Hybrid approaches to minimally invasive esophagectomy
Esophageal cancer resection usually requires a two-field or three-field surgical approach to perform the resection and the reconstruction. With the progress of anaesthesiology and surgical skills, the possibility to reduce the surgical trauma has grown up and minimally invasive esophagectomy (MIE) has widespread worldwide. The hybrid approaches to MIE are the combination of minimally invasive approaches mixed to open approaches by applying the minimally invasive techniques at one level of the two stages (abdomen or thorax) of the procedure. The hybrid techniques can be decided prior to surgery in the surgical decision-making strategy to focus and to keep open approach for one the two stages, either because of expected surgical issues or to obtain a better exposure for confection of the intrathoracic anastomosis. Sometimes, the decision to opt for hybrid techniques can also results from the necessity to convert intraoperatively at both stages during total MIE. The most described hybrid techniques are represented by the laparoscopic hybrid Ivor Lewis esophagectomy where the gastric mobilization is performed laparoscopically whereas the confection of the intrathoracic anastomosis is performed with an open approach. This technique appears safe, reproducible, and easy to teach. The recent MIRO trial has provided evidences that the unique use of laparoscopy for the abdominal part of the esophagectomy resulted in a strong benefit on postoperative respiratory outcomes, with the same magnitude to those observed with total MIE. The MIRO trial suggests that the maximum benefits of minimally invasive techniques are more provided by laparoscopy rather than thoracoscopy. Moreover the laparoscopic approach results in better short, mid and long-term outcomes compared to open approach, without any compromise regarding oncological outcomes. At last, laparoscopy seems to improve health-related quality of life. The laparoscopic approach has to be seen as a new standard approach and should be incorporated to all esophageal cancer resections whenever possible.