Early experiences of endoscopic procedures in general surgery assisted by a computer-enhanced surgical system

Comparison of short- and long-term outcomes of robotic versus laparoscopic gastrectomy for locally advanced gastric cancer after neoadjuvant therapy: a high-volume center retrospective study with propensity score matching

BACKGROUND

Although neoadjuvant therapy (NAT) for advanced gastric cancer (AGC) can benefit patient survival, few studies have compared the short- and long-term outcomes of robotic and laparoscopic gastrectomy for AGC after NAT.

METHODS

The clinical data of 321 AGC patients who received NATs and who underwent robotic gastrectomy (RG, n = 109) or laparoscopic gastrectomy (LG, n = 212) between May 2017 and September 2022 were collected and analyzed retrospectively at our center. After propensity score matching (PSM) for 1:1 matching to eliminate bias, both groups had 106 cases. Short-term clinical outcomes and long-term survival-related indicators were compared between the two groups of patients.

RESULTS

A total of 212 patients were included in the groups after matching. There were fewer overall complications (13.2% vs. 28.3%, P = 0.007) and surgical complications (8.5% vs. 17.9%, P = 0.043) in the RG group than in the LG group. Compared with the LG group, the RG group had more harvested overall lymph nodes (35.25 ± 4.99 vs. 31.45 ± 6.31, P < 0.001) and more suprapancreatic lymph nodes (13.12 ± 4.38 vs. 10.05 ± 4.13, P < 0.001). Patients in the RG group had significantly shorter surgery times (217.62 ± 47.49 vs. 267.25 ± 70.68, P < 0.001) and less blood loss (46.51 ± 27.02 vs. 70.75 ± 37.25, P < 0.001) than patients in the LG group. The RG group had significantly faster bowel function recovery, earlier liquid diet, and shorter hospital stay. Compared with LG, RG had a better 3-year RFS (75.5% vs. 62.3%, P = 0.017).

CONCLUSION

Compared with laparoscopic surgery, robotic surgery significantly increased the number of lymph node dissected, reduced intraoperative blood loss, and postoperative surgical complications rate. Although RG did not statistically improve 3-year overall survival, there was a significant improvement in RFS and could be an alternative surgical method for GC patients after NAC.

Evaluating the impact of a navigation system on the initial cases of robotic gastrectomy for gastric cancer

Robotic gastrectomy for gastric cancer presents challenges for novice surgeons owing to the lack of tactile feedback, particularly during complex procedures, such as lymph node dissection. To address these issues, a vascular navigation system was developed to enhance procedural safety and efficiency by providing three-dimensional vascular and anatomical guidance. We retrospectively analyzed 49 patients who underwent robotic distal gastrectomy at Pusan National University Yangsan Hospital. Patients were divided into two groups: those without navigation support (noRUS) and those with a vascular navigation system (RUS). We compared the dissection time, number of lymph nodes (LNs) retrieved, C-reactive protein level on postoperative day 3 (CRPD3), and postoperative recovery status. Univariate and multivariate linear regression analyses were performed. The RUS group demonstrated significantly shorter dissection times (179.85 ± 6.88 vs. 204.87 ± 9.60 min, p = 0.0478) and higher LN retrieval (41.81 ± 2.77 vs. 30.96 ± 2.31, p = 0.0048). The CRPD3, a marker of surgical trauma, was significantly lower in the RUS group (8.27 ± 0.85 vs. 11.68 ± 1.13 mg/dL, p = 0.0184). Moreover, no significant differences were observed in the complication rates or postoperative recovery. The vascular navigation system significantly improved surgical efficiency and LN retrieval and reduced surgical trauma during robotic gastrectomy. This study is the first to evaluate the impact of the navigation system on novice surgeons, highlighting its potential to overcome the learning curve earlier and improve patient outcomes.

Laparoscopic Versus Robotic Ventral Hernia Repair - An ACHQC Database 5-Year Analysis

Introduction

To compare laparoscopic and ventral hernia repair (VHR) in the last 5 years in the United States utilizing the Abdominal Core Health Quality Collaborative (ACHQC) database.

Materials and Methods

A retrospective review of prospectively collected data from the ACHQC database was performed to include all adult patients that underwent laparoscopic and robotic VHR in the last 5 years. Univariate analysis was performed to compare outcomes from laparoscopic and robotic-assisted approaches across perioperative and postoperative outcomes.

Results

ACHQC database identified 11,096 patients with midline hernias who underwent VHR with mesh. The Laparoscopic group with patients from 2018 to 2023 (LAP) had 2,063 patients, and the robotic group (ROBO) had 9,033 patients. There was no difference in sex, age, BMI, DM, smoking status and COPD between groups. Median hernia width was 4 cm (IQR 2-6) in the ROBO group and 3 cm (IQR 2-5) in the LAP group (p < 0.001). Incisional hernia was higher in the ROBO group 5,259 (58%) versus 1,099 (53%) in the LAP group (p < 0.001). Recurrent hernia was more common in the ROBO group when compared with the LAP group (p < 0.001). Both groups had more permanent synthetic mesh. Retromuscular repair was higher in the ROBO group, 3,201 (37.6%) versus 68 (4.2%) in the LAP group (p < 0.001). The intraperitoneal repair was higher in the LAP group 1,363 (83%) versus 2,925 (34%) in the ROBO group (p < 0.001) Transversus Abdominis Release (TAR) was higher in the ROBO group 1,314 (14.5%) versus 5 (0.2%) in the LAP group (p < 0.001). Fascial closure was higher in the ROBO group (8,649; 96.5% versus 1,359; 67.3% in the LAP group p < 0.001). Regarding mesh fixation, regular suture was higher in the ROBO group 92% versus 61% in the LAP group (p < 0.001). Tacks (p < 0.001) was higher in the LAP group. The ROBO group had more patients with an operative time of 240+ minutes when compared with the LAP group (p < 0.001). There was no difference in 30-days readmission rates, recurrence, reoperation, overall postoperative complications, 30-day SSI, SSO, seroma and SSOPI between the groups.

Conclusion

The Robotic approach was associated with more technically challenging ventral hernia repairs with low complication rates over time. However, no differences in postoperative complications were found between the groups.

A comprehensive review and meta-analysis comparing robot-assisted and 3D laparoscopic gastrectomy for gastric cancer

This review and meta-analysis evaluates the short-term surgical results of robot-assisted gastrectomy compared to 3D laparoscopic gastrectomy in individuals with gastric cancer. This study used scholarly articles from peer-reviewed articles of PubMed. Further, this study uses other sources, such as, Embase, CNKI, and the Cochrane Library, to gather relevant studies on gastrectomy for gastric cancer which are made public from the inception of these databases up to July 15, 2024. This study seeks to primarily draw similarities between the therapeutic efficacy of robot-assisted gastrectomy (RG) and the 3D laparoscopic gastrectomy (3D-LG). Similarly, this study will strictly adhere to the inclusion and exclusion guidelines, focusing on randomized controlled trials (RCTs) and cohort research. A total of 1231 gastric cancer patients were involved in incorporating seven retrospective cohort studies as the final analysis in the study with 533 undergoing robot-assisted gastrectomy and 698 undergoing 3D-LG. The results showed that patients who received robotic-assisted gastrectomy experienced superior outcomes regarding EBL and time-to-first postoperative exhaust compared to those who underwent 3D-LG. However, the robotic-assisted approach was related to a reduced number of LNY. Besides, there were similarities between the two surgical techniques in relation to OT, LOHS, and post-surgery complications. In summary, robot-assisted gastrectomy is acknowledged as a secure and efficient treatment option for individuals with stomach cancer. This approach demonstrated notable benefits compared to 3D-LG, particularly with regard to estimated intraoperative blood loss and the timing of the first postoperative exhaust.

Artificial intelligence in gastrointestinal cancers: Diagnostic, prognostic, and surgical strategies

GI (Gastrointestinal) malignancies are one of the most common and lethal cancers globally. The dawn of precision medicine and developing technologies have reduced the mortality rates for GI malignancies, underscoring the main role of early detection methods for survival rate improvement. Artificial intelligence (AI) is a new technology that may improve GI cancer screening, treatment, and therapeutic efficiency for better patient care. AI could accelerate the development of targeted therapies by analyzing considerable data from the genome and identifying biomarkers connected with GI tumors. This opens up new avenues toward more tailored and personalized approaches, raising efficacy while reducing undesired side effects. For instance, AI may improve treatment outcomes by accurately predicting patient responses to therapeutic regimens, helping oncologists choose the most effective treatment options. This review will outline the transformative potential of AI in GI oncology by emphasizing the incorporation of AI-based technologies to enhance patient care.

Minimally Invasive Gastrectomy

The surgical management of gastric cancer has changed significantly from the first open partial gastrectomy in 1881 to contemporary minimally invasive approaches. The approach has shifted from open surgeries to laparoscopic and robotic-assisted gastrectomies, with evidence of reduced pain, quicker recovery, and lower morbidity with these methods. Multiple randomized trials have confirmed that laparoscopic surgeries yield oncologically safe results. Moreover, robotic surgeries, while more expensive, provide similar outcomes with some procedural benefits. Herein, we discuss surgical techniques, preoperative planning, and postprocedure care, emphasizing the role of careful clinical assessment and tailored surgical approaches based on tumor location and patient condition.

