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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 5 of 10

Table 3. Intrathoracic anastomosis in RAMIE
Intrathoracic anastomosis methods Merits Limitations
Hand-sewn Can take full advantage of robot-assisted Operative field is not satisfactory in the
hand-sewing. posterior wall anastomosis
Can be performed when the length is
insufficient for staple anastomosis
Overlap No need for additional mini-thoracotomy. Cannot completely remove tissue poorly
(linear stapler × 1) + Hand-sewn Lower occurrence of stenosis. supplied with blood.
Can save stapler. Need a longer tubular stomach and esophageal
Can take full advantage of robot-assisted end than circular stapler
hand-sewing
Function No need for additional mini-thoracotomy Need a longer tubular stomach and esophageal
(linear stapler × 2) end.
Cannot completely remove tissue poorly
supplied with blood
Triangular stapling A reportedly lower rate of anastomotic The need to intrathoracically staple three times
(linear stapler × 3) complications. in three directions is a technical challenge
Lower occurrence of stenosis
Circular stapler Relatively easy to perform. Need an additional mini-thoracotomy.
Can completely remove tissue poorly supplied Need an extra circular stapler.
with blood Higher occurrence of stenosis

RAMIE: robot-assisted minimally invasive esophagectomy

demonstrate that RAMIE may be more effective for extensive LND than MIE or OE. Recurrent nerve palsy
is a complication that is especially associated with lymph node dissection in the superior mediastinum.
[31]
In the ROBOT trial, the recurrent nerve palsy rate was 9% . However, Park et al. showed a significant
[47]
learning curve on RLN palsy rates, which dropped from 55% to 0% after performing 20 cases in their study.
The length of the learning curve for RAMIE has been reported to be 20-70 cases [8,18] .

ROBOTIC INTRATHORACIC ANASTOMOSIS
The robotic intrathoracic anastomosis can be hand-sewn or performed with linear or circular staplers.
Although complete hand-sewing takes full advantage of robot assistance, it appears posterior wall
anastomoses are technically challenging because of the deep and narrow operative field . Wang et al.
[49]
[48]
showed side-to-side anastomosis to be a promising approach with the advantages of there being no need for
additional mini-thoracotomy and a lower incidence of stenosis. In their report, the authors also emphasized
the usefulness of the barbed knotless suture. Another recent study reported similar satisfactory outcomes
[50]
with end-to-side anastomosis . Those authors concluded that end-to-side anastomosis requires a shorter
length of the esophageal end, and section with poor blood supply was removed by a second stapler, which
may ensure a good blood supply to the anastomosis. Triangular stapling is another anastomotic technique,
[51]
which is reportedly associated with a lower rate of anastomotic complications . However, stapling three
times in three directions would seem to present a great technical challenge intrathoracically. Recently,
[52]
Han et al. reviewed diverse ways of intrathoracic anastomosis. Among these anastomotic methods,
mortality was equivalent, but the anastomotic leak rates differed. Further large clinical trials are still needed.
In general, each method has its merits and demerits. Surgeons should determine the anastomotic method
of every single case with the final aim of maximizing patient benefits. The methods used for anastomosis in
RAMIE are summarized in Table 3.

TRANSTHORACIC VS. TRANSHIATAL RAMIE
As with MIE, different variations of RAMIE have been established. Transthoracic RAMIE is one of the
most commonly used approaches. It has a wide operative field, and after posterior and middle mediastinal
LND, superior mediastinal LND can be performed in this operative field. However, destruction of the thoracic
[10]
wall and pleura are unavoidable and differential lung ventilation is still needed. In 2003, Talamini et al.
reported the first series of transhiatal RAMIE. Conventional transhiatal MIE has been proven as a less