Robotic Total and Near-Total (98%) Gastrectomy

Abstract

Minimally invasive techniques for gastrectomy have evolved significantly since the first laparoscopic distal gastrectomy in 1991. However, laparoscopic total gastrectomy (LTG) remains technically challenging due to the complexity of lymphadenectomy and esophagojejunostomy reconstruction. Our team pioneered LTG in 1993 and has since advanced minimally invasive approaches, including the laparoscopic near-total gastrectomy and, more recently, a fully robotic technique. The robotic approach enhances surgical precision, facilitating D2-lymphadenectomy, and optimizes hand-sewn alimentary tract reconstruction. The procedure is performed using four robotic ports and a liver retractor; there is no laparoscopic assistance. The en bloc lymphadenectomy is clockwise and follows a structured sequence, ensuring oncologic safety. The reconstruction phase, particularly esophagojejunostomy, remains the most significant technical hurdle. Our team utilizes a hand-sewn barbed suture technique for anastomosis, improving reproducibility and reducing operative time. Near-total gastrectomy follows a similar approach, preserving a minimal gastric stump. Robotic surgery addresses laparoscopic limitations by enhancing precision, reducing anastomotic tension, and streamlining suturing. The reproducibility of robotic hand-sewn anastomosis and its superior outcomes may establish it as the preferred technique for total and near-total gastrectomy, promoting wider adoption in gastric cancer treatment.