Lymphadenectomy using two instrument arms during robotic surgery for gastric cancer: A strategy to facilitate reduced-port robotic gastrectomy

Trans-Umbilical Lymphadenectomy Using an Articulating Bipolar Vessel-Sealing Device (TULAB) during Robotic Surgery for Gastric Cancer: Enhancing the Surgeon's Eye for Reduced-Port Robotic Gastrectomy

BACKGROUND

Docking the scope and instruments through a multi-channel trocar has enabled reduced-port robotic distal gastrectomy (RRDG) for gastric cancer. To facilitate lymphadenectomy over the anatomical hindrances during RRDG, we recently introduced the Vessel Sealer Extend® (VSE) (Intuitive Surgical, Sunnyvale, CA, USA), a bipolar vessel-sealing device (BVSD) with an articulating jaw.

METHODS

From May 2020 to August 2023, we performed RRDG to treat T1 gastric cancer. One endoscope arm and three instrument arms of the da Vinci® Xi Surgical System (Intuitive Surgical) were used. During the lymphadenectomy, the endoscope and VSE (Intuitive Surgical) were docked through a multi-channel trocar established on a trans-umbilical incision. Two Cardiere forceps were docked through cannulas established on each flank. A trans-umbilical lymphadenectomy using an articulating BVSD (TULAB) was then performed.

RESULTS

A total of 42 patients underwent planned RRDG with the TULAB technique. The number of retrieved lymph nodes did not differ between the patients who underwent RRDG and those who underwent conventional laparoscopic distal gastrectomies (CLDG) (p = 0.362). There was no statistically significant difference in postoperative complications between the RRDG and CLDG group (p = 0.189). The mean time to first semi-fluid diet was shorter in the patients who underwent RRDG than CLDG (p = 0.030), and the incidence of postoperative ileus was lower in the RRDG group than the CLDG group (0% and 9.9%, respectively, p = 0.034).

CONCLUSIONS

Despite use of fewer ports, RRDG with TULAB had similar outcomes to CLDG in terms of the incidence of postoperative morbidity and the number of harvested lymph nodes. Furthermore, by reducing the number of incisions, the incidence of the intra-abdominal adhesions can potentially be lowered when RRDG is used.

Fluorescence-guided Two-port Robotic Gastrectomy Versus Conventional Laparoscopic Gastrectomy: A Nonrandomized Controlled Trial

Objective

To compare the number of retrieved lymph nodes between conventional laparoscopic gastrectomy (CLG) and robotic gastrectomy integrated with fluorescence guidance and a two-port system (integrated robotic gastrectomy, IRG).

Background

The benefits of robotic surgery over laparoscopic surgery for gastric cancer have not yet been established. Using built-in features of robotic system, further benefit can be provided to the patients with effective lymphadenectomy and enhanced recovery.

Methods

A nonrandomized controlled trial was performed by a single surgeon at single-center, tertiary referral hospital between January 2018 and October 2021. Overall, 140 patients scheduled to undergo minimally invasive subtotal gastrectomy for early gastric cancer were enrolled. The primary endpoint was the number of retrieved lymph nodes. Secondary endpoints were complications, hospital stay, pain score, body image, and operative cost.

Results

This study analyzed 124 patients in the per-protocol group (IRG, 64; CLG, 60). The number of retrieved lymph nodes was higher in the IRG group than those in the CLG group (IRG vs CLG; 42.1 ± 17.9 vs 35.1 ± 14.6, P = 0.019). Moreover, other surgical parameters, such as hospital stay (4.1 ± 1.0 vs 5.2 ± 1.8, P < 0.001) and body image scale (better in 4 of the 10 questions), were significantly better in the IRG than in the CLG.

Conclusions

Robotic surgical procedures integrated with fluorescence guidance and a reduced-port system yielded more retrieved lymph nodes. In addition, the IRG group showed better perioperative surgical outcomes, particularly regarding the length of hospital stay and postoperative body image.

Trial registration

NCT03396354.

