<p>Robotic-assisted minimally invasive esophagectomy (RAMIE) has been increasingly adopted, yet the comparative outcomes of its three principal approaches—Ivor Lewis, McKeown, and transhiatal—remain inadequately defined. This study aims to provide a comprehensive comparison to guide surgical decision-making. A systematic review and meta-analysis were conducted following PRISMA guidelines. Databases were searched from January 2010 to December 2023 for studies comparing robotic Ivor Lewis, McKeown, and transhiatal esophagectomy. Primary outcomes included perioperative parameters, complication rates, and oncologic efficacy. Sixteen studies (7,339 patients) were included in the systematic review, with eight studies (3,015 patients) eligible for meta-analysis. Robotic Ivor Lewis esophagectomy demonstrated superior outcomes compared to robotic McKeown, including significantly lower rates of recurrent laryngeal nerve palsy (OR = 0.13, 95% CI = 0.06–0.31, P &lt; 0.00001), reoperation (OR = 0.60, 95% CI = 0.41–0.89, P = 0.01), anastomotic leak (OR = 0.47, 95% CI = 0.28–0.78, P = 0.003), and respiratory complications (OR = 0.53, 95% CI = 0.39–0.71, P &lt; 0.0001). Compared to transhiatal esophagectomy, transthoracic approaches (Ivor Lewis and McKeown) yielded significantly more lymph nodes (mean difference 8.3 nodes, P &lt; 0.001) but were associated with higher pulmonary complications. Transhiatal esophagectomy had shorter operative times and reduced blood loss but higher anastomotic leak rates compared to Ivor Lewis. R0 resection rates and 5-year overall survival were comparable among the approaches. Robotic Ivor Lewis esophagectomy offers an optimal balance of perioperative safety and oncologic efficacy, with lower complication rates while maintaining equivalent long-term survival. The surgical approach should be individualized based on tumor location, patient comorbidities, and surgical expertise. These findings support the tailored adoption of robotic technology in esophageal cancer surgery.</p>