Robot-Assisted Minimally Invasive Esophagectomy: Current Best Practice Open Access

Esophagectomy stands as one of the most complex and highly invasive oncological procedures, requiring both thoracic and abdominal surgery, and is the cornerstone of the curative treatment of esophageal cancer [1]. Traditional open esophageal surgery is associated with high complication rates, primarily anastomotic leakages, mediastinitis, and pneumonia. Efforts to improve patient outcomes have led to the adoption of minimally invasive esophagectomy (MIE), which offers smaller incisions and improves surgical precision due to magnification and lighting, leading to significant advantages over open surgery. These include improved lymph node yield, reduced blood loss, shorter length of hospital stay, and enhanced quality of life [2‒4]. However, postoperative complications and recovery remain challenging [5].

Since the early 2000s, robot-assisted minimally invasive esophagectomy (RAMIE) has emerged as an innovative evolution of MIE [6]. Building on the principles of minimally invasive techniques, RAMIE introduced further technological advancements, including three-dimensional visualization, instruments with seven degrees freedom of motion, and features such as tremor filtration, and motion scaling, all of which significantly enhanced surgical precision and control [7]. These innovations have expanded surgical possibilities while also paving the way for further advancements in surgical technology. This narrative review explores the current best practice and the evidence on the effectiveness, as well as future prospects of RAMIE in the surgical management of esophageal cancer, including technological advancements such as artificial intelligence (AI) and surgical systems enabling approaches like the mediastinoscopic cervical approach.

The first open (transthoracic) esophagectomy was performed in 1913, utilizing an external rubber tube for reconstruction of the intestinal tract. This demonstrated the feasibility of transthoracic esophagectomy and its potential as a curative treatment for esophageal cancer [8]. However, the technique’s high mortality rate presented significant challenges, and nearly 2 decades passed before successes were achieved [9]. In 1946, a two-stage transthoracic (Ivor Lewis) esophagectomy was introduced. This approach began with gastric mobilization and esophageal resection, followed by reconstruction through a right thoracotomy, creating an intrathoracic esophagogastric anastomosis 2 weeks after the initial laparotomy [10]. Later, in 1976, a three-stage technique (McKeown) was developed, beginning with a right thoracotomy, followed by an abdominal stage and a cervical incision to create a cervical esophagogastric anastomosis [11].

The transhiatal approach to esophagectomy was first performed in 1933 [12]. However, it was not widely adopted at the time, as the transthoracic method became preferred following the advent of general anesthesia [13]. In 1978, interest in transhiatal esophagectomy was revitalized with a series of blunt transhiatal procedures by Orringer [14]. This technique offered a less invasive option, suitable for patients unable to tolerate thoracotomy [12]. By avoiding the thoracotomy, transhiatal esophagectomy minimized pain and reduced the risk of postoperative complications such as pneumonia and mediastinitis [14]. However, due to the nature of the procedure, transhiatal esophagectomy does not allow an extensive lymphadenectomy of the upper mediastinum. Hence, a transthoracic approach is traditionally considered oncologically superior, with a reported trend towards better 5-year overall survival (OS) in transthoracic esophagectomy when compared to transhiatal esophagectomy, particularly in patients with type I esophageal cancer. However, this difference did not reach statistical significance [15].

Open esophageal surgery has been associated with high complication rates, primarily anastomotic leakages, mediastinitis, and pneumonia, even in high-volume centers. To address these challenges, minimally invasive techniques were introduced in the early 1990s, aiming to reduce complications while preserving the oncological integrity of the procedure [9]. The first thoracoscopic thoracic esophagectomy was performed in 1992, marking a key advancement in the field [16]. However, it was Luketich et al. [17] who refined and popularized the total MIE. Two randomized controlled trials demonstrated that MIE offers significant advantages, including fewer pulmonary complications, reduced blood loss, shorter hospital stay, and improved quality of life [2, 3]. Additionally, the quality of the surgical resection, such as lymph node yield, and 3-year survival are comparable or even better than those achieved with open surgery [2, 3].

Over the subsequent decade, RAMIE emerged as an innovation aimed at addressing the technical challenges often encountered during MIE, particularly during the thoracic phase. The rigid and confined nature of the chest cavity, with restricted access due to the ribs, scapula, and vertebral column, posed significant obstacles for standard minimally invasive tools [18]. Robotic systems, with their advanced technical features such as enhanced three-dimensional vision and full dexterity, offered distinct technical advantages during esophagectomy [18]. In 2003, the first RAMIE was performed [19], and in 2006, the first case series was published [6].

