Safe Introduction of Robotic Gastrectomy Facilitated by ICG-Guided Lymphography

Background/Objectives: Robotic gastrectomy (RG) for gastric cancer requires structured implementation to ensure oncological safety, particularly in Western centers with lower case volumes. Indocyanine green (ICG)-guided near-infrared lymphography may facilitate adequate lymphadenectomy and reliable tumor localization. We report our stepwise institutional introduction of RG and evaluate the perioperative outcomes and diagnostic accuracy of ICG-guided lymphography. Methods: All consecutive patients who underwent curative-intent RG at the University Medical Center Ljubljana between June 2022 and September 2025 were retrospectively analyzed. The implementation followed a structured stepwise approach, beginning with subtotal gastrectomy and progressing to total gastrectomy after formal training at Severance Hospital, Yonsei University Health System, under the mentorship of Prof. Woo Jin Hyung. ICG was administered endoscopically the day before surgery for tumor localization and intraoperative lymphatic mapping. The operative learning curve was assessed by CUSUM analysis, segmented regression, and bootstrapped plateau estimation. Results: Thirty-eight patients underwent RG (17 subtotal and 21 total). R0 resection was achieved in 100% of cases. The conversion rate was 2.6%. Major complications (Clavien-Dindo ≥ IIIb) occurred in six patients (15.8%). The 30-day mortality rate was 0%, and the 90-day mortality rate was 2.6%. Bootstrapped plateau operative times were 321.2 min (95% Bias-corrected and accelerated confidence interval (BCa CI): 278.4-344.1) for subtotal and 413.5 min (95% BCa CI: 378.1-476.1) for total gastrectomy, with the steepest learning phase confined to the first 2-4 cases. ICG was used in 23 patients. In a validation subset of five patients (259 lymph node stations), the sensitivity and negative predictive value were both 100%, with zero false negatives in 57 ICG-negative stations. Conclusions: RG can be safely introduced using a structured, stepwise strategy supported by training at a high-volume expert center. ICG-guided lymphography demonstrated 100% sensitivity for tumor-draining nodal basins in a small validation cohort (n = 5), supporting the feasibility of the technique during program introduction and warranting prospective evaluation in larger series.