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Page 2 of 12 Erodotou et al. Mini-invasive Surg 2023;7:35 https://dx.doi.org/10.20517/2574-1225.2023.95

INTRODUCTION
Esophageal cancer is the 8th most common cancer worldwide. In 2020, there were more than 600,000 new
[1]
esophageal cancer cases and about 544,000 deaths globally . The current treatment for locally advanced
esophageal cancer is multimodal and grossly consists of perioperative chemotherapy or neoadjuvant
[2,3]
chemoradiotherapy followed by esophagectomy . A variety of surgical approaches and techniques are
currently being used to perform an oncological resection of the esophagus. The type of resection depends
on the stage and localization of the tumor, the experience and preference of surgeons, and the comorbidities
[2]
of patients .

The hybrid, totally minimally invasive, and robotic-assisted minimally invasive esophagectomy (RAMIE)
are currently the most commonly used technique. In this study, RAMIE is defined as performing a
totally robotic esophagectomy or robotic thoracic phase with a laparoscopic abdominal phase and
[4-6]
intrathoracic or cervical anastomosis .
The technical feasibility and safety in terms of oncological outcomes of RAMIE compared to open or
conventional minimally invasive esophagectomy have been confirmed in several studies. In 2012, the
superiority of RAMIE compared to open esophagectomy was confirmed by the ROBOT trial . Long-term
[7]
survival and disease-free survival were reported by de Groot et al. in 2020. The overall survival and the
disease-free survival of RAMIE were similar to open transthoracic esophagectomy, supporting the
oncological safety of RAMIE . In 2012, the TIME trial showed a lower incidence of pulmonary infections
[8]
and better quality of life in the conventional minimally invasive esophagectomy group compared to the
open esophagectomy group [9,10] . In 2018, the MIRO trial showed a lower incidence of major complications in
[11]
the hybrid esophagectomy group compared to the open esophagectomy group . In 2022, Yang et al.
reported the short-term outcomes of the RAMIE trial. This study compared RAMIE to conventional
minimally invasive esophagectomy. It was demonstrated that RAMIE could achieve shorter operative time
and better lymph node dissection in patients who received neoadjuvant therapy . Seesing et al. compared
[12]
patients from the national Dutch Upper Gastrointestinal Cancer Audit (DUCA) database who underwent
open and minimally invasive transthoracic esophagectomy and observed high anastomotic leakage and
reintervention rates during the implementation of conventional minimally invasive esophagectomy. This
[13]
shows the ethical and clinical risks of implementing a new technique .

Although the thoraco-laparoscopic esophagectomy and RAMIE are both minimally invasive techniques
using the same number of ports, there are some theoretical advantages for RAMIE. Conventional
thoracoscopic approaches have some drawbacks, as the rigid instruments and 2D view limit the exposure in
the chest. In 2003, the first RAMIE was performed to overcome the technical challenges commonly
experienced during the narrow working environment of the thoracic cage [6,14,15] . The magnified 3D view, the
improved visualization, and the flexible robotic arms might provide advantages for the upper mediastinal
lymphadenectomy, the bilateral dissection of recurrent laryngeal nerves, and the intrathoracic
anastomosis [6,16] . The clinical benefit of RAMIE is currently investigated in the ROBOT2 trial, comparing
RAMIE to minimally invasive esophagectomy with intrathoracic anastomosis .
[17]
At present, several centers are increasingly adopting RAMIE for esophageal cancer. Education about the
learning curve of RAMIE is crucial for the training pathway in order to safely introduce RAMIE in centers
without pre-existing robotic esophagectomy experience. Therefore, the aim of this paper is to review the
current literature on the learning curve of RAMIE for esophageal cancer and provide guidance on how to
set up a program for RAMIE.