Intraoperative Adverse Events in Robot-assisted Minimally Invasive Esophagectomy (RAMIE)

OBJECTIVE: Assess the incidence and management of intraoperative adverse events (IAEs) during robot-assisted minimally invasive esophagectomy (RAMIE) and evaluate their impact on postoperative outcomes. BACKGROUND: IAEs are an inherent component of surgical practice and owing to its complexity, esophagectomy is no exception. Data on their incidence and management remain limited. Robotic assistance may facilitate management of these events. METHODS: This retrospective observational cohort study analyzed prospectively collected data from consecutive RAMIE performed at UMC Utrecht using the da Vinci Xi system. iAEs were categorized using the ClassIntra classification. Perioperative outcomes were compared according to major IAEs occurrence (ClassIntra ≥III). RESULTS: Between 2018 and 2025, 478 RAMIE were performed. IAEs occurred in 41 patients (8.6%; 46 events), of which 92.7% were managed robotically without conversion. Bleeding was the most common event (69.6%), followed by chyle leaks (8.7%), lung injuries (8.7%), and airway injuries (4.3%). Major IAEs occurred in 20 patients (4.2%) and were associated with increased mean blood loss (1211 vs. 296 mL, P<0.001), higher conversion rates (15.0% vs. 1.3%, P=0.005) and longer mean operative time (478.6 vs. 413.3 min, P=0.022). Major postoperative complications (35.0% vs. 37.3%, P=1.000), median hospital length of stay (11 vs. 11 d, P=0.311) and in-hospital mortality (5.0% vs. 2.7%, P=0.446) were comparable between groups. CONCLUSION: In this retrospective cohort, over 90% of IAEs during RAMIE were managed robotically without conversion, with no significant increase in postoperative morbidity. These results should be interpreted in the context of an expert center and a limited number of events.