Today, numerous approaches for esophagectomy are used worldwide, including open, minimally invasive, hybrid (combining minimally invasive and open phases), and robotic techniques [20]. Over time, the treatment paradigm for esophageal cancer has shifted, with the growing adoption of MIE and RAMIE progressively replacing traditional open procedures. Consequently, global surveys demonstrated that the use of MIE increased from 14% in 2007 to 43% in 2014 and 53% in 2021 [21, 22]. The most recent survey (2021) for the first time included questions regarding the use of robot-assisted surgery and indicated that 13% of surgeons preferred a robot-assisted thoracic phase and 6% preferred a robot-assisted abdominal phase [22].

As described, esophagectomy has historically been approached via open surgery, but advancements in minimally invasive techniques have reshaped the landscape of eligible candidates [3]. Initially, RAMIE was performed in cases similar to those treated with MIE, particularly for Barrett’s esophagus with high-grade dysplasia, end-stage achalasia, esophageal strictures, and esophageal cancers [23]. Over time, robotic techniques have expanded the range of eligible patients, enabling surgeons to consider resection in older and more comorbid patients, supported by evidence indicating a reduced rate of perioperative complications, especially respiratory complications, compared to open esophagectomy [24].

Although prior thoracic or abdominal surgeries can pose challenges, they do not constitute absolute contraindications for RAMIE. In carefully selected cases, the procedure can still be attempted depending on the surgeon’s expertise and comfort level [25]. Moreover, RAMIE has been proven to be feasible in patients with clinical T4(b) esophageal tumors that were successfully downstaged with chemoradiotherapy [26]. However, this approach is not unique to RAMIE and has also been described to be feasible with MIE and open surgery [27]. Therefore, proper patient selection remains essential to guide the choice for RAMIE, thereby avoiding unnecessary resource use and predictable conversions to open surgery. Furthermore, patients with positive lymph nodes in the upper mediastinum treated with RAMIE have demonstrated favorable oncological outcomes, including excellent lymph node yield and high R0 resection rates [28]. Additionally, RAMIE has demonstrated to be feasible and safe in patients with resectable esophageal cancer with cervical lymph node metastasis [29]. Existing evidence, therefore, supports the use of RAMIE for both routine cases and more complex presentations of esophageal cancer.

RAMIE has gained popularity for its potential advantages over traditional open and MIE techniques, with increasing evidence regarding intraoperative, postoperative, and oncologic factors. Table 1 provides an overview of key findings from randomized controlled trials and recent meta-analyses comparing RAMIE, MIE, and open esophagectomy.

RAMIE is performed using various surgical approaches, with many centers adopting a hybrid technique during the transition to robotic surgery. In the hybrid approach, the thoracic phase is conducted robotically to leverage the precision of the robotic system for complex tasks such as mediastinal lymph node dissection. The abdominal phase, however, is often initially performed laparoscopically or even via an open approach [34]. This hybrid approach was driven by the technical limitation of working in multiple quadrants with the early robotic systems. However, advancements in current robotic technology have improved their ability to perform multi-quadrant maneuvers with larger amplitudes, enabling their application in the abdominal phase [35]. Consequently, fully robotic procedures are now more feasible, and evidence increasingly suggests that this approach can improve outcomes. Full RAMIE reduces trocar movements, resulting in less abdominal wall manipulation. It has also been associated with shorter operative times and reduced upper quartile blood loss compared to the hybrid approach, although these outcomes are influenced by the skill and expertise of the surgeon and the surgical team [36]. Nevertheless, the specific benefits of robotic assistance in the abdominal phase remain an area for further investigation [37].

