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Background: During the last decade, total laparoscopic and laparoscopic-assisted distal gastrectomy for gastric cancer patients has been developed as alternatives to open resection. In recent years, this minimally invasive surgery has been extended using robotic-assisted surgery., Case Presentation: Here, we report a surgical intervention using a Da Vinci surgical robot in which a lower two-third stomach resection with subsequent Billroth II gastrojejunostomy was performed. The patient was a 53-year-old male with complete situs inversus gastric cancer who had received 2 cycles of neo-adjuvant oxaliplatin combined with S-1 medication. The operation took 3 h in total without complications. The amount of bleeding was about 50 mL, and on day 5 after the operation, the patient was discharged., Conclusions: This is the first report of a successful robot-assisted gastric cancer resection of advanced gastric cancer in a patient with the anatomical abnormality of situs inversus totalis.

Robotic gastrectomy (RG) has progressed rapidly in the last decade, overcoming many obstacles in laparoscopic technology. We compared surgical performance and short-term clinical outcomes between RG and laparoscopic gastrectomy (LG). In total, 163 patients with gastric cancer were randomly treated with RG (n=102) or LG (n=61). D2 lymphadenectomy was achieved in all patients. Digestive tract reconstruction in the RG group was performed by intracorporeal hand sewing, but extracorporeal anastomosis in the LG group was performed with a 25-mm circular stapler or linear stapler. Compared with the LG group, the RG group had less intraoperative blood loss (P=0.005) and more lymph nodes retrieved (P=0.000). Postoperative complications between the 2 groups were not significantly different during the 11-month follow-up (P=0.063). Compared with LG, RG is a feasible and safe approach with minimally invasive, satisfactory intracorporeal digestive tract reconstruction, and fast recovery. Multicenter randomized controlled studies of larger numbers of patients are needed.

Aim: To describe the application of complete robotic gastrectomy with transvaginal specimen extraction (TVSE) for gastric cancer patients., Methods: Between July and November 2014, eight female patients who were diagnosed with gastric adenocarcinoma underwent a TVSE following a full robot-sewn gastrectomy. According to the tumor location, the patients were allocated to two different groups; two patients received robotic total gastrectomy with TVSE and the other six received robotic distal gastrectomy with TVSE., Results: Surgical procedures were successfully performed in all eight cases without conversion. The mean age was 55.3 (range, 42-69) years, and the mean body mass index was 23.2 (range, 21.6-26.0) kg/m(2). The mean total operative time and blood loss were 224 (range, 200-298) min and 62.5 (range, 50-150) mL, respectively. The mean postoperative hospital stay was 3.6 (range, 3-5) d. The mean number of lymph nodes resected was 23.6 (range, 17-27). None was readmitted within 30 d of postoperation. During the follow-up, no stricture developed nor was any anastomotic leakage detected., Conclusion: It is possible to perform a TVSE following a full robot-sewn gastrectomy with standard D2 lymph node resection for female gastric cancer patients.

Background: Gastric cancer represents a great challenge for health care providers and requires a multidisciplinary approach in which surgery plays the main role. Minimally invasive surgery has been progressively developed, first with the advent of laparoscopy and more recently with the spread of robotic surgery, but a number of issues are currently being investigate, including the limitations in performing effective extended lymph node dissections and, in this context, the real advantages of using robotic systems, the possible role for advanced Gastric Cancer, the reproducibility of completely intracorporeal techniques and the oncological results achievable during follow-up., Method: Searches of MEDLINE, Embase and Cochrane Central Register of Controlled Trials were performed to identify articles published until April 2014 which reported outcomes of surgical treatment for gastric cancer and that used minimally invasive surgical technology. Articles that deal with endoscopic technology were excluded., Results: A total of 362 articles were evaluated. After the review process, data in 115 articles were analyzed., Conclusion: A multicenter study with a large number of patients is now needed to further investigate the safety and efficacy as well as long-term outcomes of robotic surgery, traditional laparoscopy and the open approach., (Copyright © 2015 IJS Publishing Group Limited. Published by Elsevier Ltd. All rights reserved.)

