Robotic Versus Laparoscopic Gastrectomy for Gastric Cancer: A Mega Meta-Analysis

Evaluating the safety of robotic total gastrectomy with D2 lymphadenectomy for gastric cancer against the conventional laparoscopic approach: a systematic review and meta-analysis

Gastric cancer poses a significant global health challenge, necessitating effective surgical interventions. A critical gap in the literature exists, as most studies do not differentiate between various surgical approaches, i.e., total, distal, and subtotal gastrectomy, and level of lymphadenectomy, when comparing robotic to conventional laparoscopic gastrectomy. This leads to a lack of clear evidence regarding the safety and efficacy of robotic total gastrectomy (RTG) specifically in the context of total gastrectomy with D2 lymphadenectomy.This systematic review and meta-analysis evaluates the safety of RTG with D2 lymphadenectomy compared to conventional laparoscopic total gastrectomy (LTG). A literature search was conducted up to November 1, 2024, following PRISMA guidelines. Eligible studies included studies comparing RTG and LTG, focusing on anastomotic leakage, Clavien-Dindo Grade ≥ III complications, conversion rates, mortality, overall complications, and reoperation rates. Data were synthesized using odds ratios (OR) and weighted mean differences (WMD), with statistical heterogeneity assessed using the I2 statistic. Five studies comprising 1131 patients (432 RTG, 700 LTG) were included. No significant differences were found in the following outcomes: anastomotic leakage (OR = 0.79 [95% CI: 0.35, 1.78], I2 = 0%, P = 0.57), Clavien-Dindo Grade ≥ III complications (OR = 0.86 [95% CI: 0.51, 1.45], I2 = 0%, P = 0.56), conversion to open surgery (OR = 0.34 [95% CI: 0.10, 1.18], I2 = 0%, P = 0.09), mortality (OR = 1.78 [95% CI: 0.23, 13.48], I2 = 0%, P = 0.58), overall complications (OR = 0.84 [95% CI: 0.62, 1.14], I2 = 0%, P = 0.26), and reoperation rates (OR = 0.88 [95% CI: 0.29, 2.67], I2 = 0%, P = 0.82). Sensitivity analysis proves the robustness of the findings. The analysis shows no significant differences in safety outcomes between RTG and LTG for gastric cancer, indicating both techniques are comparable. RTG may be a viable alternative to LTG, especially in centers with appropriate robotic capabilities. Further research is warranted to investigate long-term outcomes and the learning curve of robotic surgery.PROSPERO Registration: CRD42024606570.

Minimally Invasive Distal Gastrectomy: Evolving Surgical Techniques

Surgical management of gastric cancer has evolved over the years. Incorporation of minimally invasive techniques has led to shorter hospital stays, reduced wound complications, and earlier return to functional activity. Nevertheless, the development of minimally invasive total gastrectomy as a repertoire in the management of proximal or diffuse gastric cancer requires significant commitment and support owing to the complexity of the procedure. Here the authors describe the evolution of total gastrectomy with particular focus on laparoscopic and robotic approaches. In addition, they outline the data comparing minimally invasive total gastrectomy with traditional open surgical approaches.

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.

Comparing the Effectiveness of Open, Laparoscopic, and Robotic Gastrectomy in the United States: A Retrospective Analysis of Perioperative, Oncologic, and Survival Outcomes

INTRODUCTION

Minimally invasive surgery (MIS) is increasingly used in the surgical management of gastric cancer; however, its adoption lags that of other cancers. Most randomized controlled trials comparing MIS to open gastrectomy have been conducted in Asia, with limited data from the United States. This study aimed to compare perioperative, oncologic, and survival outcomes between open, laparoscopic, and robotic gastrectomy in a large US cohort.

METHODS

Using the National Cancer Database, we identified patients with gastric adenocarcinoma who underwent open, laparoscopic, or robotic gastrectomy between 2010 and 2020. Multivariate regression models were used to examine the association between surgical approach and various outcomes, including 30-d readmission, length of stay (LOS), surgical margin status, lymph node yield, 30- and 90-d mortality, and overall survival (OS). The interaction between surgical approach and tumor location (distal versus proximal or gastroesophageal junction [GEJ]) was also assessed.

