Robotic McKeown Esophagectomy

Curative treatment for locally advanced esophageal cancer is esophagectomy combined with neoadjuvant therapy. Various approaches for esophagectomy have been investigated including open, conventionally minimally invasive and robot-assisted minimally invasive esophagectomy (RAMIE). RAMIE was shown to be superior over open esophagectomy mainly in terms of overall postoperative complications, postoperative pain, and quality of life. The merits of RAMIE over conventional minimally invasive surgery are mostly technical. RAMIE provides a superior three-dimensional view, increased dexterity due to articulating instruments, and tremor reduction technology. This is especially helpful in the areas that are hard to reach with conventional instruments, such as the upper mediastinum. Despite the technical benefits of robotic surgery, RAMIE remains a highly complex and invasive surgical procedure and is associated with a significant learning curve of 24–70 cases. RAMIE is not yet a standardized procedure, and multiple different techniques exist including variations in anastomotic location and technique. Factors such as tumor location and invasiveness, radiation field, and location of clinically positive lymph nodes determine the location of the anastomosis. The esophagogastric anastomosis may be located in either the thorax (Ivor Lewis) or the neck (McKeown). A typical reason to go to the neck are oncological purposes to reach a radical resection in mid-upper located esophageal tumors. In this chapter the robot-assisted McKeown procedure with a two-field lymphadenectomy is demonstrated. A McKeown procedure consists of three phases, the thoracic, abdominal, and cervical phase, respectively. The procedure is demonstrated step-by-step below.