Robot-assisted esophageal surgery using the da Vinci® Xi system for Benign and malignant diseases of esophagus：Preliminary experience of robot assisted modified Sweet operation
Authors: Lu Bei , Sun Li xin , Wang Zhonghao , Yan Xi , Ai Zhenzhong , Xu Jinzhi 
Published: April 2020

Abstract
Background Since our hospital installed the DaVinci ® Xi system, we have performed 60 thoracic surgeries in four months. As 25 of these 60 patients contain various types of esophageal benign and malignant diseases, we have no time to summarize our work after understanding and learning the experience of previous experts, so as to share our preliminary experience in using DaVinci ® Xi system in esophageal surgery. Because robot surgery system is the most effective for small and hard to reach areas, we have made many attempts in benign esophageal diseases. Compared with DaVinci ® Si, DaVinci ® Xi has many new functions, so we explore new surgical methods for some special esophageal cancer cases, such as the robot assisted modified Sweet operation.Methods Using DaVinci® Xi system(Intuitive Surgical, China), we performed robotic assisted thoracoscopic surgery (RATS) on 15 patients with esophageal cancer and 10 patients with various types of esophageal benign diseases. Among all esophageal cancer patients, 6 patients with lower esophageal cancer underwent resection of left thoracic esophageal cancer and lymphadenectomy, then diaphragm was cut, stomach was separated from abdominal cavity and lymphadenectomy was performed. Finally, 5 cases were anastomosed with stomach and esophagus under the aortic arch, and 1 case was anastomosed with stomach and esophagus in the neck combined with mediastinoscopic neck lymphadenectomy. McKeown was performed in 3 of the other 9 cases. Six patients underwent the Ivor Lewis operation, one of them was converted to the left thoracogastrostomy because of the extensive adhesion of the right thoracic cavity. Other benign diseases included esophageal leiomyomectomy in 3 cases, esophageal diverticulum in 1 case, hiatal hernia in 4 cases, esophageal cyst in 1 case, achalasia in 1 case. Results All the procedures were successfully completed by robot except one patient with extensive adhesion of right thoracic cavity and only abdominal operation. The median operation time of esophageal cancer patients was 286（240-348 minutes,There were no complications during operation. One patient had a neck anastomotic leakage and the wound healed after local washing for 3 weeks. Because of the short time of observation, there is no death of malignant tumor and no serious complication of benign disease. Conclusions Through the experience of such a small series of robotic assisted thoracoscopic surgery for various esophageal diseases, we support the impression that: 1. The esophagus is an ideal organ for robotic surgery, which is a good indication for malignant tumor surgery; 2. Under the vision of the robot, each layer of esophageal mucosa can be seen clearly, which is very conducive to the resection of small leiomyoma or cyst In addition, 3. Flexible arms can be used for various anastomosis or suture operations. 4. Through the left thorax and diaphragm incision can be used as a "robot" Sweet operation for the right patient, with mediastinoscopy to clean up the upper mediastinal lymph nodes can achieve better results.