Case Report: Single-port laparoscopic total gastrectomy for gastric cancer in patient with situs inversus totalis

Situs inversus totalis (SIT) is a rare anatomical condition, where all the viscera appear in its reverse position. Although minimally invasive surgery has evolved to achieve totally laparoscopic gastrectomy for gastric cancer patients with SIT, it is difficult to perform lymphadenectomy in such a transposed anatomical condition. Recently, we performed a single-port laparoscopic total gastrectomy (SPTG) for gastric cancer in a patient with SIT. No postoperative complications or dietary problems were observed. Based on this experience, we are to design a safe strategy to perform D2 lymphadenectomy during SPTG in patients with SIT.

Modern surgical therapy for gastric cancer-Robotics and beyond

The surgical paradigm for gastric cancer has been changed from extended surgery to minimally invasive surgery. Laparoscopic surgery is a practical method for minimally invasive surgery for early gastric cancer, and the indication is expanding to advanced gastric cancer. In recent years, robotic gastrectomy has been highlighted as a breakthrough to overcome the drawbacks of laparoscopic gastrectomy. Here, we discuss the recent updates of modern surgical therapy for gastric cancer-robotics and beyond.

Intracorporeal Esophagojejunostomy during Reduced-port Totally Robotic Gastrectomy for Proximal Gastric Cancer: a Novel Application of the Single-Site® Plus 2-port System

Purpose

Intracorporeal esophagojejunostomy during reduced-port gastrectomy for proximal gastric cancer is a technically challenging technique. No study has yet reported a robotic technique for anastomosis. Therefore, to address this gap, we describe our reduced-port technique and the short-term outcomes of intracorporeal esophagojejunostomy.

Materials and Methods

We conducted a retrospective review of patients who underwent a totally robotic reduced-port total or proximal gastrectomy between August 2016 and March 2020. We used an infra-umbilical Single-Site^® port with two additional ports on both sides of the abdomen. To transect the esophagus, a 45-mm endolinear stapler was inserted via the right abdominal port. The common channel of the esophagojejunostomy was created between the apertures in the esophagus and proximal jejunum using a 45-mm linear stapler. The entry hole was closed with a 45-mm linear stapler or robot-sewn continuous suture. All anastomoses were performed without the aid of an assistant or placement of stay sutures.

Results

Among the 40 patients, there were no conversions to open, laparoscopic, or conventional 5-port robotic surgery. The median operation time and blood loss were 254 min and 50 mL, respectively. The median number of retrieved lymph nodes was 40.5. The median time to first flatus, soft diet intake, and length of hospital stay were 3, 5, and 7 days, respectively. Three (7.5%) major complications, including two anastomosis-related complications and a case of small bowel obstruction, were treated with an endoscopic procedure and re-operation, respectively. No mortality occurred during the study period.

Conclusions

Intracorporeal esophagojejunostomy during reduced-port gastrectomy can be safely performed and is feasible with acceptable surgical outcomes.

The Artisential® Articulated Laparoscopic Forceps: A Dry Lab Study to Examine Dexterity and Learning Effects in Operators with Different Levels of Laparoscopic Experience

PURPOSE

The advent of robotic surgery has highlighted the advantages of articulation. This dry-lab study examined the dexterity and learning effect of a new articulated laparoscopic instrument: the ArtiSential® forceps (LIVSMED, Seongnam, Republic of Korea).

METHODS

A peg board task was designed. Three groups of volunteers with varying levels of laparoscopic expertise were organized to perform the task: expert, intermediate and novice. The participants performed the task using articulated and straight instruments, once before a 30-min training session and once afterwards. The times required to perform the task were recorded. The performances were analyzed and compared between the groups as well as between the straight and articulated instruments.

RESULTS

The experts were significantly faster than the novices with both instruments before the 30-min training session (p = 0.0317 for each instrument). No significant time difference was found among the three groups after the 30-min training session. The decrease in the time required to perform the peg-transfer task with the articulated instrument was significantly greater in the novice and intermediate groups (p = 0.0159 for each group). No significant difference in time reduction was observed between the groups with the straight instrument. Regardless of the user, the articulated device was associated with faster task performance than the straight device after 8 hours of training (p = 0.0039).