Robotic-Assisted Colon Cancer Surgery: Faster Recovery and Less Pain Compared to Laparoscopy in a Retrospective Propensity-Matched Study

Background and Objective: Colorectal cancer (CRC) is the third most common cancer worldwide, with colon cancer accounting for approximately 60% of all CRC cases. Surgery remains the primary and most effective treatment. Robotic-assisted surgery (RAS) has emerged as a promising approach for colon cancer resection. This retrospective study compares RAS and laparoscopic-assisted surgery (LSS) for stage I-III colon cancer resections at a single medical center in East Asia. Methods: Between 1 January 2018, and 29 February 2024, patients undergoing colectomy were classified into right-side and left-side colectomies. Propensity score matching was conducted based on age group, gender, ASA score, and BMI to ensure comparability between groups. After matching, there were 50 RAS and 200 LSS cases for right colectomy (RC), and 129 RAS and 258 LSS cases for left colectomy (LC). Perioperative outcomes were compared between the two surgical approaches. The primary outcomes were recovery milestones, while secondary outcomes included complications and postoperative pain scores. Results: RAS demonstrated faster recovery milestones compared to LSS (hospital stay: 6.5 vs. 10.2 days, p = 0.005 for RC; 5.5 vs. 8.2 days, p < 0.001 for LC). RAS also resulted in lower rates of ileus (14% vs. 26%, p = 0.064 for RC; 6.2% vs. 15.9%, p = 0.007 for LC) and higher lymph node yields (31.4 vs. 26.8, p = 0.028 for RC; 25.8 vs. 23.9, p = 0.066 for LC). Major complication rates showed no significant difference between RAS and LSS (4.0% vs. 7.0%, p = 0.746 for RC; 4.7% vs. 3.1%, p = 0.563 for LC). Patients in the RAS group experienced earlier diuretic phases and reported significantly lower postoperative pain scores (3.0 vs. 4.1, p = 0.011 for RC; 2.9 vs. 4.1, p < 0.001 for LC). Conclusions: Robotic-assisted surgery is associated with faster recovery, lower rates of ileus (LC), higher lymph node yield (RC) and reduced postoperative pain compared to laparoscopic-assisted surgery for colon cancer resection.

Colorectal Robotic-Assisted Surgery in Children. Long-Term Outcomes and Pitfalls

BACKGROUND

Colorectal surgical procedures may benefit from a minimally invasive approach in children, although there are few studies.

METHODS

A retrospective, single-centre observational study was conducted on paediatric patients who underwent colorectal robotic-assisted surgery between 2011 and 2022.

RESULTS

A total of 50 patients (33 male; 17 female) were included, with a median age of 4.8 years (IQR:2.5-6.3 years). The main indication was robotic Soave pull-through for Hirschsprung's disease in 21 cases. No conversions or intraoperative complications were reported. Operative time varied depending on the procedure, with a median of 183 min (IQR:151-224 min). Median hospital stay was 4 days (IQR:3-5 days). Four postoperative complications were observed, two of them Clavien-Dindo IIIb (one colo-anal partial dehiscence and one anastomotic leak after megasigmoid resection). Regarding long-term follow-up (median 7.6 years; IQR:4.8-10.6 years), 4 patients (8%) required surgical reintervention.

CONCLUSION

Colorectal robotic-assisted surgery encompasses several procedures with low complication rates and satisfactory long-term outcomes.

A comparison between robotic-assisted and open approaches for large ventral hernia repair-a multicenter analysis of 30 days outcomes using the ACHQC database

INTRODUCTION

Over the last few decades, there has been an increase in the use of a minimally invasive (MIS) approach for complex hernias involving component separation. A robotic platform provides better visualization and mobilization of tissues for component separation. We aim to assess the outcomes of open and robotic-assisted approaches for large VHR utilizing the ACHQC national database.

METHODS

A retrospective review of prospectively collected data from the Abdominal Core Health Quality Collaborative (ACHQC) was performed to include all adult patients who had primary and incisional midline ventral hernias larger than 10 cm and underwent elective open and robotic hernia repairs with mesh from January 2013 to March 2023. Univariate and multivariate analyses were performed comparing Open and Robotic approaches.

RESULTS

The ACHQC database identified 5,516 patients with midline hernias larger than 10 cm who underwent VHR. The open group (OG) had 4,978 patients, and the robotic group (RG) had 538. The RG had a higher median BMI (33.3 kg/m2 (IQR 29.8-38.1) vs 32.7 (IQR 28.7-36.6) (p < 0.001). Median hernia width was 15 cm (IQR 12-18) in the OG and 12 cm in the RG (10-14) (p < 0.001). Sublay positioning of the mesh was the most common. The fascial closure was higher in the RG (524; 97% versus 4,708; 95%-p = 0.005). Median Length of Stay (LOS) was 5 days (IQR 4-7) in the OG and 2 days (IQR 1-3) in the RG (p < 0.001). The readmission rate was higher in the OG (n = 374; 7.5% vs n = 16; 3%; p < 0.001). 30-day SSI were higher in the OG (343; 6.9%% vs 14; 2.6%; p < 0.001). Logistic regression analysis identified diabetes (OR 1.6; CI 1.1-2.1; p = 0.006) and BMI (OR 1.04, CI 1.02-1.06; p < 0.001) as predictors of SSIs, while the robotic approach was protective (OR 0.35, CI 0.17-0.64; p = 0.002). For SSO, logistic regression showed BMI (OR 1.04, CI 1.03-1.06; p < 0.001) and smoking (OR 1.8, CI 1.3-2.4; p < 0.001) as predictors Robotic approach was associated with lower readmission rates (OR .04, CI 0.2-0.6; p < 0.001).

CONCLUSION

A robotic approach improves early 30-day outcomes compared to an open technique for large VHR. There was no difference in SSO at 30 days.

Short-Term Outcomes Analysis Comparing Open, Lap-Assisted, Totally Laparoscopic, and Robotic Total Gastrectomy for Gastric Cancer: A Network Meta-Analysis

BACKGROUND/OBJECTIVES

Total gastrectomy (TG) is the cornerstone treatment for gastric cancer (GC). While open TG (OTG) with D2 lymphadenectomy remains the gold standard, alternative techniques such as lap-assisted TG (LATG), totally laparoscopic TG (TLTG), and robotic TG (RTG) have been reported with promising outcomes. The present analysis aimed to compare the short-term outcomes of different techniques for TG comprehensively in the setting of GC.

METHODS

A systematic review and network meta-analysis were performed. The primary outcomes were overall complications (OC), severe postoperative complications (SPCs), and anastomotic leak (AL). Pooled effect-size measures included risk ratio (RR), weighted mean difference (WMD), and 95% credible intervals (CrIs).

RESULTS

Sixty-eight studies (44,689 patients) were included. Overall, 52.4% underwent OTG, 6.5% LATG, 39.2% TLTG, and 1.9% RTG. Both TLTG (RR 0.82; 95% CrI 0.73-0.92) and RTG (RR 0.75; 95% CrI 0.59-0.95) showed a reduced rate of postoperative OC compared to OTG. SPCs and AL RR were comparable across all techniques. Despite the longer operative time, LATG, TLTG, and RTG showed reduced intraoperative blood loss, time to first flatus, ambulation, liquid diet resumption, and hospital stay compared to OTG.

CONCLUSIONS

Minimally invasive approaches seem to be associated with improved OC and functional outcomes compared to OTG.

Analysis of the impact on sexual function in early-onset overweight male patients with rectal cancer following robotic surgery

The effect of radical resection of male rectal cancer on sexual function has been the focus of attention. Despite this, there remains a dearth of robust evidence regarding the influence of robotic radical resection of rectal cancer on postoperative sexual function, particularly in men diagnosed at an early age. This study aims to explore the implications of robotic radical resection of rectal cancer on sexual function in early-onset overweight male patients diagnosed with this disease. A retrospective analysis was performed on male patients under 50 years old and over 20 years old who were diagnosed with rectal cancer (cT1-3N0M0) and underwent surgical treatment in the First Affiliated Hospital of Nanchang University from May 2015 to August 2020. Sexual function was evaluated by the International Index of Erectile Function (IIEF) test and scored at 1, 3, 6, and 12 months postoperatively. The sexual function of traditional laparoscopic radical resection of rectal cancer (L-RE) and robotic radical resection of rectal cancer (R-RE) were compared. According to body mass index, L-RE and R-RE groups were further divided into normal body weight groups (LN-RE and RN-RE) and overweight groups (LO-RE and RO-RE), and the sexual function of each group was compared successively. Neither L-RE nor R-RE patients had significant differences in number of lymph nodes removed, tumour size, pathological TNM stage, or first exhaust time or time to eat liquids. The OS and DFS of the L-RE and R-RE groups, as well as the LO-RE and RO-RE groups, did not differ statistically after the logarithmic rank test (P > 0.05). IIEF scores in both the L-RE and R-RE groups declined sharply 1 month after surgery and then steadily increased. The R-RE group's IIEF scores significantly recovered in 6 months, compared to 12 months in the L-RE group. In comparison of subgroups, the results of sexual function in the LN-RE and RN-RE groups were similar to those in the L-RE and R-RE groups. Conversely, the RO-RE group showed slightly improved sexual function recovery than the LO-RE group 3 and 6 months post-surgery. 12 months after surgery, no significant difference was observed between the two groups. With similar long-term oncology outcomes, the robot-assisted surgical approach provided better protection of sexual function for men with early-onset rectal cancer, especially for those with a higher body mass index (BMI).

A systematic review on the effectiveness of robot-assisted minimally invasive gastrectomy

BACKGROUND

Robot-assisted minimally invasive gastrectomy (RAMIG) is increasingly used as a surgical approach for gastric cancer. This study assessed the effectiveness of RAMIG and studied which stages of the IDEAL-framework (1 = Idea, 2A = Development, 2B = Exploration, 3 = Assessment, 4 = Long-term follow-up) were followed.

METHODS

The Cochrane Library, Embase, Pubmed, and Web of Science were searched for studies on RAMIG up to January 2023. Data collection included the IDEAL-stage, demographics, number of participants, and study design. For randomized controlled trials (RCTs) and long-term studies, data on intra-, postoperative, and oncologic outcomes, survival, and costs of RAMIG were collected and summarized.

