Comparative outcomes of laparoscopic versus robotic esophagectomy: a systematic review and meta-analysis

Introduction
Esophagectomy is a complex surgical procedure primarily used for the treatment of esophageal malignancies and other esophageal disorders. In recent years, minimally invasive techniques, such as laparoscopic and robotic-assisted esophagectomy, have gained popularity due to their potential to reduce postoperative morbidity and enhance recovery. However, the comparative effectiveness, safety, and long-term outcomes of laparoscopic versus robotic esophagectomy remain unclear.

Aim
This study aims to conduct a systematic review and meta-analysis comparing the perioperative and long-term outcomes of laparoscopic and robotic esophagectomy, with a focus on operative time, estimated blood loss, postoperative complications, length of hospital stay, lymph node yield, R0 resection rate, and oncological outcomes.

Material and methods
A comprehensive literature search was conducted across PubMed, Embase, and the Cochrane Library from inception to January 2023. Randomized controlled trials (RCTs) and observational studies comparing laparoscopic and robotic esophagectomy were included. The primary outcomes were operative time, estimated blood loss, and postoperative complications. Secondary outcomes included length of hospital stay, lymph node yield, R0 resection rate, and long-term oncological outcomes. Meta-analyses were performed using random-effects models. Risk of bias was assessed using the Cochrane Risk of Bias tool for RCTs and the Newcastle-Ottawa Scale (NOS) for observational studies. Publication bias was evaluated using Egger’s test. Statistical analyses were conducted using Stata version 16.0, with a p-value < 0.05 considered statistically significant.

Results
A total of 24 studies (6 RCTs and 18 observational studies) involving 6,972 patients (3,433 robotic and 3,539 laparoscopic esophagectomy cases) were included. Robotic esophagectomy was associated with a longer operative time (mean difference [MD] = 55.52 minutes, 95% CI: 27.55 to 83.49, p < 0.001) but lower estimated blood loss (MD = –103.67 ml, 95% CI: –162.78 to –44.57, p = 0.001) compared to laparoscopic esophagectomy. Postoperative complications (odds ratio [OR] = 0.78, 95% CI: 0.59 to 1.04, p = 0.091) and length of hospital stay (MD = –0.74 days, 95% CI: –1.82 to 0.34, p = 0.181) were comparable between the two techniques. Robotic esophagectomy demonstrated a higher lymph node yield (MD = 2.38, 95% CI: 0.89 to 3.87, p = 0.002) and a higher R0 resection rate (OR = 1.70, 95% CI: 1.26 to 2.30, p < 0.001). Long-term oncological outcomes, including overall survival and disease-free survival, were similar between the two approaches. Egger’s test indicated no significant publication bias.

Conclusions
This meta-analysis demonstrates that robotic esophagectomy, despite longer operative times, offers advantages in terms of reduced blood loss, higher lymph node yield, and improved R0 resection rates compared to laparoscopic esophagectomy. Both techniques exhibit comparable postoperative complication rates, length of hospital stay, and long-term oncological outcomes. The choice between laparoscopic and robotic esophagectomy should be guided by surgeon expertise, patient-specific factors, and institutional resources.