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Erodotou et al. Mini-invasive Surg 2023;7:35 https://dx.doi.org/10.20517/2574-1225.2023.95 Page 3 of 12

Figure 1. Flow chart of literature review.
METHODS
This is an overview of the most recent literature on the learning curve of RAMIE, and we try to answer the
following questions:

(1) What surgical skills are needed before performing RAMIE?
(2) How many cases should the surgeon observe and assist before initiating RAMIE independently?
(3) How many RAMIE procedures are needed to reach the learning curve plateau?
(4) How is the robotic surgeon evaluated?

Search strategy and data collection
Electronic databases Pubmed and Science Direct were searched using multiple combinations and synonyms
of the keywords “esophageal cancer”, “robotic esophagectomy”, “RAMIE”, and “learning curve” from
incentive up to March 31, 2023. No further search software or extra features were used. This review
included studies that reported on the learning curve and outcomes of surgeons introduced to RAMIE.
Studies reporting results from surgeons with pre-existing robotic experience for esophageal cancer, reviews,
case reports, conference abstracts, and editorials were excluded. Only studies in the English language were
included. The author (Maria Erodotou) searched the literature and excluded duplicates. Titles and abstracts
were screened to identify citations for inclusion. Data were extracted from the full-text papers: first author’s
name, year of publication, country, number of patients, robotic technology used, prior surgical experience,
part of a procedure performed robotically, number of observational and assisting cases, method of assessing
learning curves, and learning curve plateaus. The risk of bias was not analyzed.

RESULTS
The literature search identified 116 studies for the learning curve and outcomes. Seventy-eight studies
remained after duplicates were removed. After reviewing the titles and abstracts, 31 articles remained for
screening. Finally, 18 studies were included in this review. The study selection flowchart is presented in
[Figure 1].

Characteristics of included studies
The 18 selected studies were published between the years 2013 and 2022 from seven regions: China (33.3%,