RESULTS

Of the 114 included studies, none reported the IDEAL-stage. After full-text reading, 18 (16%) studies were considered IDEAL-2A, 75 (66%) IDEAL-2B, 4 (4%) IDEAL-3, and 17 (15%) IDEAL-4. The IDEAL-stages were followed sequentially (2A-4), with IDEAL-2A studies still ongoing. IDEAL-3 RCTs showed lower overall complications (8.5-9.2% RAMIG versus 17.6-19.3% laparoscopic total/subtotal gastrectomy), equal 30-day mortality (0%), and equal length of hospital stay for RAMIG (mean 5.7-8.5 days RAMIG versus 6.4-8.2 days open/laparoscopic total/subtotal gastrectomy). Lymph node yield was similar across techniques, but RAMIG incurred significantly higher costs than laparoscopic total/subtotal gastrectomy ($13,423-15,262 versus $10,165-10,945). IDEAL-4 studies showed similar or improved overall/disease-free survival for RAMIG.

CONCLUSION

During worldwide RAMIG implementation, the IDEAL-framework was followed in sequential order. IDEAL-3 and 4 long-term studies showed that RAMIG is similar or even better to conventional surgery in terms of hospital stay, lymph node yield, and overall/disease-free survival. In addition, RAMIG showed reduced postoperative complication rates, despite higher costs.

Long-term survival outcomes of robotic total gastrectomy for locally advanced proximal gastric cancer: a prospective study

BACKGROUND

Robotic gastrectomy is a safe and feasible approach for gastric cancer (GC); however, its long-term oncological efficacy remains unclear. The authors evaluated the long-term survival outcomes and recurrence patterns of patients with locally advanced proximal GC who underwent robotic total gastrectomy (RTG).

METHODS

This prospective study (FUGES-014 study) enrolled 48 patients with locally advanced proximal GC who underwent RTG between March 2018 and February 2020 at a tertiary referral teaching hospital. Patients who underwent laparoscopic total gastrectomy (LTG) in the FUGES-002 study were enrolled in a 2:1 ratio to compare the survival outcomes between RTG and LTG. The primary endpoint of the FUGES-014 study was postoperative 30-day morbidity and has been previously reported. Here, the authors reported the results of 3-year disease-free survival (DFS), 3-year overall survival (OS), and recurrence patterns.

RESULTS

After propensity score matching, 48 patients in the RTG and 96 patients in the LTG groups were included. The 3-year DFS rates were 77.1% (95% CI: 66.1-89.9%) for the RTG and 68.8% (95% CI: 60.1-78.7%) for the LTG groups ( P =0.261). The 3-year OS rates were not significantly different between the groups (85.4 vs. 74.0%, P =0.122). Recurrence occurred in nine patients (18.8%) in the RTG and 27 (28.1%) patients in the LTG groups ( P =0.234). Recurrence patterns and causes of death were similar between the groups ( P >0.05).

CONCLUSIONS

The oncological outcome of RTG was noninferior to that of LTG. Thus, RTG might be an alternative surgical treatment for locally advanced proximal GC.

Evaluating surgical expertise with AI-based automated instrument recognition for robotic distal gastrectomy

Introduction

Complexities of robotic distal gastrectomy (RDG) give reason to assess physician's surgical skill. Varying levels in surgical skill affect patient outcomes. We aim to investigate how a novel artificial intelligence (AI) model can be used to evaluate surgical skill in RDG by recognizing surgical instruments.

Methods

Fifty-five consecutive robotic surgical videos of RDG for gastric cancer were analyzed. We used Deeplab, a multi-stage temporal convolutional network, and it trained on 1234 manually annotated images. The model was then tested on 149 annotated images for accuracy. Deep learning metrics such as Intersection over Union (IoU) and accuracy were assessed, and the comparison between experienced and non-experienced surgeons based on usage of instruments during infrapyloric lymph node dissection was performed.

Results

We annotated 540 Cadiere forceps, 898 Fenestrated bipolars, 359 Suction tubes, 307 Maryland bipolars, 688 Harmonic scalpels, 400 Staplers, and 59 Large clips. The average IoU and accuracy were 0.82 ± 0.12 and 87.2 ± 11.9% respectively. Moreover, the percentage of each instrument's usage to overall infrapyloric lymphadenectomy duration predicted by AI were compared. The use of Stapler and Large clip were significantly shorter in the experienced group compared to the non-experienced group.

Conclusions

This study is the first to report that surgical skill can be successfully and accurately determined by an AI model for RDG. Our AI gives us a way to recognize and automatically generate instance segmentation of the surgical instruments present in this procedure. Use of this technology allows unbiased, more accessible RDG surgical skill.

Robotic gastrectomy was reliable option for overweight patients with gastric cancer: a propensity score matching study

BACKGROUND

The role of minimally invasive surgery using robotics versus laparoscopy in resectable gastric cancer patients with a high body mass index (BMI) remains controversial.

METHODS

A total of 482 gastric adenocarcinoma patients with BMI ≥ 25 kg/m2 who underwent minimally invasive radical gastrectomy between August 2016 and December 2019 were retrospectively analyzed, including 109 cases in the robotic gastrectomy (RG) group and 321 cases in the laparoscopic gastrectomy (LG) group. Propensity score matching (PSM) with a 1:1 ratio was performed, and the perioperative outcomes, lymph node dissection, and 3-year overall survival (OS) and disease-free survival (DFS) rates were compared.

RESULTS

After PSM, 109 patients were included in each of the RG and LG groups, with balanced baseline characteristics. Compared with the LG group, the RG group had similar intraoperative estimated blood loss [median (IQR) 30 (20-50) vs. 35 (30-59) mL, median difference (95%CI) - 5 (- 10 to 0)], postoperative complications [13.8% vs. 18.3%, OR (95%CI) 0.71 (0.342 to 1.473)], postoperative recovery, total harvested lymph nodes [(34.25 ± 13.43 vs. 35.44 ± 14.12, mean difference (95%CI) - 1.19 (- 4.871 to 2.485)] and textbook outcomes [(81.7% vs. 76.1%, OR (95%CI) 1.39 (0.724 to 2.684)]. Among pathological stage II-III patients receiving chemotherapy, the initiation of adjuvant chemotherapy in the RG group was similar to that in the LG group [median (IQR): 28 (25.5-32.5) vs. 32 (27-38.5) days, median difference (95%CI) - 3 (- 6 to 0)]. The 3-year OS (RG vs. LG: 80.7% vs. 81.7%, HR = 1.048, 95%CI 0.591 to 1.857) and DFS (78% vs. 76.1%, HR = 0.996, 95%CI 0.584 to 1.698) were comparable between the two groups.

CONCLUSION

RG conferred comparable lymph node dissection, postoperative recovery, and oncologic outcomes in a selected cohort of patients with BMI ≥ 25 kg/m2.

Learning curve of laparoscopic and robotic total gastrectomy: A systematic review and meta-analysis

PURPOSE

Minimally-invasive total gastrectomy (MITG) is associated with lower morbidity in comparison to open total gastrectomy but requires a learning curve (LC). We aimed to perform a pooled analysis of the number of cases required to surmount the LC (NLC) in MITG.

METHODS

A systematic review of PubMed, Embase, Scopus and the Cochrane Library from inception until August 2022 was performed for studies reporting the LC in laparoscopic total gastrectomy (LTG) and/or robotic total gastrectomy (RTG). Poisson mean (95% confidence interval [CI]) was used to determine the NLC. Negative binomial regression was performed as a comparative analysis.

RESULTS

There were 12 articles with 18 data sets: 12 data sets (n = 1202 patients) on LTG and 6 data sets (n = 318 patients) on RTG. The majority of studies were conducted in East Asia (94.4%). The majority of the data sets (n = 12/18, 66.7%) used non-arbitrary analyses. The NLC was significantly smaller in RTG in comparison to LTG [RTG 20.5 (95% CI 17.0-24.5); LTG 43.9 (95% CI 40.2-47.8); incidence rate ratio 0.47, p < 0.001]. The NLC was comparable between totally-laparoscopic total gastrectomy (TLTG) and laparoscopic-assisted total gastrectomy (LATG) [LATG 39.0 (95% CI 30.8-48.7); TLTG 36.0 (95% CI 30.4-42.4)].

CONCLUSIONS

The LC for RTG was significantly shorter for LTG. However existing studies are heterogeneous.

Robotic vs. laparoscopic distal gastrectomy for gastric cancer: A propensity score-matched retrospective comparative study at a single institution

BACKGROUND

Although robotic surgery is becoming more widespread worldwide, it is still in its infancy. This study aimed to confirm the safety and feasibility of the induction of robotic-assisted gastric surgery at a local hospital.

METHODS

For five years, between 2016 and 2020, 42 laparoscopic and 71 robotic distal gastrectomies were performed at the same institution. Patients diagnosed with gastric cancer were retrieved from the database. Propensity score matching was performed based on covariates such as Age, Sex, BMI, the American Society of Anesthesiologists Physical Status, Tumor Location, pT, and pN. Clinicopathological characteristics, surgical performance, postoperative outcomes, and pathological data were retrospectively collected and compared by the Chi-square test, the Fisher's exact test, the Student's t-test, and the Mann-Whitney U test.

RESULTS

Billroth II reconstruction was often selected for the robotic group more than the laparoscopic group (59.4% and 15.6%, respectively). In addition, the number of lymph nodes harvested after D2 dissection tended to be more significant in the robotic group than in the laparoscopic group (52.1 ± 7.6 and 29.1 ± 3.7, respectively; p = 0.00934). The mean operative time was 271.4 ± 10.5 min for the robotic group and 220.8 ± 12.3 min for the laparoscopic group (p = 0.00005). There were no differences in short-term clinical outcomes between the two groups.

CONCLUSIONS

Although a single-center, small comparative study, the results showed that the robotic surgery group was not inferior to the laparoscopic group in feasibility and safety. Moreover, robotic surgery enables harvesting a higher number of lymph nodes, which may be more advantageous than laparoscopic surgery. This study also showed that as the surgeon gains experience with robotic surgery, its operative time becomes significantly shorter.

Robotic distal gastrectomy using a novel pre-emptive supra-pancreatic approach without duodenal transection in the dissection of D2 lymph nodes for gastric cancer

Background

Robot-assisted surgery has shown remarkable progress as a minimally invasive procedure for gastric cancer. This study aimed to compare the pre-emptive suprapancreatic approach without duodenal transection and the conventional approach in terms of perioperative feasibility and short-term surgical outcomes.

