Current advances and challenges in minimally invasive esophagectomy.

Advances in endoscopic equipment and thoracoscopic surgery have contributed to the increasing adoption of minimally invasive esophagectomy (MIE). Compared with open esophagectomy (OE), MIE is associated with longer operative times and offers many advantages, such as reduced blood loss and a lower incidence of pulmonary complications, including pneumonia. Two patient positions are commonly used for thoracoscopic esophagectomy (TE): left lateral decubitus position and prone position. MIE has demonstrated significant benefits in reducing postoperative respiratory complications. However, the optimal MIE technique, surgical approach, and patient positioning remain controversial. Recently, robot-assisted thoracoscopic and/or laparoscopic esophagectomy using the da Vinci Surgical System and other emerging robotic platforms has gained attention as an attractive surgical option. In addition, nonthoracic radical esophagectomy, performed via transcervical or transhiatal approaches using mediastinoscopic devices, has been developed as an alternative approach. Despite these technological advances, there is a lack of definitive scientific evidence establishing MIE as a superior alternative to OE. However, a recent randomized phase III trial (JCOG1409) confirmed the noninferiority of TE compared with OE in terms of overall survival of patients with thoracic esophageal cancer. Furthermore, MIE-including robotic-assisted and mediastinoscopic approaches-has been associated with lower pulmonary complication rates while maintaining comparable oncological outcomes. These findings support the adoption of MIE as a standard treatment modality in Japan. Future studies should focus on evaluating the long-term outcomes of MIE and determining the optimal integration of robotic assistance in the surgical management of esophageal cancer.