Laparoscopic and robot-assisted gastrectomy for gastric cancer: Current considerations

Abstract

Radical gastrectomy with an adequate lymphadenectomy is the main procedure which makes it possible to cure patients with resectable gastric cancer (GC). A number of randomized controlled trials and meta-analysis provide phase III evidence that laparoscopic gastrectomy is technically safe and that it yields better short-term outcomes than conventional open gastrectomy for early-stage GC. While laparoscopic gastrectomy has become standard therapy for early-stage GC, especially in Asian countries such as Japan and South Korea, the use of minimally invasive techniques is still controversial for the treatment of more advanced tumours, principally due to existing concerns about its oncological adequacy and capacity to carry out an adequately extended lymphadenectomy. Some intrinsic drawbacks of the conventional laparoscopic technique have prevented the worldwide spread of laparoscopic gastrectomy for cancer and, despite technological advances in recent year, it remains a technically challenging procedure. The introduction of robotic surgery over the last ten years has implied a notable mutation of certain minimally invasive procedures, making it possible to overcome some limitations of the traditional laparoscopic technique. Robot-assisted gastric resection with D2 lymph node dissection has been shown to be safe and feasible in prospective and retrospective studies. However, to date there are no high quality comparative studies investigating the advantages of a robotic approach to GC over traditional laparoscopic and open gastrectomy. On the basis of the literature review here presented, robot-assisted surgery seems to fulfill oncologic criteria for D2 dissection and has a comparable oncologic outcome to traditional laparoscopic and open procedure. Robot-assisted gastrectomy was associated with the trend toward a shorter hospital stay with a comparable morbidity of conventional laparoscopic and open gastrectomy, but randomized clinical trials and longer follow-ups are needed to evaluate the possible influence of robot gastrectomy on GC patient survival.

Keywords: Gastric cancer; Gastric resection; Laparoscopic gastrectomy; Minimally invasive surgery; Robot-assisted gastrectomy.

Figure 1

Adipose tissue including the station No. 8a lymph nodes (white arrow) is pulled up by the 2^nd robotic (R2) arm dissected by the 1^st robotic (R1) arm. Clipped on Hem-o-lock is Left gastric vein (LGV). Provided by Roviello F, University of Siena.

Figure 2

Dissection of No. 8 lymph nodes (white arrow) continues medially, through the traction of the 2^nd robotic arm (R2), exposing (A) the proper hepatic artery and (B) the common hepatic artery. Provided by A: Coratti A, University of Florence; B: Patriti A. USL2 Spoleto. PHA: Proper hepatic artery; CHA: Common hepatic artery; GDA: Gastroduodenal artery.

Figure 3

Exposition of left gastric artery after No. 7 lymph nodes dissection. Clipped on Hem-o-lock is the left gastric vein (LGV). Provided by Coratti A, University of Florence. LGA: Left gastric artery.

Figure 4

Dissection of 11p lymph nodes. Provided by Coratti A, University of Florence. SpA: Splenic artery.

Figure 5

Exposure of the supra pancreatic area after supra pancreatic lymph nodes dissection. Provided by Coratti A, University of Florence.