Robotic-assisted thoracoscopic resection of esophageal leiomyoma

Robot-assisted resection of oesophageal leiomyoma: a single-centre retrospective analysis of 57 cases

BACKGROUNDS

Oesophageal leiomyoma is the most common benign tumour of the oesophagus, and complete tumour enucleation is the preferred treatment. The aim of this study is to evaluate the clinical application and technical advantages of Robotic-assisted Thoracoscopic Surgery (RATS) during the resection of oesophageal leiomyoma.

METHODS

A retrospective study was conducted on patients who underwent robotic surgery for oesophageal diseases at our hospital from September 2017 to December 2023. Demographic statistics and clinical pathological characteristics, intraoperative and postoperative outcomes, immune histopathological staining, tumour pathology diagnosis and follow-up were analyzed.

RESULTS

A total of 57 patients were enrolled in the study, including 42 males and 15 females with an average age of 49 years All patients received surgical treatment, with 54 patients undergoing robot-assisted resection of oesophageal tumour, one patient undergoing conversion to thoracotomy, and two patients undergoing exploratory surgery. The mean surgical time was 130 minutes, and the mean blood loss was 50 mL. Of the 55 patients who underwent tumour resection, 54 were pathologically diagnosed as oesophageal leiomyoma and one as atypical leiomyoma. Only one patient developed pulmonary infection after surgery, and there was no perioperative mortality. The average postoperative hospital stay was 9 days. All patients were followed up for a median time of 16 months (range: 1 to 70 months), and there was no recurrence or long-term complications after surgery.

CONCLUSION

Robot-assisted resection of oesophageal leiomyoma is safe and feasible, and can provide ideal short-and medium-term results.

Robotic-Assisted Minimally Invasive Resection of Multiple Oesophageal Schwannomas: A Case Report

Schwannomas are rare, benign tumours arising from Schwann cells, with oesophageal cases representing a small fraction. Their variety of symptoms and nonspecific imaging features often make preoperative diagnosis challenging, frequently requiring immunohistochemical staining for confirmation. We describe the case of a 62-year-old woman with progressive dysphagia, found to have a subepithelial mass at the gastroesophageal junction (GOJ). Imaging and endoscopic ultrasound-guided biopsy confirmed an oesophageal schwannoma. The patient underwent robotic-assisted thoracoscopic excision, which allowed for precise tumour removal while avoiding a more extensive oesophagectomy. Intraoperatively, two distinct lobular tumours were identified and successfully excised without compromising the oesophageal mucosa. Postoperatively, the patient recovered well with resolution of symptoms and no evidence of residual tumour on follow-up imaging. This case highlights the potential of robotic-assisted approaches for treating oesophageal schwannomas, which can offer advantages in complex resections by improving surgical precision and reducing morbidity. Despite promising outcomes, robotic-assisted enucleation of oesophageal schwannomas remains rare, with few cases documented. This case supports robotic resection of oesophageal schwannomas as a feasible option in specialized settings, but further studies are needed to establish its role and develop recommendations.

Surgical Treatment for Esophageal Leiomyoma: 13 Years of Experience in a High-Volume Tertiary Hospital

Background

Esophageal leiomyoma is the most common benign tumor in the esophagus. Thoracotomy and thoracoscopy are both elective for esophageal leiomyoma enucleation. This study aimed at presenting surgical experience in our center and exploring more suitable surgical methods for different situations.

Methods

We conducted this retrospective study by collecting data from patients who underwent esophageal leiomyoma enucleation through thoracotomy or thoracoscopy from January 2009 to November 2021 at West China Hospital Sichuan University.

Results

A total of 34 patients were enrolled for analysis. All patients were diagnosed with a single esophageal leiomyoma. There were 25 men and 9 women. The mean age was 44.41 years (range, 18–72 years), the mean longest diameter was 4.99 cm (range, 1.4–10 cm), and the esophagus was thoroughly circled with leiomyoma in 10 patients, 10 patients underwent thoracotomy to enucleate leiomyoma, while others underwent thoracoscopic enucleation. No perioperative deaths occurred. Between the thoracotomy group and thoracoscopy group, baseline characteristics were comparable except for gastric tube status (p = 0.034). Patients were inclined to undergo the left lateral surgery approach (p = 0.001) and suffered esophagus completely encircled by leiomyoma (p = 0.002). Multivariable logistic regression analysis demonstrated that the left lateral surgery approach (p = 0.014) and esophagus completely encircled by leiomyoma (p = 0.042) were risk factors for thoracotomy of leiomyoma enucleation, while a larger tumor size demonstrated no risk. The median follow-up time was 63.5 months, and no deaths or recurrence occurred during the follow-up period.

