Several minimally invasive techniques

for performing esophagectomy are

now available.

Samuel Bak. BK1484 Followers. Oil on canvas, 18 24.

Minimally Invasive Surgery for Esophageal Cancer:

Review of the Literature and Institutional Experience
Maki Yamamoto, MD, Jill M. Weber, MPH, Richard C. Karl, MD, FACS, and Kenneth L. Meredith, MD, FACS

Background: Esophageal cancer represents a major public health problem in the world. Several minimally
invasive esophagectomy (MIE) techniques have been described and represent a safe alternative for the surgical
management of esophageal cancer in selected centers with high volume and surgeons experienced in minimally
invasive procedures.
Methods: The authors reviewed the most recent and largest studies published in the medical literature that
reported the outcomes for MIE techniques.
Results: In larger series, MIE has proven to be equivalent in postoperative morbidity and mortality to the open
esophagectomy. However, MIE has been associated with less blood loss, reduced postoperative pain, decreased time
in the intensive care unit, and shortened length of hospital stay compared with the conventional open approaches.
Despite limited data, no significant difference in survival stage for stage has been observed between open
esophagectomy and MIE.
Conclusions: The myriad of MIE techniques complicates the debate for defining the optimal surgical approach
for the treatment of esophageal cancer. Randomized controlled trials comparing MIE with conventional open
esophagectomy are needed to clarify the ideal procedure with the lowest postoperative morbidity, best quality
of life after surgery, and long-term survival.

Introduction ratio of 0.84. In the United States, approximately

Esophageal cancer is the eighth most common cancer
in the world, with an estimated 482,300 new cases
each year and 406,800 cancer deaths per year.1 Sur-
vival is poor, with a high mortality-to-incidence rate
From the Gastrointestinal Tumor Program at the H. Lee Moffitt Can-
cer Center & Research Institute, Tampa, Florida.
Submitted March 6, 2012; accepted July 18, 2012.
Address correspondence to Kenneth L. Meredith, MD, FACS, Gastro-
intestinal Tumor Program, Moffitt Cancer Center, 12902 Magnolia
Drive, FOB-2 GI PROG, Tampa, FL 33612. E-mail: Kenneth.
Meredith@Moffitt.org
No significant relationship exists between the authors and the
companies/organizations whose products or services may be ref-
erenced in this article.
17,460 patients are diagnosed with esophageal can-
cer each year, with a mortality of 15,070 (incidence
and death rates are standardized to age for the 2000
US standard million population).2 According to Sur-
veillance, Epidemiology and End Results data, 5-year
survival rates for esophageal cancer have improved
modestly throughout the last 30 years, from 5% be-
tween 1975 and 1977 to 19% between 2001 and 2007.2
Surgical resection has been the gold standard
for localized esophageal cancer for decades. How-
ever, due to a poor 5-year survival rate, which is
approximately 36% in patients undergoing esopha-
gectomy, numerous clinical trials have investigated

