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Page 2 of 9 Murillo et al. Mini-invasive Surg. 2025;9:7 https://dx.doi.org/10.20517/2574-1225.2024.55

INTRODUCTION
An estimated 500,000 people die each year from esophageal cancer with another 600,000 new cases
[1]
diagnosed each year, according to the Global Cancer Observatory . Esophageal cancer remains challenging
to treat with a 5-year survival of 21% in the United States and only a 5% increase in survival over the last 20
[1,2]
years . There is geographic variation in the histological subtype of esophageal cancer, with esophageal
squamous cell carcinoma (ESCC) more common in Eastern societies and esophageal adenocarcinoma (EA)
more prevalent in Western societies. Treatment for esophageal cancer remains reliant on upfront resection
for early-stage cancer and neoadjuvant chemoradiation followed by resection for resectable, locoregionally
advanced cancer (cT2-4aN0-3M0 and T0-1 N+ M0) . Esophagectomy remains the mainstay of surgical
[3,4]
management and is commonly performed by a transthoracic technique, the Ivor Lewis Esophagectomy or
modified McKeown Esophagectomy, due to improved feasibility of mediastinal lymphadenectomy . The
[5]
Ivor Lewis esophagectomy, commonly performed in Western countries due to the higher incidence of distal
EA, consists of a two-field thoracic and abdominal lymphadenectomy with an intra-thoracic
esophagogastric anastomosis. The modified McKeown Esophagectomy, commonly performed in eastern
countries due to the higher incidence of more proximally located ESCC, is a three-field lymphadenectomy
procedure that adds a neck dissection, and the anastomosis is performed in the left neck.

Across all surgical subspecialties, minimally invasive techniques have been increasing to improve
perioperative outcomes and reduce morbidity associated with resection. A recent Society of Thoracic
Surgery database study analyzed the incidence and 5-year trends of esophagectomy in the United States. Of
the 10,607 patients included, 54.3% underwent open esophagectomy, 33.2% underwent conventional
minimally invasive esophagectomy (MIE), and 12.4% underwent robotic-assisted MIE (RAMIE). During
the 5-year study period, there was a declining trend of open cases (P < 0.0001) and an increase of
conventional MIE and RAMIE (P < 0.0001) . When considering outcomes, the traditional invasive vs.
[6]
minimally invasive esophagectomy (TIME) trial demonstrated that conventional MIE reduced the risk of
perioperative complications compared to open esophagectomy and achieved satisfactory long-term
[7,8]
oncologic outcomes . However, conventional MIE is technically challenging, with potential for long
learning curves that could put patients at risk of high morbidity complications . Potential technological
[9]
limitations include the two-dimensional view or the restriction of movement with laparoscopic and
thoracoscopic instruments, particularly with straight instruments rotating on a fulcrum at the body wall. In
contrast, the potential advantages of the robotic platform are a three-dimensional view with full dexterity
and flexibility of the wrist joints. Similar to conventional MIE, RAMIE has demonstrated decreased
perioperative complications compared to open esophagectomy, while preserving oncologic outcomes . As
[10]
conventional MIE and RAMIE increase in prevalence for the management of esophageal carcinoma, new
evidence comparing the two modalities continues to emerge. We aim to review the current literature
comparing RAMIE to conventional MIE and discuss future trials that will continue to shape the landscape
of MIE.

CURRENT LANDSCAPE OF CONVENTIONAL MIE COMPARED TO RAMIE
Retrospective data
Numerous retrospective studies worldwide have compared conventional MIE and RAMIE outcomes [11-14] .
However, most studies are limited by small sample size and retrospective data. The largest retrospective
study to date is a single institution study from a high-volume academic center in the United States
(University of Pittsburgh), conducted over a 7-year period . The study included 246 propensity score-
[15]
matched patients with RAMIE (n = 65) vs. conventional MIE (n = 181). All operations were completed
using the Ivor Lewis esophagectomy technique. The study concluded there was no significant difference in
the primary endpoints of overall survival and disease-free survival. The authors also found no significant