PD08.04. The Technical Detail & Short-Term Outcomes of Robotic Abdominal Cervical Esophagectomy (RACE) via Cervical and Hiatal Approach: Over 100 Cases Experiences

Abstract

Esophageal Cancer: Surgical Treatment of Esophageal Cancer – technique Minimally Invasive transCervical Esophagectomy is a less invasive approach that enables dissection along the visceral sheath, but conventional non-robotic cervical mediastinoscopy has been linked to a higher risk of recurrent laryngeal nerve injury due to limited instrument control. Introducing robotic assistance through a combined cervical and transhiatal route, without thoracic entry, may reduce respiratory complications and improve precision around the recurrent laryngeal nerves. When combined with cervical lymphadenectomy, this approach allows detailed dissection of the middle and lower mediastinum. We present the surgical technique with video and evaluate the safety and feasibility of the RACE procedure. At our center, esophagectomy through a transcervical route is primarily selected for patients in whom a transthoracic approach is considered unsuitable, most commonly because of prior thoracic pathology or surgery. The procedure is routinely carried out using bilateral cervical access with continuous intraoperative recurrent nerve monitoring provided by a nerve integrity monitoring (NIM) system. This analysis included 118 consecutive patients who underwent Robotic Abdominal Cervical Esophagectomy (RACE) between 2023 and 2025, with perioperative outcomes and complications systematically assessed. All operations were conducted using the da Vinci Xi robotic platform. The standard surgical workflow involved robotic dissection of the right cervical mediastinum first, followed by the left cervical mediastinum, and subsequently completion of mediastinal dissection through a transhiatal abdominal robotic approach. The study population was elderly, with an average age just over 74 years. At diagnosis, patients were distributed across stages I to IV, with the largest groups in stages I and III. Most patients (over two thirds) had pre-existing conditions, particularly involving the respiratory system. No intraoperative complications occurred. Conversion to a transthoracic procedure was necessary in one case because of clear tracheal membranous invasion. There were no operative deaths. After surgery, recurrent laryngeal nerve dysfunction (Clavien–Dindo ≥ grade 1) was seen in 13.3% of patients, and pneumonia requiring treatment (Clavien–Dindo ≥ grade 2) developed in 7.6%. RACE demonstrated a high level of safety and procedural consistency, allowing accurate and systematic mediastinal lymph node dissection while minimizing surgical trauma. These characteristics suggest that the technique is feasible and suitable for routine clinical practice. However, additional studies are warranted to optimize its performance in anatomically challenging situations, to clarify the learning curve associated with surgeon experience, and to comprehensively evaluate long-term oncological outcomes, including disease control and survival benefits.