Four stay-sutures method: a simplified hand-sewn purse-string suture in laparoscopic circular-stapled esophagojejunostomy

Evaluating the Role of Robotic Surgery Gastric Cancer Treatment: A Comprehensive Review by the Robotic Global Surgical Society (TROGSS) and European Federation International Society for Digestive Surgery (EFISDS) Joint Working Group

INTRODUCTION

Robot-assisted minimally invasive gastrectomy (RAMIG) represents a significant advancement in the surgical management of gastric cancer, offering superior dexterity, enhanced visualization, and improved ergonomics compared to laparoscopic gastrectomy (LG). This review systematically evaluates the current evidence on perioperative outcomes, oncological efficacy, learning curves, and economic considerations, providing insights into RAMIG's potential role in modern gastric cancer surgery.

METHODS

A thorough analysis of retrospective, prospective, and meta-analytic studies was conducted to compare RAMIG with LG. Key outcomes, including operative time, intraoperative blood loss, lymph node retrieval, postoperative complications, learning curve duration, and cost-effectiveness, were assessed. Emphasis was placed on both short-term and long-term oncological outcomes to determine the clinical value of RAMIG.

RESULTS

Evidence indicates that RAMIG is associated with reduced intraoperative blood loss, lower morbidity rates, and a shorter learning curve, with proficiency achieved after 11-25 cases compared to 40-60 cases for LG. The robotic platform's articulated instruments and enhanced three-dimensional visualization enable more precise lymphadenectomy, particularly in complex anatomical regions. Despite these advantages, operative time remains longer, and costs remain higher due to system acquisition, maintenance, and consumable expenses. However, emerging data suggest a gradual narrowing of cost disparities. While short-term outcomes are favorable, further high-quality, multicenter studies are needed to validate long-term oncological efficacy and survival outcomes.

CONCLUSION

RAMIG offers significant technical and clinical advantages over conventional LG, particularly in terms of precision and learning efficiency. However, the long-term oncological benefits and economic feasibility require further validation. Future research should focus on cost optimization, advanced technological integration such as near-infrared fluorescence and artificial intelligence, and multicenter trials to solidify RAMIG's role as a standard approach for gastric cancer surgery.

A Novel Method for Thoracoscopic Overlap Esophagogastric Reconstruction With Pleural Closure following Minimally Invasive Ivor-Lewis Esophagectomy for Esophagogastric Junction Cancer

BACKGROUND

Intrathoracic esophagogastric anastomosis following minimally invasive Ivor-Lewis esophagectomy is a technically demanding surgical technique that can result in serious intrathoracic infections when anastomotic leakage occurs. Herein, we report a novel side-overlap esophagogastric anastomosis with pleural closure for esophagogastric junction cancer.

METHODS

The 3 key points of our novel technique were the following: (1) overlap esophagogastric anastomosis and closure of the entry hole were all performed using a linear stapler; (2) the pleura was closed to separate the anastomotic site from the thoracic cavity; and (3) the mediastinal drain was inserted transhiatally from the abdominal cavity.

RESULTS

This modified anastomosis procedure was performed on 8 consecutive patients at our institution. The median overall/thoracoscopic operating time and estimated blood loss were 652.5/241.5 min and 89 mL, respectively. No mortality or serious postoperative complications occurred, and the median postoperative hospital stay was 22 days (range, 17 to 37 d).

CONCLUSION

This novel thoracoscopic overlap esophagogastric reconstruction procedure with pleural closure is safe and feasible.

Bracket-like suture method: a novel, circular marked, simplest sided purse-string suture technique for intracorporeal circular-stapled oesophagojejunostomy during laparoscopic total gastrectomy

PURPOSE

Total laparoscopic total gastrectomy (TLTG) has been limited in application because of the difficulty of intracorporeal oesophagojejunostomy. Theoretically, an intracorporeal single-stapling oesophagojejunostomy using a circular stapler could be commonly used and provide favourable outcomes for TLTG, as in open total gastrectomy(OTG), in which the use of circular staplers in oesophagojejunostomy is common and the standard procedure. This could be possible if use of a laparoscopic purse-string suture along the distal oesophagus were made easy and simple. However, the simple and optimal use of this procedure remains to be developed.

METHODS

Between October 2018 and March 2020, 21 consecutive patients with gastric cancer underwent TLTG using the bracket-like suture method (BLSM) for intracorporeal circular-stapled oesophagojejunostomy in our institution. The surgical details and postoperative outcomes were analysed to evaluate this method.

RESULTS

The mean operation time was 227.6 ± 13.6 min. The median time for the two-sided purse-string suture was 4 min (range, 3-5 min). It took an average of 11.5 min for the completion of purse-string suture and anvil placement. Tumour-free margins were achieved in 21 patients with a median length of 2.5 cm (range, 2-6 cm) proximal margin. Three patients developed postoperative complications. There was no mortality. During the median follow-up period of 12 months, no anastomosis-related complications were observed.

CONCLUSION

The results suggest that the method cannot only facilitate safe and easy purse-string creation, using the simplest two-sided suture in a short amount of time by circular marking of the intended transection level for intracorporeal circular-stapled oesophagojejunostomy, but can also be completed by laparoscopic surgeons with basic laparoscopic suturing skills.

A Novel Technique for Extracorporeal Anastomosis: The Bronchus Forceps Is Applied to Reinforce the Esophageal Ring

Background: For laparoscopic gastrectomy, it is significant to reduce the incidence of anastomotic leakage. The authors develop a novel technique for safe extracorporeal anastomosis that employs the bronchus forceps to reinforce the esophageal ring. Methods: From January 2017 to July 2020, 173 consecutive patients with gastric cancer received laparoscopic total gastrectomy or laparoscopic proximal gastrectomy. One hundred thirty-one patients only underwent extracorporeal anastomosis with a purse-string suture instrument (PSI) and a 25 mm circular stapler (Ethicon Intraluminal Circular Staplers CDH25A, Ethicon) (Conventional Surgery Group). In addition to these tools for extracorporeal anastomosis, the surgeon creatively used bronchus forceps to reinforce the esophageal ring on the anvil of circular stapler in 42 patients (Bronchus Forceps Ligation Group). The condition and the mean diameter of the narrowest part of the esophageal rings, postoperative outcomes, and complications were compared between the two groups. Results: Under direct vision, the esophageal rings were more complete in the Bronchus Forceps Ligation Group. Furthermore, the mean diameter of the narrowest part of the esophageal rings in the Bronchus Forceps Ligation Group was wider than that in the Conventional Surgery Group (4.34 ± 0.84 versus 2.68 ± 0.74 mm; P < .001). Meanwhile, the incidence of anastomotic leakage was lower in the Bronchus Forceps Ligation Group. Although reinforcing the anvil with the bronchus forceps will add additional surgery time, almost all can be done in less than 5 minutes. Conclusions: With applying the bronchus forceps to reinforce the esophageal ring on the anvil of the circular stapler, the extracorporeal anastomosis can be performed more safely.