Robot-assisted distal gastrectomy for gastric cancer: initial experience

Background

This study evaluated the feasibility and safety of robotic surgery in gastrectomy for gastric cancer.

Methods

Between April and October 2009, 12 patients who were diagnosed with stage I gastric cancer underwent robot-assisted distal gastrectomy (RADG) using the da Vinci System (Intuitive Surgical, Sunnyvale, CA). The clinical and pathological characteristics of the patients and surgical outcome were analyzed.

Results

All procedures were completed successfully, with no laparoscopic or open conversion. The mean operating time was 253 minutes (range 170–365), and the mean blood loss was 135 mL (range 30–500). The resection margin was negative in all specimens, and a mean of 46 (range 21–115) lymph nodes was retrieved. The mean time to resume a soft diet and hospital stay was 4.6 and 6.6 days, respectively. Acute pancreatitis occurred in 1 patient and resolved with conservative management.

Conclusions

In our initial experience, RADG was feasible, enabling a fast patient recovery and good operative outcome.     

Laparoscopically assisted pylorus-preserving gastrectomy

apd: 12 December 2000     

Laparoscopically assisted gastric surgery using Dexterity Pneumo Sleeve

Background: Laparoscopic surgery has been successfully applied to several gastrointestinal procedures. Although the totally laparoscopic gastrectomy is feasible, tactile sensation and manipulation of the organ as well as the lesion are decreased when compared to open surgery. The Dexterity Pneumo Sleeve is a new device which allows the surgeon to insert a hand into the abdominal cavity while preserving the pneumoperitoneum. This device was used for patients who underwent laparoscopic gastric surgery. Methods: The first patient presented with a non-Hodgkin's lymphoma of the stomach. A laparoscopically assisted distal gastrectomy was performed with Roux-en-Y reconstruction. The second patient had a 5-cm leiomyoma involving the greater curve of the stomach, and this device was used for manipulation of the tumor. The last patient suffered from morbid obesity with its associated medical complications and a ventral hernia. The Sleeve was applied at the hernia site and a laparoscopically assisted gastric bypass was performed. Results: The Pneumo Sleeve was useful in these cases for tactile localization of the tumor and for retraction and manipulation of the stomach and surrounding upper abdominal organs. Conclusions: The utilization of this device resulted in a more easily performed dissection, resection, and anastomosis and was felt to decrease operation time. Received: 18 September 1996/Accepted: 26 December 1996     

Laparoscopically assisted bowel surgery for inflammatory bowel disease

Background: Laparoscopic bowel surgery was evaluated in 44 consecutive patients who underwent surgery for inflammatory bowel disease (IBD). We studied feasibility, results, and final outcome. Methods: At two academic institutes, 44 laparoscopically assisted colectomies and laparoscopic ileostomies or colostomies were attempted. All patients had histologically proven IBD and no prior surgery for IBD. Loop ileostomy (n= 4), end colostomy (n= 1), ileocecal resection (n= 26) and (procto)colectomy (n= 13) were performed. All resections were laparoscopically assisted with extracorporal resection and anastomosis. Results: Only in two patients (ileocecal resection in both) was conversion to open surgery necessary. Two patients with laparoscopic ileocolic resection had intra-abdominal abscesses, which were drained percutaneously in both. One patient in the laparoscopically assisted colectomy group had a subphrenic abscess that was drained percutaneously, and one patient had a generalized candidiasis. Conclusions: Laparoscopically assisted colectomies can be performed safely in treating IBD. The laparoscopic method with use of a small vertical umbilical or Pfannenstiel's incision seems acceptable with regard to operating time and overall costs, also allowing superior cosmesis to be maintained. Received: 12 August 1998/Accepted: 13 January 1999     

Laparoscopically assisted distal gastrectomy for early gastric cancer in the elderly

