the structures at risk (trachea, recurrent laryngeal nerves, thoracic duct, sympathetic trunk). While ventral dissection involved detachment of the esophagus from the tracheal cartilage and membranous part, the dorsal dissection plane comprised the prevertebral compartment harboring the thoracic duct and right intercosto-bronchial artery. On the left side, the esophagus was attached to the aortic arch by the aorto-esophageal ligament; on the right side, the esophagus was bordered by the azygos vein, right vagus nerve, and cardiac nerves. The stepwise, illustrated topographic anatomy addressed specific surgical demands and perspectives related to the left cervical approach and dissection of the esophagus, providing an anatomical basis to facilitate and safely implement the RACE procedure.

[Robot-Assisted Lung Surgery]. / Roboterassistierte Lungenchirurgie.

Anatomical lung resection is the standard treatment for patients with early-stage lung cancer. The conventional surgical techniques are thoracotomy and video-assisted thoracic surgery, but new methods have been added as technology has developed. The latest technological development is the robot-assisted anatomical lung resection. In this technique, a robot is used to perform an anatomical lobectomy or segmentectomy as well as lymph node dissection, as determined by oncological criteria. Comparison between the robot-assisted and video-assisted thoracic surgery is still of the greatest interest, since both minimally invasive approaches have their advantages and disadvantages. The aim of this work is to describe the development and performance of robot-assisted thoracic surgery, as well as the comparison with other surgical methods.

Technical details of the hand-sewn and circular-stapled anastomosis in robot-assisted minimally invasive esophagectomy.

The circular mechanical and hand-sewn intrathoracic anastomosis are most often used in robot-assisted minimally invasive esophagectomy (RAMIE). The aim of this study was to describe the technical details of both techniques that were pioneered in two high volume centers for RAMIE. A prospectively maintained database was used to identify patients with esophageal cancer who underwent RAMIE with intrathoracic anastomosis. The primary outcome was anastomotic leakage, which was analyzed using a moving average curve. For the hand-sewn anastomosis, video recordings were reviewed to evaluate number of sutures and distances between the anastomosis and the longitudinal staple line or gastric conduit tip. Between 2016 and 2019, a total of 68 patients with a hand-sewn anastomosis and 60 patients with a circular-stapled anastomosis were included in the study. For the hand-sewn anastomosis, the moving average curve for anastomotic leakage (including grade 1-3) started at a rate of 40% (cases 1-10) and ended at 10% (cases 59-68). For the circular-stapled anastomosis, the moving average started at 10% (cases 1-10) and ended at 20% (cases 51-60). This study showed the technical details and refinements that were applied in developing two different anastomotic techniques for RAMIE. Results markedly improved during the period of development with specific changes in technique for the hand-sewn anastomosis. The circular-stapled anastomosis showed a more stable rate of performance.

[Robot-assisted Minimally Invasive Oesophagectomy (RAMIE) - Setup, Port Placement, Stepwise Procedure Guide]. / Robotische Ösophaguresektion (RAMIE) ­ Setup, Port Placement, strukturierte OP-Schritte.

Robot-assisted minimally invasive oesophagectomy (RAMIE) can overcome the limitations of thoracoscopic surgery, particularly in the thoracic part of the operation. Thanks to more degrees of freedom of movement, anastomosis is simpler in the robotic procedure. In this work, we present our established full RAMIE-technique on the da Vinci Xi® system. Our technique is characterized by the incomplete formation of the gastric tube abdominally and an end-to-side anastomosis with a circular stapler.

Robotic-Assisted Sleeve Lobectomy Using the Four-Arm Technique in the DaVinci Si® and Xi® Systems.

Sleeve lobectomy (SL) makes it possible to resect centrally located lung carcinoma oncological correct while protecting healthy lung tissue. However, this procedure is often limited with conventional video-assisted thoracoscopic surgery, due to the limited mobility of the rigid and long instruments and the limited visualization. Therefore, these interventions are often still performed in the open conventional technique with the well-known disadvantages. Particularly in the reconstruction of the respiratory tract, precise sewing must be performed in a small space to avoid stenosis of the different diameter of the lumina. Robotic surgery offers several advantages through an enlarged three-dimensional view and flexibility of the robotic instruments, which are particularly evident when sewing. So far, there are only a few reports of robotic SL. Here, we describe our experience of performing robotic SL with four arms on both, the currently available DaVinci Xi® and Si® systems.

