Lee Shigeru, Tamura Tatsuro, Miki Yuichiro, Nishi Satoshi, Miyamoto Hironari, Ishidate Takemi, Kasashima Hiroaki, Fukuoka Tatsunari, Yoshii Mami, Shibutani Masatsune, Toyokawa Takahiro, Maeda Kiyoshi
Department of Gastroenterological Surgery, Osaka Metropolitan University Graduate School of Medicine, 1-4-3, Asahimachi, Abeno-ku, Osaka, 545-8585, Japan.
Surg Endosc. 2024 Dec;38(12):7208-7216. doi: 10.1007/s00464-024-11282-z. Epub 2024 Oct 9.
The use of robot-assisted minimally invasive esophagectomy (RAMIE) in the prone position for esophageal cancer has been currently increasing worldwide. In future, as surgical-assisted robots become more widespread, it is estimated that only two methods of transthoracic approach will remain: RAMIE and open thoracotomy for thoracic esophageal cancer. RAMIE in the left lateral decubitus position (RAMIE-LLDP) has the same field of view as open thoracotomy, is safe in emergency situations, and provides education on open thoracotomy.
Between September 2020 and April 2024, RAMIE-LLDP was performed in 64 consecutive patients with esophageal cancer. RAMIE-LLDP was performed with the operating table rotated and tilted 45° to the ventral side under artificial pneumothorax. The hand-control setting of the surgical-assist robot system was reversed left to right when the Patient Cart was rolled from the same direction as the RAMIE in the prone position.
The mean total surgery and console times during the thoracic procedure were 254-min overall and 225 min in the last 24 cases and 195-min overall and 178- min in the last 24 cases, respectively. The mean amount of blood loss was 203.4 g overall and 28.3 g in the last 24 cases. Postoperative recurrent laryngeal nerve palsy with Clavien-Dindo classification (CD) was ≥ 2 in six patients (9.4%). Postoperative pneumonia with CD ≥ 2 was observed in 11 patients (17.2%). Conversion to open thoracotomy was observed in three patients (4.7%). In all three patients, an immediate conversion to thoracotomy without patients' position change was actually possible and no serious complications were noted. No mortality occurred within 30 days postoperatively.
RAMIE-LLDP which facilitates emergency thoracotomy has perioperative results comparable to those of conventional thoracoscopic esophagectomy and is educational for open surgery. RAMIE-LLDP is the safest and most optimal surgery for esophageal cancer.
目前，在全球范围内，采用俯卧位机器人辅助微创食管癌切除术（RAMIE）治疗食管癌的应用正在增加。未来，随着手术辅助机器人的普及，预计胸段食管癌的经胸入路将仅保留两种方法：RAMIE和开胸手术。左侧卧位机器人辅助微创食管癌切除术（RAMIE-LLDP）与开胸手术具有相同的视野，在紧急情况下安全，并且能提供开胸手术相关教学。
2020年9月至2024年4月期间，连续对64例食管癌患者实施了RAMIE-LLDP。在人工气胸下，将手术台向腹侧旋转并倾斜45°进行RAMIE-LLDP。当患者推车从与俯卧位RAMIE相同方向推来时，手术辅助机器人系统的手动控制设置左右反转。
胸段手术期间的平均总手术时间和控制台时间分别为：总体254分钟，最近24例为225分钟；总体195分钟，最近24例为178分钟。平均失血量分别为：总体203.4克，最近24例为28.3克。根据Clavien-Dindo分类（CD），术后6例患者（9.4%）出现≥2级喉返神经麻痹。11例患者（17.2%）观察到CD≥2级术后肺炎。3例患者（4.7%）转为开胸手术。在所有3例患者中，实际上可以立即转为开胸手术而无需改变患者体位，且未发现严重并发症。术后30天内无死亡病例。
便于紧急开胸手术的RAMIE-LLDP围手术期结果与传统胸腔镜食管癌切除术相当，且对开放手术具有教学意义。RAMIE-LLDP是食管癌最安全、最理想的手术方式。