BACKGROUND: Open gastrectomy is associated with increased morbidity and a longer hospital stay than laparoscopically assisted gastrectomy. The aim of this study was to clarify the value of laparoscopically assisted distal gastrectomy (LDG) in the elderly, in whom co-morbid disease is generally more common. METHODS: Forty-five elderly patients (aged 70 years or more) and 57 younger patients who underwent LDG, and 28 elderly patients who underwent open distal gastrectomy (ODG) for early gastric cancer between January 1994 and April 2003 were studied. Demographics and postoperative outcomes were compared. RESULTS:: Co-morbidity was more common in elderly patients than in younger patients who underwent LDG (25 of 45 versus 16 of 57; P = 0.004). The postoperative complication rate, time to solid diet and postoperative hospital stay were similar in these two groups. Elderly patients who underwent LDG had a significantly reduced medical complication rate (two of 45 versus six of 28; P = 0.023), time to first flatus (3.7 versus 4.2 days; P = 0.042), time to solid diet (4.6 versus 5.5 days; P = 0.011) and postoperative hospital stay (16.3 versus 23.9 days; P = 0.011) than elderly patients who had ODG. CONCLUSION: LDG offers particular advantages to elderly patients with early gastric cancer, including rapid return of gastrointestinal function, fewer complications and a shorter hospital stay.     

腹腔镜辅助远端胃癌根治术

腹腔镜辅助远端胃癌根治术（LADG）是微创外科的技术之一,是现代外科的重要发展方向之一。按照日本胃癌治疗指南．LADG的适应证应严格限定在早期胃癌中,进展期胃癌应属于探索性临床研究。LADG在早期胃癌病例中应用的短期优势已得到较普遍地认可,但全腹腔镜技术尚需进一步研究探索;而LADG在进展期胃癌中的应用仍然是目前学术争议的热点之一。虽然当前有研究显示,LADG加D2淋巴结清扫对于进展期胃癌其效果与开腹手术相当,但仍需等待中国、日本和韩国目前正在进行的大样本多中心随机对照试验的结果确认。     

腹腔镜辅助下远端胃癌根治术与开放手术比较的临床研究

目的比较腹腔镜辅助下远端早、中期胃癌根治手术与传统开腹手术的疗效。方法回顾性分析我院2004年6月～2006年8月行腹腔镜辅助下根治性远端早、中期胃癌根治术19例及常规开腹远端早、中期胃癌根治术51例的临床资料。结果腹腔镜组19例均成功行腹腔镜辅助手术。腹腔镜手术和开放手术的平均时间分别为（194．5±23．21）min和（177．8±19．78）min,出血量分别为（182．4±40．21）ml和（346．8±33．98）ml,清扫淋巴结数量分别为（18．4±2．3）枚和（17．7±2．6）枚,术后肛门排气时间分别为第（4．31±1．28）d和第（4．89±1．62）d,平均住院时间分别为（14．3±2．5）d和（17．6±3．7）d,术后第1d平均白细胞计数分别为（8．79±3．54）×10^9／L和（10．43±2．78）×10^（／L。所有手术均无吻合口漏及术后死亡病例。结论腹腔镜辅助下胃癌根治术较传统开腹手术耗时长,但能达到胃癌标准根治术的淋巴结清扫范围,且具有出血少、住院时间短等优点。     

Laparoscopically assisted transsacral resection of rectal cancer with primary anastomosis

