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Page 8 of 11 Kikuchi et al. Mini-invasive Surg 2024;8:8 https://dx.doi.org/10.20517/2574-1225.2023.88

Figure 7. Cumulative volume of right pleural effusion on POD 7. Earlier, in the introduction phase of robot-assisted minimally invasive
esophagectomy, postoperative pleural effusion increased compared to that in conventional minimally-invasive esophagectomy (case
nos. 1-7). Active use of a vessel sealer instead of Maryland bipolar forceps around the thoracic duct significantly reduced postoperative
effusion (case nos. 8-14). POD: Postoperative day.

significantly reduced postoperative effusion (case nos. 8-14, Figure 7).

Postoperative RLN paralysis was assessed by Clavien-Dindo (CD) grade, in which grade ≥ I was observed in
6 (6.6%), pneumonia CD grade ≥ I in 9 (9.9%), atelectasis CD grade ≥ I in 6 (6.7%), and anastomotic leak
grade CD grade ≥ I in 13 (14.3%) cases. Both operative mortality and 30-day mortality rates were 0%.

DISCUSSION
In the present study, we demonstrated our standardized surgical procedures and the short-term outcomes
of RAMIE for esophageal and EGJ cancers.

To implement RAMIE, we established a dedicated RAMIE team composed of a console surgeon (H.T),
assistant surgeons (H.K, R.H, T.M, and Y.H), surgical nurses, medical engineers, and anesthesiologists. In
preparation for the first case, our RAMIE team visited another leading hospital with extensive experience in
RAMIE, conducted simulations of the patient placement and roll-in of the patient cart, and verified
troubleshooting for an emergency in the operating room at our hospital.

Throughout our experience with RAMIE, we modified the RAMIE procedures, including the active use of a
vessel sealer instead of Maryland bipolar forceps around the thoracic duct to reduce postoperative effusion,
a change in the patient placement to the hybrid position that provided increased space for assistant surgeons
outside of the patient, and improved retraction of the esophagus using Teflon tape below the tracheal
bifurcation. The assistant surgeons made further modifications to their assisting procedures. We initially
used Kodama Disuction (Sumitomo Bakelite, Tokyo, Japan), a relatively short suction device with a
spherical silicon head, to compress organs around the esophagus, but later transitioned to a longer and