Implementing robot-assisted minimally invasive gastrectomy (RAMIG) for gastric cancer in a European tertiary referral center

Abstract

BACKGROUND: Our European tertiary referral center implemented robot-assisted minimally invasive gastrectomy (RAMIG) in September 2020, following experience with robot-assisted esophagectomy and multiquadrant surgery using the DaVinci Xi robot. RAMIG implementation was evaluated. METHODS: This single-center prospective cohort study compared 111 MIG patients (2014-2023) with the initial 75 RAMIG patients (2020-2023), operated by two experienced robotic upper-GI surgeons. After propensity-score-matching, surgical, oncological, and textbook outcomes for overall/distal/total RAMIG and MIG were compared. Cumulative sum (CUSUM) analysis assessed learning curves for operating time and nodal yield. Additionally, the transition from laparoscopic-circular stapled (MIG/RAMIG) to robot-assisted handsewn anastomosis (RAMIG-only) was evaluated. RESULTS: After propensity-score-matching, 75 RAMIG and 75 MIG patients were analyzed; 68% underwent total gastrectomy, and 78% neoadjuvant therapy. Postoperative complications, blood loss, hospitalization, R0-resections, and textbook outcomes were similar between groups (p>0.05). Distal RAMIG showed longer median operating time (214 versus 191 min; p=0.032), but less severe complications (13 % versus 38 % grade≥3A; p = 0.041). Total RAMIG showed higher median nodal yield (35 versus 22 nodes; p < 0.001). CUSUM-analysis showed plateaus for distal/total RAMIG at cases 10 and 24 for operating time, and 8 and 17 for nodal yield. Robot-assisted handsewn esophagojejunostomy seemed to show reduced anastomotic leakage (9% versus 28%), postoperative complications (45% versus 59%), and 30-day mortality (0% versus 5%). CONCLUSIONS: Implementing RAMIG in our tertiary referral center resulted in similar perioperative outcomes with improved nodal yield, despite longer operating times. The robotic technique facilitated modification to handsewn esophagojejunostomy. Short learning curves (8-24 cases) for experienced robotic surgeons support adaption towards RAMIG.