RESULTS

Of the 34,937 included patients, 64.8% underwent open gastrectomy, 25.7% underwent laparoscopic surgery, and 9.5% underwent robotic surgery. MIS was associated with lower odds of 30-d readmission (laparoscopic: odds ratio [OR] 0.78, 95% confidence interval [CI] 0.67-0.89; robotic: OR 0.75, 95% CI 0.60-0.92), positive margins (laparoscopic: OR 0.83, 95% CI 0.74-0.93; robotic: OR 0.75, 95% CI 0.62-0.90), 30-d mortality (laparoscopic: OR 0.69, 95% CI 0.55-0.85; robotic: OR 0.66, 95% CI 0.44-0.95), and 90-d mortality (laparoscopic: OR 0.74, 95% CI 0.63-0.87; robotic: OR 0.63, 95% CI 0.47-0.84), as well as improved OS (laparoscopic: hazard ratio 0.83, 95% CI 0.79-0.87; robotic: hazard ratio 0.76, 95% CI 0.69-0.83) compared to open surgery. Considering the interaction of approach with tumor location, for proximal/GEJ tumors, the associated outcome improvements with MIS were attenuated. We observe that the odds for 30-d readmission, 90-d mortality, and OS are similar to those for open operations. However, regardless of tumor location, robotic gastrectomy was associated with decreased LOS and yielded a higher lymph node count than laparoscopic or open approaches.

CONCLUSIONS

In this large US cohort, MIS gastrectomy was associated with improved perioperative, oncologic, and survival outcomes compared to open surgery for distal gastric cancers. However, the associated benefits of MIS were attenuated for proximal/GEJ tumors, with higher odds of readmission, mortality, and worse OS. Notably, robotic gastrectomy was associated with superior lymph node yield and LOS compared to laparoscopic and open approaches, even for proximal/GEJ tumors. These findings underscore the need for further research, especially randomized controlled trials conducted in Western populations, to definitively determine the efficacy of MIS for distal and proximal/GEJ tumors and guide surgical decision-making for gastric adenocarcinoma.

A comprehensive overview of gastric cancer management from a surgical point of view

Despite advancements in medical care, surgical technologies, and the development of novel treatments over the past decade, the prognosis for patients with gastric cancer (GC) has only modestly improved. This is primarily due to the fact that the majority of patients are diagnosed at advanced stages or present with metastatic disease. Radical resection remains the cornerstone of potentially curative treatment, yet the overall 5-year survival rate remains below 35%. The management of GC varies globally, influenced by factors such as geographical disparities, patient comorbidities and performance status, surgical approaches, and available medical resources. Multidisciplinary collaboration and a multimodal treatment approach are essential for optimizing patient outcomes. Surgeons must stay updated on emerging surgical concepts and make informed decisions regarding patient selection, timing of intervention, and the adoption of appropriate surgical techniques to improve both quality of life and prognosis. This review aims to provide a surgical perspective on the management of GC across all stages, highlighting the importance of a comprehensive treatment approach. Endoscopic resection may be a viable option for early GC in patients with minimal risk of lymph node metastasis, particularly in elderly patients with high surgical risk or severe comorbidities. For advanced GC, neoadjuvant therapy followed by surgery could be a promising strategy to improve patient outcomes. Conversion surgery offers a potential survival benefit for patients who respond to treatment with tumor downstaging. The treatment of peritoneal carcinomatosis remains challenging; however, hyperthermic intraperitoneal chemotherapy combined with complete cytoreductive surgery or pressurized intraperitoneal aerosolized chemotherapy may prolong survival or improve quality of life in highly selected patients.

Clinical effectiveness of robotic versus laparoscopic and open surgery: an overview of systematic reviews

OBJECTIVE

To undertake a review of systematic reviews on the clinical outcomes of robotic-assisted surgery across a mix of intracavity procedures, using evidence mapping to inform the decision makers on the best utilisation of robotic-assisted surgery.

ELIGIBILITY CRITERIA

We included systematic reviews with randomised controlled trials and non-randomised controlled trials describing any clinical outcomes.

DATA SOURCES

Ovid Medline, Embase and Cochrane Library from 2017 to 2023.

DATA EXTRACTION AND SYNTHESIS

We first presented the number of systematic reviews distributed in different specialties. We then mapped the body of evidence across selected procedures and synthesised major findings of clinical outcomes. We used a measurement tool to assess systematic reviews to evaluate the quality of systematic reviews. The overlap of primary studies was managed by the corrected covered area method.

RESULTS

Our search identified 165 systematic reviews published addressing clinical evidence of robotic-assisted surgery. We found that for all outcomes except operative time, the evidence was largely positive or neutral for robotic-assisted surgery versus both open and laparoscopic alternatives. Evidence was more positive versus open. The evidence for the operative time was mostly negative. We found that most systematic reviews were of low quality due to a failure to deal with the inherent bias in observational evidence.

