Force feedback and vocal cord dysfunction after robotic esophagectomy: a comparison of the da Vinci 5 and Xi systems

The da Vinci 5 (DV5) is the first robotic platform to integrate force feedback (FFB), which may limit excessive traction and tissue injury. Its clinical impact in robotic transthoracic esophagectomy remains unclear. We compared perioperative outcomes between the da Vinci Xi and DV5 systems. This retrospective study included consecutive patients who underwent robotic transthoracic esophagectomy for esophageal squamous cell carcinoma by a single high-volume surgeon between December 2024 and July 2026. Patients treated with the Xi system without FFB (n = 126) and the DV5 system with FFB (n = 37) were compared. Vocal cord dysfunction (palsy or hypomobility) was assessed by routine postoperative laryngoscopy. Outcomes were analyzed using multivariable logistic regression, with stabilized inverse probability of treatment weighting (IPTW) as a sensitivity analysis. Vocal cord dysfunction was less frequent in the DV5 group (Xi, 33.3% vs. DV5, 13.5%), and the association persisted after multivariable and IPTW adjustment (adjusted odds ratio [OR], 0.33; IPTW OR, 0.27). Vocal cord palsy was also less frequent (27.8% vs. 10.8%), although the difference was not significant after adjustment. In an exploratory analysis, overall 30-day complications were less frequent in the DV5 group (74.6% vs. 54.1%; adjusted OR, 0.43), but the difference was attenuated after IPTW adjustment. Total and recurrent laryngeal nerve lymph node yields did not differ. DV5 with integrated FFB was associated with less frequent vocal cord dysfunction and comparable operative outcomes. These findings may provide the first clinical data suggesting FFB could reduce traction-related nerve injury in robotic esophagectomy.