Techniques of the Single-Port Totally Laparoscopic Distal Gastrectomy

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.

Single-incision plus one-port laparoscopic gastrectomy versus conventional multi-port laparoscopy-assisted gastrectomy for gastric cancer: a retrospective study

BACKGROUND

We compared short-term perioperative outcomes after single-incision plus one-port laparoscopic gastrectomy (SILG+1) and conventional multi-port laparoscopy-assisted gastrectomy (C-LAG) for gastric cancer.

METHODS

The work was conducted between August 2017 and October 2019. A total of 90 patients with early or advanced gastric cancer were retrospectively analyzed: 43 patients of which underwent SILG+1, and 47 of which underwent C-LAG, respectively. These were divided into two groups: the total gastrectomy group (SILT+1 and C-LATG) and the distal gastrectomy group (SILD + 1 and C-LADG). The demographics, tumor characteristics, postoperative outcomes, and short-term complications of all enrolled patients were summarized and statistically analyzed.

RESULTS

The mean incision length in SILT+1 group was 5.40 cm shorter than that in C-LATG group (3.15 ± 0.43 vs. 8.55 ± 2.72, P < 0.001). This comparison between the SILD + 1 and the C-LADG group produced comparable results. The SILT+1 group underwent a 56.32 min longer operation than the C-LATG group (273.03 ± 66.80 vs. 216.71 ± 82.61, P = 0.0205). SILG+1 group had better postoperative visual analog scale (VAS) and cosmetic score than those of the C-LATG group (P < 0.05). There were no significant differences in preoperative demographics or 30-day postoperative complication rates between the SILG+1 and C-LAG groups. Tumor-related index, including mass size, histological type, number of retrieved lymph nodes, pathological tumor-node-metastasis (TNM) stage, and proximal and distal edges were all equivalent between the SILG+1 and the C-LAG group.

CONCLUSIONS

This retrospective study demonstrates the safety and feasibility of SILG+1 with D1+ or D2 lymphadenectomy for the treatment of early and advanced gastric cancers, compared with C-LAG.

Long-Term Oncological Outcomes of Reduced Three-Port Laparoscopic Gastrectomy for Early-Stage Gastric Carcinoma: a Retrospective Large-Scale Multi-Institutional Study

Purpose

With advances in surgical techniques, reduced-port laparoscopic surgery is increasingly being performed for the treatment of gastric carcinoma. Many studies have reported satisfactory short-term outcomes after reduced 3-port laparoscopic gastrectomy (LG). The aim of this study was to investigate the long-term oncological outcomes of 3-port LG in patients with gastric carcinoma.

Materials and Methods

We reviewed the medical records of 1,117 patients who underwent LG for gastric carcinoma in three major institutions between 2012 and 2015. The data showed that 460 patients underwent 3-port LG without assistance, and 657 underwent conventional 5-port LG. We compared the overall and disease-free survival rates between the 2 groups.

Results

There were 642 male and 475 female patients with a mean age of 56.1 years. Among them, 1,028 (92.0%) underwent distal gastrectomy and 89 (8.0%) underwent total gastrectomy. In the final pathologic examination, 1,027 patients (91.9%) were stage I, 73 (6.5%) were stage II, and 17 (1.5%) were stage III, and there were no significant difference in the pathologic stage between groups. The 3- and 5-port LG groups showed no significant differences in the 5-year overall survival (94.3% vs. 96.7%, P=0.138) or disease-free survival (94.3% vs. 95.9%, P=0.231). Stratified analyses according to pT and pN stages also showed no significant differences in overall or disease-free survival between the two groups.

Conclusions

Long-term survival after 3- and 5-port LG was comparable in patients with early-stage gastric carcinoma. The 3-port technique requiring limited surgical assistance may be an appropriate surgical option for this patient population.

