Changing Complication Profiles in the Era of Robotic Ivor Lewis Esophagectomy: A Comparative Analysis of Open, Hybrid, and Fully Robotic Techniques

<b>Background:</b> Novel robotic surgical techniques have substantially improved the safety and outcomes of Ivor Lewis esophagectomy, offering greater precision, reduced surgical trauma, and more radical lymphadenectomy compared to conventional approaches. While perioperative results are increasingly promising, the adoption of robotic technology appears to be accompanied by an emerging set of procedure-specific complications not previously encountered-or encountered with different frequency-in open surgery. Understanding this evolving complication profile is essential to fully realize the oncological potential of robotic esophagectomy. <b>Methods:</b> This retrospective single-center study compared 407 consecutive patients undergoing Ivor Lewis esophagectomy at a high-volume center (OPE <i>n</i> = 163; HRB <i>n</i> = 75; FRB <i>n</i> = 169; 2012-2023) regarding three pathophysiologically motivated primary endpoints within 12 months: paraconduit herniation, chylothorax, and neo-esophagus-airway fistula. <b>Results:</b> One-year survival was 71.8%, 74.7%, and 82.2% (<i>p</i> = 0.073). Chylothorax was significantly more frequent in FRB (12.4%) than in OPE (2.5%) or HRB (2.7%) (<i>p</i> < 0.001), with surgical approach as sole independent predictor. Lymphangiography in three FRB patients demonstrated thoracic duct integrity in all; leakage originated from the celiac lymphadenectomy field ascending transhiatally-suggesting a distinct mechanism potentially linked to surgical radicality. All cases resolved conservatively. Neo-esophagus-airway fistula occured significantly less frequently with robotic approaches (FRB 0.6% vs. OPE 4.9%; <i>p</i> = 0.031). Paraconduit herniation did not differ significantly within 12 months (<i>p</i> = 0.272). <b>Conclusions:</b> The complication profile of robotic Ivor Lewis esophagectomy reflects its oncological ambition: elevated chylothorax rates may correlate with radical lymphadenectomy and represent an acceptable trade-off within a multimodal treatment strategy. Fistula risk is meaningfully reduced. These findings support robotic esophagectomy as a safe and effective approach in experienced centers.