Conclusion

Thoracotomy enucleation of the leiomyoma was recommended when the esophagus was thoroughly encircled by the leiomyoma and the left lateral surgery approach was needed. However, tumor size demonstrated less value for selecting a surgical approach.

Robotic-assisted surgery for esophageal submucosal tumors: a single-center case series

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.

Robotic enucleation of oesophageal leiomyoma technique and surgical outcomes

Introduction:

Complete enucleation of oesophageal leiomyoma is the treatment of choice, traditionally performed by open surgery. Minimally invasive thoracoscopic approaches have been proposed as an alternative to thoracotomy. Robotic surgical systems with improved dexterity, tremor filtration and stereoscopic vision are advancement over conventional thoracoscopy and may make the preservation of mucosal integrity relatively easier. We present herein our technique of robotic-assisted thoracoscopic (RATS) enucleation of oesophageal leiomyoma along with surgical outcomes and intermediate follow-up of 11 cases.

Materials and Methods:

The present study retrospectively reviews patients undergoing robotic portal oesophageal leiomyomectomy from March 2012 to October 2019. The collected data were analysed for demographic details, clinical presentation, size, shape, tumour location, operating time, post-operative complications, length of hospital stay and recurrence on follow-up.

Results:

Twelve patients underwent robotic portal oesophageal leiomyomectomy with a clinical diagnosis of oesophageal leiomyoma. Of these, 11 patients were included in the study. The average operative time was 110 min, with a mean blood loss of 26 ml. There was no conversion in this series. At a median follow-up of 44 months (range 6–78 months), all patients were symptom-free with no recurrence or diverticula.

Conclusion:

Our series demonstrates the safety and feasibility of RATS oesophageal enucleation with good short and intermediate outcomes. In our opinion, the robotic system's technical advantages are particularly beneficial for oesophageal leiomyoma enucleation.

Robot-assisted enucleation of a giant submucosal tumor in the upper esophagus

Few reports have demonstrated robotic surgery for large tumors in the upper esophagus. We report a case of a 52-year-old woman with a giant submucosal tumor in the upper esophagus successfully enucleated using robotic surgery. She presented with odynophagia and dysphagia, with subsequent evaluation revealing a submucosal mass measuring approximately 10 cm in diameter in the upper esophagus. The mass was compressing the trachea and enlarged over 3 years. Endoscopic ultrasound fine needle aspiration of the tumor was non-diagnostic. Robot-assisted esophageal submucosal tumor enucleation was performed for diagnosis and treatment. Flexible forceps control allowed for a multi-directional approach to dissect the tumor and stable forceps handling was critical in this delicate procedure. Subsequent pathological review revealed a well-differentiated esophageal liposarcoma. While surgical margins were not entirely negative, the local recurrence rate of the tumor is low. At the patient's request, we decided to observe the patient without additional resection.

Robot-assisted thoracoscopic enucleation for a large esophageal leiomyoma: a case report

Background

Video-assisted thoracoscopic surgery (VATS) is being used to treat esophageal submucosal tumors (SMTs) all over the world. However, this technique is difficult when the tumor is large and located on the left side wall of the esophagus, within the upper mediastinum. This is because, with VATS, the surgical forceps have a limited range of motion. Robot-assisted thoracoscopic surgery (RATS) using the da Vinci surgical system may be extremely useful for enucleation of esophageal SMTs within the narrow upper mediastinum.

Case presentation

A female in her thirties experiencing epigastric pain visited our hospital and was diagnosed with a large esophageal leiomyoma within the upper mediastinum. From its size (10 cm), it was judged to have malignant potential. We performed SMT enucleation using RATS with a da Vinci surgical system Xi. This was our second case using this system. The patient was placed in the left lateral position. Four da Vinci trocars (8 mm) were inserted into the 10th, 7th, 5th and 3rd intercostal spaces (ICS), and an assist port was added in the 5th ICS. We opened the superior mediastinal pleura cranially and caudally from the arch of the azygos vein and expanded the superior mediastinum after dividing the azygos vein. We made an incision in the muscular layer of the esophagus and, using a monopolar hook and monopolar scissors, enucleated the esophageal tumor in a protective manner so as not to damage its capsule or mucosa while applying appropriate robot-specific counter traction. We then sewed up the muscularis using 4–0 Vicryl, inserting the endoscope into the thoracic esophagus to substitute for a bougie. In addition, the pleura was sutured using barbed suture. The surgical procedure was straightforward and smooth. The patient was discharged on postoperative day 4 with no surgical complications. The tumor was definitively diagnosed pathologically from paraffin sections as a benign esophageal leiomyoma.

Conclusions

RATS enables more delicate and precise esophageal SMT enucleation without surgical complications, though various challenges remain to be overcome.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40792-021-01212-9.