Methods

We retrospectively analyzed all patients who underwent robotic distal gastrectomy with D2 lymph node dissection using the da Vinci Xi robotic system between December 2021 and April 2023 and categorized them into two groups for comparison. Patients treated using the pre-emptive suprapancreatic approach (observation group) were compared with those who received the conventional approach (control group). Employing one-to-one propensity score matching, we evaluated the postoperative morbidity and short-term outcomes in these two distinct groups to assess the efficacy and safety of the novel surgical technique.

Results

This study enrolled 131 patients: 70 in the observation group and 61 in the control group. After propensity score matching, the operative times were significantly longer in the control group than in the observation group (229.10 ± 33.96 vs. 174.84 ± 18.37, p <0.001). The mean blood loss was lower in the observation group than in the control group (25.20 ± 11.18 vs. 85.00 ± 38.78, p <0.001). Additionally, the observation group exhibited a higher number of retrieved lymph nodes, including suprapyloric, perigastric, and superior pancreatic lymph nodes (28.69 ± 5.48 vs. 19.21 ± 2.89, p <0.001; 4.98 ± 1.27 vs. 4.29 ± 1.21, p = 0.012; 10.52 ± 2.39 vs. 5.50 ± 1.62, p <0.001; 6.26 ± 2.64 vs. 5.00 ± 1.72, p = 0.029). Drain amylase levels in the observation group were significantly lower than those in the control group (30.08 ± 33.74 vs. 69.14 ± 66.81, p <0.001).

Conclusion

This study revealed that using the pre-emptive suprapancreatic approach without duodenal transection in the dissection of D2 lymph nodes for gastric cancer is a safe and feasible procedure in terms of surgical outcomes.

Comparison of Short-term and Three-year Oncological Outcomes Between Robotic and Laparoscopic Gastrectomy for Gastric Cancer: A Large Multicenter Cohort Study

OBJECTIVE

To compare the short-term and long-term outcomes between robotic gastrectomy (RG) and laparoscopic gastrectomy (LG) for gastric cancer.

BACKGROUND

The clinical outcomes of RG over LG have not yet been effectively demonstrated.

METHODS

This retrospective cohort study included 3599 patients with gastric cancer who underwent radical gastrectomy at eight high-volume hospitals in China from January 2015 to June 2019. Propensity score matching was performed between patients who received RG and LG. The primary end point was 3-year disease-free survival (DFS).

RESULTS

After 1:1 propensity score matching, 1034 pairs of patients were enrolled in a balanced cohort for further analysis. The 3-year DFS in the RG and LG was 83.7% and 83.1% ( P =0.745), respectively, and the 3-year overall survival was 85.2% and 84.4%, respectively ( P =0.647). During 3 years of follow-up, 154 patients in the RG and LG groups relapsed (cumulative incidence of recurrence: 15.0% vs 15.0%, P =0.988). There was no significant difference in the recurrence sites between the 2 groups (all P >0.05). Sensitivity analysis showed that RG had comparable 3-year DFS (77.4% vs 76.7%, P =0.745) and overall survival (79.7% vs 78.4%, P =0.577) to LG in patients with advanced (pathologic T2-4a) disease, and the recurrence pattern within 3 years was also similar between the 2 groups (all P >0.05). RG had less intraoperative blood loss, lower conversion rate, and shorter hospital stays than LG (all P >0.05).

CONCLUSIONS

For resectable gastric cancer, including advanced cases, RG is a safe approach with comparable 3-year oncological outcomes to LG when performed by experienced surgeons.

Systematic Review and Meta-Analysis of Laparoscopic versus Robotic-Assisted Surgery for Colon Cancer: Efficacy, Safety, and Outcomes-A Focus on Studies from 2020-2024

BACKGROUND

Minimally invasive surgery in the treatment of colon cancer has significantly advanced over the years. This systematic review and meta-analysis aimed to compare the operative outcomes of robotic and laparoscopic surgery in the treatment of colon cancer, focusing on operative time, hospital stay, conversion rates, anastomotic leak rates, and total number lymph node harvested.

METHODS

Following PRISMA guidelines, we conducted a systematic search across four databases up to January 2024, registering our protocol with PROSPERO (CRD42024513326). We included studies comparing robotic and laparoscopic surgeries for colon cancer, assessing operative time, hospital length of stay, and other perioperative outcomes. Risk of bias was evaluated using the JBI Critical Appraisal Checklist. Statistical analysis utilized a mix of fixed and random-effects models based on heterogeneity.

RESULTS

A total of 21 studies met the inclusion criteria, encompassing 50,771 patients, with 21.75% undergoing robotic surgery and 78.25% laparoscopic surgery. Robotic surgery was associated with longer operative times (SMD = -1.27, p < 0.00001) but shorter hospital stays (MD = 0.42, p = 0.003) compared to laparoscopic surgery. Conversion rates were significantly higher in laparoscopic procedures (OR = 2.02, p < 0.00001). No significant differences were found in anastomotic leak rates. A higher number of lymph nodes was harvested by robotic approach (MD = -0.65, p = 0.04). Publication bias was addressed through funnel plot analysis and Egger's test, indicating the presence of asymmetry (p = 0.006).

CONCLUSIONS

The choice of surgical method should be individualized, considering factors such as surgeon expertise, medical facilities, and patient-specific considerations. Future research should aim to elucidate long-term outcomes to further guide the clinical decision-making.

Intracorporeal versus extracorporeal anastomosis in minimally invasive right hemicolectomy: systematic review and meta-analysis of randomized controlled trials

Purpose

Compared with extracorporeal anastomosis (ECA), intracorporeal anastomosis (ICA) is expected to provide some benefits, including a shorter operation time and less intraoperative bleeding. Nevertheless, the benefits of ICA have mainly been evaluated in nonrandomized studies. Owing to the recent update of randomized controlled trials (RCTs) for minimally invasive surgery (MIS) of right hemicolectomy (RHC), the need to measure the actual effect by synthesizing the outcomes of these studies has emerged.

Methods

We performed a comprehensive search of the PubMed, Embase, and Cochrane databases (from inception to January 30, 2023) for studies that applied ICA and ECA for RHC with MIS. We included 7 RCTs. The operation time, intraoperative blood loss, conversion rate, length of incision, and postoperative outcomes such as ileus, anastomosis leakage, length of hospitalization, and postoperative pain were compared between ICA and ECA.

Results

A total of 740 patients were included in the study. Among them, 377 and 373 underwent ICA and ECA, respectively. There were significant differences in age (P = 0.003) and incision type (P < 0.001) between ICA and ECA. ICA was associated with a significantly longer operation time (P = 0.033). Although the postoperative pain associated with ICA was significantly lower than that associated with ECA on postoperative day 2 (POD 2) (P = 0.003), it was not different on POD 3 between the groups. Other perioperative outcomes were similar between the 2 groups.

Conclusion

In this meta-analysis, ICA did not significantly improve short-term outcomes compared to ECA; other advantages to overcome ICA's longer operation time are not clear.

Establishing the Learning Curve of Laparoscopic and Robotic Distal Gastrectomy: a Systematic Review and Meta-Regression Analysis

BACKGROUND

Minimally invasive distal gastrectomy (MIDG) is non-inferior compared with open distal gastrectomy for gastric cancer. However, MIDG bears a learning curve (LC). This study aims to evaluate the number of cases required to surmount the LC (i.e. NLC) in MIDG.

METHODS

PubMed, Embase, Scopus, and the Cochrane Library were systematically searched from inception to August 2022 for studies which reported NLC in MIDG. NLC on reduced-port/single-port MIDG only were separately analysed. Poisson mean (95% confidence interval (CI)) was used to determine NLC. Negative binomial regression was used to compare NLC between laparoscopic distal gastrectomy (LDG) and robotic distal gastrectomy (RDG).

RESULTS

A total of 45 articles with 71 data sets (LDG n=47, RDG n=24) were analysed. There were 7776 patients in total (LDG n=5516, RDG n=2260). Majority of studies were conducted in East Asia (n=68/71). Majority (76.1%) of data sets used non-arbitrary methods of analyses. The overall NLC for RDG was significantly lower compared to LDG (RDG 22.4 (95% CI: 20.4-24.5); LDG 46.7 (95% CI: 44.1-49.4); incidence rate ratio 0.48, p<0.001). The median number of laparoscopic gastrectomy (LG) cases prior was 0 (interquartile range (IQR) 0-105) for LDG and 159 (IQR 101-305.3) for RDG. Meta-regression analysis did not show a significant impact prior experience in LG, extent of lymphadenectomy and intracorporeal vs extracorporeal anastomosis had on overall NLC for LDG and RDG.

CONCLUSION

NLC for RDG is shorter compared to LDG, but this may be due to prior experience in LG and ergonomic advantages of RDG.

Evolution of Treatment Outcomes and Prognostic Factors in Esophageal Cancer Surgery: A Retrospective Analysis of 1500 Consecutive Esophagostomies

Objective

To clarify the surgical outcomes of esophagectomy in Japan and comprehensively evaluate trends over time. It is important to analyze data from a large number of consecutive patients from a single institution.

Methods

We evaluated the treatment outcomes, complications, and prognosis of 1500 consecutive patients who underwent esophagectomy during 5 periods: group A (n = 284), 1964-1984; group B (n = 345), 1985-1993; group C (n = 253), 1994-2002; group D (n = 297), 2003-2012; and group E (n = 321), 2013-March 2020.

