Technical feasibility of robot-sewn anastomosis in robotic surgery for gastric cancer

Totally laparoscopic total gastrectomy using intracorporeally hand-sewn esophagojejunostomy

Purpose

Laparoscopic total gastrectomy (LTG) for gastric cancer is still uncommon because of technical difficulties, especially in esophagojejunostomy (EJ). There are many reports for various laparoscopic procedures of EJ using linear or circular staplers. On the other hands, there has been no report for hand-sewn anastomosis. We report successfully performed intracorporeally hand-sewn EJ after LTG.

Materials and Methods

The clinicopathologic data and short-term surgical outcomes of 6 patients who underwent totally laparoscopic total gastrectomy for upper gastric cancer from December 2010 and July 2011 were retrospectively reviewed.

Results

The mean age was 66.5 years and mean body mass index (kg/m²) was 24.6. All patients had medical comorbidities. The mean patient ASA score was 2.17. Among the 6 patients, previous abdominal operation was performed for 2 patients and combined operation was performed for 3 patients. The mean blood loss, operation time, and EJ anastomosis time was 130 ml, 379.7 minutes, and 81.5 minutes, respectively. The mean time to first flatus, first oral intake, and postoperative hospital stay was 3.0, 3.0, and 12.5 days, respectively. There was no 30-day mortality case. Postoperative aspiration pneumonia and multiple periventricular lacunar infarctions developed in 1 patient. There were no anastomosis-related complications and other major surgical complications.

Conclusions

When the intracorporeal anastomotic technique becomes popular in LTG the intracorporeally hand-sewn EJ may be accepted as one method among the various laparoscopic procedures of EJ.

Robot-assisted total gastrectomy is comparable with laparoscopically assisted total gastrectomy for early gastric cancer

BACKGROUND

Laparoscopically assisted total gastrectomy (LATG) is technically difficult. Robot surgery has theoretical advantages such as increased degrees of freedom of instruments and a three-dimensional view. The current study aimed to determine whether a robot-assisted total gastrectomy (RATG) has a real benefit over LATG in terms of surgical and oncologic outcomes.

METHODS

A single-center case-control study was conducted. The study included 36 patients who underwent RATG and 65 patients who underwent LATG at the National Cancer Center in Korea between February 2009 and May 2011. No patients were excluded from the analysis within the study period. Clinicopathologic data, operative data, postoperative morbidity, and pathologic data were analyzed by Student's t-tests and Chi-square tests, as indicated.

RESULTS

The mean age of the patients was 53.9 ± 11.7 years in the RATG group and 56.9 ± 12.3 years in the LATG group (P = 0.236). The mean BMI was 23.2 ± 2.5 kg/m(2) in the RATG group and 23.6 ± 3.4 kg/m(2) in the LATG group (P = 0.494). The mean postoperative hospital stay was 8.8 ± 3.3 days in the RATG group and 10.3 ± 10.8 days in the LATG group (P = 0.416). The mean operative time was 305.8 ± 115.8 min in the RATG group and 210.2 ± 57.7 min in the LATG group (P < 0.001). The mean number of dissected lymph nodes was 42.8 ± 12.7 in the RATG group and 39.4 ± 13.4 in the LATG group (P = 0.209). Postoperative complications were experienced by 6 patients (16.7%) in the RATG group and 10 patients (15.4%) in the LATG group (P = 0.866).

CONCLUSION

Despite early experiences, RATG was shown to be comparable with LATG in terms of surgical and oncologic outcomes. However, no apparent benefit is associated with RATG to date.

Current status of robot-assisted gastric surgery

In an effort to minimize the limitations of laparoscopy, a robotic surgery system was introduced, but its role for gastric cancer is still unclear. The objective of this article is to assess the current status of robotic surgery for gastric cancer and to predict future prospects. Although the current study was limited by its small number of patients and retrospective nature, robot-assisted gastrectomy with lymphadenectomy for the treatment of gastric cancer is a feasible and safe procedure for experienced laparoscopic surgeons. Most studies have reported satisfactory results for postoperative short-term coutcomes, such as: postoperative oral feeding, gas out, hospital stay and complications, compared with laparoscopic surgery; the difference is a longer operation time. However, robotic surgery showed a shallow learning curve compared with the familarity of conventional open surgery; after the accumulation of several cases, robotic surgery could be expected to result in a similar operation time. Robotic-assisted gastrectomy can expand the indications of minimally invasive surgery to include advanced gastric cancer by improving the ability to perform lymphadenectomy. Moreover, ”total” robotic gastrectomy can be facilitated using a robot-sewing technique and gastric submucosal tumors near the gastroesophageal junction or pylorus can be resected safely by this novel technique. In conclusion, robot-assisted gastrectomy may offer a good alternative to conventional open or laparoscopic surgery for gastric cancer, provided that long-term oncologic outcomes can be confirmed.

Economic evaluation of da Vinci-assisted robotic surgery: a systematic review

BACKGROUND

Health technology assessment (HTA) is frequently used when a new and expensive technology is being introduced into clinical practice. This certainly is the case with the da Vinci surgical robot, with costs ranging from $1 to $2.5 million for each unit. This systematic review documents major variability in the reported cost evaluation studies of da Vinci robot-assisted operations compared with those performed by the direct manual laparoscopic approach.

METHODS

Published studies in the English language related to the period 2000-2010 were searched using economic and clinical electronic databases.

RESULTS

All 11 reports included some form of cost analysis, which made it possible for the authors to extract information on certain specific economic outcomes: operating room time, hospital stay, and total costs. With the exception of two studies, the reported operating room time was higher with the robotic approach than with manual laparoscopic surgery, and the hospital stay was the same for the two techniques. Robotic surgery is significantly more expensive if the purchase and maintenance costs of the robot system are included in the total costs. Only 3 of the 11 publications included these costs.

CONCLUSIONS

The disadvantage of robotic surgery is its higher costs related to purchase and maintenance of technology and its longer operating room time. However, emerging evidence shows that operating room time decreases with experience using the robot. From the HTA viewpoint, the result of this review is that the jury still is out on the HTA of da Vinci-assisted robotic surgery.