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Khaitan et al. Mini-invasive Surg 2020;4:51 I http://dx.doi.org/10.20517/2574-1225.2020.34 Page 11 of 14

robotic cancer operations is on the rise [28,29] . A major advantage of current robotic systems, compared to
the performance of an open esophagectomy, is the seven degrees-of-freedom in the wristed instruments,
allowing the surgeon to operate ergonomically with angulation comparable to the human wrist. This
dexterity allows the surgeon to complete esophageal and nodal dissections similar to an open procedure,
facilitates intracorporeal suturing and knot tying, and enhances the surgeon’s ability to operate in difficult-
to-reach places such as the apex of the chest, subcarinal space, and splenic flexure. The additional
advantages of current robotic platforms include three-dimensional visualization, 10-fold magnification, and
a 6-Hertz motion filter designed to eliminate tremor. In addition, robotic surgical platforms offer longer
instruments compared to other minimally invasive systems with a fixed fulcrum supported by robotic
arms, potentially leading to reduced stress on the chest and abdominal wall. An operating console for a
second surgeon is used in some robotic operating rooms, allowing surgeons to perform surgery in tandem
with, and facilitating training in a dynamic and supportive manner.

Given these advantages, the increasing utilization of surgical robotics in the performance of esophagectomy
should come as no surprise. While the initial experiences with RAMIE were associated with higher
complication rates, subsequent reports have shown that RAMIE can be performed with superior
perioperative outcomes, and equivalent oncologic survival when compared to open and traditional
minimally invasive approaches [14,15] . Such experiences suggest that the potential disadvantages of current
surgical robots, including the lack of haptic feedback and the positioning of the surgeon at a remote console
in a non-sterile environment, can be mitigated by surgeon experience and the presence of trained assistants
in the sterile field. The incidence of associated complications, such as major uncontrolled hemorrhage,
appears to be at an acceptably low level.

Ongoing studies about RAMIE
Numerous retrospective studies have supported the role of MIE and RAMIE when compared to open
esophagectomy. Only a limited number of prospectively designed, randomized controlled trials (RCTs),
however, have been reported to date. An RCT of 115 patients from 5 European centers (the TIME trial)
evaluated the outcomes of 59 patients randomly assigned to MIE compared to 56 patients randomized to
[1,4]
open esophagectomy. Initial results were published in 2012, and long-term results in 2017 . While the
baseline demographics and clinical characteristics were similar in both groups, the overall 3-year survival
was higher in the MIE group (50.5% vs. 40.4%), although the difference was not statistically significant (P =
0.207). Disease-free 3-year survival rates were also similar between the two groups [40.2% for MIE, 35.9%
for open; HR = 0.691 (95%CI: 0.389-1.239)]. Of note, pulmonary complications were significantly lower in
the MIE group (12% vs. 34%, P = 0.005), as was blood loss (200 mL vs. 475 mL, P < 0.001) and hospital stay
(11 days vs. 14 days, P = 0.044) despite conversions from MIE to open in eight cases. The anastomotic leak
rate, re-operative rates, and 30-day mortality rates were similar between groups.

[5]
The ROBOT trial, published in 2019, was an RCT from a single institution in the Netherlands . Patients
with esophageal cancer were randomized to RAMIE (n = 54) or open esophagectomy (n = 55). Findings
were similar to those from TIME, with less overall surgery-related complications following RAMIE (59%
vs. 80%; P = 0.02), fewer pulmonary complications (32% vs. 58%; P = 0.005), and a lower incidence of atrial
fibrillation (22% vs. 46%, P = 0.01). On the contrary, no differences were noted in anastomotic leak rates or
mortality rates between the two groups. Median ICU stay, hospital stay, R0 resection rates, and lymph node
retrieval numbers were not significantly different between the two groups. Functional recovery, patient
reported pain scores, and short-term quality of life assessments all favored the RAMIE approach. Overall,
the study found improved short-term outcomes following robotic esophagectomy compared to the open
approach.

While several retrospective studies, as well as these RCTs, have compared both MIE and RAMIE to open
esophagectomy, no studies have compared RAMIE to MIE. A recently opened trial (RAMIE trial) is