Results

The incidences of squamous cell carcinoma and adenocarcinoma were 93.8% and 3.3%, respectively. The proportion of adenocarcinoma cases has gradually increased over time. The in-hospital mortality rates for groups A, B, C, D, and E were 12%, 4.6%, 1.2%, 2.9%, and 1.5%, respectively. Group A had a significantly higher mortality rate than the other groups (P < 0.0001). Three-year survival rates were 22.2%, 47.8%, 53.4%, 69.9%, and 72.6% in groups A-E, respectively, 5-year survival rates were 17.2%, 41.3%, 49.2%, 63.9%, and 68.4%, respectively (P < 0.0001, group A vs groups D and E). The prognosis improved over time. Multivariate analysis revealed that depth of invasion, lymph node metastasis, the extent of lymph node resection, curative resection, pulmonary complications, and anastomotic leakage were significant independent prognostic factors. However, for recent surgeries (groups D and E), only the depth of invasion, lymph node metastasis, and curative resection were significant independent prognostic factors.

Conclusions

Valuable changes in background and prognostic factors occurred over time. These findings will help optimize esophageal cancer management and improve patient outcomes.

Impact of Hospital Volume on Utilization of Minimally Invasive Surgery for Gastric Cancer

BACKGROUND

Minimally invasive surgery (MIS) for gastric cancer is increasingly performed. The purpose of this study is to evaluate trends in utilization of laparoscopic and robotic techniques compared to open surgery as well as utilization based on hospital volume.

METHODS

We used the National Cancer Database to query patients who underwent gastrectomy from 2010 to 2017 for adenocarcinoma. Regression analyses were used to determine associations between MIS and clinical factors, the trend of MIS over time, and survival.

RESULTS

A total of 18,380 patients met inclusion criteria. The annual rates of MIS increased for all hospital volumes, though lower volume centers were less likely to undergo MIS. MIS was associated with a shorter length of stay compared to open, and robotic gastrectomy had a higher rate of obtaining at least 15 lymph nodes and lower rate of having a positive margin.

CONCLUSIONS

MIS utilization for resection of gastric cancer increased over time, with robotic surgery increasing at a higher rate than laparoscopic surgery. Importantly, this occurred without increased in mortality or sacrificing adequate oncologic outcomes.

Evaluation of an established colorectal robotic programme at an NHS district general hospital: audit of outcomes and systematic review of published data

INTRODUCTION

Robotic-assisted surgery (RAS) offers potential advantages over traditional surgical approaches. This study aimed to assess outcomes from a district general hospital (DGH) robotic colorectal programme against published data.

MATERIALS AND METHODS

The robotic programme was established following simulator, dry/wet lab training, and proctoring. We performed a case series analysing technical, patient, and oncological outcomes extracted from a prospective database of colorectal RAS cases (2015-2022). A registered systematic review (PROSPERO CRD42022300773; PubMed, Web of Science, EMBASE) of single-centre colorectal series from established robotic centres (n>200 cases) was completed and compared to local data using descriptive summary statistics. Risk of bias assessment was performed using an adapted version of the Cochrane ROBINS-I tool.

RESULTS

Two hundred thirty-two RAS cases were performed including 122 anterior resections, 56 APERs, 19 rectopexies, and 15 Hartmann's procedures. The median duration was 325 (IQR 265-400) min. Blood loss was < 100 ml in 97% of cases with 2 (0.9%) cases converted to open. Complications (Clavien-Dindo 3-5) occurred in 19 (8%) patients, with 3 (1.3%) deaths in < 30 days. Length of stay was 7 (IQR 5-11) days. In 169 rectal cancer cases, there were 9 (5.3%) cases with a positive circumferential or distal margin and lymph node yield of 17 (IQR 13-24). A systematic review of 1648 abstracts identified 13 studies from established robotic centres, totaling 4930 cases, with technical, patient, and oncological outcomes comparable to our own case series.

CONCLUSIONS

Outcomes from our robotic colorectal programme at a UK DGH are comparable with the largest published case series from world-renowned centres. Training and proctoring together with rolling audit must accompany the expansion of robotic surgery to safeguard outcomes.

Safety and efficacy of indocyanine green near-infrared fluorescent imaging-guided lymph node dissection during robotic gastrectomy for gastric cancer: a systematic review and meta-analysis

BACKGROUND

In Asia, particularly, robotic gastrectomy has grown in popularity as a treatment for stomach cancer. Indocyanine green (ICG) and near-infrared (NIR) fluorescent imaging technology has been reported for robotic gastrectomy. However, the clinical value still should be further evaluated. In this meta-analysis, we investigated the safety and efficacy of ICG near-infrared fluorescent imaging-guided lymph node (LN) dissection during robotic gastrectomy.

MATERIAL AND METHODS

Through July 2022, systematic searches of PubMed, Embase, Web of Science, and the Cochrane Library were conducted to find studies comparing ICG fluorescence imaging with conventional treatment in patients with gastric cancer. The current meta-analysis was performed according to the preferred reporting items for systematic review and meta-analysis guidelines. A pooled analysis was performed for the available data regarding the number of lymph node dissections, other operative outcomes and postoperative complications. R studio software 4.2.2 was used for this meta-analysis.

RESULTS

This analysis includes five studies with a total of 312 gastric cancer patients (128 in the ICG group and 184 in the non-ICG group). In this meta-analysis, the number of retrieved LNs in the ICG group was significantly higher (weighted mean difference [WMD] = 8.80, 95% confidence intervals [CI]: 4.37-13.22, p < 0.05) than that in the non-ICG group with moderate heterogeneity (p < 0.0001, I2=53.3%). Intraoperative blood loss and postoperative complications were all comparable and without significant heterogeneity. Additionally, ICG near-infrared fluorescent imaging was associated with a reduced operative time (WMD= -11.85, 95% CI: -22.40 to -1.30, p < 0.05) with low heterogeneity (p = 0.027, I2= 2.1%).

CONCLUSIONS

ICG near-infrared fluorescent imaging-guided lymphadenectomy was considered to be safe and effective in robotic gastrectomy. ICG was used to increase the number of LNs harvested while reducing operative time without increasing intraoperative blood loss or postoperative complications.

Minimally Invasive and Open Gastrectomy for Gastric Cancer: A Systematic Review and Network Meta-Analysis of Randomized Clinical Trials

BACKGROUND AND OBJECTIVES

Optimal surgical management for gastric cancer remains controversial. We aimed to perform a network meta-analysis (NMA) of randomized clinical trials (RCTs) comparing outcomes after open gastrectomy (OG), laparoscopic-assisted gastrectomy (LAG), and robotic gastrectomy (RG) for gastric cancer.

METHODS

A systematic search of electronic databases was undertaken. An NMA was performed as per the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA)-NMA guidelines. Statistical analysis was performed using R and Shiny.

RESULTS

Twenty-two RCTs including 6890 patients were included. Overall, 49.6% of patients underwent LAG (3420/6890), 46.6% underwent OG (3212/6890), and 3.7% underwent RG (258/6890). At NMA, there was a no significant difference in recurrence rates following LAG (odds ratio [OR] 1.09, 95% confidence interval [CI] 0.77-1.49) compared with OG. Similarly, overall survival (OS) outcomes were identical following OG and LAG (OS: OG, 87.0% [1652/1898] vs. LAG: OG, 87.0% [1650/1896]), with no differences in OS in meta-analysis (OR 1.02, 95% CI 0.77-1.52). Importantly, patients undergoing LAG experienced reduced intraoperative blood loss, surgical incisions, distance from proximal margins, postoperative hospital stays, and morbidity post-resection.

CONCLUSIONS

LAG was associated with non-inferior oncological and surgical outcomes compared with OG. Surgical outcomes following LAG and RG superseded OG, with similar outcomes observed for both LAG and RG. Given these findings, minimally invasive approaches should be considered for the resection of local gastric cancer, once surgeon and institutional expertise allows.

Safety and efficacy of robotic-assisted versus laparoscopic distal gastrectomy after neoadjuvant chemotherapy for advanced gastric cancer

BACKGROUND

Robot-assisted distal gastrectomy (RADG) has been used in the minimally invasive surgical treatment of gastric cancer, but the research on advanced gastric cancer (AGC) after neoadjuvant chemotherapy (NAC) has not been reported. This study aimed to analyze the outcomes of RADG versus laparoscopic distal gastrectomy (LDG) after NAC for AGC.

METHODS

This was a retrospective propensity score-matched analysis from February 2020 and March 2022. Patients who underwent RADG or LDG for AGC (cT3-4a/N +) following NAC were enrolled and a propensity score-matched analysis was performed in a 1:1 manner. The patients were divided into RADG group and LDG group. The clinicopathological characteristics and short-term outcomes were observed.

RESULTS

After propensity score matching, 67 patients each in the RADG and LDG groups. RADG was associated with a lower intraoperative blood loss (35.6 vs. 118.8 ml, P = 0.014) and more retrieved lymph nodes (LNs) (50.7 vs. 39.5, P < 0.001), more extraperigastric (18.3 vs. 10.4, P < 0.001), and suprapancreatic LNs (16.33 vs. 13.70, P = 0.042). The RADG group showed lower VAS scores at postoperative 24 h (2.2 vs 3.3, P = 0.034), earlier ambulation (1.3 vs. 2.6, P = 0.011), aerofluxus time (2.2 vs. 3.6, P = 0.025), and shorter postoperative hospital stay (8.3 vs. 9.8, P = 0.004). There were no significant differences in the operative time (216.7 vs.194.7 min, P = 0.204) and postoperative complications between the two groups.

CONCLUSION

RADG may be a potential therapeutic option for patients with AGC after NAC considering its advantages in perioperative period compared with LDG.

Indocyanine Green Tracer-Guided Radical Robotic Distal Gastrectomy Using the Firefly™ System Improves the Quality of Lymph Node Dissection in Patients with Gastric Cancer

BACKGROUND

This study investigated indocyanine green (ICG) as an intraoperative tool for improving lymph node dissection quality in radical robotic distal gastrectomy (RDG) for gastric cancer by comparing the rate of lymph node (LN) noncompliance with or without use of the Firefly™ system.

METHODS

Patients with potentially resectable gastric cancer including cT1-T4a, N0/ + , M0 were registered in a prospective nonrandomized cohort study at our institution between March 2019 and December 2022. Patients were assigned to the da Vinci surgical system with Firefly system (F group) or that without Firefly system (non-F group). F group patients received endoscopic peritumoral injection of ICG to the submucosa one day before surgery. Rate of LN noncompliance, number of harvested LNs, and short-term outcomes were compared.