Background/aims: We presented a series of single-incision laparoscopic distal gastrectomies for early gastric cancer patients through a type of homemade single port access device and some other conventional laparoscopic instruments., Methodology: A single-incision laparoscopic distal gastrectomy with D1 + α lymph node dissection was performed on a 46 years old male patient who had an early gastric cancer., Results: This single port access device has facilitated the conventional laparoscopic instruments to accomplish the surgery and we made in only 6 minutes. Total operating time for this surgery was 240 minutes. During the operation, there were about 100 milliliters of blood loss, and 17 lymph-nodes were retrieved., Conclusion: This homemade single port access device shows its superiority in economy and convenience for complex single-incision surgeries. Single-incision laparoscopic distal gastrectomy for early gastric cancer can be conducted by experienced laparoscopic surgeons. Fully take advantage of both SILS and fast track surgery plan can bring to successful surgeries with minimal postoperative pain, quicker mobilization, early recovery of intestinal function, and better cosmesis effect for the patients.

Background/aims: The aim of this study was to report on the feasibility of esophagojejunostomy reconstruction using a robot-sewing technique during a completely robotic total gastrectomy for gastric cancer., Methodology: Between May 2011 and July 2012, 65 patients in whom gastric adenocarcinoma was diagnosed underwent a completely robotic total gastrectomy, including a robot-sewing esophagojejunal anastomosis. We demonstrated the surgical techniques with analysis of clinicopathologic data and short-term surgical outcomes., Results: All robotic surgeries were successfully performed without conversion. Among the 65 patients, 46 were men and 19 were women. The mean age (± SD) was 57.8 ± 6.5 y. The mean total operative time (± SD), EJ anastomosis time (± SD), and blood loss (± SD) were 245 ± 53 min, 45 ± 26 min, and 75 ± 50 ml, respectively. The mean (± SD) post-operative hospital stay was 5.4 ± 2.5 d. One patient was readmitted for an intestinal obstruction and underwent re-operation 14 d post-operatively; he recovered uneventfully and was discharged 10 d post- operatively. During the follow-up, no patients developed an esophgojejunostomy stricture., Conclusions: A robot-sewing anastomosis for esophagojejunostomy reconstruction during robotic total gastrectomy for gastric cancer is feasible. Indeed, a robot-sewing anastomosis for esophagojejunostomy reconstruction may become a standard surgical technique during completely robotic total gastrectomy for gastric cancer.

Aim: To evaluate the feasibility and safety of full robot-assisted gastrectomy with intracorporeal robot hand-sewn anastomosis in the treatment of gastric cancer., Methods: From September 2011 to March 2013, 110 consecutive patients with gastric cancer at the authors' institution were enrolled for robotic gastrectomies. According to tumor location, total gastrectomy, distal or proximal subtotal gastrectomy with D2 lymphadenectomy was fully performed by the da Vinci Robotic Surgical System. All construction, including Roux-en-Y jejunal limb, esophagojejunal, gastroduodenal and gastrojejunal anastomoses were fully carried out by the intracorporeal robot-sewn method. At the end of surgery, the specimen was removed through a 3-4 cm incision at the umbilicus trocar point. The details of the surgical technique are well illustrated. The benefits in terms of surgical and oncologic outcomes are well documented, as well as the failure rate and postoperative complications., Results: From a total of 110 enrolled patients, radical gastrectomy could not be performed in 2 patients due to late stage disease; 1 patient was converted to laparotomy because of uncontrollable hemorrhage, and 1 obese patient was converted due to difficult exposure; 2 patients underwent extra-corporeal anastomosis by minilaparotomy to ensure adequate tumor margin. Robot-sewn anastomoses were successfully performed for 12 proximal, 38 distal and 54 total gastrectomies. The average surgical time was 272.52 ± 53.91 min and the average amount of bleeding was 80.78 ± 32.37 mL. The average number of harvested lymph nodes was 23.1 ± 5.3. All specimens showed adequate surgical margin. With regard to tumor staging, 26, 32 and 46 patients were staged as I, II and III, respectively. The average hospitalization time after surgery was 6.2 d. One patient experienced a duodenal stump anastomotic leak, which was mild and treated conservatively. One patient was readmitted for intra-abdominal infection and was treated conservatively. Jejunal afferent loop obstruction occurred in 1 patient, who underwent re-operation and recovered quickly., Conclusion: This technique is feasible and can produce satisfying postoperative outcomes. It is also convenience and reliable for anastomoses in gastrectomy. Full robotic hand-sewn anastomosis may be a minimally invasive technique for gastrectomy surgery.