Robotic Thoracic Surgery

Minimally invasive surgery for diseases of the chest offsets the morbidity of painful thoracic incisions while allowing for meticulous dissection of major anatomic structures. This benefit translates to improved outcomes and recovery following the surgical management of benign and malignant esophageal pathologic condition, mediastinal tumors, and lung resections. This anatomic region is particularly amenable to a robotic approach given the fixed space and need for complex intracorporeal dissection. As robotic platforms continue to evolve, more complex thoracic surgical interventions will be facilitated, translating to improved outcomes for our patients.

[Leiomyoma of the esophagus : A further indication for robotic surgery?]

BACKGROUND

Leiomyomas of the esophagus are rare tumors but the most common benign lesion of the esophagus originating from smooth muscle cells. The symptoms are mainly determined by the size of the tumor and are caused by dysphagia and/or retrosternal pain. The majority of patients are however asymptomatic. The diagnostics include esophagoscopy, endosonography and chest computed tomography. Surgery is considered the treatment of choice and ideally involves enucleation of the tumor but may lead to esophagectomy. In addition to the classical open procedures, minimally invasive procedures are also used. Regardless of the selected procedure, a lesion of the mucosa should be avoided.

OBJECTIVE

A review of the literature on thoracoscopic and robotic resections in the treatment of leiomyomas was carried out and an illustration of a clinical case is presented.

MATERIAL AND METHODS

A review of minimally invasive surgical treatment of esophageal leiomyomas is presented. The literature search was carried out in PubMed for publications of thoracoscopic and robotic-assisted thoracic enucleation of leiomyomas of the esophagus. In addition, the robotic-assisted thoracic enucleation of a horseshoe-shaped leiomyoma in the middle third of the esophagus is described.

RESULTS

The enucleation of the esophageal leiomyoma was carried out through a right-sided robotic-assisted operation with one lung ventilation. The surgery time was 143 min. There were no intraoperative or postoperative complications. On the 3rd postoperative day a light diet was started and the thorax drainage was removed. Histopathology confirmed a leiomyoma. The patient was discharged on the 5th postoperative day and free of complaints.

CONCLUSION

Robotic-assisted surgery for leiomyomas of the esophagus is a safe procedure. Taking the available data into account, robotic-assisted thoracic enucleation of leiomyomas was characterized by less mucosal lesions, general complications and a lower conversion rate as well as a shorter hospital stay compared to classical thoracoscopic enucleation. Thus, robotic-assisted surgery can be the method of choice for leiomyomas of the esophagus.

Robot assisted thoracoscopic resection of giant esophageal leiomyoma

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Esophageal leiomyoma is most common benign esophageal tumor.

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Robot assisted surgery allows for resection of giant esophageal leiomyoma using minimally invasive approach.

INTRODUCTION

Esophageal leiomyoma represents the most common benign esophageal tumor. Robot-assisted thoracoscopic surgery has provided ability to remove it successfully using a minimally invasive approach.

PRESENTATION OF CASE

A 63-year old female with history of chronic chest pain presented with an esophageal mass on chest CT and endoscopic ultrasound. Robot-assisted surgery was performed using three robot arms, a camera and an assistant port. A 10 cm leiomyoma was enucleated and removed through a 2 cm myotomy. Completion endoscopy confirmed integrity of the esophagus. Patient's chest pain resolved postoperatively, and she was discharged on postoperative day 3.

DISCUSSION

Our case describes successful removal of the giant esophageal leiomyoma (10 cm) by robot assisted minimally invasive resection through a 2 cm myotomy.

CONCLUSION

Use of robot allows for removal of large esophageal leiomyoma. The improved dexterity and patient outcome offered by robot suggests its potential as the mainstay technique for giant esophageal leiomyoma removal.

Robotic benign esophageal procedures

Robotic master-slave devices can assist surgeons to perform minimally invasive esophageal operations with approaches that have already been demonstrated using laparoscopy and thoracoscopy. Robotic-assisted surgery for benign esophageal disease is described for the treatment of achalasia, epiphrenic diverticula, refractory reflux, paraesophageal hernias, duplication cysts, and benign esophageal masses, such as leiomyomas. Indications and contraindications for robotic surgery in benign esophageal disease should closely approximate the indications for laparoscopic and thoracoscopic procedures. Given the early application of the technology and paucity of clinical evidence, there are currently no procedures for which robotic esophageal surgery is the clinically proven preferred approach.

Robot-assisted gastrectomy and oesophagectomy for cancer

BACKGROUND

Robot-assisted surgery is a technically feasible alternative to open and laparoscopic surgery, which is being more frequently used in general surgery. We undertook this review to investigate whether robotic assistance provides a significant benefit for oesophagogastric cancer surgery.

METHODS

Electronic databases were searched for original English-language publications for robotic-assisted gastrectomy and oesophagectomy between January 1990 and October 2013.