RESULTS

Of the 94 patients in this study, 55 underwent Firefly system-guided RDG and 39 underwent conventional RDG. The mean [SD] total number of harvested lymph nodes in F group, 31.2 [10.2], was significantly higher than that harvested in non-F group (25.6 [12.6]; p = 0.026). The LN noncompliance rate in F group was lower than that in non-F group (32.7% vs. 61.5%, p = 0.006). The mean number of LNs harvested in F group was significantly higher than that harvested in non-F group (31.2 [10.2] vs. 25.7 [12.6], p = 0.02). Significant differences were found between the F vs. non-F groups in blood loss and postoperative hospital stay (83.9 [75.1] vs. 301.9 [766.7] mL; p = 0.003 and 13.4 vs. 17.4 days, p = 0.049).

CONCLUSION

The Firefly system-assisted ICG tracer improved LN dissection quality without compromising safety.

Intraoperative performance and outcomes of robotic and laparoscopic total gastrectomy for gastric cancer: A high-volume center retrospective propensity score matching study

BACKGROUND

Studies on robotic total gastrectomy (RTG) are currently limited. This study aimed to compare the intraoperative performance as well as short- and long-term outcomes of RTG and laparoscopic total gastrectomy (LTG).

METHODS

A total of 969 patients underwent robotic (n = 161) or laparoscopic (n = 636) total gastrectomy between October 2014 and October 2021. The two groups of patients were matched 1:3 using the propensity score matching (PSM) method. The intraoperative performance as well as short- and long-term outcomes of the robotic (n = 147) and the laparoscopic (n = 371) groups were compared.

RESULTS

After matching, the estimated intraoperative blood loss was lower (80.51 ± 68.77 vs. 89.89 ± 66.12, p = 0.008), and the total number of lymph node dissections was higher (34.74 ± 12.44 vs. 29.83 ± 12.22, p < 0.001) in the RTG group compared with the LTG group. More lymph node dissections at the upper edge of the pancreas were performed in the RTG group than in the LTG (12.59 ± 4.18 vs. 10.33 ± 4.58, p = 0.001). Additionally, postoperative recovery indicators and laboratory data were greater in the RTG group than those in the LTG group, while postoperative complications were comparable between the two groups (19.0% vs. 18.9%, p = 0.962). For overweight or obese patients with body mass indexes (BMIs) ≥25, certain clinical outcomes of the RTG remained advantageous, and no significant differences in three-year overall survival (OS) or relapse-free survival (RFS) were observed.

CONCLUSIONS

Robotic total gastrectomy demonstrated better intraoperative performance, could improve the short-term clinical outcomes of patients, and was more conducive to patient recovery. However, the long-term efficacies of the two approaches were similar. Robotic surgical systems may reduce surgical stress responses in patients, allowing them to receive postoperative chemotherapy sooner.

Comparison of short-term efficacy and safety between total robotic and total 3D laparoscopic distal radical gastrectomy for gastric cancer in Enhanced Recovery After Surgery (ERAS) protocol: a propensity score matching study

BACKGROUND

The application of Enhanced Recovery After Surgery (ERAS) protocol in gastrointestinal surgery has been widely accepted. The aim of this study was to compare the effect of ERAS in total robotic distal gastrectomy (TRDG) versus 3D total laparoscopic distal gastrectomy (3D-TLDG) for gastric cancer.

METHODS

We retrospectively evaluated 73 patients underwent TRDG and 163 patients who received 3D-TLDG. The propensity score was used for matching analysis according to a 1:1 ratio, so that there was no significant difference in the baseline data between the two groups. The short-term effect and safety of the two groups were compared.

RESULTS

The TRDG group had a less intraoperative bleeding (30.21 ± 13.78 vs. 41.44 ± 17.41 ml, P < 0.001), longer intraoperative preparation time (31.05 ± 4.93 vs. 15.48 ± 2.43 min, P < 0.001), shorter digestive tract reconstruction time (32.67 ± 4.41 vs. 39.78 ± 4.95 min, P < 0.001), shorter postoperative ambulation time (14.07 ± 8.97 vs. 17.49 ± 5.98 h, P = 0.007), shorter postoperative anal exhaust time (1.78 ± 0.79 vs. 2.18 ± 0.79 days, P = 0.003), shorter postoperative hospital stay (7.74 ± 3.15 vs. 9.97 ± 3.23 days, P < 0.001), lower postoperative pain score (P = 0.006) and higher hospitalization cost (89,907.15 ± 17,147.19 vs. 125,615.82 ± 11,900.80 RMB, P < 0.001) than the 3D-TLDG group.

CONCLUSION

TRDG and 3D-TLDG under ERAS protocol are safe and feasible. Compared with 3D-TLDG, the TRDG has better intraoperative bleeding control effect and greater advantages in digestive tract reconstruction. After the combination of ERAS protocol, TRDG also has certain advantages in the recovery process of patients after surgery.

Extended Lymphadenectomy for Gastric Cancer in the Neoadjuvant Era: Current Status, Clinical Implications and Contentious Issues

Despite its decreasing incidence, gastric cancer remains an important global healthcare problem due to its overall high prevalence and high mortality rate. Since the MAGIC and FNLCC/FFCD trials, the neoadjuvant chemotherapy has been recommended throughout Europe in gastric cancer. Potential benefits of preoperative treatments include a higher rate of R0 resection achieved by downstaging the primary tumor, a likely effect on micrometastases and isolated tumor cells in the lymph nodes, and, as a result, improved cancer-related survival. Nevertheless, distortion of anatomical planes of dissection, interstitial fibrosis, and sclerotic tissue changes may increase surgical difficulty. The collection of at least twenty-five lymph nodes after neoadjuvant therapy would seem to ensure removal of undetectable node metastasis and reduce the likelihood of locoregional recurrence. It is not what you take but what you leave behind that defines survival. Therefore, para-aortic lymph node dissection is safe and effective after neoadjuvant chemotherapy, in both therapeutic and prophylactic settings. In this review, the efficacy of adequate lymph node dissection, also in a neoadjuvant setting, has been investigated in the key studies conducted to date on the topic.

Effects of robotic and laparoscopic-assisted surgery on lymph node dissection and quality of life in the upper third of gastric cancer: A retrospective cohort study based on propensity score matching

Objective

The objective of this study was compare the effects of robot-assisted and laparoscopic-assisted surgery on lymph node dissection and quality of life in upper third gastric cancer patients undergoing radical total gastrectomy.

Methods

The clinical and follow-up data of 409 patients with upper third gastric cancer who underwent total gastrectomy from July 2016 to May 2021 were enrolled. The patients were divided into a robotic group (n = 106) and a laparoscopic group (n = 303). Age, sex, body mass index, American Society of Anesthesiologists score, tumor size and location, pathological type, cT, cN, and cTNM were adjusted to offset selection bias. The patient characteristics, operative procedures, surgical outcomes, oncologic and pathologic outcomes, number of lymph node dissections, quality of life assessment, and nutritional status were compared between the two groups.

Results

After propensity score matching, 61 cases were included in the robotic group and 122 cases were included in the laparoscopic group. The number of dissected lymph nodes (37.3 ± 13.5 vs. 32.8 ± 11.8, P = 0.022) significantly differed between the two groups. The number of lower mediastinal and subphrenic lymph nodes in the robotic group was greater than that in the laparoscopic group, and the difference was statistically significant (P < 0.001). Compared with the laparoscopic group, the total score of physical symptoms in the robotic group was significantly lower at 6 and 12 months after surgery (P = 0.03 and P = 0.001, respectively). The total social function score at 6 and 12 months after surgery was higher in the robotic group (P = 0.006 and P = 0.022). The quality of life scores were statistically significant only at 3 months after the operation (P = 0.047). A higher patient-generated subjective global assessment (PG-SGA) score is when the score significantly correlated (P < 0.001) with a higher related physical symptoms score, lower social function score, and lower quality of life score.

Conclusion

Compared with laparoscopic radical gastrectomy, robotic radical gastrectomy is safe and feasible. Compared with laparoscopic radical gastrectomy, robotic radical gastrectomy was more refined, was associated with less surgical bleeding, and increased the quality of lymph node dissection. In addition, patients in the robotic group showed better postoperative quality of life.

Global scientific trends in laparoscopy and gastric cancer in the 21st century: A bibliometric and visual mapping analysis

Aims

To use visual mapping and bibliometrics to analyze and summarize the valuable information on laparoscopic surgery for gastric cancer (GC) obtained in the last 20 years, so as to determine the research hotspots and trends in this field.

Methods

We screened all literature on laparoscopic surgery for GC in the Web of Science published from 2000 to 2022 and analyzed the research hotspots and trends in this field using VOSviewer.

Results

A total of 2796 reports from 61 countries and regions were selected. Japanese researchers published the most papers (n=946), followed by those from China (n=747) and South Korea (n=557). Papers from Japan also had the most citations (n=21,836). Surgical Endoscopy and Other Interventional Techniques published the most reports on laparoscopic surgery for GC (n=386) and also had the highest total number of citations (n=11,076), making this journal the most authoritative in this field. Among the institutions, researchers from Seoul National University in South Korea had the highest numbers of published papers and citations. The keywords of the articles could be divided into five categories: surgical methods for GC, short-term and long-term efficacy of laparoscopic surgery, guiding role of laparoscopy in the treatment of advanced GC, diagnosis and treatment of early gastric cancer (EGC), and lymph node dissection. Keywords such as "laparoscopic proximal gastrectomy", "surgical outcomes", and "esophagogastric junction" have emerged recently, and relevant studies on laparoscopic surgery for adenocarcinoma of esophagogastric junction(AEG)have gradually become a hot topic and trend.

Conclusion

This study adopted bibliometric analysis to identify the current research hotspots and research trends in the field of laparoscopic surgery for GC. Five main research hotspots of laparoscopic surgery for GC were also identified. Laparoscopic surgery for AEG may become an important research focus in the future.

