Combined thoracoscopic and laparoscopic robotic-assisted minimally invasive esophagectomy using a four-arm platform: experience, technique and cautions during early procedure development†

While four-arm RAMIE may offer advantages over standard minimally invasive esophagectomy approaches, its adoption in a structured program, with critical evaluation of adverse events and subsequent adjustment of technique, is paramount to maximize patient safety, minimize complications and improve the conduct of operation early in the learning curve. Particular technical consideration should be given to prevention of airway complications.