Robotic D2 Lymph Node Dissection During Distal Subtotal Gastrectomy for Gastric Cancer: Toward Procedural Standardization.

BACKGROUND: This study was undertaken to outline, in detail, the procedures for robotic D2 lymph node dissection during distal gastrectomy for middle- or lower-third gastric cancer, and to present data that may suggest the safety and feasibility of robotic D2 lymph node dissection.1 (-) 4 METHODS: From July 2005 to December 2009, a total of 316 robotic gastrectomies were performed at the Severance Hospital, Yonsei University Health System, Seoul, Korea. Of these, 95 distal subtotal gastrectomies with D2 lymph node dissection with partial omentectomy for gastric cancer were robotically performed. The operative procedures for robotic distal subtotal gastrectomy using the da Vinci (®) Si system are demonstrated in a step-by-step manner, with technical tips for each step, in the video clip. Short- and long-term follow-up results are also presented. RESULTS: The mean age of patients was 53.3 years (range 26-80) and the average body mass index was 23.2 kg/m(2) (range 16.9-33.3). All surgeries were successfully performed without open or laparoscopy conversion. The overall mean operation time was 215.7 min (range 131-296 min, and the mean estimated blood loss was 56.1 mL (range 4-396). No immediate postoperative mortality was observed, and 11 patients (11.6 %) experienced a complication after surgery. The operation-related complications consisted of six wound complications, one intra-abdominal fluid collection and abscess, one anastomosis leakage, one anastomosis stenosis, one intraluminal bleeding, and one postoperative pancreatitis. The TNM stages according to the 7th American Joint Committee on Cancer (AJCC) classifications were distributed as follows: 58 stage Ia, 13 stage Ib, four stage IIa, four stage IIb, six stage IIIa, six stage IIIb, and four stage IIIc cases. No microscopic tumor involvement of the resection line was noted. A mean of 41.8 lymph nodes (range 11-89) was retrieved. Less than 15 lymph nodes were retrieved in two patients and less than 25 lymph nodes were harvested in 4 of 95 patients. The mean follow-up period was 60.5 months (range 5-97 months, median 59.5 months), with the last follow-up date being 31 December 2014. The overall survival was 92.8 % and relapse-free survival was 91.8 %. CONCLUSIONS: Our large case series demonstrates the feasibility and safety of robotic D2 lymph node dissection during distal subtotal gastrectomy. The adoption of robotic surgery could improve the quality of surgery and facilitate D2 lymph node dissection for gastric cancer.restrictio