130 Cancer Control April 2013, Vol. 20, No. 2

the role for multimodality therapy.3,4 A review of
randomized controlled trials evaluating neoadjuvant
chemoradiotherapy vs surgery alone demonstrated
no major difference in overall survival.5 However, all
the studies in the review were inconsistent with their
regimens of chemotherapy, doses of radiotherapy,
timing of chemotherapy in conjunction with radio-
therapy, surgical procedure performed, and histo-
logic subtypes enrolled in the trials. Furthermore,
esophagectomy has the highest mortality among all
elective gastrointestinal surgery, with rates as high
as 23%.6 Reductions in surgical mortality up to 32%
have been attributable to specialized high-volume
centers.7-9 Advances in surgical technology, staging,
and perioperative care could further impact a reduc-
tion in surgical morbidity and mortality. Of these
advances, minimally invasive esophagectomy (MIE)
has the greatest potential to improve outcomes in
patients who undergo esophageal surgery.
Minimally invasive procedures involving laparo-
scopic surgery, thoracoscopic surgery, or both are the
mainstay surgical approach for a variety of benign
esophageal disorders and are associated with equiva-
lent functional results compared with open proce-
dures.10 These techniques offer the potential advan-
tages of enhanced recovery, a reduction in pain, and
a quicker return to normal function, although larger
studies are needed to provide definitive evidence of
these benefits. The application of minimally invasive
surgery has been explored and found to be feasible
in the management of esophageal cancer, although
concern has been expressed about its safety, efficacy,
oncologic value, and other advantages that justify lon-
ger operative times and higher costs. This article
discusses MIE indications, techniques, and outcomes
in the management of esophageal cancer.
Indications for Minimally Invasive Surgery in
Esophageal Cancer
Patient selection represents the most important factor
in MIE. At our institution, all patients with esophageal
carcinoma undergo staging with endoscopic ultraso-
nography, computed tomography (CT) of the thorax
and abdomen, and whole-body positron emission
tomography/CT scans. Thoracoscopic staging, lapa-
roscopic staging, or both are performed in selected
patients who are found to have advanced locoregional
disease on imaging studies. The utility of laparoscopy
in staging is more relevant with adenocarcinomas of
the lower esophagus compared with more proximal
tumors.11 Laparoscopy has been reported to be more
sensitive and specific than CT scans in detecting lymph
node, peritoneal, and liver metastases. This procedure
is safe with low morbidity and avoids unnecessary
operative procedures.12 However, some studies have
reported a small yield.13,14 Therefore, minimally inva-
April 2013, Vol. 20, No. 2
sive techniques for staging purposes are used mainly
at the time of planned surgical extirpation.
MIE is indicated in patients with early-stage
esophageal cancer and in patients who are diagnosed
with Barretts esophagus with high-grade dysplasia.
Neoadjuvant chemotherapy and radiation are routine-
ly recommended for patients with locally advanced
esophageal cancer. We and other investigators15,16
have found that MIE can be safely performed in pa-
tients who have received neoadjuvant therapy, while
others do not recommend the procedure in patients
with prior radiation.17,18 The impact of neoadjuvant
therapy has been evaluated in several randomized
studies demonstrating that chemoradiotherapy does
not significantly increase the morbidity, mortality, or
oncologic outcome compared with conventional sur-
gery.19-21 Therefore, the current standard for patients
with locally advanced esophageal cancer who receive
neoadjuvant chemoradiation is esophagectomy, and
the minimally invasive approach may be offered to
these patients without compromising surgical or on-
cologic outcomes.
Contraindications for MIE
Contraindications to thoracoscopy include extensive
pleural adhesions, prior pneumonectomy, bulky tu-
mors, and locally infiltrative tumors, especially those
with airway involvement. Adequate cardiac and pul-
monary function is necessary for thoracoscopic MIE
due to prolonged single-lung ventilation.22 Relative
contraindications to laparoscopy may include prior
abdominal operations and major gastric resections.
MIE Techniques
Several surgical techniques for the treatment of esoph-
ageal cancer are available, and the choice of technique
depends on tumor location, extent of lymphadenecto-
my, and surgeons preference. The two most frequent
open techniques are the transhiatal esophagectomy
(THE) and transthoracic (Ivor Lewis) esophagectomy
(TTE).23 Classic THE involves a laparotomy to mobi-
lize the stomach from its vascular attachments and a
celiac/left gastric lymphadenectomy, while still pre-
serving the right gastroepiploic vessel for which the
future gastric conduit relies on. Variations, includ-
ing the pyloric drainage procedure, feeding jejunal
tube placement, and mobilization (Kocher maneu-
ver) of the duodenum, can be performed during the
laparotomy. However, we do not routinely perform
pyloric drainage and the Kocher maneuver at our
institution. With adequate gastric mobilization, the
gastric conduit will routinely have sufficient length
