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Page 12 of 14 Abe et al. Mini-invasive Surg 2023;7:28 https://dx.doi.org/10.20517/2574-1225.2023.15

The incidence of RLN palsy was reduced in the RAMIE group, and the number of retrieved mediastinal
lymph nodes and estimated intraoperative blood loss did not differ between groups. However, it is the
surgeon, not the robot, who performs better lymph node dissection. We should not confuse the surgeon
[30]
operating the robot with the robot . We believe that the fact that this study was performed by two
surgeons experienced in both esophageal cancer surgery and robotic surgery contributed to these favorable
results.

This study had several limitations. First, this was a retrospective study. Therefore, additional multicenter
prospective studies are needed to fully clarify the superiority of RAMIE compared to MIE. Second, this
study was ≤ 4 years in duration, and although the surgical technique and perioperative patient management
were consistent, some of the surgical instruments differed. Third, although console operating time is one of
the most important factors for achieving the learning curve, there are other important factors, such as the
amount of blood loss, the number of retrieved mediastinal lymph nodes, and the time density of the surgical
volume and operation frequency. This study did not consider all these factors in the learning curve.
Regarding the amount of blood loss and the number of retrieved mediastinal lymph nodes, no difference
was observed between the two groups in this study, and similar reports are available in the literature [7,31] .
However, we believe that one of the limitations of this study is the fact that the time density of surgical
volume and operation frequency were not considered in the study.

In conclusion, RAMIE required 29 cases to achieve surgical proficiency. Our results suggest that the
introduction and standardization of prone robot-assisted esophagectomy may decrease the incidence of
RLN palsy in patients compared to MIE. Further analysis of more cases in future multicenter studies will
clarify the potential impact of RAMIE in esophageal cancer.

DECLARATIONS
Authors’ contributions
Conception and design: Abe T
Data collection: Abe T
Establishment of study materials or enrolment of patients: Abe T, Higaki E, Fujieda H, Shimizu Y
Data scrutiny, analysis, and clarification: Abe T
Writing and revision of the manuscript: Abe T
Study supervision: Shimizu Y
Read and agree with the final manuscript: Abe T, Higaki E, Fujieda H, Saito H, Narita K, Komori K, Ito S,
Shimizu Y

Availability of data and materials
Not applicable.

Financial support and sponsorship
None.

Conflicts of interest
All authors declared that there are no conflicts of interest.

Ethical approval and consent to participate
All patients provided written informed consent before treatment, and the study was approved by the Ethics
Committee of Aichi Cancer Center Hospital. This work conformed to the guidelines set forth in the
Helsinki Declaration of 1975 and later versions. The Review Board of the Aichi Cancer Center Hospital