Intraoperative Monitoring of Recurrent Laryngeal Nerve in Robotic Ivor Lewis Esophagectomy
Overview
This study demonstrates the feasibility of intraoperative nerve monitoring (IONM) for identifying the recurrent laryngeal nerve (RLN) during totally robot-assisted Ivor Lewis esophagectomy with extended 2-field lymphadenectomy. IONM facilitated precise nerve localization, potentially reducing the risk of vocal cord paresis (VCP) and associated complications.
Background
The recurrent laryngeal nerve is at risk of injury during esophagectomy, especially during lymphadenectomy along the RLN chain, which can cause vocal cord paresis leading to aspiration pneumonia, voice impairment, or respiratory insufficiency. While the DaVinci Xi robotic system provides enhanced visualization, distinguishing the RLN from the vagal nerve remains challenging, particularly after neoadjuvant treatment. Prior studies in open and minimally invasive esophagectomy have shown that IONM reduces postoperative VCP rates. The application of IONM in robot-assisted minimally invasive esophagectomy (RAMIE) had not been previously described.
Data Highlights
Patients with lower esophageal cancer and intact preoperative vocal cord function underwent standardized videolaryngeoscopic evaluation and perioperative management including gastroscopy and antibiotic prophylaxis. IONM was performed intermittently with 7 Hz, 200 μs, 2 mA stimulation during RAMIE using the Da Vinci Xi system. All surgeries were performed by a single surgeon to ensure consistency. Postoperative laryngoscopy was conducted before hospital discharge to assess vocal cord function.
Key Findings
IONM was successfully integrated into totally robot-assisted Ivor Lewis esophagectomy with extended 2-field lymphadenectomy.
Intermittent nerve stimulation enabled reliable identification of the RLN despite challenges from neoadjuvant treatment effects.
Use of IONM may reduce the risk of intraoperative RLN injury and subsequent vocal cord paresis.
Robotic system’s enhanced 3D visualization combined with IONM facilitates precise dissection in the upper mediastinum.
Postoperative vocal cord function was systematically evaluated, supporting the safety of the technique.
Clinical Implications
Incorporating IONM during RAMIE can improve RLN identification and preservation, potentially decreasing postoperative complications such as aspiration pneumonia and voice impairment. Surgeons performing robotic esophagectomy should consider IONM to enhance nerve safety, especially during upper mediastinal lymphadenectomy. Standardized pre- and postoperative vocal cord assessments are recommended to monitor nerve integrity.
Conclusion
This study establishes the feasibility of intraoperative nerve monitoring during fully robotic Ivor Lewis esophagectomy, supporting its role in enhancing RLN identification and preservation. IONM integration may improve surgical outcomes by reducing nerve injury-related complications.
References
University Medical Center Mainz Study -- Intraoperative Monitoring of the Recurrent Laryngeal Nerve in Fully Robotic Ivor Lewis Esophagectomy