CONCLUSION

The ArtiSential® articulated device can improve dexterity. A significantly greater learning effect was observed in the novice and intermediate groups in comparison with experts. A plateau in the learning curve was observed after a few hours of training.

Usefulness of articulating laparoscopic instruments during laparoscopic gastrectomy for gastric adenocarcinoma

Purpose

Conventional straight-shaped laparoscopic surgical instruments have limitations that, unlike robotic surgery, the wrist joint cannot be used. This study aimed to analyze the short-term safety and feasibility of ArtiSential (Livsmed), a new articulating laparoscopic instrument, which obviates the limitations of conventional laparoscopic surgery and allows the wrist joint to be used freely over 360° as in robotic surgery.

Methods

The study included patients who underwent conventional laparoscopy or laparoscopy with the ArtiSential instrument. Patients who underwent laparoscopic gastrectomy for primary gastric adenocarcinoma in our institution were retrospectively reviewed. The groups were propensity score matched in a 11 ratio. Primary endpoint was incidence of early postoperative complication (postoperative 30-day morbidity and mortality) and secondary endpoints were operative outcomes.

Results

A total of 327 patients (147 of the conventional group and 180 of the ArtiSential group) were propensity score matched. After propensity score matching was performed, each group comprised of 122 patients. Both groups were comparable with regard to operation time, estimated blood loss, number of retrieved lymph nodes, and length of hospital stay. The ArtiSential group had a faster time to a fluid diet (2.6 ± 1.3 days vs. 2.3 ± 0.6 days, p = 0.015). There was no statistically significant difference in early postoperative complications between the two groups (the conventional group, 23.0%; the ArtiSential group, 26.2%; p = 0.656).

Conclusion

The current study showed that the use of ArtiSential is a safe and feasible option without increasing operation time, length of hospital stay, and intraoperative bleeding.

Is it Beneficial to Utilize an Articulating Instrument in Single-Port Laparoscopic Gastrectomy?

PURPOSE

As the number of gastric cancer survivors is increasing and their quality of life after surgery is being emphasized, single-port surgery is emerging as an alternative to conventional gastrectomy. A novel multi-degree-of-freedom (DOF) articulating device, the ArtiSential® device (LivsMed, Seongnam, Korea), was designed to allow more intuitive and meticulous control for surgeons facing ergonomic difficulties with conventional tools. In this study, we evaluated the feasibility of this new device during single-port laparoscopic distal gastrectomy (SP-LDG) for early gastric cancer (EGC) patients.

MATERIALS AND METHODS

Consecutive patients diagnosed with EGC who underwent SP-LDG with ArtiSential® (LivsMed) graspers between April 2018 and August 2020 were enrolled in the study. The clinical outcomes were compared with those of a control group, in which prebent graspers (Olympus Medical Systems Corp) were used for the same procedures.

RESULTS

Seventeen patients were enrolled in the ArtiSential® group. There was no significant difference in operative time (205.4±6.0 vs. 218.1±9.9 minutes, P= 0.270) or the quality of surgery, in terms of the number of retrieved lymph nodes (49.5±3.5 vs. 45.9±4.0, P=0.473), length of hospital stay (15.4±2.0 vs. 12.4±1.3 days, P=0.588), and postoperative complications (40.0% vs. 41.2%, P=0.595), between the ArtiSential® group and the control group.

CONCLUSIONS

The new multi-DOF articulating grasper is feasible and can be used as an alternative for prebent graspers during SP-LDG.

D2 Lymph Node Dissections during Reduced-port Robotic Distal Subtotal Gastrectomy and Conventional Laparoscopic Surgery Performed by a Single Surgeon in a High-volume Center: a Propensity Score-matched Analysis

Purpose

Various studies have indicated that reduced-port robotic gastrectomies are safe and feasible for treating patients with early gastric cancer. However, there have not been any comparative studies conducted that have evaluated patients with clinically advanced gastric cancer. Therefore, we aimed to compare the perioperative outcomes of D2 lymph node dissections during reduced-port robotic distal subtotal gastrectomies (RRDGs) and conventional 5-port laparoscopic distal subtotal gastrectomies (CLDGs).