CONCLUSION

Robotic surgery has a strong clinical effectiveness evidence base to support the expanded use of robotic-assisted surgery in six common intracavity procedures, which may provide an opportunity to increase the proportion of minimally invasive surgeries. Given the high incremental cost of robotic-assisted surgery and longer operative time, future economic studies are required to determine the optimal use of robotic-assisted surgery capacity.

Impact of robotic-assisted surgery on length of hospital stay in Paris public hospitals: a retrospective analysis

The number of available hospital beds is decreasing in many countries. Reducing the length of hospital stay (LOS) and increasing bed turnover could improve patient flow. We evaluated whether robot-assisted surgery (RAS) had a beneficial impact on the LOS in a French hospital trust with a long-established robotic program (Assistance Publique-Hôpitaux de Paris, AP-HP). We extracted data from "Programme de Médicalisation des Systèmes d'Information" to determine the median LOS for adults in our trust after RAS versus laparoscopy and open surgery in 2021-2022 for eight target procedures, and compared data nationally and at similar academic centres (same database). We also calculated the number of hospitalisation days 'saved' using RAS. Overall, 9326 target procedures were performed at AP-HP: 3864 (41.4%) RAS, 2978 (31.9%) laparoscopies, and 2484 (26.6%) open surgeries. The median LOS for RAS was lower than laparoscopy and open surgery for all procedures, apart from hysterectomy and colectomy (equivalent to laparoscopy). Results for urological procedures at AP-HP reflected national values. The equivalent of 5390 hospitalisation days was saved in 2021-2022 using RAS instead of open surgery or laparoscopy at AP-HP; of these, 86% represented hospitalisation days saved using RAS in urological procedures. Using RAS instead of open surgery or laparoscopy (particularly in urological procedures) reduced the median LOS and may save thousands of hospitalisation days every year. This should help to increase patient turnover and facilitate patient flow.

Comparison of totally robotic and totally laparoscopic gastrectomy for gastric cancer: a propensity score matching analysis

BACKGROUND

With the improvements in laparoscopic or robotic surgical techniques and instruments, a growing number of surgeons have attempted to complete all digestive tract reconstruction intracorporeally; these procedures include totally robotic gastrectomy (TRG) and totally laparoscopic gastrectomy (TLG). This study aimed to evaluate the safety and feasibility of the TRG and compare the short-term outcomes of the TRG and TLG in patients with gastric cancer.

METHODS

Between January 2018 and June 2023, 346 consecutive patients who underwent TRG or TLG at a high-volume academic gastric cancer specialty center were included. 1:1 propensity score matching (PSM) was performed to reduce confounding bias. The surgical outcomes, postoperative morbidity, and surgical burden were compared in PSM cohort.

RESULTS

After PSM, a well-balanced cohort of 194 patients (97 in each group) was included in the analysis. The total operation time of the TRG group was significantly longer than that of the TLG group (244.9 vs. 213.0 min, P < 0.001). There was no significant difference in the effective operation time between the 2 groups (217.8 vs. 207.2 min, P = 0.059). The digestive tract reconstruction time of the TRG group was significantly shorter than that of the TLG group (39.4 vs. 46.7 min, P < 0.001). The mean blood loss in the TRG group was less than that in the TLG group (101.1 vs. 126.8 mL, P = 0.014). The TRG group had more retrieved lymph nodes in the suprapancreatic area than that in the TLG group (16.6 vs 14.2, P = 0.002). The TRG group had a lower surgery task load index (38.9 vs. 43.1, P < 0.001) than the TLG group. No significant difference was found in terms of postoperative morbidity between the 2 groups (14.4% vs. 16.5%, P = 0.691).

CONCLUSION

This study demonstrated that TRG is a safe and feasible procedure, and is preferable to TLG in terms of invasion and ergonomics. The TRG may maximize the superiority of robotic surgical systems and embodies the theory of minimally invasive surgery.

Da Vinci robot-assisted endoscopic full-thickness gastric resection with regional lymph node dissection using a 3D near-infrared video system: a single-center 5-year clinical outcome

BACKGROUND

Endoscopic full-thickness gastric resection (EFTGR) with regional lymph node dissection (LND) has been used for early gastric cancer (EGC) exceeding the indications for endoscopic submucosal dissection (ESD). The extent of the dissected lymph nodes is crucial. A 3D near-infrared (NIR) video robot system significantly enhances visualization of the lymphatic system. However, this system has not been used in EFTGR with LND. Thus, this study assessed the benefits of the 3D NIR video robot system in a clinical setting.

