Implementation and effectiveness of robot-assisted minimally invasive oesophagectomy (RAMIO): a systematic review using the IDEAL framework

Abstract

BACKGROUND: Robot-assisted minimally invasive oesophagectomy (RAMIO) is increasingly used for oesophageal cancer surgery, yet its adoption may have outpaced structured evaluation. This systematic review assessed RAMIO's development through the IDEAL framework and synthesized evidence from RCTs and long-term studies. METHODS: A systematic search was conducted in PubMed, Embase, Web of Science, and the Cochrane Library on 1 June 2025 for studies comparing RAMIO with open oesophagectomy or minimally invasive oesophagectomy. Non-comparative, non-English, protocol, and review articles were excluded. Two reviewers independently screened and extracted data, classifying studies according to IDEAL stages. Outcomes were presented in a narrative overview. Risk of bias was assessed using RoB-2 for RCTs and ROBINS-I for long-term studies. The protocol was registered in PROSPERO (CRD42022352208). RESULTS: A total of 104 studies involving 133 107 patients published between 2002 and 2025 were included. Of these, 86 were IDEAL stage 2B, four stage 3 (RCTs), and 14 stage 4 (long-term follow up studies). Generally, RAMIO research followed the IDEAL pathway, although several stage 4 studies preceded stage 3 evaluations. None explicitly referenced the IDEAL framework. RCTs demonstrated some benefits of RAMIO, including fewer complications and faster recovery, whereas long-term outcomes remain uncertain. Studies on long-term outcomes varied in design and were often at risk of bias. CONCLUSION: RAMIO may offer perioperative benefits, but high-quality evidence is limited. Few RCTs exist, and long-term benefits are unclear. Although RAMIO development aligns broadly with IDEAL stages, explicit framework adherence is lacking. Future trials should adopt structured IDEAL-guided designs and standardised reporting.