Robotic total gastrectomy: Key operative maneuvers and optimal use of the fourth arm

The robotic platform offers distinct advantages for total gastrectomy, particularly through effective use of the fourth robotic arm.¹ When used deliberately, the fourth arm enables stable counter-traction, single-surgeon control, and creation of a consistent surgical workspace, facilitating precise dissection and safe reconstruction.².

We present a video of robotic total gastrectomy performed for a patient with gastric adenocarcinoma. Key technical elements include port placement optimized for fourth-arm engagement (Fig. 1)³, external liver retraction using a Penrose drain, and indocyanine green injection proximal to the tumor to confirm the esophageal transection level.⁴ The fourth arm was used strategically to elevate vascular pedicles and lymph node basins during D2 lymphadenectomy⁵, including infrapyloric, suprapancreatic, and left gastric artery dissections. Reconstruction included creation of a retrocolic Roux limb, hand-sewn esophagojejunostomy, jejunojeju- nostomy, and meticulous closure of all mesenteric and hiatal defects.

The fourth arm provided consistent counter-traction during lymphadenectomy, improved visualization of critical vascular anatomy, and enabled precise, tension-controlled suturing during esophagojejunostomy and jejunojejunostomy. Operative time was 5 h and 17 min with estimated blood loss < 100 mL. Final pathology demonstrated pT4aN3a poorly differentiated gastric adenocarcinoma with adequate lymph node harvest. The patient recovered uneventfully and was discharged on postoperative day 4.

Thoughtful, dynamic use of the fourth robotic arm enhances exposure, ergonomics, and precision during robotic total gastrectomy. Mastery of fourth-arm techniques is critical for safe D2 lymphadenectomy, tension-free reconstruction, and reproducible outcomes in complex gastric surgery.