RESULTS

Sixty-one publications were included. Thirty-five included gastrectomy, 31 included oesophagectomy and five included both operations. Several publications suggest that robot-assisted subtotal gastrectomy can be as safe and effective as an open or laparoscopic procedure, with equal outcomes with regard to the number of lymph nodes resected, overall morbidity and perioperative mortality, and length of hospital stay. Robotic assistance is associated with longer operation times but also with less blood loss in some reports. A significant benefit for robotic assistance has not been shown for the more extensive operations of oesophagectomy or total gastrectomy with D2-lymphadenectomy. There are very few oncologic data regarding local recurrence or long-term survival for any of the robotic operations.

CONCLUSIONS

No significant differences in morbidity, mortality or number of lymph node harvested have been shown between robot-assisted and laparoscopic gastrectomy or oesophagectomy. Robotic surgery, with its relatively short learning curve, may facilitate reproducible minimally invasive surgery in this field but operation times are reportedly longer and cost differences remain unclear. Randomized trials with oncologic outcomes and cost comparisons are needed.

Thoracoscopic enucleation of esophageal leiomyoma in prone position and single lumen endotracheal intubation

INTRODUCTION

Esophageal leiomyomas are the most common benign tumors of the esophagus. Surgical enucleation is warranted for symptomatic patients. Thoracoscopic enucleation is the preferable approach for being less invasive by avoiding the discomfort and complications associated to larger thoracic incisions. The purpose of this study was to review our experience with enucleation of esophageal leiomyoma using a prone-position thoracoscopy technique.

METHODS

Between January 2009 and July 2012, ten patients underwent resection of esophageal leiomyoma by thoracoscopy approach in prone position. Indications for surgical treatment were symptomatic tumors (dysphagia). All patients were followed postoperatively for at least 3 months with contrast x-ray of the esophagus. After single-lumen endotracheal intubation (nonselective intubation) in supine, patients were placed in prone position. Pneumothorax was kept at 6 to 8 mmHg using CO2 insufflation. A myotomy was performed over the tumor using hook cautery carefully protecting the mucosa from injuries. The myotomy was closed with continuous sutures.

RESULTS

The procedures were completed in the prone position in all cases, without any conversion. Mean operative time was 89.2 ± 28.7 minutes. Bleeding was negligible, and there were no intraoperative or postoperative complications. No intensive care unit support was needed for any patient. Chest x-ray in the first postoperative day showed no significant changes in any patient. The mean hospital stay was 3.2 days. Contrast x-ray of the esophagus was normal in all patients at 3 months postoperatively.

CONCLUSIONS

Thoracoscopic enucleation of esophageal leiomyoma is a feasible, simple, and safe procedure. Thoracoscopy in the prone position with CO2 insufflation allows the use of usual technique of intubation and also provides optimal operative field. The advantages of the thoracoscopic approach are less postoperative discomfort and lower risk of complications from open thoracotomy (especially pulmonary).

Robotic-assisted enucleation of a large lower esophageal leiomyoma and review of literature

Leiomyoma is the most common benign esophageal neoplasm. Different invasive surgical approaches have been described for management of such lesions. The literature is reviewed and a robotic assisted left thoracoscopic enucleation with the patient in the right side position is described. A 40-year-old male patient, otherwise healthy, found to have a lower midiastinal mass on screening X-ray, is described. Physical examination and blood tests were within normal limits. Diagnostic work-up included: computerized tomography (CT) scanning of the chest and midiastinum that revealed a 40 × 30 mm mass of the distal esophagus, an upper gastrointestinal endoscopy showed a lower protruding esophageal submucosal mass with intact mucosa, a filling defect was apparent on esophagography. Endoscopic ultrasonography (EUS) showed the same findings, biopsies were taken and leimyoma was diagnosed. Under general anesthesia with a double-lumen endotracheal tube, the patient was positioned on his right side. A 30 robotic scope was introduced in the left 7th intercostal space on the posterior axillary line. Two 8-mm robotic trocars were inserted in the left 5th and 9th intercostals spaces on the same line. Operative field was clearly exposed and an additional 5-mm ethicon trocar was inserted. The inferior pulmonary ligament was released, the parietal pleural space opened, proximal and distal control was achieved using Penrose. The muscular layer of the lower esophagus was opened by coagulation hook, the lesion was enucleated without mucosal penetration. Intraoperative endoscopy permitted localization of the lesion and ensured mucosal integrity. The muscular layer was not closed and the chest drain was left. Total operative time was 200 min and blood loss was less than 20 mL. A Gastrograffin swallow on the first post-operative day showed good esophageal clearance and absence of leak, the patient was allowed a liquid diet. He was discharged on the third post-operative day in a good general condition, benign pathology was confirmed.

