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Liu et al. Mini-invasive Surg 2020;4:44 I http://dx.doi.org/10.20517/2574-1225.2020.20 Page 3 of 10

Table 2. Characteristics of each approach to esophagectomy
OE MIE RAMIE
Difficulty level of technique Relatively easy Highly complex Easier than MIE
Special points Conventional operative method Better vision Zoomed-in enhanced three-
with a lot of history A two-dimensional view dimensional vision
Gold standard method Reduced eye-hand coordination Better overview
Restricted range of movement Increased range of movement
Tremorless actions
Flexible endo-wrists
Ergonomic conditions Normal Worst Best
Blood loss More Less Least
Operative time Shorter Longer Longer
Postoperative pain score High Lower Lower
Postoperative respiratory More Less Less
complications
Difficulty and exactness of Difficult to access More challenging maneuver than Easier than MIE
upper mediastinum lymph OE
node dissection Equivalent Equivalent More exact
Postoperative recurrent Equivalent Equivalent Reduced
laryngeal nerve paralysis
Intrathoracic hand-sewn Difficult The most difficult Easy compared to MIE
anastomosis
Acute immunological More Less Same as total MIE
response
Functional recovery Slowest Fast Same as total MIE
Length of hospital stay Longest Short Same as total MIE
Mortality Equivalent Equivalent Equivalent
Cost Equivalent Equivalent Highest
Survival Equivalent Equivalent Equivalent
OE: open esophagectomy; MIE: minimum invasive esophagectomy; RAMIE: robot-assisted minimally invasive esophagectomy

anastomotic leakage was the determining parameter (the anastomotic leakage rate dropped from 18.8%
[18]
to 4.5%) . The learning phase of MIE was also considered to be a likely explanation for the higher re-
operation rates as compared to OE in multiple population-based studies [19-22] . This may explain the findings
from a survey amongst esophageal surgeons in 2014, which showed that only 43% of the respondents
[23]
reported MIE as their preferred approach . Indeed, due to its high technical complexity, MIE has not been
adopted as the standard approach for esophageal cancer. These issues are summarized in Table 2.

A hybrid MIE (HMIE), which combines laparoscopy with a conventional thoracotomy, or combines
[24]
a thoracoscopy with a conventional laparotomy, has been suggested as an alternative to total MIE .
[25]
Messager et al. reported that patients undergoing HMIE showed less mortality at both 30 (3.3% vs. 5.7%)
and 90 days (6.9% vs. 10%) when compared to OE. In addition, Mariette et al. reported a randomized
[26]
phase III trial (MIRO trial), which found that HMIE had a lower incidence of perioperative complications
(36% vs. 64%), especially pulmonary complications (18% vs. 30%), with equivalent 3-year survival (67% vs.
55%) when compared to OE. Studies comparing HMIE with total MIE are scarce. In one study, however,
Bonavina et al. compared a series of 80 total MIE versus 80 HMIE patients and found no differences
[27]
[28]
in early postoperative complications or mortality. In addition, Grimminger et al. reported a series of
75 patients (HMIE 25, total MIE 25, RAMIE 25), which showed comparable morbidity and short-term
outcomes in the three groups, although the total minimally invasive approaches appear to be associated
with a lower incidence of complications such as pneumonia and wound infections. Those studies showed
that although HMIE is a transitional operative method between OE and total MIE, because of its relatively
lower difficulty level, somewhat reduced invasiveness and satisfactory clinical outcomes, it is a valuable
operative method worth being performed.

To overcome the disadvantages of total MIE and HMIE, a robotic surgical system was developed
and applied clinically. Transhiatal RAMIE was first introduced in 2003 , and transthoracic RAMIE
[11]