title: Evaluation of the combined laparoscopic and mediastinoscopic esophagectomy technique.
abstract: BACKGROUND
  Laparoscopic esophagectomy is technically difficult especially during dissection in the upper mediastinum. This limitation may be surpassed with the help of mediastinoscopy or of the recently introduced robotic surgical systems. The aim of the present study was to evaluate in an experimental porcine model the feasibility of the combined laparoscopic and mediastinoscopic transhiatal esophagectomy technique and to compare it with the robotic-assisted transhiatal and conventional approaches.
  
  
  METHODS
  Transhiatal esophagectomy was performed in Landrace pigs under general anesthesia using three different techniques: Group A (n = 9): combined laparoscopic and mediastinoscopic, group B (n = 4): robotic-assisted and group C (n = 8): conventional "open". The feasibility, difficulty and accuracy of the procedure along with operative time, blood loss, intraoperative incidents and overall satisfaction of the surgical team were assessed for each technique.
  
  
  RESULTS
  Operations in group A were feasible and reproducible. Although the procedure was technically difficult, the constant view on the operative field was highly appreciated by the operative team and facilitated an accurate and safe dissection. The main intraoperative complications were related to the side-effects of tension pneumothorax accompanying pleural injuries. In group B the features of the robotic system reduced the difficulty of dissection and obviated the need for mediastinoscopy. Operations in group C were quick and almost incident-free, facilitated also by the particularities of the animal model that could not reproduce identically the clinical situation.
  
  
  CONCLUSIONS
  The combined laparoscopic and mediastinoscopic esophagectomy technique is feasible and offers certain advantages over the open approach while the robotic-assisted approach is an emerging less difficult alternative. Further studies are required to establish whether the advantages of minimally-invasive approach compensate for the increased technical difficulty and prolonged operative time.
authors.affiliation: Department of Surgery, 1st Surgical Clinic, University of Medicine and Pharmacy, Cluj Napoca, Romania. vabintintan@yahoo.com
authors.forename: V V
authors.initials: VV
authors.lastname: Binţinţan
authors.forename: A
authors.initials: A
authors.lastname: Mehrabi
authors.forename: H
authors.initials: H
authors.lastname: Fonouni
authors.forename: M
authors.initials: M
authors.lastname: Golriz
authors.forename: J
authors.initials: J
authors.lastname: Köninger
authors.forename: A
authors.initials: A
authors.lastname: Kashfi
authors.forename: Gh
authors.initials: G
authors.lastname: Funariu
authors.forename: M W
authors.initials: MW
authors.lastname: Buechler
authors.forename: C
authors.initials: C
authors.lastname: Ciuce
authors.forename: C N
authors.initials: CN
authors.lastname: Gutt
mesh_terms: D000818:Animals; D004195:Disease Models, Animal; D016629:Esophagectomy / Q000009:adverse effects / Q000295:instrumentation* / Q000379:methods*; D005240:Feasibility Studies; D010535:Laparoscopy / Q000379:methods*; D008481:Mediastinoscopy / Q000379:methods*; D011030:Pneumothorax / Q000209:etiology; D012371:Robotics; D025321:Surgery, Computer-Assisted; D034421:Sus scrofa; D013552:Swine