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Page 8 of 11 Bongiolatti et al. Mini-invasive Surg 2020;4:41 I http://dx.doi.org/10.20517/2574-1225.2020.28
[19]
Dunn et al. in 2012 achieved 94.7% of radical resection with a median of 20 lymph nodes retrieved and
a median overall survival of 20 months after trans-hiatal RAMIE. Another paper regarding laparoscopic
trans-hiatal esophagectomy showed a median overall survival of 28 months with 3.7% of local recurrence,
[23]
22% regional and 37% distant recurrence .
DISCUSSION
RAMIE has gained popularity in the past decade due to increased experience in Western countries and the
availability of the robotic platform through Eastern countries, where the incidence of esophageal carcinoma
is higher. Large multi-center studies and RCTs have demonstrated that minimally-invasive esophagectomy
is safe and oncologically adequate, but it is a technically demanding procedure due to drawbacks from
thoracoscopy and laparoscopy [1,5-9] .

The robot-assisted approach has some advantages over the thoraco-laparoscopic one: first, the magnified
and three-dimensional intra-corporeal view; secondly, better dexterity due to the articulated instruments
with tremor filtering, which allows fine dissection of mediastinal and abdominal structures; and finally,
longer instruments with the fulcrum inside the body instead of the abdominal or chest wall, which could
decrease post-operative pain. On the other hand, the lack of tactile feedback, longer operative time and
costs are the main reported disadvantages of RAMIE. The latest version of the available robotic platform
(DaVinci Xi), has four arms that work in a more parallel way than the previous version and with longer
instruments, that facilitates meticulous dissection in narrow fields such as the esophageal hiatus and the
upper region of the thorax [10,14,40] . The visceral and lymph node dissections in the cervico-mediastinal outlet
could be more accurate and ergonomic with the RAMIE approach, avoiding injuries to other nervous,
vascular or respiratory structures. Furthermore, these characteristics have a significant impact on lymph
node dissection such that it can be performed in a safe manner due to the magnified view of the operating
field and the small instrument tips. Some studies have demonstrated that lymph node dissection in the
celiac area, subcarinal and paratracheal is safe and oncologically adequate with reduced nerve injury with
RAMIE .
[32]
Moreover, for tumors of the esophagogastric junction or lower thoracic esophagus, the robotic
platform permits easy handling of instruments to perform hand-sewn or mechanical intrathoracic
anastomosis [20,21,25,26,36] . Anastomotic leak is still the Achilles’ heel of esophagectomy and no anastomotic
subtype was superior in terms of leakage or stricture. Some factors are associated with anastomotic leaks
and a poorly perfused conduit is a well-known risk factor for anastomotic dehiscence. This issue could be
reduced with the use of NRF (Near InfraRed Fluorescence) associated with the intravenous administration
of indocyanine green. With NRF, the surgeon could obtain a real-time gastric conduit perfusion,
identifying inadequately perfused or ischemic areas and then the surgeon could construct the esophago-
gastric anastomosis on a well-perfused conduit [30,41] . Moreover, the latest robotic platform is armed with
robotic staplers and the surgeon can create a mechanical end-to-side esophagogastric anastomosis with
easier handling.

Although evidence about RAMIE are still weak, data from large institutional studies and from the only
published RCT supported the application of RAMIE in the treatment of EC in a multimodal treatment
pathway [3,4,10,42] . Some recent papers reported a variable, but high use of induction chemotherapy and
chemoradiation therapy with potentially improved long-term results. Long-term OS and DFS were
evaluated in few papers, but RAMIE was demonstrated not to be inferior to MIE or OE [14,17,22,31] .

The main issue of robot-assisted surgery remains the high costs to buy the platform and instruments,
to start a program and for periodical technical assistance. The actual monopoly of Intuitive Surgical is