without additional duodenal mobilization. In addi-
tion, prospective randomized trials have not yielded
any long-term benefits from surgical pyloric drain-
age procedures,24,25 specifically pyloromyotomy or
Cancer Control 131
pyloroplasty. We routinely perform percutaneous in- ity, or long-term survival.31 In this analysis, TTE had
traoperative injection of 300 U botulinum toxin into a higher risk for pulmonary complications, chylous
the pylorus, which is less invasive than traditional leaks, and wound infection, while THE was associated
pyloric drainage procedures and improves short-term with an increased incidence of anastomotic leaks and
outcomes. Martin et al26 retrospectively evaluated 48 recurrent laryngeal nerve injury. Because no clear
patients who underwent intrapyloric botulinum toxin consensus has established the ideal surgical resec-
injection during esophagectomy and examined their tion, MIE has been explored in both TTE and THE
rate of early vs late delayed gastric emptying. Two pa- approaches with the purpose of overcoming their
tients developed clinically significant delayed gastric intrinsic limitations. Multiple minimally invasive ap-
emptying in the early postoperative period, while 3 proaches to esophagectomy have been described that
patients developed late symptoms (> 3 months post- combine thoracoscopic procedures, laparoscopic pro-
operatively) that resolved with endoscopic therapies cedures, or both with various operative positions for
(dilatation vs endoscopic botulinum injection). This the patient and anastomotic techniques (Table 1).
minimally invasive technique eliminates the small but MIE for the management of esophageal cancer
devastating complication of duodenal leak seen in was first described by Cuschieri et al32 in 1992, and it
more invasive surgical drainage procedures. Subse- was later refined by Collard et al33 in 1993. These first
quent blunt dissection of the thoracic esophagus is efforts involved thoracoscopic esophageal mobiliza-
considered an advantage, particularly in patients with tion with subsequent laparotomy for gastric mobiliza-
poor lung function who may not be able to tolerate tion and a cervical anastomosis. This approach avoids
thoracotomy. The anastomosis is created with a left the morbidity of thoracotomy and permits a complete
cervical incision to form the final cervical esophago- and thorough mediastinal dissection. Several groups
gastric anastomosis.7 have reported their experience with excellent results
By contrast, TTE has an identical abdominal por- with this technique, which currently represents the
tion of the operation. The blunt thoracic esophageal most popular MIE technique.34-38
dissection is replaced with right thoracotomy and me- Refinements in the thoracoscopic technique have
ticulous radial dissection around the thoracic esopha- been pioneered by Luketich et al,16,39 who have de-
gus with its surrounding mediastinal lymphatic tissue. scribed thoracolaparoscopic esophagectomy. This
The anastomosis is created within the thoracic space technique involves video-assisted thoracoscopic
rather than the neck. The theoretical advantage with esophageal mobilization in the left lateral decubitus
the thoracic approach is the oncologic resection of position, followed by supine laparoscopic gastric mo-
mediastinal lymph nodes and a wider radial margin bilization and preparation of the gastric conduit with
of the primary tumor.27 Other modifications of these a standard cervical anastomosis. This combination
two classic approaches include left thoracotomy, thora- offers the potential benefit of avoiding the need for
coabdominal incision, and the 3-field approach
(McKeown procedure).28,29 Table 1. Minimally Invasive Esophagectomy (MIE) Techniques
Determining which esophagectomy tech-
Surgical Technique Abdominal Portion Thoracic Portion Anastomosis
nique will result in less morbidity and in-
creased survival is controversial. Hulscher Open transthoracic Open Open Intrathoracic
et al30 reported their data from a randomized (Ivor Lewis)
trial involving 220 patients assigned to THE or Open transhiatal Open NA Cervical
TTE with extended en-bloc lymphadenectomy.
Open 3-field Open Open Cervical
They concluded that perioperative morbidity (McKeown)
was higher after TTE but saw no significant
difference in in-hospital mortality. THE was Hybrid transthoracic Laparoscopic or Open Intrathoracic
hand-assisted
associated with a shorter operative time (3.5 vs
6.0 hours), lower median blood loss (1.0 vs 1.9 Hybrid transthoracic Open Thoracoscopic Intrathoracic
L), fewer pulmonary complications, decreased Hybrid 3-field Open Thoracoscopic Cervical
chylous leaks, shorter duration of mechanical
ventilation, and shorter stay in the intensive MIE 3-field Laparoscopic or Thoracoscopic Cervical
hand-assisted
care unit (ICU) and hospital. However, after
a median follow-up of nearly 5 years, no sig- MIE transthoracic Laparoscopic or Thoracoscopic Intrathoracic
nificant difference was seen in overall survival hand-assisted
between the THE and TTE groups (29% and MIE transhiatal Laparoscopic or NA Cervical
39%, respectively). A meta-analysis involving hand-assisted
7,527 patients from 50 studies demonstrated
NA = not applicable.
no significant difference in morbidity, mortal-

