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Page 2 of 11 Bongiolatti et al. Mini-invasive Surg 2020;4:41 I http://dx.doi.org/10.20517/2574-1225.2020.28

37.5%) and vocal cord palsy (9.1%-35%) were the most frequent. The evidence for long-term outcomes is weak,
with no significant differences in overall survival, disease-free survival and recurrence identified in comparison
with other approaches. The selected papers showed that RAMIE had comparable outcomes between the open
and thoraco-laparoscopic approaches within a multimodal treatment pathway.

Conclusion: RAMIE also seems to be associated with better lymph node dissection, nerve sparing and quality of
life, but larger studies are needed to obtain more evidence.

Keywords: Robot-assisted minimally invasive esophagectomy, esophageal cancer, robotic surgery

INTRODUCTION
In the multimodal treatment pathway for esophageal carcinoma (EC), esophagectomy still remains an
[1-5]
important component for curative and radical treatment. Current international guidelines recommend
combined treatment for patients with localized esophageal or esophagogastric cancer and support the use
of minimally invasive surgery such as minimally-invasive thoraco-laparoscopic esophagectomy (MIE)
[5]
and also RAMIE. Esophagectomy is still associated with several post-operative complications due to
surgical trauma and pre-operative clinical condition of the patient (advanced age, malnutrition, weight
loss, chemoradiation). To reduce the consequent mortality and morbidity rates, surgeons have developed
[6-9]
minimally invasive techniques also for a complex procedure such as esophagectomy .

Furthermore, post-operative and oncological outcomes after esophagectomy are influenced by surgical
volume and optimized by referral to specialized centers . Several concerns have limited acceptance of
[10]
MIE such as its technical complexity and doubts about its oncological value. The robotic platform (DaVinci
system® Intuitive Surgical Inc, Sunnyvale, CA) has several advantages that could overcome the drawbacks
typical of MIE such as a magnified and three-dimensional endoscopic view, and articulated instruments
with digitally filtered movements . From the innovative and pioneering experiences of Giulianotti et al.
[12]
[11]
[13]
and Kernstine et al. , RAMIE has gained popularity amongst surgeons because it seems to ensure
adequate oncological outcomes with lower surgical trauma, and fewer post-operative complications in a
[14]
[15]
[14]
stable and comfortable environment . A recent randomized controlled trial (RCT) , a meta-analysis
and some multicenter retrospective studies [16,17] have demonstrated the safety and oncological adequacy of
RAMIE, but other well-designed comparative long-term studies are needed to validate and establish the
role of RAMIE.
The objective of this systematic review is to report some recent experiences and to compare RAMIE and
other approaches for esophagectomy, with a focus on the technical and oncological aspects.

Technical aspects of RAMIE
Indications
The selection criteria and indications for RAMIE are the same as standard trans-thoracic open or MIE [8-10]
and nowadays, some centers perform it after neo-adjuvant chemotherapy or radiation therapy [14,15,17] .
Relative contraindications to MIE include: poor performance status, impaired lung function to tolerate
[18]
one-lung ventilation, previous mediastinal surgery or extensive radiation therapy to the mediastinum .
Some types of esophagectomy are available, principally due to localization of the tumor, surgeon preference
and the reconstructive options, but the most used are the trans-hiatal and trans-thoracic approaches with
reconstruction of the digestive tract in the neck (McKeown esophagogastrostomy) or chest (Ivor Lewis
esophagogastrostomy) [18-22] .