Gastrointestinal
Full Robotic Gastrectomy with Extended (D2) Lymphadenectomy for Gastric Cancer: Surgical Technique and Preliminary Results

https://doi.org/10.1016/j.jss.2010.11.881Get rights and content

Background

Widespread diffusion of minimally-invasive surgery for gastric cancer treatment is limited by the complexity of performing an extended D2-lymphadenectomy. This surgical step can be facilitated by using robot-assisted surgery. The aim of this study is to describe our technique and short-term results of a consecutive series of full robotic gastrectomies with D2-lymphadenectomy for gastric cancer, using the da Vinci Surgical System.

Materials and Methods

Between May 2004 and December 2009, we performed 24 consecutive full robot-assisted total and subtotal gastrectomies with extended D2-lymphadenectomy for histologically-proven gastric adenocarcinoma. Data referring to 11 robot-assisted total gastrectomies and 13 subtotal gastrectomies were collected in a database and analyzed.

Results

Median operative time was 267.50 min (255–305). Median intraoperative blood loss was 30 mL. Median number of harvested lymph nodes was 28 (23–34). Resection margins were negative in all cases. No conversions occurred. Surgery-related morbidity was 8%. Thirty-day mortality was 0%. Liquid diet started on postoperative d 5 (2–5). Median length of stay was 6 d (5–8).

Conclusions

Robot-assisted gastrectomy with D2-lymphadenectomy is a safe technique and allows achieving an adequate lymph node harvest and optimal R0-resection rates with low postoperative morbidity and the learning curve appears to be shorter than in laparoscopic surgery. Longer follow-up and randomized clinical trials are needed to define the role of robot-assistance in gastric cancer surgery.

Introduction

Minimally invasive surgery is currently applied for many surgical procedures. In the field of gastric cancer, laparoscopic gastrectomy was rapidly adopted in Eastern countries, initially on early stage diseases where a limited lymphadenectomy (D1) is accepted.

The current standard of care for resectable locally advanced gastric cancer, in Japan and Europe, is R0-gastrectomy with extensive D2 lymph node dissection [1, 2.

The Japanese Research Society for Gastric Cancer (JRSGC) classified the regional lymph nodes of the stomach into three groups (group 1–group 3) of numbered stations (s1–s112) [3]. The definition of the level of the dissection, usually identified by a prefix “D”, is based on this classification and varies according to the site of the primary lesion: D1, D2, and the more extensive levels of dissection D3 and D4 (paraortic lymph node dissection). D1 dissection involves group 1 lymph nodes: s1–s6 for lower middle and upper third localizations; s3, s4d, s5, s6 for lower third and duodenal localizations; s1, s3, s4sb, s4d, s5, s6 for middle third-lower localizations; s1–s6 for upper third-middle localizations; s1–s3, s4sa, s4sb for upper third localizations.

D2 lymphadenectomy involves group 1 plus group 2 stations: s1, s3, s4d, s4sb, s5–s7, s8a, s9, s11p, s12a for middle third localizations and s1, s3, s4d, s5–s7, s8a, s9, s11p, s12a, s14v for lower third-duodenal localizations.

Although laparoscopic D2-lymphadenectomy has been described and found to be feasible by several authors 4, 5, 6, 7, 8, 9, widespread use of this technique was limited by the pitfalls of this complex procedure [10]. Even experienced minimally-invasive surgeons, indeed, reported laparoscopic lymph node dissection around hepatic artery, celiac trunk, left gastric and splenic arteries as a complex procedure [11].

Recently, robot-assisted surgery for gastric cancer has been demonstrated to overcome intrinsic limitations of traditional laparoscopic surgery thanks to the articulated movement of the robotic instruments, the elimination of physiologic tremor, the 3-D vision and the steady image, thus minimizing surgical trauma and blood losses [12].

Herein we describe our technique and short-term results of a consecutive series of robotic gastrectomy with D2-lymphadenectomy for gastric cancer, using the da Vinci Surgical System (Intuitive Surgical Inc., Sunnyvale, CA). Moreover, we evaluated the influence of the robotic technique on the learning curve.

Section snippets

Materials and Methods

Between May 2004 and December 2009, we performed 24 consecutive full robot-assisted total and subtotal gastrectomies with extended D2-lymphadenectomy for histologically-proven gastric adenocarcinoma. Patients presenting organ invasion (T4) or metastatic disease at preoperative work-up and preliminary laparoscopic exploration were excluded from this study. Preoperative, intraoperative, and postoperative data were collected in a database. Patients’ demographics are shown in Table 1.

The robotic

Results

This study was based on 24 consecutive gastrectomies with extended (D2) lymphadenectomy performed with the da Vinci Surgical System for gastric adenocarcinoma. Eleven robot-assisted total gastrectomies (RATG) and 13 robot-assisted distal gastrectomies (RADG) were performed. Intraoperative results and early outcomes are shown in Table 2. Median overall operative time was 267.5 (255–305) min. Median docking time was 6 (5–13) min. Intraoperative blood loss (IBL) was 30 mL (IQR, 0–100). Liquid diet

Discussion

R0 surgery with extended (D2) lymphadenectomy is widely considered the optimal therapeutic option for resectable gastric cancer. In our study, we demonstrated that robotic total and subtotal gastrectomies with D2-lymphadenectomy are technically feasible and safe, with acceptable surgical and oncological short-term results.

After the initial controversies about the role of the D2-lymphadenectomy in the treatment of gastric cancer, some recent trials have clearly confirmed the therapeutic role as

Conclusions

In our experience, robot-assisted D2-lymphadenectomy in total and subtotal gastrectomy for gastric cancer appears to be a safe technique allowing to achieve an adequate lymph node harvest and optimal R0-resection rates with low postoperative morbidity.

Robot-assisted surgery can facilitate some surgical steps that are technically challenging in laparoscopic surgery, and the learning curve appears to be shorter than in laparoscopic surgery, thus representing a useful tool for a wider diffusion of

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