Robotic-assisted total mesorectal excision (TME) for rectal cancer results in a significantly higher quality of TME specimen compared to the laparoscopic approach-report of a single-center experience.

AIM: Robotic surgery allows for a better visualization and more precise dissection especially in the narrow male pelvis and mid and lower third of the rectum. However, superiority to laparoscopic TME has yet to be proven. We therefore analyzed short-term outcomes of laparoscopic and robotic low anterior rectal resection for rectal cancer. PATIENTS AND METHODS: From 2011 to 2016, 44 robotic (RTME) and 41 laparoscopic (LTME) low anterior rectal resection with total mesorectal excision were performed at a single institution. Specimen quality was assessed and reported by an independent pathologist following international guidelines. RESULTS: The groups did not differ significantly regarding gender, age, ASA stage, BMI, and distance of the lower tumor margin from the anal verge. More patients in the RTME group underwent preoperative chemoradiation (43.2 vs. 19.5%, p = 0.019). The quality of the TME specimen was significantly better in the RTME group (complete/nearly complete/incomplete for RTME 97/0/3% and for LTME 78/17/5%, p = 0.03). The conversion rate tended to be lower in the RTME group (7 vs. 17%, p = 0.143). There was no difference in CRM positivity between the groups. CONCLUSION: Robotic surgery is safe and can improve the quality of TME for rectal cancer compared to laparoscopy. Any effect on long-term survival remains to be established.

Detection of Circulating and Disseminated Tumor Cells and Their Prognostic Value under the Influence of Neoadjuvant Therapy in Esophageal Cancer Patients.

Detection of circulating (CTC) or disseminated tumor cells (DTC) are correlated with negative prognosis in esophageal cancer (EC) patients. In this study, DTC- and CTC-associated markers CK20 and DEFA5 were determined by RT-PCR in EC patients and correlated with clinical parameters to determine their prognostic impact. The blood and bone marrow (BM) of 216 EC patients after tumor resection with or without neoadjuvant therapy and as control blood samples from 38 healthy donors and BM from 24 patients with non-malignant diseases were analyzed. Both markers were detected in blood and BM of EC patients and the control cohort. A cut-off value was determined to define marker positivity for correlation with clinical data. CK20 expression was detected in 47/206 blood samples and in 49/147 BM samples of EC patients. DEFA5 positivity was determined in 96/206 blood samples and 98/147 BM samples, not correlating with overall survival (OS). However, CK20 positivity in BM and DEFA5 negativity in blood were associated with reduced OS in EC patients without neoadjuvant therapy, while in patients with neoadjuvant therapy DEFA5 positivity in BM was associated with improved OS. Overall, our study suggests DEFA5 as a prognostic biomarker in liquid biopsies of EC patients which requires further validation.

[Robot-assisted thoracic surgery-Areas of application and limitations]. / Roboterassistierte Thoraxchirurgie ­ Anwendungsgebiete und Limitationen.

The proportion of robot-assisted thoracic surgery (RATS) is continuously increasing. The main areas of clinical application are anatomical lung resections with lymphadenectomy and resection of mediastinal tumors. Especially in the area of the thymus robot-assisted procedures can now be considered the gold standard. Overall, the limitations of video-assisted thoracoscopic surgery (VATS) can be overcome by the use of robot-assisted surgery and thus a larger proportion of patients can be treated with minimally invasive procedures. The safety of the RATS procedure has been repeatedly demonstrated, although it remains difficult to demonstrate scientifically measurable benefits. With the introduction of new systems on the market further technical evolution and improvement can be expected in the future.

[Robotics in thoracic surgery]. / Robotik in der Thoraxchirurgie.

The number of interventions using robot-assisted thoracic surgery (RATS) is increasing in Germany, following the previous international development. Robot-assisted surgery provides some technical advantages and can overcome existing limitations of video-assisted thoracic surgery (VATS), especially in the case of extended resections, thus enabling the proportion of minimally invasive operations to be further increased. The safety of the procedure, even in extended resections, has repeatedly been demonstrated but whether there are clinically relevant benefits from RATS is currently the subject of scientific discussions. In addition, a further technical evolution of the RATS can be postulated by the upcoming market introduction of new robotic systems.

