The concept of “minimally invasive surgery” is no longer new to us, and many procedures such as lung surgery, cholecystectomy, and appendectomy can be performed using minimally invasive methods. In the surgical treatment of esophageal cancer, minimally invasive techniques have also been used for many years.
What is minimally invasive surgery for esophageal cancer? Is it different from endoscopic surgery?
Minimally invasive esophagectomy (MIE) primarily refers to the treatment of esophageal cancer through thoracoscopy or combined thoracoscopy + laparoscopy. Compared with open-chest and open-abdomen procedures, minimally invasive esophageal cancer surgery causes less trauma and is basically the same as the former in terms of resection scope and anastomosis.
Minimally invasive surgery includes both the most widely used handheld thoracoscopic procedures and the currently hotly developed robotically operated thoracoscopically assisted procedures.
Many people will wonder if endoscopic excisional or nonexcisional treatment is the same thing as thoracoscopy.
The answer, of course, is no. Endoscopic treatment is based on the gastroscope, which has no wound on the surface of the body, whereas thoracoscopy still has an opening on the surface of the body, which is why it is called “minimally invasive surgery”. The two procedures are also not suitable for the same population.
Why did the doctor choose minimally invasive? Will it cut cleanly?
Esophageal cancer surgery consists of two core steps: “resection” and “reconstruction”. Thanks to the efforts of scientists, modern surgical techniques are advancing, and the traditional open-chest/open-abdomen approach is gradually being replaced by a “minimally invasive” approach. The term “minimally invasive” means “minimally invasive” in terms of both surgical access incision and visceral resection/reconstruction.
- Smaller incisions;
- Less intraoperative blood loss;
- Fewer postoperative complications;
- Shorter ICU admission and total hospital stay;
- Better postoperative preservation of pulmonary function.
As mentioned earlier, thoracoscopic esophagectomy with robotic-assisted surgery is the currently recommended surgical approach, whose extent of surgical resection is essentially equivalent to that of open-heart surgery.
Studies have shown that for patients who meet the indications for surgical treatment of esophageal cancer, nonrobotic minimally invasive esophageal cancer surgery offers many advantages over open-heart surgery, including: less patient blood loss, less hospital stay, lower incidence of respiratory disease, and less time for closed chest drainage.
A prospective multicenter randomized controlled clinical study found a lower rate of in-hospital lung infections in patients who underwent minimally invasive radical esophageal cancer surgery (12% vs 34%). It has also been shown that partial robotic-assisted thoracoscopic surgery is superior to nonrobotic minimally invasive surgery, primarily in terms of less intraoperative bleeding, shorter operative time, and lower morbidity and overall mortality from perioperative complications.
However, thoracoscopic surgery is not for everyone. Its relative contraindications include inadequate pulmonary compensation, extensive pleural adhesions, prior pneumonectomy, giant tumors, and locally invasive tumors, especially when the airway is involved.
To summarize, from the patient’s point of view, thoracoscopic surgery with enlarged surgical field lenses is more delicate, uniform, and has less bleeding and less tissue damage with the assistance of a long forceps or instrumentation arm; from the surgeon’s point of view, thoracoscopic surgery is more simulable, which means it is easier to learn.
The dual benefit to the physician and patient promotes refinement of minimally invasive surgery, as well as improved surgical quality, and also reduces the incidence of complications. In terms of cost, patients can have less trauma, fewer complications, and shorter hospital stays, and the cost of minimally invasive esophageal cancer surgery, such as combined thoracoscopic and laparoscopic, is generally not higher than open-chest and open-abdominal surgery.
Therefore, we recommend thoracoscopic-assisted radical esophagectomy, or robotic-assisted radical esophagectomy for esophageal cancer, as far as conditions allow.