132 Cancer Control April 2013, Vol. 20, No. 2

thoracotomy and laparotomy, while minimizing pain
in the postoperative period and possibly leading to
rapid recovery.
A minimally invasive THE was initially described
by DePaula et al40 in 1995 and then by Swanstrom
and Hansen41 in 1997 as the first totally laparoscopic
esophagectomy. This procedure has been utilized by
other groups and has undergone several modifica-
tions.42-44 The main advantage is direct visualization
of the lower mediastinum without blind dissection.
Using this technique, a laparotomy is avoided.
To facilitate the abdominal procedure, some
groups use a laparoscopic-assisted hand-port system,
which provides more tactile control and may poten-
tially decrease operative time.45 Furthermore, a hand-
assisted system may be used in the thoracoscopic
phase of the procedure to facilitate exposure into
the right thoracic cavity (hand-assisted laparoscopic
and thoracoscopic surgery).46 Other modifications to
this technique include a thoracoscopic mobilization
of the esophagus and mediastinal lymphadenectomy
in the prone position.47 The main advantages de-
scribed for prone thoracoscopic mobilization of the
esophagus are shorter anesthesia time and better
postoperative respiratory function compared with
the left lateral position.47
Additional modifications to MIE involve the use of
mediastinoscopic methods to aid superior mediastinal
dissection.48,49 This has been explored in conventional
THE and laparoscopic esophagectomy. A mediastino-
scope is used for dissection of the upper mediastinum.
The utility of this approach is limited by the extent of
possible lymph node dissection. Other techniques to
aid mediastinal dissection involve placing the laparo-
scopic trocars into the neck to facilitate esophageal
mobilization of the upper mediastinum.50,51 The me-
diastinoscopic technique is not routinely performed
due to technical limitations and rarely offers any ad-
ditional benefit.
Robotic Esophagectomy
Some limitations of the laparoscopic and thoraco-
scopic approaches to esophagectomy include instru-
mentation, the narrow field of the mediastinum, and
the two-dimensional view of conventional equipment.
Robotic systems provide the possibility to overcome
some of these limitations. Some groups have report-
ed their early experience with robotically assisted
THE.52-54 This involves laparoscopic gastric mobiliza-
tion, mediastinal robotic dissection, and conventional
transhiatal dissection through the cervical incision.
This technique allows three-dimensional visualiza-
tion, improved magnification, and a greater range of
instrument motion. This potentially could diminish
intraoperative complications during the esophageal
dissection in the mediastinum.
April 2013, Vol. 20, No. 2
At our institution, we have begun to utilize this
technology with our approach to esophagectomy.
The robotic technique can be performed during the
thoracic dissection of the esophagus, gastric mobili-
zation, and intrathoracic anastomosis. It can also be
performed in combination with laparoscopic, hand-as-
sisted laparoscopic, or thoracoscopic approaches. For
the robotic abdominal approach, three 8-mm ports are
placed, one in the right subcostal location and two in
the left subcostal position. The camera is placed in the
supraumbilical position and a 10-mm assistant port is
placed in the right paramedian location. A Nathanson
liver retractor is placed through a small stab incision in
the subxiphoid area. The laparoscopic approach has
a similar location as the ports (with the 8-mm ports
exchanged for 5-mm ports), and only one is placed in
the right subcostal and one is placed in the left subcos-
tal region. The assistant and camera ports are in the
same location. The hand-assisted approach requires
a 5-cm right subcostal incision, which allows for the
placement of the GelPort device (Applied Medical,
Rancho Santa Margarita, CA). Two additional 5-mm
trocars are placed in the left subcostal and left para-
median locations. The feeding jejunostomy is brought
out through a port site on the left for all approaches,
thus eliminating an additional incision.
After insufflation is performed, the abdomen is
inspected for evidence of metastatic or locally un-
resectable disease. The stomach is mobilized away
from its vascular attachments, protecting the right
gastroepiploic pedicle. The short gastric vessels are
transected using a Harmonic scalpel. The left gastric
vessels are dissected down to the origin of the celiac
artery and transected using a vascular stapler to com-
plete the upper abdominal lymphadenectomy. The
pylorus is then injected with botulinum toxin. The
gastric conduit is created using several firings of the
surgical stapler. A feeding jejunostomy tube is placed
through one of the left abdominal trocar sites. The
patient is then placed in the left lateral decubitus
position and the right lung is deflated.
The thorax is entered into the fifth intercostal
space using a 10-mm port. Two additional ports are
placed, one in the ninth intercostal space (4-cm inci-
sion to be shared by the assistant and one of the robot
arms) and another in the third intercostal space. The
azygos vein is isolated and transected using a vascu-
lar stapler. The esophagus is meticulous dissected
en bloc with surrounding mediastinal lymph nodes.
The specimen is removed and margins are checked
with pathology. The final intrathoracic anastomosis
has been described with a variety of stapled vs sewn
techniques.55 The recent introduction of a transoral
circular stapler has obviated the need for the technical
expertise in securing a free anvil in the esophageal
remnant. The anastomotic leak rate (0%9.8%) with
Cancer Control 133
this new technique is comparable with other stapled
techniques.56,57 An omental pedicle flap is then placed
over the anastomosis.
MIE Outcomes
Major intraoperative complications, including bleed-
ing, tracheobronchial injury, and recurrent laryngeal
nerve injury, have been reported with MIE.58-61 Con-
version to open surgery is required in approximately
10% of patients.16,34,39
As surgical techniques improve, incidence of in-
traoperative complications could potentially decrease.
MIE is a technically advanced surgical procedure
with a prolonged learning curve. Technical compli-
cations are known to be operator-, technique-, and
instrument-dependent. It has been reported that a
minimum of 17 cases were necessary to acquire MIE
skills, and more than 35 cases were needed to see an
outcomes difference.22,62 Most of the major compli-
cations in MIE were described in initial experience
series; therefore, the full potential may not have been
realized. Finally, because of the multitude of exist-
ing MIE techniques, the ability to compare results
with those of conventional esophagectomy is difficult
(Table 2).16,35,47,62-67
In theory, obviating the need of a thoracotomy,
laparotomy, or both may reduce postoperative pain,
wound infections, ventilator dependence, cardiopul-
monary complications, ICU and hospital stays, and
mortality rates. However, a clear advantage with
MIE over conventional esophagectomy has not been
demonstrated.63 Reasons for a lack in difference in
postoperative outcomes may result from an inability to
detect differences in small series and historic control
comparisons. The lack of well-designed trials, publi-
cation bias of satisfactory outcomes, and the myriad
of MIE techniques complicate this debate.
Smithers et al64 reported outcomes after esopha-
gectomy and compared 114 patients with open pro-
cedures, 309 patients with a thoracoscopic-assisted
approach, and 23 patients with a total thoracoscopic/
laparoscopic approach. Operative time was not sig-