Background: The management of rectal cancer has been changing to include more sphincter-sparing procedures. We report our initial experience with a new technique incorporating laparoscopy and a transsacral approach for low or midlevel rectal cancer. Here, we tried to determine whether this sphincter-sparing method could produce acceptable morbidity and recurrence rates. Methods: Patients with rectal cancer 4 to 8 cm from the dentate line underwent laparoscopically-assisted transsacral resection (LTR) with primary anastomosis. With this technique, the rectosigmoid is mobilized via laparoscopy while the patient is in the supine position. Next, the patient is placed in the prone jackknife position, and a segment of rectum is resected by a transsacral approach. Age, estimated blood loss, length of time in the operating room, length of stay, and postoperative complications were noted. Aspects of the tumor pathology regarding stage, lymph nodes, tumor size, and presence of tumor at resection margins also were recorded. Results: A total of 13 patients, ages 26 to 70 years (mean, 52.5 years), underwent the procedure. No perioperative deaths occurred. The mean hospital stay was 9.6 days. The average size of the rectal lesion was 4.3 cm in the largest dimension. The average specimen contained 11.5 total, and 2.0 metastatic lymph nodes. Postoperative complications included two anastomotic breakdowns and two other wound complications. Late follow-up evaluation ranged from 10 to 30 months, with 11 of 13 patients alive (85% survival). Two local recurrences and three distant recurrences were noted at long-term follow-up assessment. Conclusions: In selected patients with low or midlevel rectal cancer, LTR may be a viable option. Further experience is necessary to define its oncologic efficacy and whether routine temporary diverting colostomy is indicated. Received: 16 June 1999/Accepted: 1 November 1999/Online publication: 12 July 2000     

腹腔镜D2根治术治疗进展期胃癌的近期疗效分析

目的:探讨腹腔镜与开腹胃癌根治术治疗进展期胃癌的近期疗效。方法:回顾分析手术治疗的89例进展期胃癌患者的临床资料,其中46例行腹腔镜下胃癌根治术(腹腔镜组),43例行传统开腹胃癌根治术(开腹组),対比分析两种术式的优缺点。结果:腹腔镜组与开腹组手术时间[(188.37±9.50)min vs.(167.33±6.76)min]、术中失血量[(65.54±6.34)ml vs.(111.05±14.74)ml]、术后排气时间[(59.74±14.86)h vs.(82.88±15.45)h]、术后进食时间[(61.93±14.90)h vs.(84.91±15.42)h]、术后镇痛药应用次数[(2.87±1.15)vs.(4.12±1.07)]及术后住院时间[(12.28±1.63)d vs.(15.28±0.77)d]等方面差异有统计学意义(P0.05);术后并发症发生率[2(4.35%)vs.5(11.63%)]、清扫淋巴结数量[(25.87±1.22)枚vS.(25.91±1.11)枚]差异无统计学意义(P0.05)。结论:腹腔镜下D2根治术治疗进展期胃癌是安全、可行的,相较传统开腹手术存在多方面优势。     

Laparoscopy-assisted distal gastrectomy for early gastric cancer

Background Laparoscopy-assisted distal gastrectomy (LADG) is gaining wider acceptance for the treatment of early gastric cancer. However, firm evidence supporting its safety and usefulness is scant, and no study has compared the outcomes of various procedures for LADG. We examined the surgical outcomes of LADG performed using different methods for lymph node dissection. Methods Between September 1998 and January 2005, we performed LADG in 111 patients with early gastric cancer. In the 55 patients treated initially, group 2 lymph node dissection was performed through a small, 7-cm-long incision (minilaparotomy). In 43 of these patients, hand-assisted laparoscopic surgery (HALS) was done. In the 56 patients treated more recently, lymph node dissection was performed laparoscopically. In 31 of these patients, the celiac branches of the vagus nerve were preserved. Clinical outcomes of these procedures were compared. Results In the first 55 patients, HALS significantly shortened the operation time (277 vs 243 min, p < 0.05). In the latter 56 patients, LADG with preservation of the celiac branches of the vagus nerve was associated with a longer operation time (283 vs 228 min, p < 0.01) and higher blood loss (150 vs 92 g, p < 0.05) than with LADG without celiac branch preservation. There were no differences among the various operative procedures in postoperative course, including the length of the postoperative hospital stay or the rate of complications. Conclusions LADG is a safe and technically feasible procedure for the treatment of early gastric cancer. Laparoscopic lymph node dissection provided a good visual field and was easier to perform and required less time when the celiac branches of the vagus nerve were not preserved, with no negative effect on outcome.     

