Nowadays, multimodal therapeutic approaches with surgery as cornerstone achieve 5-year-survival rates up to 50%[1]. Due to the high technical complexity of the totally minimally invasive esophagectomy (MIE), open esophagectomy or hybrid esophagectomy (laparoscopic & open thoracic) is still common practice for resectable esophageal cancer. As 6th most fatal malignancy with approximately 500,000 new cases worldwide per year, esophageal cancer represents a serious oncological burden [2]. Thereby, two factors appear extraordinarily challenging when performing an esophagectomy. Firstly, the esophagus & stomach are embedded in both the thorax & the abdomen. While performing an oncological esophagectomy, both abdominal & thoracic lymph node compartments must be dissected for a radical two field lymphadenectomy. Therefore, a two-compartment intervention is inevitable. Secondly, the thoracic esophagus is located right next to delicate & essential structures like the trachea & the bronchi, the cardiac atrium, & large vessels like the aorta, azygos vein, & pulmonary vein as well as crucial nerve structures[3]. Hence, in regard to a recent international benchmark study, surgical esophagectomy—although performed in high-volume centers—is accompanied by an overall complication rate up to 60% [4]. The procedure needs to be performed in a way allowing most precise & exact preparation while keeping it as little invasive as possible to avoid complications, without compromising oncological principles. These requirements are leading towards minimally invasive surgery. This article reviews the origin & current clinical evidence of MIE as well as the surgical techniques & limitations[5].

A total of 25 patients underwent surgeries for esophageal cancer was enrolled for 01 Year at MNJIO & RCC/Osmania Medical College, Hyderabad. All patients were performed preoperative histopathologic diagnoses of esophageal cancer by gastroscopy & pathological display. Moreover, locations of tumors were noticed in the middle or upper segment of the esophagus. By preoperative chest preparation & upper abdominal enhanced CT examination, the size of the tumor & the extent of surrounding lymph nodes invasion were assessedfor eliminating metastasis of distant tissues & organs.

Then apply ultrasonic scalpel complete resection of esophagus along the thoracic esophageal bed from the top of the right thoracic cavity to the hiatus of esophageal diaphragm, lymph nodes were dissected routinely (posterior superior vena cava, right recurrent laryngeal nerve, left-right recurrent laryngeal nerve, carina, paraesophageal, inferior pulmonary vein, & cardiac side), finally place a drainage tube & sew up the incisions.

Table No. 1: Baseline Characteristics of Patients

Table No. 2: Primary tumor site

Table No. 3: Postoperative Complications & Mortality

Postoperative complications & mortality were shown in above Table, the incidence of Regurgitation & anastomotic leakage was most common. Moreover, the risk of pulmonary infection was followed; the results did not show a statistical significance.

For patients with esophageal cancer, surgical resection with the combination of neoadjuvant chemoradiotherapy or chemotherapy was considered as the only potential path for a radical cure currently [6]. However, patients underwent OE were extremely traumatic & suffered from severe postoperative complications, including pulmonary infection & poor quality of life. Since 1992 the first application of minimally invasive technique adopted for resection of esophageal cancer. As it produced great potential in minimizing invasions & accelerating rehabilitation, the application of this technique gained popularity in the medical front. However, many scholars hold a conservative attitude on MIE including the complexity of the procedure, adequacy of resection & nodal clearance in upper third tumors, & availability of MIE in patients who performed chemoradiotherapy [7]. As science & technology advance over the past 30 years, technologyies including high-definition imaging, novel energy devices, & enhanced stapling had been widely used in modern medicine. Meanwhile, a variety of modified MIE procedures had been widely implemented in major medical centers all over the world. No consensus has been reached on whether MIE tends to be superior to OE or notamong centers. However, many comparative studies on the clinical effects of MIE & OE, namely the clinical randomized controlled researches [8], confirmed that there were no significant differences in both techniques.

Contrary to general expectations, results in comparing MIE with OE had shown that MIE was associated with lower operative blood loss, shorter ICUand hospital stays, fewer postoperative respiratory complications, better relieved pain & short-term postoperative quality of life [9]. The outcome of postoperative hospital stay in MIE was significantly shorter than in OE (9.68 ± 2.97 vs 15.64 ± 6.05, P < 0.0001) in our study. A growing number of clinical trials of esophagectomy showed that MIE could shorten hospital stay[10].

A natural channel for early lymphatic returns & distant skip metastases were provided due to the extensive submucosal lymphatic plexus under the esophageal wall (i.e., lymph nodes adjacent to the primary tumor are not affected, but more distant-located lymph nodes contain metastases) [11]. Thus, the early metastases of lymph nodes were one of the characteristics of esophageal cancer. Studies had reported that about 20–40% of patients with submucosal esophageal cancer developed local lymph node metastasis [12]. Consequently, extensive lymph nodes dissection can maximize the clearance of malignant lymph nodes which played an essential role in inhibiting tumor recurrence & facilicating a long survival time for patients with esophageal cancer.

Until today, the multimodal concept treating esophageal cancer with a combination of chemo(radio)therapy & surgery is a most promising approach for extended long-term survival. Thereby, minimally invasive surgery proved to have reduced perioperative morbidity with equivalent oncological radicality & outcomes compared with open esophagectomy. So far, it seems that in locally advanced tumors & complex cases, robotic assistance allows highest oncological radicality without risking more complications. Furthermore, today’s improvements of existing robotic platforms lay the foundation for future innovations such as artificial intelligence as well as data & skill sharing.

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