Fig. 23.1
Lymph node stations in gastric cancer
Oncologic Outcome
As robotic gastrectomy is a relatively new approach, long-term oncologic outcome is lacking for robotic gastrectomy specifically. However, meta-analyses demonstrate no significant difference in histopathologic margins or lymph nodes retrieved between laparoscopic and robotic gastrectomy, nor are there significant differences in 3- or 5-year disease-free and overall survival [8, 9]. One meta-analysis demonstrated that robotic gastrectomy was associated with a significantly larger distal resection margin compared to laparoscopic resection [10].
One of the main advantages of robotic surgery is enhanced three-dimensional visualization allowing for precise dissection around the splenic vessels and successful removal of D2 lymph nodes . This was recently demonstrated in a prospective trial by Kim et al., who showed that a D2 lymphadenectomy was able to be completed successfully in a higher percentage of robotic-assisted gastrectomy resections compared to laparoscopic cases [11]. Another group reported greater number of retrieved lymph nodes in a D2 spleen-preserving dissection compared to laparoscopy alone [12]. One meta-analysis demonstrated a trend towards greater number of retrieved lymph nodes with an open approach versus robotic, but this did not reach statistical significance [9]. Laparoscopic gastrectomy for early gastric cancer has been found to have equivalent long-term survival compared to open gastrectomy as well [13], while a recent Cochrane review found laparoscopic versus open gastrectomy for gastric cancer to have no difference in short-term or long-term outcomes [14].
Description of Technique
Extent of Resection
Curative resection for gastric cancer involves resection of at least two thirds of the stomach with adequate lymphadenectomy. Depending on the location of the tumor, this may range from a total gastrectomy, distal gastrectomy, pylorus-preserving distal gastrectomy, or proximal gastrectomy. According to the Japanese Gastric Cancer Guideline, a proximal margin of at least 3 cm is recommended for T2 or greater lesions. For T1 tumors, a gross resection margin of at least 2 cm is required. Any local invasion into surrounding structures such as pancreas or colon mandates a total gastrectomy regardless of tumor location with en bloc resection of the involved organ [5].
Distal Gastrectomy
A distal gastrectomy involves resection of the distal two thirds of the stomach. Ports are placed as shown in Fig. 23.2, with robotic and laparoscopic trocars identified as such. Initial diagnostic laparoscopy is performed to rule out metastatic disease. The robot is typically docked directly over the patient or over the left shoulder. The assistant grasps the greater curve of the stomach, while the surgeon using an advanced energy source divides the gastrocolic ligament under the omentum. Dissection is carried towards the pylorus, where the right gastroepiploic artery is identified, ligated, and divided. Associated lymph nodes are kept with the specimen. Using a dissector, a retroduodenal tunnel is created from inferior to superior in the avascular plane at the point of transaction (Fig. 23.3). Attention is then taken to the superior border of the duodenum, including lymph nodes along the porta hepatis. The right gastric artery is identified, ligated, and divided between ties or clips. The advanced energy source then completes the retroduodenal tunnel. A 60 mm stapler is introduced and the duodenum is divided. The stomach is then retracted cephalad, and any attachments between the stomach and the pancreas are divided. The lesser omentum is dissected close to the liver to include associated lymph nodes along the hepatic artery and the left gastric artery in the resected specimen. Either hook electrocautery or ultrasonic shears can be used for this dissection. The necessity to take the left gastric vasculature and associated lymph nodes is typically dictated by location of the lesion, with more distal lesions allowing for preservation of the vessels, and body and proximal lesions requiring inclusion. A linear stapler is introduced through the left lower port and the stomach is transected with appropriate height staple loads. The specimen is removed through the left lower port. Reconstruction is left to the discretion of the operating surgeon and may include gastro-jejunostomy, gastro-duodenostomy, or Roux en-Y. Intraoperative pathology of frozen margins should be obtained to ensure that the submucosa is free of residual tumor, after which reconstruction is carried out as detailed below.
Fig. 23.2
Robot trocar placement: (a) laparoscopic 12 mm trocar for stapler and free-needle suture; (b) robotic trocar; (c) nathanson liver retractor; (d) robotic camera; (e) robotic trocar; (f) laparoscopic 5 mm trocar (for distal gastrectomy) or 15 mm trocar (for total gastrectomy in anticipation of using EEA stapler for Roux-en-Y reconstruction)
Fig. 23.3
Intraoperative creation of the retroduodenal tunnel during robotic gastrectomy
Total Gastrectomy
The initial steps of a total gastrectomy are described above. After omentectomy and division of the right gastroepiploic artery and duodenum, the lesser omentum is divided close to the liver to the esophagogastric junction. The left gastric artery is ligated and divided close to its origin at the celiac trunk (Fig. 23.4). Attention is turned to the greater curvature, and the short gastric arteries are taken close to spleen with an advanced energy source. After the fundus is fully mobilized, nodal tissue along the splenic artery (station 11) and adjacent to the splenic hilum (station 10) are dissected and removed with the specimen. Once the stomach is fully mobilized, the intra-abdominal esophagus is divided with a linear stapler, with associated lymph nodes in the phreno-esophageal ligaments included in the specimen. Intraoperative pathology analysis of specimen margins should be performed prior to reconstruction.
