Division of Gastrointestinal Surgery, Department of Surgery, Graduate School of Medicine, Kobe University, Kobe, Hyogo, Japan.
Division of Minimally Invasive Surgery, Department of Surgery, Graduate School of Medicine, Kobe University, Kobe, Japan.
Ann Surg Oncol. 2021 Sep;28(9):4918-4927. doi: 10.1245/s10434-021-09738-w. Epub 2021 Mar 8.
Given the worldwide popularization of conventional minimally invasive esophagectomy (C-MIE), robot-assisted MIE (RAMIE) can be expected to provide a finer procedure. However, controversy remains regarding whether RAMIE is superior to C-MIE in preventing recurrent laryngeal nerve (RLN) palsy. Considering the shallow learning curve for RAMIE, a novel procedure for lymphadenectomy along the RLN during RAMIE is needed.
Based on a logical and simple understanding of the left upper mediastinum anatomy, the authors developed a novel "modified bascule method" for RAMIE that could simplify lymphadenectomy along the left RLN and prevent it from being touched and stretched. Between 2018 and 2020, 46 patients with esophageal carcinoma underwent RAMIE using this method at Kobe University.
The modified bascule method was used to perform RAMIE for 29 men and 17 women with a median age of 67 years (range, 49-82 years). The median thoracoscopic procedure time was 438 min (range, 344-625 min), and the median console time was 351 min (range 273-518 min). The study harvested a median of 24 (range, 8-34) lymph nodes from the thoracic portion and 4 (range, 0-10) lymph nodes from along the left RLN. The mortality rate was 0%. Postoperative left RLN palsy classified as Clavien-Dindo (C-D) grade 1 or higher was observed for 9 patients (19%), whereas grade 2 or higher was not seen (0%). Pneumonia and anastomotic leakage rates higher than C-D grade 2 were respectively 13% and 19%.
The novel modified bascule method for RAMIE can promote feasible lymphadenectomy along the left RLN even when performed during the learning period.
鉴于传统微创食管切除术（C-MIE）在全球范围内的普及，机器人辅助 MIE（RAMIE）有望提供更精细的手术。然而，关于 RAMIE 是否优于 C-MIE 预防喉返神经（RLN）麻痹仍存在争议。考虑到 RAMIE 的学习曲线较浅，需要为 RAMIE 期间的 RLN 淋巴结清扫开发一种新的程序。
基于对左纵隔上部解剖结构的逻辑和简单理解，作者为 RAMIE 开发了一种新的“改良跷跷板方法”，可以简化沿左 RLN 的淋巴结清扫，并防止其受到触摸和拉伸。在 2018 年至 2020 年间，神户大学的 46 名食管癌患者采用该方法接受了 RAMIE 治疗。
改良跷跷板方法用于 29 名男性和 17 名女性患者，中位年龄为 67 岁（范围为 49-82 岁）。中位胸腔镜手术时间为 438 分钟（范围为 344-625 分钟），中位控制台时间为 351 分钟（范围 273-518 分钟）。研究从胸部采集了中位数为 24 个（范围为 8-34 个）淋巴结，从左 RLN 采集了中位数为 4 个（范围为 0-10 个）淋巴结。死亡率为 0%。观察到 9 例（19%）术后左侧 RLN 麻痹分类为 Clavien-Dindo（C-D）等级 1 或更高，而未观察到等级 2 或更高（0%）。肺炎和吻合口漏发生率高于 C-D 等级 2 分别为 13%和 19%。
RAMIE 的新型改良跷跷板方法即使在学习期间也可以促进可行的左 RLN 淋巴结清扫。
