Totally robotic proximal gastrectomy with esophagogastrostomy using a double-flap technique

Proximal gastrectomy (PG) with D1 + lymphadenectomy and anti-reflux reconstruction is a standard surgical procedure for early-stage (EGC) proximal gastric cancer (PGC) in the East. The double-flap technique (DFT) for esophagogastrostomy has been established as an optimal anti-reflux reconstructive method after PG. However, its technical difficulty makes it a procedure not yet performed in the West. We present the technique of robotic PG with D1 + lymphadenectomy and DFT. The technique was learned during a period of attendance at the National Cancer Center Hospital East, Japan. A 70-year-old patient was submitted to endoscopic submucosal dissection for EGC-PGC. The pathologic report showed pT1b R1 disease. Additional surgery was recommended. Surgery was accomplished via a totally robotic approach (da Vinci Xi Surgical System). The patient was placed in a supine position with legs apart. Four robotic trocars and two laparoscopic trocars were placed above the transversal umbilical line. The surgical steps are summarized as follows: opening of the lesser omentum; dissection of the abdominal esophagus and lymphadenectomy of no. 1, 2 stations; partial omentectomy with lymphadenectomy of no. 4sa and 4sb stations and ligation of the left gastro-epiploic vessels; lymphadenectomy of no. 3a, 7, 8a, 9, 11p stations; transection of the esophagus; proximal gastrectomy; dissection of the posterior aspect of the remnant stomach; creation of the seromuscular flap; posterior esophageal suspension; anastomosis; flap closure. Pathology report showed the absence of residual disease with 27 lymph nodes collected from the specimen. After 1 year, the patient is disease free; no reflux esophagitis, weight loss, or anastomotic stricture was reported on follow-up. To the best of our knowledge, no other previous cases have been reported in the West describing the present surgical technique. The authors propose that PG with DFT seems feasible in a Western setting, representing an important and desirable skill for any referral center for gastric cancer surgical oncology.