Robotic Roux-en-Y Gastric Bypass Procedure Guide.

PURPOSE: This is a step-by-step procedural guide to help new and unexperienced surgeons with the implementation of a robotic program for the surgical treatment of morbid obesity. METHODS: Based on our vast robotic experience, we present our standardized technique and also, with a PubMed research, discuss the different surgical aspects. RESULTS: We present our trainings pathway towards the first robotic Roux-en-Y gastric bypass, a step-by-step procedural guide with helpful hints when it comes to troubleshooting and also discuss some surgical aspects. CONCLUSION: The robotic Roux-en-Y gastric bypass is safe and feasible, and might offer some advantages in comparison to the laparoscopic approach.

Long-Term, Health-Related Quality of Life after Open and Robot-Assisted Ivor-Lewis Procedures-A Propensity Score-Matched Study.

Esophagectomies are among the most invasive surgical procedures that highly influence health-related quality of life (HRQoL). Recent improvements have helped to achieve longer survival. Therefore, long-term postoperative HRQoL needs to be emphasized in addition to classic criterions like morbidity and mortality. We aimed to compare short and long-term HRQoL after open transthoracic esophagectomies (OTEs) and robotic-assisted minimally invasive esophagectomies (RAMIEs) in patients suffering from esophageal adenocarcinoma. Prospectively collected HRQoL-data (from the European Organization for Research and Treatment of Cancer Core Quality of Life Questionnaire-C30 (EORTC QLQ-C30)) were correlated with clinical courses. Only patients suffering from minor postoperative complications (Clavien-Dindo Classification of < 2) after R0 Ivor-Lewis-procedures were included. Age, sex, body mass index (BMI), American Society of Anesthesiologists physical status-score (ASA-score), tumor stage, and perioperative therapy were used for propensity score matching (PSM). Twelve RAMIE and 29 OTE patients met the inclusion criteria. RAMIE patients reported significantly better emotional and social function while suffering from significantly less pain and less physical impairment four months after surgery. The long-term follow up confirmed the results. Long-term postoperative HRQoL and self-perception partly exceeded the levels of the healthy reference population. Minor operative trauma by robotic approaches resulted in significantly reduced physical impairments while improving HRQoL and self-perception, especially in the long-term. However, further long-term results are warranted to confirm this positive trend.

Current status and evolution of robotic-assisted thoracic surgery in Germany-results from a nationwide survey.

BACKGROUND: Robot-assisted surgery has made a significant entry into surgical practice within Germany, including thoracic surgery. As no published data exists regarding robotic-assisted thoracic surgery (RATS), we conducted a survey to investigate its current status. METHODS: We performed a nationwide survey of all centers active in RATS, using a standardized questionnaire. The annual number of operations, mean duration of surgery, docking time, length of hospital stay(s), conversions, chest tube duration, the RATS program start date, robot system used, operating room capacity, and staplers and instruments used were recorded. RESULTS: Of the 22 centers contacted, 14 responded. In total, 786 RATS interventions were recorded. Most were anatomical lung resections, comprising 372 (bi-) lobectomies and 80 segmentectomies. During the study period, eight bronchoplastic procedures were performed robotically. There were 93 wedge lung resections, 148 thymectomies, 26 sympathectomies, and 59 other RATS procedures, and a single-center series of around 1,000 RATS thymectomies (excluded from statistical analysis). The average incision-suture time of the RATS lobectomy was 245 (range, 80-419) minutes, average residence time seven days. The conversion rate was 6.7% across all interventions, with significant inter-intervention differences. All surveyed centers plan to further expand RATS, with OR capacity being a frequent impediment. Five RATS interventions were performed in Germany in 2013, versus 320 in 2018. CONCLUSIONS: Overall, RATS is becoming more established in everyday clinical practice in Germany. The number of operations, active centers, and trained RATS surgeons has increased steadily since 2013. A German-speaking operation course for entry into RATS already exists. Even extended resections can be carried out safely, and RATS has become standard procedure in some centers.