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

Abstract

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.

Keywords: D2 lymphadenectomy; Gastric cancer; Laparoscopic total gastrectomy; Minimally invasive surgery; Robotic total gastrectomy; Stomach.