[Mediastinoscopic and Transabdominal Robotic Esophagectomy Using da Vinci Xi]

Mediastinoscopic esophagectomy (ME) for esophageal cancer, first reported by Tangoku et al. in 2004, has evolved into a standardized procedure incorporating radical lymphadenectomy. The surgery is performed using a mediastinoscope from the neck and a laparoscope from the abdomen, creating a connected operative field within the mediastinum. ME avoids thoracotomy and one-lung ventilation, preserving respiratory muscles and significantly reducing postoperative pneumonia, while maintaining pulmonary function and quality of life. Meta-analyses have shown that although recurrent laryngeal nerve palsy is relatively common, ME results in shorter operative time, less blood loss, lower incidence of pneumonia, and a reduced overall complication rate compared to conventional approaches. Its greatest advantage lies in expanding surgical indications to patients who were previously considered inoperable due to thoracic adhesions, poor pulmonary function (e.g., chronic obstructive pulmonary disease (COPD)), or prior thoracic surgery. These patients often cannot tolerate radiation either, making ME particularly valuable. As Japan's population continues to age, the need for ME is expected to grow. Although ME was covered by national insurance in 2018, evidence from Japan remains limited. The 2022 esophageal cancer guidelines refrain from recommending ME due to insufficient data. However, recent retrospective studies using propensity score matching have shown significantly better overall and disease-free survival compared to thoracotomy, and prospective multicenter trials are underway.