The range of anastomotic techniques includes handsewn methods as well as mechanical options such as circular or linear stapling, each offering distinct advantages and challenges. Most esophageal surgeons tend to utilize techniques they are already familiar with from open esophagectomy or MIE [38, 39]. Handsewn suturing and linear stapling grant the surgeon the ability to perform a completely robotic-assisted anastomosis with direct control [40]. In contrast, circular stapling requires undocking of the robotic arms and a trained assistant but is often considered the most reproducible technique for surgeons transitioning to robotic procedures [38]. Despite the variety of available techniques, determining the most effective method remains a subject of debate. Postoperative outcomes, including anastomotic leakage rates, have yet to conclusively favor one approach over another [41]. Consequently, no consensus has been reached regarding the optimal anastomotic technique in RAMIE; therefore, the choice depends on the surgeon’s preference [39]. However, regardless of the technique used to create the esophagogastric anastomosis, it must be reproducible, with the goal of establishing a viable, tension-free, and nonobstructive anastomosis with adequate margins.

In terms of efficiency, studies such as the ROBOT trial that compared robotic to open esophagectomy, have generally found that RAMIE is associated with longer operative times compared to the open approach (349 versus 296 min, p < 0.001) [24]. However, when comparing RAMIE to MIE, operative times are often comparable (326 versus 310 min, p = 0.21) [33]. Moreover, a recent RCT demonstrated that RAMIE required a significant shorter operating time than conventional MIE (204 versus 245 min, p < 0.001) [30]. Regarding intraoperative blood loss, RAMIE consistently demonstrates less blood loss compared to open procedures, though this advantage does not extend to comparisons with MIE [24, 30‒33]. Additionally, RAMIE has been associated with a lower likelihood of conversion to open surgery compared to MIE (OR: 0.57, 95% CI: 0.32–0.99), underscoring its effectiveness in preserving a minimally invasive approach [42].

RAMIE has been associated with lower overall complication rates compared to open procedures [32]. The ROBOT trial demonstrated significantly fewer surgery-related complications in robotic surgery (59% versus 47%, p = 0.02), including pulmonary (32% versus 58%, p = 0.005) and cardiac complications (22% versus 47%, p = 0.006) [24]. When compared to MIE, a meta-analysis reported similar overall complication rates but found that RAMIE was associated with a lower incidence of pneumonia (9.61% versus 14.74%, p = 0.01) [33]. Better preservation of structures such as vagal nerve branches might explain these positive outcomes in RAMIE [43]. Additionally, the REVATE trial, which focused on patients with esophageal squamous cell carcinoma, showed a higher success rate of left recurrent laryngeal nerve lymph node dissection (i.e., removal of at least one lymph node without causing nerve injury) in the robotic group both at 1 week (88.3% versus 69%, p = 0.029) and 6 months (5.8% versus 20%, p = 0.003) [31]. Regarding length of hospital stay, no significant differences have been observed between robotic and open procedures [24], nor between robotic and MIE [30, 31, 33, 32].

In terms of patient reported outcomes, the ROBOT trial demonstrated that patients who underwent RAMIE experienced significantly less postoperative pain compared to those undergoing open procedures (visual analog scale [VAS] 1.86 versus 2.62, p < 0.001) [24]. Similarly, a prospective trial, which focused on quality of life as a primary outcome, reported reduced immediate postoperative pain severity and interference in patients treated with RAMIE [44]. This benefit may be attributed to the fixed pivot point of the robotic platform’s longer instruments, preventing levering over the ribs and thereby minimizing trauma [45]. Additionally, a study found that at 24 months, patients who underwent RAMIE reported significantly better global quality of life and emotional function, along with reduced levels of fatigue, pain, and insomnia, compared to those treated with MIE [46].

The features that robotic systems offer enable thorough dissection of peri-esophageal tissues adjacent to vital structures, even in dynamic environments influenced by breathing and the pulsatile movements of the heart and aorta [37]. Effective lymphadenectomy is fundamental in the treatment of esophageal cancer, as a higher lymph node yield has been associated with improved OS and disease-free survival [47]. RAMIE has shown potential in facilitating extended lymph node dissection, particularly in the upper mediastinum. In many studies, robotic procedures have demonstrated higher lymph node yields compared to open surgery [48]. However, the ROBOT trial did not find a significant difference in lymph node yields (27 versus 25, p = 0.41) [24]. When comparing RAMIE to MIE, a recent meta-analysis by Zhang et al. [33] reported significantly higher lymph node yields with RAMIE. This advantage was further supported by the REVATE trial that demonstrated a higher mediastinal lymph node yield in robotic procedures (median 16 versus 14, p = 0.035) [31]. Similarly, the RAMIE trial, comparing RAMIE and MIE after neoadjuvant chemoradiotherapy in patients with esophageal squamous cell carcinoma, found a superior mediastinal lymph node yield in RAMIE (15 versus 12, p = 0.033) [30].

