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. 2025 Sep;39(9):6213-6221.
doi: 10.1007/s00464-025-11889-w. Epub 2025 Jul 17.

Learning curve of Robotic Assisted Minimally Invasive Ivor Lewis Esophagectomy (RAMIE): initial experience

Andres Ramos-Fresnedo  1 , Keouna Pather  1 , Chelsea R Yap  1 , Brian G Celso  1 , Erin M Mobley  1 , Ziad T Awad  2
Affiliations

Learning curve of Robotic Assisted Minimally Invasive Ivor Lewis Esophagectomy (RAMIE): initial experience

Andres Ramos-Fresnedo et al. Surg Endosc. 2025 Sep.

Abstract

Introduction: The aim of the study was to investigate the learning curve and perioperative outcomes of implementing Robotic Assisted Minimally Invasive Ivor Lewis Esophagectomy (RAMIE) at a tertiary referral center.

Methods: Retrospective review of patients ≥ 18 years old between June 2019 and June 2024 of 70 consecutive patients who underwent RAMIE. The primary outcome was operative time. Secondary outcomes included estimated blood loss (EBL), conversion rate, lymph node yield, positive proximal margin and in-hospital mortality. Cumulative sum (CUSUM) analyses were performed to identify proficiency for operating time and intraoperative blood loss. A multivariable general linear model (GLM) was utilized to measure the strength and direction of the associations that exist between the predictor variables, Age, Sex, Race, BMI, Neoadjuvant treatment, Tumor stage, Cancer type, Clavien-Dindo and EBL, with the outcome variable, operative time. A Kaplan-Mayer survival curve was calculated over the duration of the study. A t-test was calculated to compare survival based on whether cancer was present or not.

Results: 70 RAMIE procedures were performed during the study period. The operative time analysis showed technical proficiency was acquired at 55 cases. No significant change in intraoperative blood loss was indicated. The multivariable modeling approach showed Sex was significantly associated with operative time (F = 226.62, p < .001). The Kaplan-Meier survival curve showed overall survival was statistically significant when compared by cancer stage (Mantel-Cox Log Rank χ2 = 7.13, p = 0.008). Survival since the day of surgery was statistically significantly less for those patients with evidence of cancer (t = 2.87, p = 0.006).

Conclusions: RAMIE appears to have a short learning curve. Prospective studies examining the learning curve and outcomes of robotic esophagectomies compared to the outcomes of non-robotic cases is suggested.

Keywords: Minimally invasive surgery; Oesophagectomy; da Vinci.

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Conflict of interest statement

Declarations. Disclosures: Drs. Ramos-Fresnedo, Pather, Yap, Mobley, Celso, and Awad declare no conflict of interest.

References

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    1. Awad ZT et al (2020) Minimally Invasive Ivor Lewis Esophagectomy (MILE): technique and outcomes of 100 consecutive cases. Surg Endosc 34(7):3243–3255 - DOI - PubMed
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    1. Glatz T et al (2017) 2017 Hybrid minimally invasive esophagectomy vs. open esophagectomy: a matched case analysis in 120 patients. Langenbecks Arch Surg 402(2):323–331 - DOI - PubMed
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