METHODS

Between February 2015 and September 2018, 24 patients with EGC exceeding the indications for ESD were treated with EFTGR and LND using a 3D NIR video system with the da Vinci surgical robot. Indocyanine green (ICG) was injected endoscopically around the tumor, and basin node (BN) dissection around the nodes was examined using the 3D NIR video system of the da Vinci Si surgical robot. Subsequently, robot-assisted EFTGR was performed. The primary outcome was the 5-year survival rate.

RESULT

During a 5-year follow-up of all 24 patients, an 80-year-old patient with an ulcer and T2 invasion was lost to follow-up. Among the remaining 23 patients, no mortality or recurrence was observed.

CONCLUSION

No metastasis or mortality occurred using the da Vinci robot-assisted EFTGR with LLND and a 3D NIR video system for patients who required radical gastrectomy for EGC in over 5 years. Hence, this may be a safe and effective method for radical gastrectomy; further studies are required confirming its effectiveness.

The Evolving Surgical Landscape: A Comprehensive Review of Robotic Versus Laparoscopic Gastrectomy for the Treatment of Gastric Cancer

Robotic gastrectomy has been gaining ground in the past 20 years. This study aims to (a) provide an updated and all-encompassing comprehensive review including post-operative outcomes, rate of complications, surgical efficiency and costs, pathology, overall survival, mortality and recurrence, and disease-free survival of robotic versus laparoscopic gastrectomy, (b) report research gaps, and (c) identify ongoing or forthcoming clinical trials that could potentially shed light on underreported findings within the existing literature. Regarding the methodology, PubMed and Google Scholar were searched for randomized controlled trials, systematic reviews, and meta-analyses published between January 2012 and October 2023. ClinicalTrials.gov was searched for related clinical trials currently underway or recruiting. Robotic gastrectomy, when compared to laparoscopic gastrectomy, for the treatment of gastric cancer, performs equally well or shows superiority in terms of the length of hospitalization, overall complications rates, rate of conversion to open surgery, surgical complications, anastomotic leakage, pancreatic complications, blood loss, mortality rates, time to first flatus, time to oral intake, distal and proximal resection margins, recurrence rate, reoperation rates, and overall survival. However, it is associated with higher costs and longer operative time. Parameters such as duodenal stump leakage, anastomosis stenosis, intestinal obstruction, ileus, delayed gastric emptying, wound complications, acute pancreatitis, pancreatic fistula, direct costs, time to initiation of adjuvant chemotherapy, postoperative morbidity, recurrence, and disease-free survival are currently underreported in the literature and necessitate for further research. Lastly, four clinical trials are currently underway or recruiting that could possibly bridge the research gap.

Surgery Matters: Progress in Surgical Management of Gastric Cancer

OPINION STATEMENT

The surgical treatment of gastric carcinoma has progressed significantly in the past few decades. A major milestone was the establishment of multimodal therapies for locally advanced tumours. Improvements in the technique of endoscopic resection have supplanted surgery in the early stages of many cases of gastric cancer. In cases in which an endoscopic resection is not possible, surgical limited resection procedures for the early stages of carcinoma are an equal alternative to gastrectomy in the field of oncology. Proximal gastrectomy is extensively discussed in this context. Whether proximal gastrectomy leads to a better quality of life and better nutritional well-being than total gastrectomy depends on the reconstruction chosen. The outcome cannot be conclusively assessed at present. For locally advanced stages, total or subtotal gastrectomy with D2 lymphadenectomy is now the global standard. A subtotal gastrectomy requires sufficiently long tumour-free proximal resection margins. Recent data indicate that proximal margins of at least 3 cm for tumours with an expansive growth pattern and at least 5 cm for those with an infiltrative growth pattern are sufficient. The most frequently performed reconstruction worldwide following gastrectomy is the Roux-en-Y reconstruction. However, there is evidence that pouch reconstruction is superior in terms of quality of life and nutritional well-being. Oncological gastric surgery is increasingly being performed laparoscopically. The safety and oncological equivalency were first demonstrated for early carcinomas and then for locally advanced tumours, by cohort studies and RCTs. Some studies suggest that laparoscopic procedures may be advantageous in early postoperative recovery. Robotic gastrectomy is also increasing in use. Preliminary results suggest that robotic gastrectomy may have added value in lymphadenectomy and in the early postoperative course. However, further studies are needed to substantiate these results. There is an ongoing debate about the best treatment option for gastric cancer with oligometastatic disease. Preliminary results indicate that certain patient groups could benefit from resection of the primary tumour and metastases following chemotherapy. However, the exact conditions in which patients may benefit have yet to be confirmed by ongoing trials.