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J Thorac Cardiovasc Surg 2010;139:53-59
© 2010 The American Association for Thoracic Surgery

General Thoracic Surgery

Thoracoscopic esophagectomy for esophageal cancer: Feasibility and safety of robotic assistance in the prone position

^a Department of Thoracic and Cardiovascular Surgery, Yonsei University College of Medicine, Seoul, Korea
^b Department of Surgery, Yonsei University College of Medicine, Seoul, Korea

Received for publication December 7, 2008; revisions received April 29, 2009; accepted for publication May 31, 2009.

^_* Address for reprints: Dae Joon Kim, MD, Department of Thoracic and Cardiovascular Surgery, Yonsei University College of Medicine, 250 Seongsan-no, Seodaemun-gu, 120-752 Seoul, Korea. (Email: kdjcool{at}yuhs.ac).

Objective: To assess the feasibility and safety of robot-assisted thoracoscopic esophagectomy for esophageal cancer in the prone position.

Methods: Twenty-one patients underwent robot-assisted thoracoscopic esophagectomy in the prone position by a surgical oncologist who had no prior experience with thoracoscopic esophagectomy. Hemodynamic and respiratory parameters were serially recorded to monitor changes in prone positioning.

Results: All thoracoscopic procedures were completed with a robot-assisted technique followed by cervical esophagogastrostomy. R0 resection was achieved in 20 patients (95.2%), and the number of dissected nodes was 38.0 ± 14.2. Robot console time was significantly reduced from 176.3 ± 12.3 minutes in the initial 6 patients (group 1) to 81.7 ± 16.5 minutes in the latter 15 patients (group 2) (P = .000). In group 2, there was less blood loss (P = .018), more patients could be extubated in the operating room (P = .004), and the number of dissected mediastinal nodes tended to be increased (P = .093). There was no incidence of pneumonia or 90-day mortality. Major complications included anastomotic leakage in 4 patients, vocal cord palsy in 6 patients, and intra-abdominal bleeding in 1 patient. The prone position led to an elevation of central venous pressure and mean pulmonary arterial pressure and a decrease in static lung compliance. However, cardiac index and mean arterial pressure were well maintained with the acceptable range of partial pressure of arterial oxygen and carbon dioxide.

Conclusion: Robotic assistance in the prone position is technically feasible and safe. Prone positioning was well tolerated, but preoperative risk assessment and meticulous anesthetic manipulation should be carried out.