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Table 1. RAMIE history
Year
1960s Start of development of a remote operation system
1998 DVSS enters clinical trials, first commercial sale
2000 DVSS obtains Food and Drug Administration clearance
2001 Performance of the first transatlantic surgery (robotic cholecystectomy)
2003 The first transhiatal RAMIE
2004 The first transthoracic RAMIE
DVSS: Da Vinci Surgical System; RAMIE: robot-assisted minimally invasive esophagectomy

chemotherapy or chemoradiotherapy, and there is much surgical effort towards improving operative
techniques . This has led to the evolution from open esophagectomy (OE) to thoracoscopic minimally
[4,5]
[6]
invasive esophagectomy (MIE) , and from MIE to robot-assisted minimally invasive esophagectomy
[7]
(RAMIE) . Despite the many advantages of MIE, there are several associated limitations. RAMIE,
which has advantages in terms of an enhanced three-dimensional magnified view, tremorless action, and
articulated instruments, is being applied clinically to overcome the limitations of MIE . In this article, we
[8]
review the trends in the evolution from thoracoscopic esophagectomy to MIE and RAMIE.

HISTORY OF RAMIE
In the 1960s, the US Army and NASA began research on surgical robots with the aim of developing a
remote operative system. It took nearly 30 years to complete the first fully functional surgical robot system.
Called the Da Vinci Surgical System (DVSS), it has been clinically applied in the USA since 1997. In 1998,
DVSS entered clinical trials and became commercially available in the USA. In 2000, DVSS was approved
by the USA Food and Drug Administration. In 2001, a French surgeon, Jacques Marescaux, successfully
[9]
performed the first transatlantic robotic-assisted cholecystectomy while working in the USA . In 2003,
[10]
Talamini et al. reported the first series of transhiatal RAMIE. This was 8 years after the first transhiatal
[11]
conventional MIE was reported by DePaula et al. in 1995. In 2004, Kernstine et al. reported the
[12]
first series of transthoracic RAMIEs, which was 12 years after the first transthoracic conventional MIE
[6]
was reported by Cuschieri et al. in 1992. Since then, RAMIE has been performed worldwide in many
institutions. Moreover, given its many unique advantages, further clinical application of RAMIE is now
being widely investigated. The history of RAMIE is summarized in Table 1.

CHARACTERISTICS OF THE OPERATIVE APPROACHES TO ESOPHAGECTOMY
MIE was introduced to improve outcomes and/or reduce the invasiveness of OE, and it has produced
[13]
satisfactory results. In 2003, Luketich et al. reported the first large series of total MIEs and reported
impressively low incidence of morbidity and mortality among 222 patients. Total MIE is performed by
starting with a transthoracic MIE, followed by laparoscopic surgery to mobilize the stomach and perform
upper abdominal lymphadenectomy. Transthoracic MIE provides improved magnified vision, less chest
wall injury and relatively easy access to the upper thoracic structures, while laparoscopic surgery has less
abdominal wall injury and less blood loss due to the pneumonic pressure. The first published randomized
[14]
control trial in 2012, the TIME trial, is considered to be the cornerstone of MIE studies . Between 2009
and 2017, eight meta-analyses were published, comparing postoperative and oncologic outcomes of MIE
[15]
and OE . MIE was generally found to be superior to OE in terms of intraoperative blood loss, acute
immunological response, postoperative pulmonary infections, length of hospital stay, postoperative pain
scores, and quality of life. Furthermore, the lymph node dissection (LND) yield and 3-year survival were
equivalent [14,16,17] . However, the two-dimension view, reduced eye-hand coordination, narrow operative
field, restricted freedom of movement of operative instruments, moving targets, and nearby vital structures
are all limitations such that MIE remains a highly complex procedure to be mastered by the surgeon [8,18] .
For example, the learning curve for an intrathoracic anastomosis was 119 cases when the incidence of