Right-first bilateral transcervical single-port robotic esophagectomy: a cadaveric feasibility study toward a safer extrapleural strategy

Abstract Background Left transcervical extrapleural esophageal mobilization can avoid pleural entry and one-lung ventilation but is limited by challenging exposure of the right paratracheal compartment and a relevant risk of left recurrent laryngeal nerve (RLN) injury. Prior bilateral transcervical approaches have been constrained by instrument collisions and limited caudal reach. Methods In a fresh-frozen cadaver, a right-first, bilateral transcervical single-port (SP) robotic strategy was performed with sequential right-then-left cervical docking under low-pressure pneumomediastinum. Feasibility endpoints were predefined: (i) reproducible access to the paratracheal and subcarinal planes, (ii) identification and preservation of the RLNs, (iii) maintenance of an extrapleural corridor to the diaphragmatic hiatus, and (iv) collision-free workflow. Results Right-sided transcervical docking enabled near-circumferential thoracic esophageal mobilization with early identification of the right RLN and systematic mediastinal lymphadenectomy, including reliable exposure of the subcarinal station. The SP configuration allowed stable traction with two working instruments, facilitating controlled dissection without relevant internal or external collisions. The subsequent left-sided phase focused on completion of residual mobilization and targeted lymphadenectomy along the left RLN with minimal traction and limited energy application. All predefined feasibility criteria were met. Conclusions A threshold-guided (~ 85%) right-first bilateral transcervical SP robotic approach is feasible in a cadaveric model. This strategy improves access to the right paratracheal nodal stations and may reduce traction on the left RLN by shifting traction-intensive steps to the right. Prospective clinical translation is warranted to benchmark RLN outcomes, nodal yield, pleural integrity, and recovery against current transcervical and transthoracic techniques. Graphical Abstract