Robot-assisted thoracoscopic surgery: current status and prospects

The most favorable advantage of robotic surgery is the markedly free movement of joint-equipped robotic forceps under 3-dimensional high-vision. Accurate operation makes complex procedures straightforward, and may overcome weak points of the previous thoracoscopic surgery. The efficiency and safety improves with acquiring skills. However, the spread of robotic surgery in the general thoracic surgery field has been delayed compared to those in other fields. The surgical indications include primary lung cancer, thymic diseases, and mediastinal tumors, but it is unclear whether the technical advantages felt by operators are directly connected to merits for patients. Moreover, problems concerning the cost and education have not been solved. Although evidence is insufficient for robotic thoracic surgery, it may be an extension of thoracoscopic surgery, and reports showing its usefulness for primary lung cancer, myasthenia gravis, and thymoma have been accumulating. Advancing robot technology has a possibility to markedly change general thoracic surgery.

Esophageal fibroma: a report of one case

Fibroma is a benign tumor derived from fibrous connective tissue. Esophageal fibroma is a very rare form of benign esophageal tumor. Here, we report a case of esophageal fibroma in a 41-year-old female and review the relevant literature.

Robotic Fourth-Arm Enucleation of an Esophageal Leiomyoma and Review of Literature

Esophageal leiomyomas are resected in symptomatic and/or malignancy-suspicious cases. Traditionally, they have been removed by laparotomy or thoracotomy and more recently by thoracoscopy and laparoscopy. Mucosal injury is reported as high as 7% of cases but may be higher in unreported general practice. Robotic technology seems to offer advantages. We describe a robotic approach that seems to minimize mobilization of the esophagus, potentially decreasing the likelihood of mucosal injury and postoperative recovery time. We review the literature to evaluate the reports of mucosal injury with the open, minimally invasive, and robotic techniques and describe our own method. To improve efficiency, we use a four-arm technique.

Enucleation of a leiomyoma of the mid-esophagus through a right thoracoscopy with the patient in prone position

BACKGROUND

Leiomyoma is the most common benign esophageal neoplasm. Different open and minimally invasive approaches have been described. We describe a right thoracoscopic enucleation with the patient in the prone position.

METHOD

A 49-year-old woman consulted us about solid-diet dysphagia without other symptoms. Preoperative work-up showed the presence of 50 x 28-mm leiomyoma of the middle esophagus, without satellite lymph nodes. The patient underwent general anesthesia with a double-lumen endotracheal tube, and subsequently was placed in the prone position. A 30 degrees scope was introduced in the right 7th intercostal space on the posterior axillary line. Perioperative gastroscopy permitted localization of the lesion, which appeared to be situated at the level of the azygos vein. Two 5-mm trocars were inserted in the right 5th and 9th intercostal spaces on one line with the first one. The azygos vein was ligated. The muscular layer of the mid-esophagus was opened by coagulating hook. Due to a 2-mm trocarless Cadière's forceps (Microfrance, France), introduced into the right 7th intercostal space, the operative field was well exposed and the lesion was enucleated without mucosal perforation. The muscular layer was closed by interrupted silk 2/0 stitches. A drain was left in the chest cavity.

RESULTS

Total operative time was 85 min and blood loss was less than 20 ml. The gastrograffin swallow on postoperative day 2 showed good clearance of the esophagus and absence of leak, hence the patient was allowed a liquid diet. The patient was discharged on postoperative day 3. Benign pathology was confirmed.

CONCLUSION

Thoracoscopy in the prone position permits the surgeon to reach the esophagus under excellent working conditions, despite an only partially deflated lung. Gravity displaces blood loss eventually, which allows good visualization, and the surgeon can operate in an ergonomic position. This approach allows for fewer trocars which favorably influences the patient's comfort and reduces the length of hospital stay.

Thoracoscopic enucleation of esophageal leiomyoma: a retrospective study on 40 cases

Esophageal leiomyoma is the most common benign esophageal tumor. Thoracoscopic enucleation is currently a preferred approach to most of these lesions. We present our experiences of enucleation of these tumors using thoracoscopic approach. A retrospective review of 40 patients who underwent enucleation of esophageal leiomyoma from 1997 to 2007 in our institute was conducted. Presenting symptoms, operative approach, tumor size, tumor shape, outcomes, and indication for this approach were analyzed. Forty patients were identified. Postoperative histopathology confirmed the leiomyoma in all patients. The thoracoscopic enucleation was completed in 34 cases, and the operation was converted to open procedure in six cases. Reasons for conversion included too small tumors to be visualized in two cases, thoracic cavity adhesion in one case, and the too large tumors in three cases. The median operating time was 70 min (50 to 210 min). Mean tumor size was 3.7 cm (0.5-10 cm). There were no major postoperative complications. Symptoms especially dysphasia were relieved postoperatively. Short- and long-term follow-up was satisfactory with none of the patients having tumor recurrences or other problems. Thoracoscopic enucleation of esophageal leiomyoma is technically safe and effective. It is currently the best choice for management of esophageal leiomyoma 1 to 5 cm in diameter. It can also be tried on a tumor larger than 5 cm, although the possibility of conversion to thoracotomy increases along with tumor growing and surrounding the esophagus.

