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Page 2 of 14 Khaitan et al. Mini-invasive Surg 2020;4:51 I http://dx.doi.org/10.20517/2574-1225.2020.34
[1-5]
those found from open procedures . These results have translated more recently to robotic surgery as
[6]
well. The first minimally invasive esophagectomy (MIE) was reported in 1992 , and the first robotic-
assisted minimally invasive esophagectomy (RAMIE) with an intrathoracic anastomosis was published
[7]
in 2002 . This report was followed by the first transhiatal robotic esophagectomy in 2003 and the first
[8,9]
McKeown robotic esophagectomy with cervical anastomosis in 2004 . Since then, numerous authors have
reported the perioperative safety, efficacy, and potential advantages of robotic-assisted esophageal resection.
The early experience with RAMIE suggested an increased incidence of complications, including
anastomotic leaks and conduit loss [10-13] , compared to open and traditional MIE approaches. The more
recent literature, however, has shown a complication profile comparable to MIE [2,14,15] . This evolution in
outcomes following RAMIE is likely due to the steep learning curve associated with the introduction of
a new technology, especially for a complex operation such as esophagectomy. Improvements over time
may also be attributable to the adoption of structured protocols for the teaching and proctoring of robotic
operations intended to enhance surgeon proficiency and safety .
[16]

This review will focus on the technical details of performing and outcomes following 2-field, 3-field, and
transhiatal RAMIE, including recent and ongoing studies, as well as potential future trends.

INDICATIONS FOR SURGERY
The indications for RAMIE are the same as for open esophagectomy or traditional MIE, including
esophageal cancer, Barrett’s esophagus with high-grade dysplasia (unamenable to, or having failed,
endoscopic therapy), recalcitrant esophageal stricture, and end-stage achalasia. A contraindication to
RAMIE is the presence of extensive thoracic or abdominal adhesions that preclude a minimally invasive
approach. In addition, if the stomach has been resected or its vascularity interrupted by prior surgery,
an alternate esophageal replacement conduit, such as the colon or jejunum, may be required. An open
operation may be necessary in such cases, as the experience with robotic approaches to utilizing conduits
other than the stomach is limited.

TWO-FIELD RAMIE (IVOR LEWIS RAMIE)
Patient positioning and abdominal port placement
An Ivor Lewis RAMIE is started with the patient supine. Four robotic ports (one 12 mm and three 8 mm)
are typically employed as seen in Figure 1A. A 12 mm right upper quadrant port is needed to create a
gastric conduit with the use of a robotic stapler. The abdomen is entered with either a Hassan or Optiview
technique using a 0-degree, 5 mm camera in the left upper quadrant. This port is later converted to an 8 mm
robotic port. Once the peritoneal cavity is entered, carbon dioxide is insufflated to a sustained pressure of
15 mmHg. The remaining ports are placed under direct visualization. Three other robotic ports (one 8 mm
midline, one 8 mm left lateral quadrant, and one 12 mm right upper quadrant) are employed. These
incisions are all equidistant from the xiphoid process. A 5 mm liver retractor port can be placed either
laterally in the right upper quadrant or near the subxiphoid process. Finally, an assistant port is positioned
low in the pelvis, typically on the patient’s right, to facilitate placement of a feeding jejunostomy in the left
lower quadrant. We use a 12 mm valveless insufflation port (AirSeal; Conmed, Utica, NY) as our assistant
port. It serves the dual roles of providing controlled air insufflation while being sufficiently large to allow
passage of cigar-shaped sponges, topical hemostatic agents, and Penrose drains throughout the case.

Abdominal portion of the procedure
Following thorough exploration for metastatic disease, abdominal dissection begins by creating the gastric
conduit. The right gastroepiploic artery is identified within the greater omentum [Figure 1B]. Starting at
the level of the pylorus, the gastrocolic ligament is divided along the greater curvature of the stomach using