Robotic-assisted totally transhiatal lymphadenectomy in the middle mediastinum for esophageal cancer

Robotic-assisted esophagectomy has been introduced as a minimally invasive esophagectomy; however, transhiatal esophagectomy with extended lymphadenectomy in the middle retromediastinal field has never been reported so far. We have developed a totally transhiatal robotic manipulation which enables middle retromediastinal lymph dissection. With this method, transthoracic approach, which is associated with risk of lung injury and loss of ventilatory function, can be avoided in radical esophageal cancer surgery. The robotic arms and camera entered the mediastinum passing the hiatus, and the dissection was performed along the medial aspect of the mediastinal pleura, the pericardia, and the aorta. The devices were able to reach the middle mediastinum, and lymph nodes on the bilateral main bronchi and the carina were retrieved by robotic manipulation. We present here our first experience of laparoscopic transhiatal lymphadenectomy of the middle mediastinal field, including a video, which could not have been possible without robotic-assisted surgery.