Objective: To compare the clinical efficacy of robot-assisted procedure with laparoscopic surgery for gastric cancer., Methods: The clinical data of patients who underwent gastrectomy in the Department of General Surgery in the Affiliated Jinling Hospital, Nanjing University Medical College from January 2009 to December 2011 were retrospectively analyzed. There were 97 patients undergoing robotic gastrectomy(ROB group) and 70 patients undergoing laparoscopic gastrectomy (LAP group). The following parameters were compared between these two groups: intraoperative factors, oncologic outcomes, and short-term surgical outcomes., Results: All the operations were performed successfully without conversion. Compared with the LAP group, the ROB group had less intraoperative blood loss [(80.8±53.1) vs. (153.7±26.4) ml, P=0.001], more number of lymph node dissection [(23.1±5.4) vs. (20.0±4.3), P=0.001], longer operative time [(272.3±46.1) vs. (240.3±89.1) min, P=0.001], earlier semifluid diet time [(3.2±0.8) vs. (3.6±1.2) d, P=0.002], shorter postoperative hospital stay [(6.1±2.6) vs. (6.9±2.3) d, P=0.037]. There were no significant differences in the length of distal and proximal margin, postoperative ambulation time, ventilation time and postoperative complications(all P>0.05)., Conclusions: The robotic gastrectomy is safe and feasible for gastric cancer. It has many advantages such as less blood loss, more number of lymph node dissection and quicker recovery. Similar radical resection can be achieved compared to laparoscopic gastrectomy.

Laparoscopic gastrectomy has not become a common procedure for gastric cancer due to the difficulties of performing D2 lymphadenectomy and reconstruction of digestive tract by the conventional laparoscopic instruments. The da Vinci system provides 3D visualization, enhanced magnification, and seven degrees of freedom of the instruments to suture and knot in the narrow surgical space, so it can perform totally robotic gastrectomy with D2 lymphadenectomy and robot-sewing anastomosis for reconstruction. Application of robotic system can expand the indications of minimally invasive surgery in treatment of gastric cancer. Combination fast-track surgery to optimize the perioperative management with the technique of minimally invasive surgery can enhance the recovery of surgical gastric cancer patients.

Objective: To evaluate the safety, feasibility, and efficacy of robotic gastrectomy for gastric cancer using da Vinci surgical system., Methods: A total of 120 patients who underwent robotic gastrectomy using da Vinci surgical system for gastric cancer from May 2010 to April 2012. Data regarding surgical and early oncological outcomes were systematically collected in a specific database for statistical analysis., Results: There were 74 males and 46 females, with a mean age of 58.5 (22-80) years old. The type of robotic operation included 62 distal subtotal gastrectomies, 35 total gastrectomies, and 23 proximal gastrectomies. Reconstruction of the alimentary tract was achieved using extracorporeal method through a minilaparotomy in 55 cases, and intracorporeal robot-sewn anastomosis in 65 cases. There was 1 conversion (0.9%). The operative time was (245±50) min and the docking time (17±5) min. The blood loss was (70±45) ml. The number of harvested lymph nodes was 22.5±10.7. The resection margins were negative in all surgical specimens. The postoperative pathological stage consisted of stage I B in 24 cases, stage II in 28, stage III A in 47, and stage III B in 21. Six patients (5%) developed postoperative complication including 1 case of duodenal stump leakage, 2 cases of esophagus-gastric leakage, 1 case of small bowel obstruction, 1 case of delayed gastric emptying, and 1 case of abdominal bleeding. All the complications were cured by reoperation or conservative therapy, and there were no postoperative 30-day deaths. The postoperative hospital stay was (6.3±2.6) days., Conclusion: Robotic gastrectomy for the treatment of gastric cancer is a feasible and safe procedure, and is advantageous in terms of lymphadenectomy and alimentary tract reconstruction.

