Robotic vs. Laparoscopic Total Gastrectomy Protocols

All of the RATG and LATG procedures were performed by a specific surgeon (TYL) with extensive experience in laparoscopic gastrectomy. All patients were conducted with endotracheal intubation and general anesthesia. During surgeries, the patients were placed in the supine and reverse Trendelenburg position with the legs elevated approximately 15°-20°and separated. Most of the operative steps in the RATG were the same as those in the LATG. Both operation procedures used a total of five trocars, adopts “W type” in RATG group and “U type” in LATG group. The camera port was inserted in the infraumbilical area by the closed method with a 12-mm trocar in RATG and a 10-mm trocar in LATG. Pneumoperitoneum was established with an intra-abdominal pressure of 12–15 mmHg by CO₂ gas. Two 8-mm trocars for the first and the third robotic arm in RATG (one 12-mm trocar for operator and one 5-mm trocar for assistant in LATG) were placed in the left and right anterior axillary line just 2 cm below subcostal. One 8-mm trocar for second robotic arm and one 12-mm trocar for an assistant port in RATG (Two 5-mm trocars for operator and assistant in LATG) were placed through the left and right midclavicular line just 2 cm below (or above in LATG) umbilicus. The adjacent trocar distance is more than 8 cm to avoid interference between the manipulator. Standard D2 lymphadenectomy was performed in all procedures in accordance with the version 4 of Japanese Gastric Cancer Treatment Guidelines [15 (link)]. Afterward, the specimen was removed through a 6–8 cm mid-abdominal incision and Roux-en-Y esophagojejunostomy was performed with a 25 mm circular stapler. Seromuscular layer embedded was used to reinforce duodenal stump in all patients. Finally, two drainage tubes were placed near the duodenal stump and splenic recess respectively. The criteria to remove drainage tubes were the following: 1) the abdominal drainage volume less than 10 ml per day; 2) the drainage without odor; 3) patients without fever or peritonitis symptoms; 4) 4 days after operation.