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Hasson et al. Mini-invasive Surg 2020;4:46 I http://dx.doi.org/10.20517/2574-1225.2020.10 Page 11 of 16

effectiveness of these techniques. More importantly, as Klapper et al. [104] stated, “the onus is on our field to
establish the clear cost advantages of robotic applications if we desire formal acceptance and integration
into our practices”.

Discussion
Surgical treatment of esophageal cancer has evolved from an open procedure involving thoracotomy and
laparotomy to minimally invasive hybrid techniques, to completely minimally invasive and/or robotic-
assisted/totally robotic procedures. While the advantages of minimally invasive procedures and the needed
learning curve for implementation of minimally invasive esophageal resection techniques is still not
completely clear, robotic-assisted esophagectomies have consistently demonstrated lower rates of overall
complications, better scores in factors related to patient satisfaction, and have produced sound oncologic
outcomes. Specifically, robotic techniques result in less surgery-related and cardiopulmonary complications
overall, lower postoperative pain which appeared to improve short-term quality of life, and a better short-
[96]
term recovery from a functional standpoint in the postoperative period compared to OTTE . Oncological
[96]
outcomes are also comparable and in line with current standards . Until the ROBOT trial, no study had
specifically surveyed long term, 5-year outcomes or quality of life metrics. This information will hopefully
enable more programs to consider implementation of robotic surgery for esophageal cancer operations in
the future.

Nevertheless, the expense of the robotic platform and surgeon experience limit their utility in some
hospital settings. Interestingly, while some have touted the needed learning curve of robotic surgery to be
prohibitive to its incorporation in surgical practice (described as the longer initial operating times that
eventually decrease with experience), van der Sluis et al. [95,96] reported a much steeper learning curve for the
robotic approach compared to the traditional MIE (e.g., laparoscopic or thoracoscopic approaches), which
significantly reduces the number of surgeries needed to plateau, and may be of interest to smaller robotic
centers. Most experts agree that the proctor’s experience with robotic surgery and the learning surgeon’s
willingness to practice simulation are the most important in working to reduce the time to robotic
competency.

There are several limitations for this review. First, with the exception of high-volume centers,
esophagectomy in general is a procedure that is performed somewhat rarely overall. Given this, the cohorts
used for comparison are often quite small. Specifically, when comparing institutional experience of MIE
vs. robotic procedures, MIE has a breadth including 1000s of cases with excellent outcomes compared to
the best robotic experiences, which only include 100s of cases. While MIE has certainly been tested in
regards to oncologic outcomes, and lower morbidity, robotic surgery still needs to duplicate such volumes
at experienced institutions to demonstrate durability. Second, there is significant breadth in the types
of esophagectomy that one can perform depending on a surgeon’s experience with open, laparoscopic,
thoracoscopic, and robotic techniques. Furthermore, even if the same procedure is performed, there are
often variations in each individual step that make comparison difficult (the use of pyloric procedures,
amount of Kocher mobilization employed, use of jejunostomy tubes, etc.). The perioperative pathways can
also significantly differ in the pre-, peri-, and postoperative setting, leading to even more variance and
decrease the ability to compare different groups. There are procedural guides that can help to limit this
perioperative variation, which we recommend for all surgeons, especially those just entering practice or
learning new robotic techniques. Third, IL esophagectomy is the most commonly performed esophageal
cancer procedure, hence most outcome metrics are based on study of this procedure type alone. While
there are some data on transhiatal and McKeown techniques, this is less abundant and is often limited to
small cohorts or single institution studies. Fourth, mention of the specific robotic platform used in the
reporting of operating times for the robotic studies has been mostly absent. Inclusion of this detail in future
reports will help surgeons understand the relatability of these results to their specific practice. Last, the