Background: The aim of this trial was to compare multimodal optimization with conventional perioperative management in a consecutive series of patients undergoing gastrectomy procedures., Methods: According to randomized controlled studies and conclusions made by meta-analyses in colorectal surgery, optimized perioperative measures were designed and applied in gastrectomy surgery. Thirty-three patients were randomized to the optimized group and 30 patients to a control group. Two groups were treated in 1 center by a single surgical team in different wards. Both groups used patient-controlled intravenous analgesia for postoperative analgesia. The primary end point was length of postoperative hospital stay. Secondary outcomes included bowel function recovery after surgery, perioperative changes of inflammatory factors, glucocorticoid, insulin resistance, and body composition. Perioperative complications and adverse events were also recorded., Results: The groups were similar in terms of age, sex ratio, and Physiological and Operative Severity Score for the enUmeration of Mortality and morbidity (POSSUM score). The optimized group was associated with a significantly shorter postoperative hospital stay compared with the conventional care group (P < .001). Durations of urinary catheterization and abdominal drainage were also less (P < .001). The diet program in the optimization group was well tolerated and was associated with an earlier recovery of gut function (P < .001). Proinflammatory factors were less elevated and body composition was more stable in the optimized group than in controls. There were no differences in morbidity or mortality between the groups., Conclusions: Optimization of care in gastrectomy can shorten postoperative hospital stay and provides multiple beneficial outcomes, including hastening the return of gut function, without increasing morbidity.

Objective: To investigate the safety and efficacy of fast track surgery (FTS) management in gastric cancer undergoing D2 gastrectomy., Methods: Eighty gastric cancer patients undergoing D2 gastrectomy were recruited prospectively. Patients were assigned to receive FTS management (n = 40) or conventional perioperative care (n = 40). The FTS care included shorten preoperative fasting time, no nasogastric decompressing tubes and abdominal drainage placed, early postoperative oral feeding, multimodal analgesia, and early mobilisation. The length of postoperative hospital stay, medical cost, nutritional status, gut function, and postoperative complications in the two groups were recorded and compared., Results: FTS group was associated with a significantly shorter postoperative hospital stay compared with conventional care group [(5.6 +/- 1.3) d vs. (9.4 +/- 1.9) d, P < 0.05]. Medical cost was less [(18 620 +/- 2360) Yuan vs. (20 370 +/- 2440) Yuan, P < 0.05] and duration of intravenous infusion [(3.5 +/- 1.4) d vs. (5.8 +/- 1.9) d, P < 0.05] was also shorter. First passage of flatus was earlier in FTS group than in conventional care group [(4.3 +/- 0.4) d vs. (5.5 +/- 0.9) d, P < 0.05]. Loss of body weight in the postoperative period was less in FTS group [(3.2 +/- 0.8) kg vs. (4.3 +/- 1.6) kg, P < 0.05]. There was no difference in morbidity or mortality between the two groups., Conclusion: FTS in D2 gastrectomy is safe and efficient, and it can shorten postoperative hospital stay and hasten return of gut function.

AimTo investigate the role of minimally invasive surgery for gastric cancer and determine surgical, clinical, and oncological outcomes.MethodsThis is a propensity score-matched case-control study, comparing three treatment arms: robotic gastrectomy (RG), laparoscopic gastrectomy (LG), open gastrectomy (OG). Data collection started after sharing a specific study protocol. Data were recorded through a tailored and protected web-based system. Primary outcomes: harvested lymph nodes, estimated blood loss, hospital stay, complications rate. Among the secondary outcomes, there are: operative time, R0 resections, POD of mobilization, POD of starting liquid diet and soft solid diet. The analysis includes the evaluation of type and grade of postoperative complications. Detailed information of anastomotic leakages is also provided.ResultsThe present analysis was carried out of 1026 gastrectomies. To guarantee homogenous distribution of cases, patients in the RG, LG and OG groups were 1:1:2 matched using a propensity score analysis with a caliper = 0.2. The successful matching resulted in a total sample of 604 patients (RG = 151; LG = 151; OG = 302). The three groups showed no differences in all baseline patients characteristics, type of surgery (P = 0.42) and stage of the disease (P = 0.16). Intraoperative blood loss was significantly lower in the LG (95.93 ± 119.22) and RG (117.91 ± 68.11) groups compared to the OG (127.26 ± 79.50, P = 0.002). The mean number of retrieved lymph nodes was similar between the RG (27.78 ± 11.45), LG (24.58 ± 13.56) and OG (25.82 ± 12.07) approach. A benefit in favor of the minimally invasive approaches was found in the length of hospital stay (P < 0.0001). A similar complications rate was found (P = 0.13). The leakage rate was not different (P = 0.78) between groups.ConclusionLaparoscopic and robotic surgery can be safely performed and proposed as possible alternative to open surgery. The main highlighted benefit is a faster postoperative functional recovery.