Single-incision Laparoscopic Gastrectomy for Gastric Cancer

The implementation of national cancer screening has increased the detection rates of early gastric cancer (EGC) in Korea. Since the successful introduction of laparoscopic gastrectomy for gastric cancer in the early 1990s, this technique has demonstrated improved short-term outcomes without compromising long-term oncologic results. It is associated with reduced pain, shorter hospitalization, reduced morbidity rates, better cosmetic outcomes, and equivalent mortality rates as those for open surgery. Laparoscopic gastrectomy improves patients' quality of life (QOL) and provides favorable prognosis. Single-incision laparoscopic gastrectomy (SILG) is one extremely minimally invasive method, theoretically offering improved cosmetic results, less postoperative pain, and earlier recovery after surgery than conventional multiport laparoscopic gastrectomy. In this context, SILG is thought to be an optimal method to promote and maximize patients' QOL in the acute postoperative phase. However, the technical difficulties of this procedure have limited its use. Since the first report describing single-incision distal gastrectomy in 2011, only 16 studies to date have evaluated SILG. Most of these studies have focused on the technical feasibility and safety of SILG because its long-term outcomes have not been reported. This article reviews the advantages and limitations of SILG.

Single-Port Laparoscopic Proximal Gastrectomy with Double Tract Reconstruction for Early Gastric Cancer: Report of a Case

In Korea, proximal gastrectomy has recently attracted attention as a better choice of function-preserving surgery for proximal early gastric cancer than total gastrectomy. Of the various strategies to overcome reflux symptoms from remnant stomach, double tract reconstruction not only reduces the incidence of anastomosis-related complications, but is also sufficiently reproducible as a laparoscopic procedure. Catching up with the recent rise of single-port laparoscopic surgeries, we performed a pure single-port laparoscopic proximal gastrectomy with DTR. This procedure was designed by merging the function-preserving concept of proximal gastrectomy with single-port laparoscopic total gastrectomy.

Reduced port laparoscopic gastrectomy for gastric cancer

The use of reduced port laparoscopic surgery (RPS) has become increasingly popular. The concept of RPS includes all procedures derived from various efforts minimizing the invasiveness of surgery, with single-incision laparoscopic surgery (SILS) being the ultimate reduced port technique. Reduced-port laparoscopic gastrectomy (RPLG) for gastric cancer has not yet been fully established and still has issues such as feasibility, oncological validity, training, and education. The short-term results of reported studies are acceptable. However, long-term results that verify positive results or radical cure even in cases of cancer have not yet been published. Patients for whom RPLG is indicated should be selected carefully. Prospective multicenter studies should be conducted to establish RPS as a truly evidence-based practice that addresses not only cosmesis but also the appropriate balance between minimal invasiveness and radical cure.

Comparison of single-port and reduced-port totally laparoscopic distal gastrectomy for patients with early gastric cancer

BACKGROUND

Laparoscopy-assisted distal gastrectomy (LADG) is a treatment method for patients with early gastric cancer; however, single- or reduced-port LADG for these patients has been rarely reported.

OBJECTIVE

To compare surgical outcomes of patients with gastric cancer undergoing single-port totally laparoscopic distal gastrectomy (TLDG) to those of patients undergoing reduced-port (three ports) TLDG.

METHODS

This retrospective study included 94 patients with early gastric cancer who underwent single-port or reduced-port TLDG at Samsung Medical Center between May 2014 and December 2014. Surgical outcomes were compared between operation methods.

RESULTS

There are more female patients (54.2 vs. 19.6 %, p = 0.001) and less obese patients (21.1 ± 2.1 vs. 24.6 ± 3.2 kg/m(2), p = 0.001) in the single-port TLDG group. There were no significant differences in blood loss during surgery, the number of dissected lymph nodes, and the pain score at postoperative first day between two groups. The variance in operation time for the reduced-port TLDG was significantly greater than that for single-port TLDG (p = 0.01). Complication rates in the single-port and reduced-TLDG groups were similar (20.8 vs. 21.7 %, p = 1.000). No postoperative deaths occurred in either group.

CONCLUSIONS

Single-port TLDG might be considered as a treatment option for a limited subset, such as females or less obese patients with early gastric cancer.