Robotic extirpation of complex massive esophageal leiomyoma

Esophageal leiomyomas are the most common benign mesenchymal esophageal tumors, but they occur rarely in the pediatric population. Leiomyomas are conventionally treated with extramucosal enucleation via an open thoracotomy. In this paper, we report a case of a complex massive retrocardiac esophageal leiomyoma that was successfully extirpated by using a robotic-assisted thoracoscopic technique. Intraoperative esophagoscopy and transillumination were useful adjuncts in identifying the esophagus and developing a safe extramucosal dissection plane.

Minimally invasive therapy for benign tumors of the distal third of the esophagus--a single institute's experience

INTRODUCTION

Traditionally, the treatment of benign esophageal tumors is enucleation achieved via a thoracotomy. Since 1992, many reports of thoracoscopic and laparoscopic approaches have been published. In this paper, we present a retrospective study of 18 patients with benign distal esophageal tumors who underwent minimally invasive procedures.

MATERIALS AND METHODS

A total of 18 patients were treated in our institute form 1994 to 2006. Tumors of the middle third were approached thoracoscopically, and laparoscopic transhiatal enucleation was performed for tumors of the lower third. One patient had associated achalasia cardia, for which a cardiomyotomy with Toupet fundoplication was also performed, and another patient underwent an esophagectomy for a large tumor.

RESULTS

There were 12 males and 6 females and the average age was 59 years. The majority of the tumors were in the lower third, and the most common type of tumor was leiomyoma. Postoperative complications were recorded.

DISCUSSION

Leiomyomas are the most common benign tumors and are located frequently in the middle and lower third. Based on our experience, we feel that lower esophageal tumors are best approached by a laparoscopic transhiatal route and midesophageal tumors by a right thoracoscopic approach.

CONCLUSIONS

Minimally invasive surgery for benign esophageal tumors is ideal, reducing the morbidity of conventional methods.

Robot-assisted thoracoscopic esophagectomy for a giant upper esophageal leiomyoma

This is the first report of a thoracoscopic esophagectomy for a giant leiomyoma of the upper esophagus aided by a robotic system. A 37-year-old man presented with progressive dysphagia and nocturnal aspiration. Endoscopic ultrasound and CT scan of the chest revealed an upper esophageal tumor of 9 x 4 cm arising from the muscularis mucosae. A fine needle aspiration showed clustering of mesenchymal cells, confirming the diagnosis of a stromal cell tumor. A mesenchymal malignancy was suspected because the tumor was located in the upper esophagus and was arising from the muscularis mucosae, both uncommon for a leiomyoma. Moreover, tumor size, an indicator of potential malignancy if >3 cm, was 9 cm. Therefore, an esophagectomy was performed thoracoscopically with the formation of a gastric conduit via laparotomy and a hand-sewn end-to-side cervical anastomosis. The thoracoscopic phase was performed with support of the da Vincitrade mark robotic system, which allowed for an excellent 3-dimensional view and a precise dissection of the esophagus along the vital mediastinal structures. The duration of the thoracoscopic part was 115 min and that of the total procedure was 270 min. Blood loss during the thoracoscopic phase was 50 mL; total blood loss was 200 mL. The patient was ventilated for 1 day; his total intensive care stay was 2 days. He left the hospital in good condition on the 11th postoperative day. Histopathological examination combined with immunohistochemistry revealed a leiomyoma of 9.0 x 5.0 x 2.5 cm. After 3 years of follow-up, the patient is in good health.

Development of a navigation system for minimally invasive esophagectomy

BACKGROUND

A major challenge of minimally invasive esophagectomy is the uncertainty about the exact location of the tumor and associated lymph nodes. This study aimed to develop a navigation system for visualizing surgical instruments in relation to the tumor and anatomic structures in the chest.

METHODS

An immobilization device consisting of a vacuum mattress fixed to a stretcher was built to decrease patient movement and organ deformation. Computer tomography (CT) markers were embedded in the stretcher at a defined distance to a detachable plate with optical markers on the side of the stretcher. A second plate of optical markers was fixed to the operating instrument. These two optical marker plates were tracked with an optical tracking system. Their positions were then registered in a preoperative CT data set using the authors' navigation software. This allowed a real-time visualization of the instrument and target structures. To assess the accuracy of the system, the authors designed a phantom consisting of a box containing small spheres in a specific three-dimensional layout. The positions of the spheres were first measured with the navigation system and then compared with the known real positions to determine the accuracy of the system.

