Minimally Invasive Esophagectomy for Esophageal Cancer: Current Evidence and Future Perspectives.

Aim: Esophageal cancer is a highly aggressive malignancy with regional variations in histological subtypes. Adenocarcinoma predominates in Western countries, whereas squamous cell carcinoma is more common in Asia. Despite advances in multimodal therapy, esophagectomy remains the cornerstone of curative treatment, and the development of various minimally invasive esophagectomies (MIE) has been promoted to reduce invasiveness and complications. The status of the MIE has been outlined. Methods: A comprehensive literature review was conducted using PubMed/MEDLINE to identify relevant studies on MIE published up to June 2025. The search focused on thoracoscopic, robot-assisted, and mediastinoscopic approaches, with an emphasis on randomized trials and high-quality comparative studies. Results: Thoracoscopic MIE, especially in the prone position, demonstrated reduced pulmonary complications and shorter recovery times than open surgery, as supported by randomized trials such as TIME, MIRO, and MONET. Robot-assisted MIE (RAMIE) further enhances lymph node dissection and improves preservation of the recurrent laryngeal nerve, as demonstrated in trials such as REVATE and RAMIE. Mediastinoscopic esophagectomy via the transcervical and transhiatal approaches is emerging as a promising alternative for high-risk patients, offering favorable perioperative outcomes with reduced pulmonary complications. Further evaluation is required to determine the efficacy of lymph node dissection and the risk of recurrent laryngeal nerve damage. Conclusion: MIE, including the thoracoscopic, robot-assisted, and mediastinoscopic approaches, is evolving into an effective and less invasive alternative to open surgery. Future research should focus on conducting standardized, multicenter trials to establish optimal surgical strategies based on tumor characteristics and patient-specific factors.