Page 26 - Read Online

Erodotou et al. Mini-invasive Surg 2023;7:35 https://dx.doi.org/10.20517/2574-1225.2023.95 Page 9 of 12

According to the study results by Rebecchi et al., the learning curve plateau for the operating time was
observed after 22 cases. They also performed a risk-adjusted cumulative sum (RA-CUSUM) analysis for
[29]
postoperative complications, which indicated a change point after case 19 .
Grimminger et al. did not assess the learning curves; however, they reported comparable results regarding
morbidity and short-term outcomes between minimally invasive esophagectomy, RAMIE, and hybrid
esophagectomy .
[30]
Evaluation
In the study by Sarkaria et al., the junior surgeon received feedback from the proctor surgeon regarding
technical imperfections and advice for improvement. In case of postoperative complications, a discussion
was held between the study surgeon and the consultant surgeon, together with a video review to identify
possible contributing factors . During the UGIRA pathway, the surgeon and proctor kept in contact to
[22]
solve potential issues. The procedures were recorded and registered for future evaluation and assessment of
perioperative outcomes. The proctor re-visited the adopting surgeon after 10-20 independent RAMIE
procedures. During this visit, the proctor evaluated the surgeon’s proficiency level by completing a scoring
form and reviewing the perioperative outcomes .
[21]

DISCUSSION
Esophagectomy is a highly demanding and complex procedure, and RAMIE should be taken up by surgeons
only after a proper training program. Despite the encouraging results of RAMIE, extensive training and
proctoring are needed before this procedure can be safely established. According to the included studies, the
surgeons should first master open and minimally invasive esophagectomy. Supposing that the surgeons
have been trained only in open esophagectomy, they must first complete a basic laparoscopic general
surgery skill course on live animal models or cadavers and gain more experience in less technically
challenging procedures such as laparoscopic cholecystectomy, Heller myotomy, and diaphragmatic hernia
repair. After that, they can proceed to conventional minimally invasive esophagectomies . Sarkaria et al.
[21]
suggested that completing a formal advanced Upper Gastrointestinal fellowship program in a high-volume
center is an important step for the training pathway .
[22]
The transition from a laparoscopic surgeon to a robotic surgeon must be done slowly and in a similar
manner. The minimally invasive surgeon should ideally complete an upper gastrointestinal robotic surgery
hands-on cadaver course and succeed in the simulation robotic training at an expert level. Following that,
the surgeon can start performing less complex robotic procedures for benign esophageal cases before
proceeding to proctor RAMIE [21,23] . RAMIE is a time-consuming surgical procedure, with the gastric
interposition and esophagogastric anastomosis being the most complex part. Without a doubt, pre-existing
minimally invasive esophagectomy experience and robotic training on less complex procedures are
mandatory before implementing RAMIE.

Case observation and assisting with robotic procedures are essential. Additional committed staff, including
anesthesiologists, operating room (RAMIE-trained) scrub nurses, and circulating staff, are also important to
achieve shorter learning curves . According to the UGIRA structured training pathway for RAMIE, the
[21]
surgical team, together with the dedicated esophagogastric anesthetic team, should observe at least one full
RAMIE case in an expert center . The competence of the bedside assistant surgeon performing docking,
[21]
undocking, and exchanging instruments is crucial for a successful RAMIE. Hence, the assistant surgeon
should be trained and familiar with all steps of RAMIE .
[25]