Table 2. Review of Minimally Invasive Esophagectomy (MIE) Studies

Study Surgical No. of EBL Operative Length of Morbidity Anastomotic Mortality 5-yr Survival
Technique Patients (cc) Time Hospital Stay (%) Leak (%) (%)
(min) (d) (%)

Luketich16 MIE 222 7. 32 11.7 1.4 36

Nguyen65 MIE 46 279 350. 8. 17 4.3 4.3 57a

Osugi62 T 80 274 220. 35 1.3 0.

Yamamoto35 T 112 134 112. 19. 26 8.0 0.8 52

Palanivelu47 T/L prone 130 180 220. 8. 21 2.31 1.54 47a

Smithers64 Open 114 600 300. 14. 67 8.7 2.6 30a

T 309 400 285. 13. 62 5.5 2.2 46
MIE 23 300 330. 11. 61 4.0 0. 33

Meredith63 Open (Ivor Lewis) 427 250 289 10.5 4. 3.

MIE (TH) 78 150 242 10. 7. 2.6
Hybrid 57 125 320. 8.5 0. 0.

Luketich66 MIE (Ivor Lewis) 530 7. 4. 0.9

MIE (3-field) 481 8. 5. 2.5

Sihag67 Open 76 250 365.5 9. 2.6 2.6

MIE 38 200 360.5 7. 0. 0.

EBL = estimated blood loss, L = lymphadenectomy, MIE = combined thoracoscopic and laparoscopic esophagectomy, T = thoracoscopic esophagec-
tomy, THE = transhiatal esophagectomy.
a
3-year overall survival.