Current Status of Robotic Gastrointestinal Surgery

Development of surgical support robots began in the 1980s as a navigation and auxiliary device for endoscopic surgery. For remote surgery on the battlefield, a master-slave-type surgical support robot was developed, in which a console surgeon operates the robot at will. The da Vinci surgical system, which currently dominates the global robotic surgery market, received United States Food and Drug Administration and regulatory approval in Japan in 2000 and 2009 respectively. The latest, fourth generation, da Vinci Xi has a good field of view via a three-dimensional monitor, highly operable forceps, a motion scale function, and a tremor-filtered articulated function. Gastroenterological tract robotic surgery is safe and minimally invasive when accessing and operating on the esophagus, stomach, colon, and rectum. The learning curve is said to be short, and robotic surgery will likely be standardized soon. Therefore, robotic surgery training should be systematized for young surgeons so that it can be further standardized and later adapted to a wider range of surgeries. This article reviews current trends and potential developments in robotic surgery.

Robotic Gastrectomy Versus Laparoscopic Gastrectomy for Gastric Cancer: A Multicenter Cohort Study of 5402 Patients in China

OBJECTIVE

A large-scale multicenter retrospective cohort study was conducted to compare the short- and long-term outcomes of robotic gastrectomy (RG) and laparoscopic gastrectomy (LG) for gastric cancer.

SUMMARY OF BACKGROUND DATA

RG is being increasingly used worldwide, but data from large-scale multicenter studies on the short- and long-term oncologic outcomes of RG versus LG are limited. The potential benefits of RG compared with LG for gastric cancer remain controversial.

METHODS

Data from eligible patients who underwent RG or LG for gastric cancer of 11 experienced surgeons from 7 centers in China between March 2010 and October 2019 were collected. The RG group was matched 1:1 with the LG group by using propensity score matching. The primary outcome was postoperative complications.

RESULTS

After propensity score matching, a well-balanced cohort of 3552 patients was included for further analysis. The occurrence of overall complications (12.6% vs 15.2%, P = 0.023) was lower in the RG group than in the LG group. RG was associated with less blood loss (126.8 vs 142.5 mL, P < 0.001) and more retrieved lymph nodes in total (32.5 vs 30.7, P < 0.001) and in suprapancreatic areas (13.3 vs 11.6, P < 0.001).The long-term oncological outcomes were comparable between the two groups.

CONCLUSIONS

The results of this multicenter study demonstrate that RG is a safe and effective treatment for gastric cancer when performed by experienced surgeons, although longer operation time and higher costs are still concerns about RG. This study provides evidence suggesting that RG may represent an alternative surgical treatment to LG.

Perioperative outcomes of robotic versus laparoscopic distal gastrectomy for gastric cancer: a meta-analysis of propensity score-matched studies and randomized controlled trials

Background

Da Vinci robotic surgery system, a novel type of surgery, was widespread in surgical field. However, the perioperative outcomes of robotic distal gastrectomy (RDG) are still controversy, despite several observational studies and randomized controlled trials (RCT) had been reported. Therefore, we performed a meta-analysis of propensity score-matched (PSM) and RCT studies to evaluated the perioperative feasibility and safety of RDG.

Methods

Studies were systematically searched in PubMed, Web of Science, Cochrane Library, and Embase database, and screened according to the defined limitations. The quality of PSM studies and RCT studies were respectively assessed by ROBINS-I and Cochrane risk-of-bias tool. Extracted data were analyzed by Review Manager 5.4.

Results

7 PSM studies and 1 RCT with a total of 2763 patients were included in this analysis. The longer operative time (MD = 31.42, 95% CI [22.88, 39.96], p < 0.00001), less blood loss (MD = − 25.89, 95% CI [− 36.18, − 15.6], p < 0.00001), more retrieved lymph nodes (MD = 3.46, 95% CI [2.94, 3.98], p < 0.00001), shorter time to first flatus (MD = − 0.08, 95% CI [− 0.13, − 0.02], p = 0.006) and liquid intake (MD = − 0.13, 95% CI [− 0.22, − 0.05], p = 0.002) were observed in RDG group compared with LDG group. There are no statistically significant in time to start soft diet, postoperative hospital stays, overall complications, complications Grade I–II, complications Grade ≥ III, anastomotic leakage, bleeding, intra-abdominal bleeding, intraluminal bleeding, ileus, abdominal infection, delayed gastric emptying and wound complications.

Conclusions

RDG showed less blood loss and more retrieved lymph nodes, revealed less time to first flatus and liquid intake after operation. But the operative time was longer in RDG group than in LDG. The incidence rate of postoperative complications was comparable between RDG and LDG.

Performing robot-assisted pylorus and vagus nerve-preserving gastrectomy for early gastric cancer: A case series of initial experience

BACKGROUND

Pylorus and vagus nerve-preserving gastrectomy (PPG) is a function-preserving surgery for early gastric cancer (GC) that has gained considerable interest in the recent years. The operative technique performed using the Da Vinci Xi robot system is considered ideal for open and laparoscopic surgery.

AIM

To introduce Da Vinci Xi robot-assisted PPG (RAPPG)-based operative procedure and technical points as well as report the initial experience based on the clinical pathology data of eight cases of early GC.

METHODS

Da Vinci Xi robot-assisted pylorus and vagus nerve-preserving gastrectomy (RAPPG) was performed for 11 consecutive patients with middle GC from December 2020 to July 2021. Outcome measures were postoperative morbidity, operative time, blood loss, number of lymph nodes harvested, postoperative hospital stay, time to first flatus, time to diet, and resection margins.

RESULTS

Eight of the 11 patients who were pathologically diagnosed with early GC were enrolled in a retrospective study to assess the feasibility and safety of RAPPG. The mean operative time, mean blood loss, mean number of lymph nodes harvested, length of preserved pylorus canal, distal margin, and proximal margin were 330.63 ± 47.24 min, 57.50 ± 37.70 mL, 18.63 ± 10.57, 3.63 ± 0.88 cm, 3.50 ± 1.31 cm, and 3.63 ± 1.19 cm, respectively. None of the cases required conversion to laparotomy. Postoperative complications occurred in two (25.0%) patients. Postoperative complications were hyperamylasemia and gastric stasis in one case and incision infection in the other. Time to first flatus was 3.75 ± 2.49 d after the operation, and postoperative hospital stay was 10.13 ± 4.55 d.

CONCLUSION

The core technique in the Da Vinci Xi RAPPG is lymph node dissection and the anatomic method of the nerve. Robotic surgical procedures are feasible and safe. With the progress of surgical technology, optimization of medical insurance structure, and emergence of evidence-based medicine, automated surgery systems will have a broad application in clinical treatment.

Fifty years of progress in gastric cancer

As with every human malignancy, the diagnosis, staging, and treatment of patients with gastric cancer have undergone enormous evidence-based change over the last 50 years, largely as a result of increasingly rapid developments in technology and science. Some of the changes in clinical practice have derived from prospective randomized controlled trials (RCTs), whereas others have come from study of meticulously maintained prospective databases, which define the disease's natural history over time, and occasionally from in-depth analysis of a single patient with an unexpectedly good or poor outcome. Herein we summarize the more important changes in gastric cancer management and the data supporting those changes.

Clinical efficacy and safety of robotic distal gastrectomy for gastric cancer: a systematic review and meta-analysis

BACKGROUND

Robotic distal gastrectomy (RDG) is a new technique that is rapidly gaining popularity and may help overcome the limitations of laparoscopic distal gastrectomy (LDG); however, its safety and therapeutic efficacy remain controversial. Therefore, this meta-analysis was performed to evaluate the safety and efficacy of RDG.

METHODS

We searched PubMed, EMBASE, the Cochrane Library, and Web of Science for studies that compared RDG and LDG and were published between the time of database inception and May 2021. We assessed the bias risk of the observational studies using ROBIN-I, and a random effect model was always applied.

RESULTS

The meta-analysis included 22 studies involving 5386 patients. Compared with LDG, RDG was associated with longer operating time (Mean Difference [MD] = 43.88, 95% CI = 35.17-52.60), less intraoperative blood loss (MD = - 24.84, 95% CI = - 41.26 to - 8.43), a higher number of retrieved lymph nodes (MD = 2.41, 95% CI = 0.77-4.05), shorter time to first flatus (MD = - 0.09, 95% CI = - 0.15 to - 0.03), shorter postoperative hospital stay (MD = - 0.68, 95% CI = - 1.27 to - 0.08), and lower incidence of pancreatic fistula (OR = 0.23, 95% CI = 0.07-0.79). Mean proximal and distal resection margin distances, time to start liquid and soft diets, and other complications were not significantly different between RDG and LDG groups. However, in the propensity-score-matched meta-analysis, the differences in time to first flatus and postoperative hospital stay between the two groups lost significance.

CONCLUSIONS

Based on the available evidence, RDG appears feasible and safe, shows better surgical and oncological outcomes than LDG and, comparable postoperative recovery and postoperative complication outcomes.

Comparison of Long-Term and Perioperative Outcomes of Robotic Versus Conventional Laparoscopic Gastrectomy for Gastric Cancer: A Systematic Review and Meta-Analysis of PSM and RCT Studies

Background

To investigate the perioperative and oncological outcomes of gastric cancer (GC) after robotic versus laparoscopic gastrectomy (RG versus LG), we carried out a meta-analysis of propensity score matching (PSM) studies and randomized controlled study (RCT) to compare the safety and overall effect of RG to LG for patients with GC.

Methods

PubMed, Web of Science, EMBASE, and Cochrane Central Register were searched based on a defined search strategy to identify eligible PSM and RCT studies before July 2021. Data on perioperative and oncological outcomes were subjected to meta-analysis.

