Implementation of the robotic abdominal phase during robot-assisted minimally invasive esophagectomy (RAMIE): results from a high-volume center

BACKGROUND: Evidence on the added value of robotic-assistance in the abdominal phase during esophagectomy is scarce. In 2003, our center implemented the robotic thoracic phase for esophagectomy. In November 2018 the robot was also implemented in the abdominal phase. The aim of this study was to evaluate the implementation of the abdominal phase during robot-assisted minimally invasive esophagectomy (RAMIE). METHODS: Consecutive patients who underwent full RAMIE with intrathoracic anastomosis for esophageal cancer were included. Patients were extracted from a prospectively maintained institutional database. A cumulative sum (CUSUM) analysis was performed for abdominal operation time and abdominal lymph node yield. Intraoperative, postoperative and oncological outcomes including collected lymph nodes per abdominal lymph node station were reported. RESULTS: Between 2018 and 2021, 70 consecutive patients were included. The majority of the patients had an adenocarcinoma (n = 55, 77%) and underwent neoadjuvant chemo(radio)therapy (n = 65, 95%). The median operative time for the abdominal phase was 180 min (range 110–233). The CUSUM analysis for abdominal operation time showed a plateau at case 22. There were no intraoperative complications or conversions during the abdominal phase. The most common postoperative complications were pneumonia (n = 18, 26%) and anastomotic leakage (n = 14, 20%). Radical resection margins were achieved in 69 (99%) patients. The median total lymph node yield was 42 (range 23–83) and the median abdominal lymph node yield was 16 (range 2–43). The CUSUM analysis for abdominal lymph node yield showed a plateau at case 21. Most abdominal lymph nodes were collected from the left gastric artery (median 4, range 0–20). CONCLUSIONS: This study shows that a robotic abdominal phase was safely implemented for RAMIE without compromising intraoperative, postoperative and oncological outcomes. The learning curve is estimated to be 22 cases in a high-volume center with experienced upper GI robotic surgeons.