RESULTS

In the accuracy assessment, the navigation system showed a precision of 0.95 +/- 0.78 mm. In a test data set, the instrument could be successfully navigated to the tumor and target structures.

CONCLUSION

The described navigation system provided real-time information about the position and orientation of the working instrument in relation to the tumor in an experimental setup. Consequently, it might improve minimally invasive esophagectomy and allow for surgical dissection in an adequate distance to the tumor margin and ease the location of affected lymph nodes.

Robotic foregut surgery

BACKGROUND

Computer-assisted surgical systems, or surgical robots as they are more commonly called, are complex new devices which may be used to perform minimally invasive surgical procedures. There are certain technical limitations to a traditional laparoscopic approach that these devices can help a surgeon to overcome. Several surgical teams have applied these new devices to surgical procedures of the upper gastrointestinal tract and foregut.

METHODS

A retrospective review of the currently published literature on robotic foregut surgery.

RESULTS

Robotic foregut surgery appears to be feasible and safe. These procedures may be associated with increased operative time and cost when compared to their traditional laparoscopic counterparts. Procedures that require complex manoeuvres, delicate dissection, or a magnified high-definition image may be best suited to a computer-assisted approach.

CONCLUSIONS

Robotic foregut surgery is an exciting new field with tremendous potential for growth and dissemination.

Combined thoracoscopic and endoscopic management of mid-esophageal benign lesions: use of the prone patient position

BACKGROUND

Both benign tumors and mid-esophageal diverticula are rare conditions; underlying disorders may be present in case of diverticula. Traditionally, thoracotomy was the preferred route to approach these lesions. Now, more surgeons are using minimally invasive techniques to treat these benign mid-esophageal lesions.

PATIENTS AND METHODS

A total of 12 patients with symptomatic mid-esophageal lesions were studied, benign tumors were seven cases and five cases of diverticula. We present our experiences with thoracoscopic enucleation of benign tumors and diverticulectomy aided by peroperative endoscopy. All the patients were placed in the prone position and approached via a right thoracotomy.

RESULTS

Two patients had minor complications of pneumonitis and dysphagia, which were treated conservatively. One patient had a leak from the staple line that needed a second-look thoracoscopy and evacuation of abscess.

DISCUSSION

In this study, we highlight the use of the prone patient position, the advantages of a right thoracoscopic approach and the value of peroperative endoscopy. The prone position was first described in 1994, but has not been popular. Peroperative endoscopy accurately localizes diverticula and determines level of stapler application.

CONCLUSION

Thoracoscopy has definite benefits regarding reduced morbidity. The combined modality of peroperative endoscopy is useful in diverticulectomy. Based on our experience, we believe the prone patient position is the ideal position for esophageal surgery.

Thoracoscopic management of benign tumors of the mid-esophagus: a retrospective study

Benign esophageal tumors are rare conditions. Traditionally, thoracotomy was the preferred route to approach these lesions. Now, increasingly more surgeons are using minimally invasive techniques to treat these benign mid-esophageal lesions. We present our experiences from a specialised minimally invasive surgery unit. We have managed 12 patients with benign tumors of the mid-esophagus from 1995 to 2007 in our institute. The enucleation was achieved with the patient placed in the prone position and approached via a right thoracoscopy in all cases. Hospital stay was 3-5 days and there were minor postoperative complications in 2 patients. Mortality was nil. There were 10 patients with leiomyoma and 2 with GISTs, as proved by immunohistochemistry. Short and long-term follow up was satisfactory, with none of the patients having recurrences or other problems. Leiomyomas and GISTs, respectively, are the commonest benign tumors of the esophagus. Tumors more than 5 cm have to be enucleated, and thoracotomy has been the traditional approach to these lesions. Thoracoscopy has definite benefits regarding reduced morbidity. The combined modality of peroperative endoscopy is useful in locating the lesion as well as confirming its complete removal. Based on our experience, a right thorax approach and the prone patient position is the ideal for thoracoscopic procedures.

The robotic approach for mediastinal lesions

BACKGROUND

We report here our institutional experience and reflect the relevant literature concerning the robotic approach in diagnostic and therapeutic interventions for mediastinal lesions.

METHODS

During August 2001-December 2005, 33 patients (15 males and 18 females aged 18-77 years) with mediastinal masses were operated on minimally invasively using the da Vinci robotic system. There were 22 thymectomies (nine thymomas), four resections of paravertebral neurinomas, one ectopic mediastinal parathyroidectomy, one resection of a lymphangioma, one resection of ectopic goitre, one resection of lymph node metastasis of thyroid carcinoma and three oesophageal procedures (one leiomyoma, one traction diverticulum and one foregut cyst).

