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Page 8 of 12 Erodotou et al. Mini-invasive Surg 2023;7:35 https://dx.doi.org/10.20517/2574-1225.2023.95

Table 2. Ten - (10) Training pathway steps for implementing RAMIE
Training pathway Implementing RAMIE
steps
Step 1 Experience in open esophagectomy.
Step 2 Basic laparoscopic general surgery skill course.
Step 3 Laparoscopic experience in less technically challenging procedures (e.g. laparoscopic cholecystectomy, Heller
myotomy, diaphragmatic hernia repair).
Step 4 Experience in minimally invasive esophagectomy.
Step 5 Upper gastrointestinal robotic surgery hands-on course.
Step 6 Simulation robotic training at expert level.
Step 7 Experience in less complex robotic procedures for benign esophageal cases.
Step 8 Proctoring RAMIE:
a. case observation
b. assisting
c. perform RAMIE under strict supervision
Step 9 Perform RAMIE independently.
Step 10 Evaluation.

RAMIE: Robotic-assisted minimally invasive esophagectomy.

curve plateaus to achieve an acceptable proficiency level. Τhe plateaus for the total operative time, the vocal
cord palsy rates, and the lymph node yield varied between 20-80, 15-80, and 18-73 cases, respectively.

According to Kingma et al., 22 cases were needed to achieve the learning curve plateau for both the thoracic
operating time and intraoperative blood loss. Shorter operating time, less intraoperative blood loss, and
[21]
increased lymph node yield were reported in patients who underwent surgery after the plateau .

Park et al. and Hernandez et al. published similar results with at least 20 cases to achieve proficiency in
upper mediastinal dissection with less vocal cord palsy rates and a significant reduction in operative time
with low complication rates, respectively [20,26] . One study reported reaching the learning curve plateau of
total operating time and thoracic console time at case 26. However, the length of the hospital stay, the blood
loss, the conversion to open rate, and the number of major comorbidities remained consistent after case 26,
confirming the safety of RAMIE during the early stage of experience .
[25]

In our study, the surgeon reached the maximum of the CUSUM curve after 13 months and 24 cases.
However, after case 49, more challenging cases were included, resulting in increased operating times,
proving that easier cases may influence the learning curve .
[23]

Only one study compared the learning curve plateau between two different types of anastomoses.
Proficiency in the stapled anastomosis required 29 cases, while mastering the hand-sewing anastomosis
[16]
required 15 .

Park et al. used risk-adjusted O-E CUSUM curves to assess meticulously the surgeon’s robotic skills. After
30 cases, the lymph node yield increased from 25 to 45 lymph nodes, and after 60 cases, the vocal cord palsy
rates decreased from 36% to 17%. After 80 cases, the total operation time, the length of the hospital stay, and
[27]
the anastomotic leakage rates also decreased .
Yang et al. noticed improvements in operative time, blood loss, and conversion rates after the 40th case. A
decrease in the rates of anastomotic leakage and vocal cord palsy was observed after 80 cases. Specifically,
the lymph node yield along the recurrent laryngeal nerve reached the plateau after 40 cases .
[28]