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Page 2 of 16 Hasson et al. Mini-invasive Surg 2020;4:46 I http://dx.doi.org/10.20517/2574-1225.2020.10

[2]
among all patients , and the American Cancer Society estimates approximately 17,650 new esophageal
[3]
cancer cases will be diagnosed in 2020, with an estimated 16,170 cases resulting in death . While
esophageal resection, with or without neoadjuvant chemoradiation therapy, remains the most likely route
[4]
of cure for these patients, less than 50% present with locoregional disease , a prerequisite for surgical
[5]
intervention . Furthermore, despite the oncologic benefits, traditional open esophagectomy is associated
with considerable morbidity and mortality, complication rates range from 26% to 41%, with perioperative
[4-6]
mortality as high as 4%-10% .
Fortunately, of those patients who are candidates, survival increases to 40% among patients who successfully
[2]
undergo curative surgery , and resection can also palliate the debilitating symptoms of dysphagia that
[7]
often accompany the disease . Hence, surgical resection remains the gold standard for cure and definitive
symptom management. The choice of technique depends on several factors with the location of the
[7]
tumor, an institution’s resources, and surgeon experience being the most relevant . Traditionally, open
esophagectomy (OE), utilizing either a transthoracic (OTTE) or transhiatal (OTHE) approach has been the
surgical treatment of choice with Ivor Lewis, via thoracotomy and laparotomy; McKeown via thoracotomy,
laparotomy, and cervical incision; and Transhiatal via laparotomy and cervical incision comprising the
standard methods of resection.

Minimally invasive techniques were introduced in the early 1990s to help lessen the morbidity associated
[5,8]
with this procedure and have increasingly become more common over the last 30 years . They were
designed to decrease the high morbidity and mortality associated with open resection through utilization of
[9]
a combination of laparoscopy and thoracoscopy . Although multiple studies have demonstrated a decrease
in perioperative complications, the data describing oncologic outcomes, specifically regarding the extent of
lymph node dissection, are varied.

More recently, robotic-assisted minimally invasive esophagectomy (RAMIE) is an alternative to standard
minimally invasive esophagectomy (MIE), and has been increasingly applied to the treatment of esophageal
[10]
cancer . Its benefits include a superior quality 3D image and free articulation of the tips of the robotic
[10]
[10]
instruments that can assist in more precise movements , especially enhancing the lymph node
dissections. More and more studies are demonstrating that robotic approaches to esophagectomy reduce
morbidity and mortality, and patients report better overall quality of life, physical function, and less
[11]
fatigue and pain at three months after surgery . Nonetheless, while robotic-assisted esophagectomy
is a promising procedure, technical difficulties, long operating times, and lack of experience make this
[12]
procedure difficult to adopt for many hospitals . Today, convincing data on how beneficial and to
what extent RAMIE resection provides superior perioperative and oncologic outcomes, increased cost-
[5]
effectiveness, and improved quality of life remain unclear . The aim of this work is to review the available
literature regarding robotic-assisted esophagectomy and its origins; compare perioperative, oncologic, and
quality of life outcomes with open and minimally invasive approaches; and explore future directions.

MATERIALS AND METHODS
A literature search was conducted in Medline (PubMed), which queried the keywords “Esophageal Cancer,
Esophagectomy, Open Esophagectomy, MIE, RAMIE, Robotic Esophagectomy, Lymph Node Dissection,
Ivor Lewis, McKeown, and Transhiatal Esophagectomy”. All articles that were in the English language
and discussed open, laparoscopic, thoracoscopic, combined approaches, and robotic-assisted techniques
were reviewed. For data acquisition, articles were included if they met the above inclusion criteria and
were comparative studies of minimally invasive and open esophageal resection, minimally invasive and
robotic resection, open and robotic resection, or all three techniques with the goal to detail their historical
development, contemporary outcomes and future directions.