Additionally, a meta-analysis indicated that patients undergoing RAMIE had a significantly higher number of abdominal lymph nodes harvested compared to those undergoing MIE (9.05 versus 7.75, p = 0.02) [33]. To build on these findings, the ongoing ROBOT-2 trial aims to determine whether RAMIE offers superior lymph node yields in both the abdominal and mediastinal regions compared to MIE [49]. Radical resection (R0) rates do not show significant differences and appear to be similar across open, minimally invasive, and robotic procedures [24, 30, 31, 33, 48].

Considering long-term survival outcomes, the association between a higher lymph node yield and improved disease-free survival and OS suggests that RAMIE may offer advantages over open esophagectomy and MIE [47]. Although promising, future studies are warranted to determine whether this increased mediastinal and/or abdominal lymph node yield ultimately translates to survival benefits in RAMIE in comparison to MIE.

Economic considerations are also important in the implementation and subsequent evaluation of RAMIE outcomes. While RAMIE incurs higher initial costs (EUR 8.601 versus EUR 5.937, p = 0.004), a cost analysis of the ROBOT trial found that total expenses, including hospitalization and postoperative care, were comparable to those of open procedures (EUR 40.211 versus EUR 39.495, p = 0.932) [50]. Similarly, a German cost analysis comparing RAMIE to MIE found higher robotic surgery costs (EUR 12.370 versus EUR 10.059, p < 0.001) but ultimately similar total costs (EUR 30.510 versus EUR 29.180, p = 0.460), driven primarily by fewer (pulmonary) complications and shorter hospital stay [51]. This suggests that while robotic surgery requires a greater initial investment, its overall financial impact aligns with other approaches due to its potential to reduce complications. Furthermore, both cost analyses included expenses directly related to the surgical procedure. Therefore, it is important to consider this relatively small cost difference within the broader context of the overall oncological treatment, including (neo)adjuvant therapy.

As environmental sustainability gains importance in healthcare, evaluating the environmental impact of robotic surgery is essential. Current studies suggest that robotic procedures impose a significant environmental burden, but data specific to esophageal surgery remain limited [52]. Sustainable strategies, such as reusable materials, improved packaging, and increased staff awareness, might help mitigate this impact. However, further research, particularly into these complex oncological procedures, is needed to better understand their ecological cost and guide more sustainable advancements in robotic surgery.

Esophagectomy is a highly demanding and complex procedure, regardless of the surgical approach. In RAMIE, the primary surgeon operates remotely from a console, without direct physical contact with the organ being operated on, no presence at the bedside, and no need to maintain sterility [53]. The main technical challenge in robotic surgery is the absence of direct tactile feedback, which can lead to the risk of applying excessive or insufficient force on tissues [54]. Experienced surgeons mitigate this challenge by relying on visual cues to judge tension and force effectively. Effective communication with the bedside surgeon is also critical to ensure smooth transitions, such as (un)docking, and to address any intraoperative challenges promptly [55].

While robotic assistance offers technical advantages, mastering RAMIE requires navigating a significant learning curve. To support surgeons adopting this approach, structured training pathways have been developed. The Upper GI International Robotic Association (https://ugira.org) has created such a comprehensive training program consisting of three phases. The first preparation phase includes case observation by the entire surgical and anesthetic team, completion of basic laparoscopic and robotic skills courses, cadaver-based procedure-specific training, and clinical practice on less complex robotic procedures. During the second, initiation phase, the surgeon performs at least 2 robotic esophagectomies under the supervision of a proctor at the adopting center. In the third, implementation phase, the surgeon independently performs robotic esophagectomies, records and registers perioperative outcomes, and undergoes evaluation by the proctor after completing 10–20 independent cases. This structured pathway has proven effective in ensuring safe adoption of RAMIE, even in centers without prior experience in robotic esophagogastric surgery [56].

Advancing the field of RAMIE requires collaboration among robotic upper gastrointestinal and thoracic surgeons. Building networks to share experiences, refine techniques, and establish best practice is crucial for improving patient outcomes. Proctoring programs, dual-console systems, and the establishment of surgical robotic societies like UGIRA play a pivotal role in supporting safe and effective implementation of robotic surgery globally [18]. These initiatives also help expand access to robotic procedures, especially in regions where they are not yet widely available.

