Robot-assisted laparoscopic management of cardia carcinoma according to Siewert recommendations

Resection of cardia and upper gastric carcinoma is considered a demanding procedure in laparoscopic surgery. Robotics could aid laparoscopic dissection of the oesophago-gastric junction and oesophageal anastomosis, enlarging indications for a minimally invasive approach to these tumours.

Data from 17 consecutive patients with histologically proved cardia carcinoma were collected in a prospective database to assess the feasibility and safety of laparoscopic robot-assisted radical surgery, using the four-arm da Vinci surgical system. The type of surgery was chosen according to Siewert recommendations. Outcome measures were conversion rate, intra- and post-operative morbidity and mortality, operative time, blood loss, number of lymph nodes harvested and macroscopic and microscopic evaluation of resection margins.

Seventeen laparoscopic operations were completed without conversion (14 extended gastrectomies, two transhiatal distal oesophagectomies and one transthoracic distal oesophagectomy). Extended lymph node dissection and oesophago-jejunal anastomosis were successfully carried out using the da Vinci system. Mean operative time was 327.2 ± 93.4 min and blood loss 279 ± 199 ml. The mean number of nodes retrieved was 28 ± 9 and all resection margins were negative. There was no mortality and overall morbidity was acceptably low (41.1%). During a mean follow-up time of 20 months, four recurrences were recorded (two multivisceral, one to the lung and one nodal), with two recurrence-related deaths.

Robot-assisted laparoscopic radical surgery of the oesophago-gastric junction is feasible and safe. Longer follow-up time and randomized studies are needed to evaluate the long-term outcome and advantages for the patient of this new technology.