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Page 10 of 16 Hasson et al. Mini-invasive Surg 2020;4:46 I http://dx.doi.org/10.20517/2574-1225.2020.10

[94]
Chao et al. also performed a propensity-matched analysis evaluating lymph node procurement in
robotic and minimally invasive procedures, reporting no conversion to open thoracotomy in either group
[94]
and similar rates of intraoperative blood loss and the need for blood transfusions . The mean number
of dissected nodes was similar in the two study groups, except for the area of the left recurrent laryngeal
nerve. Notably, there was no significant difference between the RAILE and TAIL groups in regard to rates
of recurrent laryngeal nerve palsy (20.6% vs. 29.4%, respectively, P = 0.401) and pulmonary complications
[94]
(5.9% vs. 17.6%, respectively, P = 0.259) .
Regarding direct comparison of open to robotic esophagectomy, van der Sluis et al. [95,96] conducted a
randomized controlled trial evaluating the robot-assisted minimally invasive thoraco-laparoscopic
esophagectomy versus open transthoracic esophagectomy for resectable esophageal cancer (ROBOT trial)
in an attempt to answer this question. Notably, this study represents the only report evaluating long-term,
5-year robotic-assisted esophagectomy outcomes. This was an investigator-initiated and investigator-driven
single-center randomized controlled parallel-group, superiority trial including all adult patients (age ≥ 18
and ≤ 80 years) with histologically proven, surgically resectable (cT1-4a, N0-3, M0) esophageal carcinoma
of the intrathoracic esophagus who demonstrated a performance status in line with the European Clinical
[95]
Oncology Group scoring of 0, 1 or 2 . The percentage of overall complications (Grade 2 and higher)
according to the modified Clavien-Dindo classification was the primary outcome. It started in January 2012
and patients were followed for 5 years. In total, 112 patients diagnosed with surgically resectable esophageal
cancer were randomly assigned to either RAMIE or OTTE. Occurrence of surgery-related postoperative
complications was the primary endpoint (designated using the modified Clavien-Dindo classification,
Grades 2-5).

The RAMIE (59%) population experienced fewer surgery-related postoperative complications compared
to the OTTE (80%) population (RR with RAMIE 0.74; 95%CI, 0.57-0.96; P = 0.02), less median blood
loss (400 mL vs. 568 mL, P < 0.001), fewer pulmonary (RR 0.54; 95%CI, 0.34-0.85; P = 0.005) and cardiac
complications (RR 0.47; 95%CI, 0.27-0.83; P = 0.006), and less postoperative pain (mean visual analog scale,
[96]
1.86 vs. 2.62; P < 0.001) compared to OTTE . Regarding quality of life, by POD 14, participants reported
better functional recovery in the RAMIE population (RR 1.48, 95%CI: 1.03-2.13; P = 0.038) and the quality
of life (QOL) score was better at discharge [mean difference QOL score 13.4 (2.0-24.7, P = 0.02)] and 6 weeks
thereafter [mean difference 11.1 QOL score (1.0-21.1; P = 0.03)]. Most importantly, comparable oncologic
[96]
outcomes were appreciated in both the short- and long-term periods at a medium follow-up (40 months) .
Finally, it is important to mention the cost variations among the open, minimally invasive, and robotic
techniques. Proponents of minimally invasive and robotic techniques have stated that, although they incur
a higher surgical expense, this is often counterbalanced by the savings accrued through an accelerated
recovery both in hospital and at home. Conversely, critics suggest that the added cost of MIE and robotic
procedures is often not recovered in the postoperative period, despite the decreased or lack of ICU stay. The
[97]
review of the literature supports both sides of the argument. Lee et al. utilized a decision-analysis model
to compare the estimated costs of MIE to OE and found that, over a 1-year time period, MIE cost less than
OE, with the differences mostly attributed to variations in length of stay. Others found similar findings of
lower overall cost at different time points, which were also attributed to decreased postoperative costs [98,99] .
Conversely, Liu et al. [100] compared MIE to OE and found that, even though the postoperative costs of MIE
were significantly lower, this did not offset the higher procedural expense, as was found by other authors

performing similar analyses [101-103] .

Unfortunately, there is a paucity of data comparing the cost-effectiveness of either open to robotic
esophagectomies or minimally invasive to robotic esophagectomies. Ultimately, more cost studies
evaluating robotic versus open and minimally invasive approaches is needed to validate the cost-