Fig. 23.4
Dissection of the left gastric artery and vein during robotic gastrectomy
Reconstruction
Reestablishment of gastrointestinal continuity after resection depends on the extent of gastric resection, patient anatomy, and surgeon preference. Following distal gastrectomy, reconstructive options include a Billroth I gastro-duodenostomy, Billroth II gastro-jejunostomy, or Roux-en-Y gastro-jejunostomy (most common option). Reconstruction may be done wholly intracorporeally, extracorporeally, or a combination of both. One advantage of robotic surgery with its increased dexterity and visualization is the ability to complete wholly intracorporeal anastomoses during reconstruction (Fig. 23.5), which is technically much more demanding when performed laparoscopically.
Fig. 23.5
Robotic Roux-en-Y reconstruction
Potential Benefits
Two randomized-controlled trials (RCTs ) comparing long-term survival after minimally invasive surgery for advanced gastric cancer are currently underway in Japan and Korea. Short-term outcomes from the Korean trial demonstrate decreased morbidity with similar mortality between laparoscopic and open distal gastrectomy groups in patients with stage 1 gastric cancer [15].
Meta-analyses, prospective, and retrospective studies all consistently demonstrate a significantly decreased intraoperative blood loss in the robotic gastrectomy compared with laparoscopic or open approaches (Table 23.1). Bleeding during laparoscopic gastrectomy is commonly described from injury to branches of the left gastric artery, coronary vein, or short gastric arteries [2]. Decreased blood loss in robotic gastrectomy is likely due to enhanced stereoscopic visualization and tremor filtration allowing for precise dissection of vascular structures, as well as improved dexterity to control bleeding should it occur. This potentially may lead to a decreased need for transfusions and associated transfusion-related complications, which is an advantage in the treatment of any malignancy.
Table 23.1
Review of open versus laparoscopic versus robotic gastrectomy
Authors | Year | Study type | Operations (n) | Op time (min) | EBL | Retrieved LN | Prox margin | Distal margin | Morbidity | LOS (days) | ROBF (days) |
|---|---|---|---|---|---|---|---|---|---|---|---|
Xiong et al. [8] | 2012 | Meta-analysis | RAG (268) vs LAG (650) | RAG > LAG (WMD = 68.77a) | LAG > RAG (WMD = −41.88a) | RAG = LAG | NR | NR | RAG = LAG | RAG = LAG | NR |
Xiong et al. [17] | 2013 | Meta-analysis | RAG (736) vs LAG (1759) | RAG > LAG (WMD = 48.64a) | RAG < LAG (WMD = −33.56a) | RAG = LAG | RAG = LAG | RAG < LAG (WMD = 1.13a) | RAG = LAG | RAG = LAG | RAG = LAG |
Hyun et al. [18] | 2013 | Meta-analysis | RAG vs LAG vs open | RAG > LAG (WMD = 61.99a), RAG > open (WMD = 65.73a) | RAG = LAG, open > RAG (WMD = −154.18a) | RAG = LAG, RAG = open | RAG = LAG, RAG = open | RAG > LAG (WMD = −1.14a), RAG = open | RAG = LAG, RAG > open (WMD = 1.82a) | RAG = LAG, open > RAG (WMD = −2.18a) | NR |
Shen et al. [10] | 2014 | Meta-analysis | RAG vs LAG | RAG > LAG (WMD = 48.46a) | RAG < LAG (WMD = −38.4a) | RAG = LAG | RAG = LAG | RAG > LAG (WMD = 1.04a) | NR | RAG = LAG | NR |
Marano et al. | 2013 | Meta-analysis | RAG vs LAG vs open | RAG > LAG (WMD = 63.7a), RAG > open (WMD = 95.83a) | LAG > RAG (WMD = −35.53a), RAG = Open | RAG = LAG, RAG = Open | NR | NR | RAG = LAG, RAG = open | RAG = LAG, Open > RAG (WMD = −2.92a) | NR |
Zong et al. [19] | 2014 | Meta-analysis | RAG vs LAG vs OG | RAG > OG (WMD = 68.47a), RAG > LAG (WMD = 57.15a) | OG > RAG (WMD = 68.47a), RAG = LAG
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