Materials and Methods

We retrospectively evaluated 118 patients with clinically advanced gastric cancer who underwent minimally invasive distal subtotal gastrectomies with D2 lymph node dissections between February 2016 and November 2019. To evaluate the patient data, we performed a 1:1 propensity score matching (PSM) according to age, sex, body mass index, American Society of Anesthesiologists physical status classification score, and clinical T status. The short-term surgical outcomes were also compared between the two groups.

Results

The PSM identified 40 pairs of patients who underwent RRDG or CLDG. The RRDG group experienced a significantly longer operation time than the CLDG group (P<0.001), although the RRDG group had significantly less estimated blood loss (P=0.034). The number of retrieved extraperigastric lymph nodes in the RRDG group was significantly higher than that of the CLDG group (P=0.008). The rate of postoperative complications was not significantly different between the two groups (P=0.115).

Conclusions

D2 lymph node dissections can be safely performed during RRDGs and the perioperative outcomes appear to be comparable to those of conventional laparoscopic surgeries. Further studies are needed to compare long-term survival outcomes.

Current perspectives on the safety and efficacy of robot-assisted surgery for gastric cancer

INTRODUCTION

Robotic gastrectomy is performed worldwide as part of the treatment for gastric cancer and is associated with good clinical outcome. This review aims to describe the current issues, debates, and future directions associated with the use of robotic gastrectomy for gastric cancer.

AREA COVERED

Here, we review the current evidence surrounding the safety and efficacy of robotic gastrectomy, including our institutional experience. Current issues associated with robotic gastrectomy, including feasibility, perioperative outcomes, and oncological outcomes, are described.

EXPERT OPINION

Sophisticated movements, articulating instruments, and the rapid introduction of fast-developing novel technology make robotic gastrectomy use more frequent. However, the need for well-designed prospective randomized trials is warranted.

Prospective randomized controlled study for comparison of 2-dimensional versus 3-dimensional laparoscopic distal gastrectomy for gastric adenocarcinoma

BACKGROUND

Due to the technological advance in resolution and stereoscopic depth, the 3-dimensional (3D) laparoscopic system has been widely used in real surgery. However, there have been few studies to confirm the clinical usefulness of the 3D laparoscopic distal gastrectomy (LDG). This study aimed to compare perioperative outcomes between the 2-dimensional (2D) and 3D LDG for gastric cancer patients.

METHODS

This was a prospective, randomized controlled, single-center, and superiority trial. This study was carried in Seoul National University Bundang Hospital. Patients with histologically confirmed gastric adenocarcinoma which could be radically resected by LDG were randomly assigned (1:1) to the 2D or 3D group. From October 2016 to August 2018, 84 patients were included in this study and randomly assigned into the 2D group (44 patients) or the 3D group (40 patients). A total of 5 patients were excluded; 3 in the 2D group and 2 were in the 3D group. Consequently, the data from 79 patients were analyzed (2D: 41 cases; 3D: 38 cases). For the LDG procedure, 3D and 2D camera and display system were applied according to the assigned group. The primary end point was the duration of total laparoscopic operation time. Secondary end points included the amount of intraoperative blood loss (IBL), the number of harvested lymph nodes, postoperative complications and open conversion rate.

RESULTS

There were no differences between 2 and 3D groups with respect to clinicopathologic characteristics. The total operation time in 3D groups was significantly shorter than 2D group (122 [106.5-161] versus 101 [77.75-125.5] minutes; P = 0.001). The postoperative complication rates in the 3D groups was significantly lower than 2D group (24.4% versus 7.9%, respectively; P = 0.045).

CONCLUSION

3D LDG shorten the operation time compared with 2D LDG in gastric cancer patients. And 3D laparoscopy provided the benefit of less postoperative complications.

TRIAL REGISTRATION

cris.nih.go.kr number KCT0003717.