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Page 4 of 12 Erodotou et al. Mini-invasive Surg 2023;7:35 https://dx.doi.org/10.20517/2574-1225.2023.95

n = 6), USA (22.2%, n = 4), Netherlands (11.1%, n = 2), South Korea (11.1%, n = 2), Germany (11.1%, n = 2),
Italy (5.5%, n = 1), and Taiwan (5.5%, n = 1). Approximately 72.2% (n = 13) of the selected studies were
retrospective, and 22.2% (n = 4) were prospective. No randomized control trials (RCTs) were included in
this review. In total, 2,123 patients underwent RAMIE using the Da Vinci S (11.1%, n = 2), Si (33.3%, n = 6),
or Xi (44.4%, n = 8) robotic surgical systems. RAMIE was performed using the McKeown (61.1%, n = 11)
and Ivor Lewis (44.4%, n = 8) approaches. Most of the included studies (55.5%, n = 10) performed
esophagectomy using the robot on both thoracic and abdominal phases. The characteristics of the included
studies are shown in [Table 1].

Surgical skills
A summary for the training pathway steps of implementing RAMIE according to the included studies is
shown in [Table 2].

Fourteen studies reported pre-existing minimally invasive experience, and seven studies reported prior
robotic experience for benign diseases or experience on observing and assisting robotic procedures or
experience on cadaveric robotic training. Sun et al. and Hsieh et al. reported prior experience on video-
assisted thoracoscopic esophagectomy, while Park et al. reported no thoracoscopic experience before
performing RAMIE. However, after initiating robotic esophagectomy, they started with VATS
esophagectomy based on their robotic experience [18-20] .

Only four studies reported specific training pathways. In 2020, Kingma et al. published the Upper
Gastrointestinal International Association (UGIRA) training pathway. They reported prior experience with
ten benign robotic cases, and they suggested that pre-existing minimally invasive esophagectomy skills are
[21]
needed before implementing RAMIE . Sarkaria et al. trained surgeons with a single cadaveric operation to
plan the technical aspects of RAMIE and identify possible pitfalls. They also highlighted that RAMIE
procedures should be performed in high-volume centers by surgeons with experience in challenging
esophageal cases, including formal fellowship in minimally invasive esophagectomy and robotic-assisted
procedures . Similarly, our group reported that the 18-month upper gastrointestinal fellowship experience
[22]
[23]
of the adopting surgeon, resulted in shorter learning curves . Fuchs et al. reported a six modular set-up
approach to RAMIE. The newly introduced robotic surgeons first completed simulation and animal model
robotic training to become certified as console surgeons. Following, they proceeded to 30 training
procedures with increasing difficulty (cholecystectomy, fundoplication). A good proficiency level was
[24]
achieved, resulting in more favorable learning curve outcomes . One study described a single robotic
operation of anterior teratoma resection before performing RAMIE .
[25]
Observe and assist RAMIE
Only five studies reported information for the preparation of the adopting surgeon before implementing
RAMIE. During the proctoring program, our group reported five observational cases and 20 procedures as
assisting table surgeons before proceeding to the supervised cases . During the training pathway of 50
[23]
RAMIE procedures by Sarkaria et al., the two attending surgeons alternated between the console and
assisting roles . In addition, two studies described 50 observational and assisting robotic esophagectomies
[22]
before operating independently [19,20] .

Initiating RAMIE
During the second phase of the UGIRA’s pathway, RAMIE was initiated by the new surgeon under the
supervision of an experienced proctor surgeon. Depending on the adopting surgeon’s robotic level, this
phase was extended according to the proctor’s judgment. The proficiency of the adopting surgeon was
recorded using a proctor checklist and an evaluation form. Following this, the new surgeon proceeded to