RESULTS

There were three (9%) open conversions due to surgical problems, 30 procedures (91%) were completed successfully using the da Vinci robot. There was no surgical mortality, no relevant intraoperative blood loss and no major surgical complication in any of the patients. As a minor complication (3%), an incomplete and transient palsy of the left laryngeal recurrent nerve was observed after resection of a tumour from the aortopulmonary window. The median overall operation time was 134 (range 54-314) min, including 103 (range 39-272) min for the robotic act.

CONCLUSIONS

Various different mediastinal procedures have been shown to be feasible and safe when performed with the robot. As the technical benefits of the da Vinci system are most advantageous in tiny and difficult-to-reach anatomical regions, the mediastinum should remain an area of special interest for robotic surgeons. Randomized trials and follow-up studies have been initiated in order to evaluate the clinical impact of the robotic approach.

Robotic-Assisted Thoracoscopic Surgery (RATS) for Benign and Malignant Esophageal Tumors

BACKGROUND

Robotic surgical systems are most effective for operations in areas that are small and difficult to reach. Ideal indications for this new technology have yet to be established. The esophagus possesses attributes that are interesting for general thoracic robotic surgeons.

METHODS

Robotic-assisted thoracoscopic surgery (RATS) using the da Vinci system (Intuitive Surgical, Inc, Mountain View, CA) was performed in six patients with esophageal tumors. This comprised the dissection of the intrathoracic esophagus including lymph node dissection in four patients suffering from esophageal cancer and the extirpation of a benign lesion (one leiomyoma and one foregut cyst) in the remaining two patients.

RESULTS

All procedures were completed successfully with the robot. The median overall operating time was 173 (160-190) minutes in the oncologic cases and 121 minutes in the benign cases, including the robotic act of 147 (135-160) minutes and 94 minutes, respectively. There were no intraoperative complications. One patient had to undergo a redo thoracoscopy because of a persistent lymph fistula. One cancer patient died after 12 months due to tumor progression and another patient had to be stented due to local tumor recurrence 19 months postoperatively.

CONCLUSIONS

This first small series of various esophageal pathologies treated by robotic-assisted thoracoscopic surgery supports the impression that the esophagus is an ideal organ for a robotic approach. The potential of the da Vinci system, especially for oncologic indications, remains to be proven in future clinical trials.

Robots en cirugía general: presente y futuro

Robotic surgery is an emerging technology. We began to use this technique in 2000, after it was approved by the Food and Drug Administration. Our preliminary experience was satisfactory. We report 4 years' experience of using this technique in our institution. Between August 2000 and December 2004, 399 patients underwent robotic surgery using the Da Vinci system. We performed 110 gastric bypass procedures, 30 Lap band, 59 Heller myotomies, 12 Nissen fundoplications, 6 epiphrenic diverticula, 18 total esophagectomies, 3 esophageal leiomyoma resections, 1 pyloroplasty, 2 gastrojejunostomies, 2 transduodenal sphincteroplasties, 10 adrenalectomies and 145 living-related donor nephrectomies. Operating times for fundoplications and Lap band were longer. After the learning curve, the operating times and morbidity of the remaining procedures were considerably reduced. Robot-assisted surgery allows advanced laparoscopic procedures to be performed with enhanced results given that it reduces the learning curve as measured by operating time and morbidity.

Minimally invasive treatment of esophageal cancer: laparoscopic staging to robotic esophagectomy

Minimally invasive surgical (MIS) procedures have become commonplace in modern surgical practice. The term minimally invasive surgery has been and continues to be interchangeably applied to describe laparoscopic, laparoscopic-assisted, thoracoscopic, and telesurgical (robotic) procedures. Minimally invasive surgical procedures for the treatment of benign and malignant disorders of the esophagus are being developed, refined, and clinically applied in parallel with the exponential availability of novel technologies and instrumentation. Herein, we review the progression from laparoscopic/thoracoscopic esophagectomy to telesurgical esophagectomy, presently termed minimally invasive esophagectomy, and describe the telesurgical procedure as well as early the clinical outcome experience.

Robotics in thoracic surgery

Surgical use of robotics, or computer-assisted surgical systems (CAS), has evolved over the last 10 years; for the treatment of chest diseases, however, the development has really occurred in the last 3 to 4 years. This brief history means that there have been few publications in the medical literature, and those that exist are mostly case reports. Moreover, because of this modest experience, robotic thoracic procedures currently take more time than nonrobotic cases and, thus, are more expensive. The surgical learning curve appears to be steep, especially for the more complex procedures. As surgeons gain greater experience and the complexity and cost of the equipment are reduced, we should expect to see greater utility of CAS in thoracic surgery.