134 Cancer Control April 2013, Vol. 20, No. 2

nificantly different for the open and thoracoscopic-
assisted groups; however, the total laparoscopic ap-
proach took significantly longer than the other two
procedures. The total laparoscopic and thoracoscop-
ic-assisted groups were associated with a significant
decrease in blood loss and transfusions as well as a
shorter length of stay in the ICU and overall hospi-
talization. Nonetheless, overall complication rates
were similar. The incidence of respiratory infections
was not different, nor was the need to return to the
ICU. The mortality rate was 2.6% in the open group,
2.2% in the thoracoscopic-assisted group, and 0% in
the total laparoscopic group.
We previously reported our MIE experience with
the use of a hand-assist port and recently updated
our series to include the hybrid approach (laparo-
scopic abdominal and minithoracotomy; Table 2).63
We found no difference in the median operative time
between the MIE, hybrid, and open groups (242, 320,
and 289 minutes, respectively; P = .059). However,
there was a trend toward longer operative times in the
hybrid cohort. In addition, we found no differences
in blood loss between the MIE and open groups (150,
125, and 250 mL; P = .45). Our data support the con-
cept that MIE is safe and comparable to open surgery.
One of the most controversial issues with MIE is
whether its disease-free and overall survival rates are
comparable with conventional surgery. The role of
MIE in esophageal cancer has been questioned because
the extent of lymphadenectomy may be compromised.
Nevertheless, the largest randomized trial comparing
open approaches proved no significant difference in
survival between THE and TTE with extended en-bloc
lymphadenectomy.30 With multiple MIE techniques,
the quality of lymph node dissection is difficult to
evaluate, and many series fail to report on lymph node
dissection. The only prospective study that compared
this outcome between the open approach and MIE
demonstrated no significant difference in the number
and location of harvested lymph nodes.64
Other concerns include the adequacy of micro-
scopically negative (R0) resection, inadequate staging,
local recurrence due to inadequate margins, port-site
recurrence, and tumor dissemination during MIE. A
retrospective study investigated the recurrence pat-
terns in patients undergoing open TTE compared
with patients undergoing a thoracoscopic-assisted
approach and demonstrated no difference in recur-
rence rates (local, regional, or distant).68 In addition,
no differences were seen in the ability to achieve
R0 margins with either approach. More importantly,
comparable long-term survival has been reported in
the majority of series when their results are compared
with historic controls or to open surgery.22,34 Smithers
et al64 reported no difference in 3-year survival when
open, thoracoscopic-assisted, and total thoracoscopic/
April 2013, Vol. 20, No. 2
laparoscopic approaches were compared stage for
stage. It is clear that surgical oncologic principles,
such as adequate margin resections and lymphad-
enectomy, are feasible with refinements of MIE and
the increasing experience of surgeons. In addition,
Luketich et al16 found that at a mean follow-up of 19
months, patients who underwent MIE had quality of
life scores comparable with preoperative values.
Robotic Outcomes
Since robotic technology is relatively recent, data
regarding the safety and, more importantly, the on-
cologic efficacy of this technique are limited. At
our institution, the first 50 patients who underwent
robotic-assisted TTE were analyzed.69 Although long-
term survival has not been studied, a substitute for
oncologic efficacy through the mean number of lymph
nodes retrieved (20.6 9.3) and the percentage of mi-
croscopically negative margins (100%) would indicate
that robotic approaches are at least equivalent to the
open approach. A steep learning curve was illustrated
in the decrease in mean operative time (479 minutes
for the first half of cases vs 428 minutes for the second
half; P < .05) and a decrease in morbidity after 28
cases (35% vs 13%; P = .04). Due to the technologic
expertise required for this procedure, this technique
should be limited to high-volume centers with sur-
geons who have substantial experience in both the
open approach and MIE. Learning curves associated
with historical minimally invasive approaches may
also apply to the robotic approach.
Conclusions
Several minimally invasive esophagectomy (MIE)
techniques have been described and represent safe
alternatives for the surgical management of esopha-
geal cancer in centers with high volume and sur-
geons experienced in MIE. In larger series, MIE has
proven to have equivalent postoperative morbidity
and mortality rates to open esophagectomy. MIE
has also been associated with less blood loss, less
postoperative pain, and shorter length of stay in the
intensive care unit and hospital. Despite limited data,
no significant difference in survival has been observed
between open approaches and MIE. The myriad of
MIE techniques complicates the debate of defining
the optimal approach for the treatment of esophageal
cancer. Randomized controlled trials comparing MIE
with open esophagectomy are needed to clarify the
ideal procedure with the lowest postoperative morbid-
ity, the best quality of life, and the longest long-term
survival. Robotic approaches may offer advantages
over conventional approaches to MIE. However, simi-
lar to MIE, these techniques should be performed at
high-volume centers by surgeons who have sufficient
experience with the open and MIE techniques.
Cancer Control 135
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