Robot-assisted gastrectomy for locally advanced gastric cancer and complex clinical scenarios: technical evolution, evidence gaps, and future directions

Robot-assisted gastrectomy has evolved over two decades from a technical curiosity into a feasible operative option, but its role in locally advanced gastric cancer and complex clinical scenarios remains unsettled. This narrative review is based on a documented search of PubMed/MEDLINE, Embase, Scopus, Web of Science, the Cochrane Library, and the China National Knowledge Infrastructure (January 2002 through September 2026) and synthesizes evidence on technical evolution, perioperative and oncological outcomes, and the use of robotic platforms in obesity, advanced age, high comorbidity burden, post-neoadjuvant fibrosis, and total gastrectomy with esophagojejunostomy. Most comparative evidence is observational (propensity-matched and single-center), and evidence for advanced or complex disease is partly extrapolated from early-stage and mixed-stage cohorts. Robotic gastrectomy is associated consistently with less blood loss and, in some series, higher lymph node yields at anatomically demanding stations, whereas operative time is longer, overall complication rates are generally similar, and no adequately powered randomized trial has shown a survival advantage. One randomized phase II trial in distal gastrectomy met a non-inferiority criterion for 3-year disease-free survival; an exploratory survival difference in that trial and observational signals of improved recurrence-free survival in stage III disease remain hypothesis-generating. High-quality patient-reported and functional outcomes, and data from non-East Asian populations, are scarce. Higher costs, a learning curve of approximately 25-50 cases, and the absence of phase III superiority data temper broad endorsement. Single-port systems, alternative platforms, and artificial-intelligence and augmented-reality tools are emerging but are not yet validated in gastric cancer surgery. We map each claim to its source population, distinguish direct from extrapolated evidence, and identify the trial designs and patient-centered endpoints needed to define the appropriate role of robotic gastrectomy.