Results

Overall, we identified 19 PSM studies and 1 RCT of RG versus LG, enrolling a total of 13,446 patients (6,173 and 7,273 patients underwent RG and LG, respectively). The present meta-analysis revealed nonsignificant differences in tumor size, proximal resection margin distance, distal resection margin distance, abdominal bleeding, ileus, anastomosis site leakage, duodenal stump leakage rate, conversion rate, reoperation, overall survival rate, and long-term recurrence-free survival rate between the two groups. Alternatively, comparing RG with LG, RG has a longer operative time (p < 0.00001), less blood loss (p <0.0001), earlier time to first flatus (p = 0.0003), earlier time to oral intake (p = 0.0001), shorter length of stay (p = 0.0001), less major complications (p = 0.0001), lower overall complications (p = 0.0003), more retrieved lymph nodes (P < 0.0001), and more cost (p < 0.00001).

Conclusions

In terms of oncological adequacy and safety, RG is a feasible and effective treatment strategy for gastric cancer but takes more cost in comparison with LG.

Mid-term functional and quality of life outcomes of robotic and laparoscopic ventral mesh rectopexy: multicenter comparative matched-pair analyses

Background

The aim of this study was to compare patients’ mid-term functional and quality of life (QoL) outcomes following robotic ventral mesh rectopexy (RVMR) and laparoscopic ventral mesh rectopexy (LVMR).

Methods

The data of consecutive female patients who underwent minimally invasive ventral mesh rectopexy for external or symptomatic internal rectal prolapse at 3 hospitals in Finland between January 2011 and December 2016 were retrospectively collected. Patients were matched by age and diagnosis at a 1:1 ratio. A disease-related symptom questionnaire was sent to all living patients at follow-up in July 2018.

Results

After a total of 401 patients (RVMR, n = 187; LVMR, n = 214) were matched, 152 patients in each group were included in the final analyses. The median follow-up times were 3.3 (range 1.6–7.4) years and 3.0 (range 1.6–7.6) years for the RVMR and LVMR groups, respectively. The postoperative QoL measures did not differ between the groups. Compared with the LVMR group, the RVMR group had lower postoperative Wexner Incontinence Score (median 5 vs. median 8; p < 0.001), experienced significant ongoing incontinence symptoms less often (30.6% vs. 49.0%; p < 0.001) and reported less postoperative faecal incontinence discomfort evaluated with the visual analogue scale (median 11 vs. median 39; p = 0.005). RVMR patients had a shorter hospital stay (2.2 days vs. 3.8 days; p < 0.001) but experienced more frequent de novo pelvic pain (31.8% vs. 11.8%; p < 0.001).

Conclusion

RVMR and LVMR patients had equal functional and QoL outcomes. Those who underwent RVMR had lower mid-term anal incontinence symptom scores but suffered more frequent de novo pelvic pain.

Supplementary Information

The online version contains supplementary material available at 10.1007/s10151-021-02563-z.

Potential advantages of robotic total gastrectomy for gastric cancer: a retrospective comparative cohort study

Laparoscopic total gastrectomy (LTG) is a highly technical surgery that can lead to postoperative complications. Whether the recently introduced robotic surgery overcomes the drawbacks of laparoscopic surgery in total gastrectomy remains controversial. Therefore, we aimed to elucidate the potential benefits of robotic total gastrectomy (RTG) and compare the short-term outcomes of RTG and LTG. We retrospectively analyzed 56 patients with primary gastric or esophagogastric junction cancer who underwent RTG or LTG between June 2017 and July 2021. The groups were compared in terms of operative outcomes and postoperative complications. Potential risk factors associated with postoperative complications were assessed by performing multivariable analysis using logistic regression models via the exact method. Operation time was significantly longer, and postoperative hospital stay was significantly shorter in the robotic group (550 vs. 466 min, P < 0.001; 13 vs. 18 days, P = 0.013, respectively). The incidence of overall postoperative complications of Clavien-Dindo grade ≥ II was 18.5% and 24.1% in the RTG and LTG groups, respectively. Pancreatic fistulas were not observed, but other local complications were observed in 0% and 17.2% of the RTG and LTG groups, respectively (P = 0.052). In the multivariable analysis, the independent risk factors for local complications were laparoscopic surgery (odds ratio [95% confidence interval] 8.542 [1.065-∞], P = 0.045) and esophagogastric junction cancer (16.646 [2.559-∞], P = 0.005). Compared with LTG, RTG was associated with fewer local complications (mainly anastomotic leakage), especially in cases of esophagogastric junction cancer with high anastomotic sites.

Comparison of short-term outcomes of robotic-assisted and laparoscopic-assisted D2 gastrectomy for gastric cancer: a meta-analysis

Aim

The aim of the study was to compare the outcomes of robot-assisted (RAGD2) and laparoscopy-assisted gastrectomy with D2 lymphadenectomy (LAGD2) for patients with gastric cancer.

Material and methods

Relevant articles published up to September 2020 were searched. The weighted mean difference (WMD) was used to pool continuous variables, while risk ratio (RR) was calculated for dichotomous outcomes.

Results

RAGD2 required a longer operating time (WMD = 29.78, 95% confidence interval (CI): 15.97-43.59) and had less operative blood loss (WMD = -31.93, 95% CI: -44.03 to -19.83), shorter time to first flatus (WMD = -0.13, 95% CI: -0.22 to -0.04), shorter time to liquid diet (WMD = -0.20, 95% CI: -0.28 to 0.12), and fewer severe complications (RR = 0.62, 95% CI: 0.43-0.90) and overall complications (RR = 0.75, 95% CI: 0.62-0.91) than LAGD2.

Conclusions

RAGD2 could be beneficial in reducing operative blood loss and postoperative complications relative to LAGD2.

Robotic Surgery: At the Crossroads of a Data Explosion

BACKGROUND

For the last 20 years, controversies in robotic surgery focused on cost reduction, development of new platforms and technologies, creation and validation of curriculum and virtual simulators, and conduction of randomized clinical trials to determine the best applications of robotics [Leal Ghezzi and Campos in World J Surg 40:2550-2557, 2016].

METHODS

This review explores the robotic systems which are currently indicated for use or development in gastrointestinal/abdominal surgery. These systems are reviewed and analyzed for clinical impact in these areas. In a MEDLINE search of articles with the search terms abdominal, gastrointestinal, review and robotic surgery, a total of 4306 total articles as of 2021 were assessed. Publicly available information, highest cited articles and reviews were assessed by the authors to determine the most significant regarding clinical outcomes.

RESULTS

Despite this increased number of articles related to robotic surgery, ongoing controversies have led to limitation in the use of current and future robotic surgery platforms [Connelly et al. in J Robotic Surg 14:155-165, 2020]. Newer robotic platforms have limited studies or analysis that would allow meaningful definite conclusions. A multitude of new scenarios are possible due to this limited information.

CONCLUSION

Robotic surgery is in evolution to a larger conceptual field of computationally enhanced surgery (CES). Various terms have been used in the literature including computer-assisted surgery or digital Surgery [Ranev and Teixeira in Surg Clin North Am 100:209-218, 2020]. With the growth of technological changes inherent in CES, the ability to validate these improvements in outcomes will require new metrics and analytic tools. This learning feedback and metric analysis will generate the new opportunities in simulation, training and application [Julian and Smith in Int J Med Robot 15:e2037, 2019].

Robotic versus laparoscopic gastrectomy for gastric cancer: an umbrella review of systematic reviews and meta-analyses

An umbrella review was performed to summarize literature data and to investigate benefits and harm of robotic gastrectomy (RG) compared to laparoscopic (LG) approach. To overcome the intrinsic limitations of laparoscopy, the robotic approach is claimed to facilitate lymph-node dissection and complex reconstruction after gastrectomy, to assure oncologic safety also in advanced gastric cancer. A literature search was conducted in PubMed, Cochrane and Embase databases for all meta-analyses published up to December 2019. The search strategy was previously published in a protocol. We selected fourteen meta-analyses comparing outcomes between LG and RG with curative intent in patients with diagnosis of resectable gastric cancer. We highlight that RG has a longer operation time, inferior blood loss, reduction in hospital stay and a more rapid recovery of bowel function. In meta-analyses with statistical significance the number of nodes removed in RG is higher than LG and the distal margin of resection is higher. There is no difference in terms of total complication rate, mortality, morbidity, anastomotic leakage, anastomotic stenosis, intestinal obstruction and in conversion rate to open technique. The safety and efficacy of robotic gastrectomy are not clearly supported by strong evidence, suggesting that the outcomes reported for each surgical technique need to be interpreted with caution, in particular for the meta-analyses in which the heterogeneity is large. Certainly, robotic gastrectomy is associated with shorter time to oral intake, lesser intraoperative bleeding and longer operation time with an acceptable level of evidence. On the other hand, the data regarding other outcomes are insufficient as well as non-significant, from an evidence point of view, to draw any robust conclusion.

Role of minimally invasive techniques in gastrointestinal surgery: Current status and future perspectives

In recent years, the incidence of gastrointestinal cancer has remained high. Currently, surgical resection is still the most effective method for treating gastrointestinal cancer. Traditionally, radical surgery depends on open surgery. However, traditional open surgery inflicts great trauma and is associated with a slow recovery. Minimally invasive surgery, which aims to reduce postoperative complications and accelerate postoperative recovery, has been rapidly developed in the last two decades; it is increasingly used in the field of gastrointestinal surgery and widely used in early-stage gastrointestinal cancer. Nevertheless, many operations for gastrointestinal cancer treatment are still performed by open surgery. One reason for this may be the challenges of minimally invasive technology, especially when operating in narrow spaces, such as within the pelvis or near the upper edge of the pancreas. Moreover, some of the current literature has questioned oncologic outcomes after minimally invasive surgery for gastrointestinal cancer. Overall, the current evidence suggests that minimally invasive techniques are safe and feasible in gastrointestinal cancer surgery, but most of the studies published in this field are retrospective studies and case-matched studies. Large-scale randomized prospective studies are needed to further support the application of minimally invasive surgery. In this review, we summarize several common minimally invasive methods used to treat gastrointestinal cancer and discuss the advances in the minimally invasive treatment of gastrointestinal cancer in detail.