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Murillo et al. Mini-invasive Surg. 2025;9:7 https://dx.doi.org/10.20517/2574-1225.2024.55 Page 3 of 9

difference in perioperative outcomes including blood loss, operative time, anastomotic leak, complete
resection rates, or postoperative complications. There was also no difference in readmission or mortality
within 90 days. Notably, the only significant difference was in the oncologic resection, with more lymph
[15]
nodes harvested in the RAMIE group (32 vs. 29, P = 0.02) .

A recent meta-analysis identified 18 studies comparing RAMIE and conventional MIE, with 17
retrospective studies and one randomized control trial (the RAMIE trial). The RAMIE trial will be covered
in full detail later in this review as the only published randomized control trial comparing conventional MIE
to RAMIE. The meta-analysis contained 2,932 patients with resectable esophageal cancer (92.88% squamous
cell carcinoma, 29.83% neo- adjuvant therapy, 15.07% adjuvant therapy, and 38.93% stage III-IV). Studies
included both the Ivor Lewis Esophagectomy and the modified McKeown Esophagectomy, along with
hybrid approaches. A total of 1,418 underwent RAMIE and 1,514 underwent conventional MIE, with no
significant difference in histology, stage, the use of neoadjuvant treatment, and the use of adjuvant
treatment between the two groups. The meta-analysis also found no significant difference in perioperative
outcomes between RAMIE and conventional MIE including no difference in blood loss, operative time,
length of stay, or mortality within 90 days. In the postoperative outcomes, the two groups had similar
outcomes except that RAMIE had a significantly decreased incidence of pneumonia . This result was in
[16]
accordance with recent studies suggesting a reduced risk of pneumonia with RAMIE due to the improved
visualization, which may reduce injury of the lung parenchyma and pulmonary vagal nerves [17-21] . In terms of
oncologic resection, RAMIE had a significant increase in total harvested lymph nodes [mean difference
(MD) = 1.18; 95% confidence interval (CI): 0.06-2.30; P = 0.04), left recurrent laryngeal nodes (MD = 0.22;
95%CI: 0.09-0.35; P < 0.001) and abdominal lymph nodes (MD = 1.04; 95%CI: 0.19-1.89; P = 0.02)]. The
findings of this meta-analysis highlight not only the increased number of total lymph nodes, but
additionally, more lymph nodes along the recurrent laryngeal nerve (RLN) which are considered to be the
most challenging with high morbidity. To date, this is the only meta-analysis comparing long-term
outcomes including disease-free survival and long-term survival. Notably, this study found improved 3-year
disease-free survival in the RAMIE group [odds ratio (OR) = 1.42; 95%CI: 1.11-1.83; P = 0.006)], which
could be hypothesized to be related to the increased lymph node resection, but additional long-term
[16]
oncology data will be needed to clarify this .

When examining long-term oncology data more closely, studies are limited. Single-center studies have
found RAMIE to deliver similar long-term survival outcomes compared to other modalities . When
[22]
comparing outcomes between modalities, a National Cancer Database (NCDB) study found RAMIE to be
superior . The authors analyzed the overall survival of 5,170 patients who underwent esophagectomy from
[23]
2010-2017, with 428 undergoing RAMIE, 1,417 MIE, and 3,325 open esophagectomy. There were no
significant differences between demographics or baseline characteristics between the three groups. When
compared to RAMIE, there was an increased risk of death for those that underwent either MIE [hazard ratio
(HR) = 1.19; 95%CI: > 1.00 to 1.41; P < 0.047)] or open esophagectomy (HR = 1.22; 95%CI: 1.04 to 1.43; P <
0.017). Findings suggest potential increased survival for patients undergoing RAMIE, though findings are
limited by retrospective nature and lack of disease-specific mortality.

Upper GI International Robotic Association
Across the world, robotic esophagogastric surgery has been increasing, leading to the founding of Upper GI
International Robotic Association (UGIRA) in 2017. UGIRA is a multicontinental group of robotic
surgeons, striving to facilitate the worldwide implementation and advancement of robotic esophagogastric
surgery. To provide quality control and gain deeper insights into outcomes, UGIRA established a
comprehensive international registry for RAMIE. Using data from this registry, UGIRA provided a
snapshot on transthoracic RAMIE for cancer between 2016 and 2019. During this period, 856 RAMIE