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

provide further evidence on the cost comparison between the two modalities as part of their secondary
outcomes.

CONCLUSION
Both conventional MIE and RAMIE are increasing in frequency for the management of esophageal cancer.
The TIME and ROBOT-1 trials demonstrated that minimally invasive surgery decreased morbidity while
preserving oncologic outcomes, when compared to open esophagectomy. When comparing minimally
invasive techniques, thoracoscopic/laparoscopic vs. robotic, the current literature consistently demonstrates
a superior lymphadenectomy with RAMIE. The RAMIE trial also provided evidence for the superiority of
RAMIE in lymphadenectomy in patients following neoadjuvant therapy. The REVATE trial demonstrated
RAMIE offered higher success of total lymphadenectomy and RLN lymphadenectomy with decreased RLN
palsy. Another benefit of RAMIE included decreased operative times compared to conventional MIE.
Finally, some studies support decreased postoperative risk of pneumonia and decreased ICU stay in patients
undergoing RAMIE, but the causality of this requires further investigation [16-20,35] . A common hypothesis for
this finding is the superiority of robotic platforms including a magnified three-dimensional view of the
operative field, tremor filtration that enables precise dissection, and improved dexterity due to the flexibility
of the wristed surgical instruments . However, neither modality has consistently demonstrated superiority
[12]
in reducing postoperative outcomes, with most studies showing no significant difference. Additionally, the
impact on quality of life remains unclear, though the ROBOT-2 study aims to provide further insight on
this topic. The overall cost difference between the two modalities appears minimal with primary predictors
of cost being complications or hospital stay, not surgical modality. Therefore, RAMIE may offer improved
oncologic resection with decreased perioperative complications compared to conventional MIE, with an
overall net neutral total cost of care. Currently, published randomized control trials have limited long-term
survival with only 90-day outcomes reported. Future trials will continue to define the role for RAMIE and
conventional MIE in the management of esophageal cancer, including long-term oncologic outcomes such
as locoregional recurrence and survival.

DECLARATIONS
Authors’ contributions
Made substantial contributions to conception and design of the study: Oh, DS
Performed data acquisition, analysis and interpretation: Murillo A, Brian R

Availability of data and materials
Not applicable.

Financial support and sponsorship
None.

Conflicts of interest
Oh DS is an Associate Medical Officer at Intuitive Surgical. Murillo A and Brian R receive funding as
participants in the Intuitive Surgical University of California San Francisco (UCSF) Simulation-Based
Surgical Education Research Fellowship.

Ethical approval and consent to participate
Not applicable.