A Modified Approach in Robotic Gastrectomy for Gastric Cancer

Robotic gastrectomy for gastric cancer is safe and feasible, but the robotic system poses challenges in surgical field exposure and digestive tract reconstruction, often prolonging operative time. This protocol presents a Modified Approach in Robotic Gastrectomy (MARG) designed to standardize procedures, improve surgical quality, and reduce operative duration. The technique repositions trocars: Arm 1 (ultrasonic shear) is placed at the left lower quadrant, Arms 2 and 3 symmetrically at the upper abdomen, and the assistant port on the right side to prevent instrument collisions. A triangular surgical plane created by Arm 2, Arm 3, and the assistant enhances tissue exposure during lymphadenectomy while minimizing arm switching and camera repositioning. The right-sided assistant port facilitates totally stapled intracorporeal anastomosis without requiring a second assistant port or surgeon-assistant position changes. The protocol is demonstrated through distal gastrectomy with Billroth-II reconstruction and side-to-side jejunostomy. In this single-center, uncontrolled series of 25 consecutive patients who underwent this modified approach, 20 underwent distal gastrectomy with intracorporeal stapled anastomosis, and five underwent total or proximal gastrectomy; the median console time was 137.0 min (interquartile range [IQR] 115.3-166.3), and the median reconstruction time for the 20 distal-gastrectomy patients was 18.5 min (IQR 15.3-24.6). Mean blood loss was 70.4 mL (range 20-300), and no patient developed grade ≥III complications (Clavien-Dindo). Stapled anastomosis was associated with a shorter reconstruction time than the 40-60 min typically reported for robot-sewn anastomoses. Because the MARG modifications do not alter the standard extent of surgery, they are not expected to affect long-term oncologic outcomes; the present report, therefore, focuses on perioperative safety. Patients were followed up for 1 month postoperatively. This approach may enable surgeons to perform robotic gastrectomy more efficiently, with favorable perioperative outcomes in this preliminary series.