Robotic Lung Cancer Surgery Leaves Woman Unable to Swallow in Rare Case

But in between, she experienced something so unusual that her surgical team felt compelled to document it in detail: within days of robot-assisted lung surgery, her esophagus simply stopped working. The case, published in General Thoracic and Cardiovascular Surgery Cases, describes only the third reported instance of achalasia appearing after lung surgery, and it offers a sobering lesson about what can happen when surgical instruments work close to the nerves that control swallowing.

The woman had never smoked. Her lung nodule was found by accident during magnetic resonance imaging performed to evaluate fatty liver, and a biopsy confirmed adenocarcinoma. Computed tomography placed the tumor in the left lower lobe, and staging showed no distant metastases, giving a clinical classification of cT1cN0M0, stage IA3. Before surgery, she had no trouble eating or swallowing, a detail that would later become central to understanding what went wrong.

Surgeons performed a robot-assisted left lower lobectomy with systematic mediastinal lymph node dissection using the da Vinci Si system. The operation itself was technically uneventful: 167 minutes of total operative time, 82 minutes at the console, and blood loss of just 10 milliliters. The final pathology confirmed lung adenocarcinoma at pT1bN0M0 with an R0 resection, meaning the tumor was completely removed with clear margins. Yet during the operation, two things happened that the report’s authors would later scrutinize closely. The sheath of the left vagus nerve was grasped and retracted with robotic forceps during mediastinal lymph node dissection, and its cardiac and pulmonary branches were identified and dissected. Then, during subcarinal lymph node dissection, the surgical team dissected lymph nodes away from the anterior wall of the esophagus using monopolar electrosurgery, a Permanent Cautery Spatula connected to an E-100 generator in coagulation mode at 40 watts. No macroscopic injury to the left vagus nerve was observed at any point.

Oral intake began routinely on postoperative day 1. On day 2, the patient began vomiting and could not eat. Chest computed tomography revealed two alarming findings: consolidation in the left upper lobe suggestive of aspiration pneumonia, and a dilated esophagus packed with retained food. Oral intake was stopped on day 3, but the dysphagia persisted. Esophagography on the same day showed absent esophageal peristalsis, narrowing at the esophagogastric junction, and contrast medium pooling in the esophagus. Upper gastrointestinal endoscopy found impaired lower esophageal peristalsis but, crucially, no mechanical obstruction. Something functional had gone wrong.

The diagnostic picture crystallized on postoperative day 10, when high-resolution manometry measured a mean integrated relaxation pressure of 28.8 millimeters of mercury, with absent normal peristalsis and premature contractions in 40 percent of swallows, a pattern consistent with achalasia. That pattern is the manometric signature of achalasia, a rare motility disorder in which the lower esophageal sphincter fails to relax and the esophagus loses its coordinated squeezing motion. The condition is thought to arise from dysfunction of inhibitory neurons in the myenteric plexus, the network of nerves embedded in the esophageal wall. Two days after the dilation, esophagography demonstrated improved relaxation at the esophagogastric junction, oral intake resumed, and the patient was discharged on postoperative day 24.

Her recovery proved durable. Four months after surgery, esophagography showed no obstruction at the esophagogastric junction, and repeat manometry showed the mean integrated relaxation pressure had fallen to 12.2 millimeters of mercury. Acotiamide was continued until the four-month mark and then discontinued entirely. From that point on, she received no further medical treatment, and six years after the operation she remained well with no recurrence of achalasia.

Why did this happen? The authors systematically worked through the possibilities. Dysphagia had been absent before surgery, endoscopy excluded a mechanical blockage, no electrolyte abnormalities were found, and symptoms persisted even after opioids were stopped early. That left intraoperative neural injury as the leading suspect. Postoperative achalasia after lung surgery is extremely rare, with only two cases previously reported in the literature, and in both, vagal nerve injury was suspected. The vagus nerves and their esophageal branches form an interconnected plexus around the esophagus, which means injury can take several anatomical forms: isolated damage to the left vagal trunk, combined damage to the left trunk and the esophageal plexus, or bilateral vagal trunk injury.

The anatomy of the case narrowed the field considerably. Isolated left vagal injury is anatomically possible during a left lower lobectomy, but unilateral damage alone may be insufficient to cause clinically overt achalasia because the contralateral vagus can compensate. Direct injury to both vagal trunks, meanwhile, is unlikely during a left-sided approach because the right vagal trunk is not ordinarily exposed. That leaves the authors’ favored explanation: combined injury to the left vagal trunk and the esophageal plexus, producing functional impairment of bilateral vagal input without direct injury to both trunks. In this case, the left vagus nerve was retracted with robotic forceps, and 40-watt monopolar electrocautery was applied during subcarinal dissection directly adjacent to the anterior esophageal wall. Although no macroscopic vagal injury was seen, the authors propose that lateral thermal spread from the monopolar electrosurgery may have injured fine, visually unidentifiable vagal branches within the esophageal plexus without any direct electrode contact. They also note a counterintuitive point about surgical energy devices: bipolar electrosurgery theoretically delivers energy more locally, but it can still cause thermal injury and cannot be considered inherently safer near the esophageal plexus.

Is the robot itself to blame? The authors argue it is not, at least not specifically. Vagal or esophageal plexus injury can occur during conventional video-assisted thoracic surgery or open thoracotomy just as well. However, robotic platforms introduce two distinct considerations. First, the absence of tactile feedback may make excessive traction on delicate structures difficult for the surgeon to recognize. Second, three-dimensional high-definition visualization and enhanced instrument dexterity may facilitate deeper and more extensive lymphadenectomy than conventional video-assisted techniques, and extensive subcarinal dissection extending toward the contralateral side could theoretically injure vagal branches and a broader portion of the esophageal plexus on either side. The authors are careful to flag that this proposed mechanism remains speculative and requires further investigation; the causal mechanism in this case could not be established.

The practical takeaways are concrete. During robotic subcarinal lymph node dissection, the authors recommend that vagal branches be carefully identified and preserved, that direct grasping or excessive traction of the vagus nerve be avoided, and that energy activation adjacent to the esophageal wall be minimized regardless of which electrosurgical modality is used, with sharp dissection without energy activation considered when feasible. For clinicians on the diagnostic side, the message is equally direct: in any patient with persistent dysphagia after lung surgery, mechanical obstruction should be excluded first, and high-resolution manometry should be pursued when an esophageal motility disorder is suspected. A single pneumatic dilation restored esophagogastric junction relaxation, and six years of follow-up found no recurrence, but the episode stands as a reminder that the nerves threading around the esophagus are silent, invisible, and unforgiving neighbors during chest surgery.

Subject of Research: Postoperative esophageal achalasia after robotic lung cancer surgery

Article Title: Postoperative esophageal achalasia after robotic left lower lobectomy for lung cancer: a case report

Article References: Watanabe, Y., Fukui, M., Hattori, A., Matsunaga, T., Takamochi, K., & Suzuki, K. (2026). Postoperative esophageal achalasia after robotic left lower lobectomy for lung cancer: a case report. General Thoracic and Cardiovascular Surgery Cases, 5(1), Article 51. https://doi.org/10.1186/s44215-026-00285-y

Image Credits: AI Generated

DOI: 10.1186/s44215-026-00285-y

Keywords: esophageal achalasia, robotic surgery, lung cancer, vagus nerve, lobectomy, lymph node dissection, high-resolution manometry, pneumatic dilation, dysphagia, esophageal plexus, case report, surgical complication