Proficiency in RAMIE, however, extends beyond the surgeon. The entire hospital team must adapt to the technique’s complexities, as emphasized in the first training phase of UGIRA. Credentialing guidelines, ongoing performance evaluations, and fostering multidisciplinary collaboration are essential to optimize outcomes and ensure patient safety. Ultimately, the feasibility of RAMIE depends on a thorough evaluation of patient operability, tumor resectability, and the surgical team’s expertise [55].

Minimally invasive techniques have secured a prominent place as part of the new standard of care in esophageal surgery in much of the world, significantly reducing morbidity while maintaining oncologic outcomes [3]. RAMIE enhances this paradigm. This evolution is not a passing trend; RAMIE has established itself as an integral part of modern surgical practice and will continue to advance, setting the stage for ongoing innovation in this field.

The integration of AI technologies and advancements in robotic platforms are set to evolve RAMIE. Emerging AI-assisted tools have the potential to enhance surgeon proficiency, improve training, and reduce postoperative complications. Computer vision, a field of study and technology that allows computers and machines to gain visual understanding from digital images or videos, plays a key role [57]. Through machine learning, systems can learn from data and make predictions by recognizing patterns, which can be applied for skill evaluation and surgical education [57]. Additionally, it can aid in anatomy recognition and orientation during complex procedures such as RAMIE, potentially reducing the learning curve for less experienced surgeons [58]. In clinical decision-making, the predictive capabilities of AI can optimize surgical strategies, guide surgical approaches, and anticipate potential challenges [59]. Over time, AI algorithms are expected to enable robotic systems to adapt to changing conditions, compensate for physiological motion, and further refine surgical precision [57]. However, prospective studies are needed to evaluate the practical applicability of these innovations in clinical settings [58].

Furthermore, the development of single-port systems, such as the da Vinci SP system (Intuitive Surgical Inc.) [18], has expanded the potential of the mediastinoscopic cervical approach. These systems may reduce pulmonary complications and expand surgical options for patients with comorbidities, while enabling effective mediastinal dissection and esophageal mobilization [60, 61]. By addressing the challenges of conventional dissection in the narrow mediastinal space, single-port systems show potential for treating high esophageal tumors and patients unsuitable for one-lung ventilation and thus transthoracic surgery. However, further clinical evaluation and validation is warranted [60].

These advancements collectively promise to broaden the range of patient who can benefit for RAMIE while potentially improving patient outcomes in this complex surgical procedure. With continued innovation and collaboration, RAMIE is on track to define the standard of care in esophageal surgery.

RAMIE has emerged in recent decades as an innovative technique that aimed to overcome the limitations of open and conventional minimally invasive approaches. With advantages, such as three-dimensional vision, enhanced instrument dexterity, and motion scaling, it improves surgical precision and is likely to expand the range of patients eligible for this procedure. The approach has shown particularly promising results in expanding the boarders of patients previously not amenable to surgery, such as those with high upper mediastinal tumors, and has also proven to be feasible for conversion surgery in cT4b cases. Furthermore, it facilitates lymph node dissection and improves postoperative outcomes, while apparently maintaining hospital costs. Given the considerable learning curve, international collaboration and shared expertise through UGIRA are essential for optimizing outcomes after RAMIE. Advances in robotic platforms and AI are expected to further refine this approach. As innovation continues, RAMIE is well positioned to become the standard of care for esophageal cancer surgery.

Prof. Richard van Hillegersberg serves a consulting and/or advisory role for Intuitive Surgical, Medtronic, and Olympus. Prof. Jelle P. Ruurda serves a consulting and/or advisory role for Intuitive Surgical and Medtronic. Prof. Richard van Hillegersberg and Prof. Jelle P. Ruurda were both members of the journal’s editorial board at the time of submission. The other authors declare no conflicts of interest.

This study was not supported by any sponsor or funder.

C.D.K.: study design, writing of the first draft, and final version of the manuscript. L.G. and B.F.K.: study design and writing and review of the manuscript. R.H.: esophageal surgeon, study design, supervision, and writing and review of the manuscript. J.P.R.: esophageal surgeon, study design, supervision, and writing and review of the manuscript.