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Kikuchi et al. Mini-invasive Surg 2024;8:8 https://dx.doi.org/10.20517/2574-1225.2023.88 Page 9 of 11

articular suction device with a metallic head. Although its longer shaft enabled active traction of the distant
organ from the assistant port, the metallic suction head decreased friction and caused difficulty retracting
the organs. Therefore, we eventually settled on using a long and articulating suction device covered with
Lapaclear D, a cotton pouch shaped like a slipper, which maximized counter traction even in fields distant
from the assistant port. In upper mediastinal lymphadenectomy, the console surgeon initially used a small
clip applier (Intuitive Surgical, Inc.) on the third arm. After handling several cases, we changed the
application method of small clips to target small vessels around the RLNs using a Challenger (B Braun,
Tokyo, Japan), which was used by the first assistant to reduce the application time for small clips. Notably, a
tremor-less application of clips is necessary to avoid RLN injury; however, assistant surgeons with good
experience in using a Challenger device in conventional MIE can safely place small clips around the RLN in
RAMIE. These assistant techniques are unique and first described in the literature.

The concepts of upper mediastinal lymphadenectomy in RAMIE are consistent with those of conventional
MIE in the following manner: fine dissection in the proper layer while preserving the lymphatic chain,
preservation of the RLNs in the original position, early sectioning of the esophageal branch of the RLNs,
and proper use of surgical devices with a gentle approach to the RLNs for curative lymphadenectomy and
prevention of RLN paralysis. Compared with the conventional MIE, RAMIE has advantages regarding the
stability of surgical devices, cameras, and improved retraction of the esophagus or surrounding organs.
These merits of robotic systems may significantly help surgeons perform safe and precise lymphadenectomy
in RAMIE and potentially reduce postoperative complications, such as RLN paralysis [8-11] . In a randomized
control trial (RCT) conducted at a single center in the Netherlands, RAMIE resulted in a lower percentage
of overall surgery-related and cardiopulmonary complications than open esophagectomy . In a
[10]
multicenter RCT conducted in China, significantly shorter operation time was taken in RAMIE than MIE,
and RAMIE can achieve better lymph node dissection in patients who received neoadjuvant therapy . To
[11]
fully validate the benefits of RAMIE vs. MIE, further investigations are ongoing, including a multicenter,
open-label RCT in Taiwan and mainland China [Robotic-assisted Esophagectomy vs. Video-Assisted
Thoracoscopic Esophagectomy (REVATE)], in which the primary outcome measure is the rate of
unsuccessful lymph node dissection along the left RLN .
[12]
In locally advanced esophageal cancer, the circumferential resection margin (CRM) is an important
prognostic factor after esophagectomy. Robotic systems can create and maintain proper traction between
the esophagus and surrounding organs [13-15] . Additionally, clear, bright, and magnified images in the
surgeon’s console aid in recognizing the resectable layers around advanced tumors [8,16] . RAMIE could be
advantageous in recognizing the proper layer for resection of locally advanced cancers and achieving
curative CRM.

Future research and comparative studies are warranted to address several clinical questions regarding the
safety and superiority of RAMIE in terms of short-term and long-term oncological outcomes, as RAMIE
has the potential to become a safe and less invasive surgical procedure for esophagectomy with mediastinal
lymphadenectomy.

CONCLUSION
RAMIE enables precise dissection techniques and holds the potential to improve short-term outcomes of
esophagectomy for thoracic esophageal and EGJ cancers.