Hand-assisted laparoscopic distal gastrectomy with abdominal wall-lift method

We performed a hand-assisted laparoscopic resection of the distal stomach for treatment of gastric cancer with use of an abdominal wall-lift method. The surgeon's left hand, which was inserted through a right lower quadrant incision, was extremely useful in accomplishing D2 lymph node dissection, application of a pursestring instrument, and approximation of a circular stapler to carry out a Billroth I anastomosis. Abdominal wall-lift enabled us to perform the gastrectomy without any concern about gas leakage. The combination of the wall-lift method and hand assistance seems to further enlarge the possibilities of laparoscopic procedures, especially in gastrointestinal surgery. Received: 22 July 1998/Accepted: 17 March 1999     

进展期远端胃癌腹腔镜与开腹根治术的对照研究

目的探讨腹腔镜远端胃癌根治术治疗进展期远端胃癌的可行性、安全性及近期疗效．方法回顾性分析2007年1月至2008年6月间135例接受外科手术的远端胃癌患者的临床资料．其中腹腔镜远端胃癌根治术66例．开腹远端胃癌根治术69例。结果腹腔镜组与开腹组患者年龄、性别和TNM分期的差异均无统计学意义（均P〉0．05）。腹腔镜组均在腹腔镜下成功完成根治性胃切除手术,无中转开腹和手术死亡。与开腹组比较,腹腔镜组患者手术时间更长[（266．1±55．1）min比（223．8±26．8）min];但术中出血量更少[（131．9±88．7）ml比（342．3±178．7）ml],术后肠道恢复功能更快[（3．18±1．22）d比（4．50±1．59）d],术后住院时间更短[（9．20±3．39）d比（11．35±4．61）d];差异均有统计学意义（均P〈0．01）。两组清扫淋巴结数目[（25．81±12．53）枚比（27．47±10．28）枚]和术后并发症发生率[6．1％（4／66）比15．94％（11／69）1的差异均无统计学意义（均P〉0．05）。术后随访1～19个月．两组均未见肿瘤复发或肿瘤相关死亡病例。结论腹腔镜远端胃癌根治术是治疗进展期远端胃癌安全、可行、微创、有效的方法。     

完全腹腔镜远端胃癌D2根治术

近年来,随着腹腔镜手术技术和器械的发展,完全腹腔镜远端胃癌根治术在国内逐渐开展,主要难点问题仍集中于消化道重建。完全腹腔镜远端胃癌根治术的消化道重建方式主要有B-Ⅰ式三角吻合,B-Ⅱ式吻合和Roux-en-Y吻合等。B-Ⅰ式三角吻合法操作简便,但较适合于早期胃癌患者;B-Ⅱ式操作简单,但易出现碱性反流性胃炎;Roux-en-Y吻合能有效避免反流,但术后停滞综合征发生率较高,且全腹腔镜下操作繁琐。笔者2013年9月在国内率先开展全腔镜下胃空肠Uncut Roux-en-Y吻合,该方式既保证了肠道的连续性,降低了停滞综合征的发生率,又有效阻断了胆胰液反流至胃肠吻合口,且全腔镜下实施简便、并发症少,安全有效,值得推荐。     

Laparoscopically assisted total gastrectomy with lymph node dissection for upper and middle gastric cancer

Background  In recent years, laparoscopic gastrectomy has been applied for the treatment of gastric cancer in Japan and Western countries. This report describes the short- and long-term results for patients with gastric cancer who underwent laparoscopically assisted total gastrectomy (LATG) with lymph node dissection. Methods  From September 1999 to December 2007, 20 patients underwent LATG, and 18 underwent conventional open total gastrectomy (OTG) for upper and middle gastric cancer. The indications for LATG included depth of tumor invasion limited to the mucosa or submucosa and absence of lymph node metastases in preoperative examinations. The LATG and OTG procedures for gastric cancer were compared in terms of pathologic findings, operative outcome, complications, and survival. Results  No significant difference was found between LATG and OTG in terms of operation time (254 vs 248 min.), number of lymph nodes (26 vs 35), complication rate (25% vs 17%), or 5-year cumulative survival rate (95% vs 90.9%). Differences between LATG and OTG were found with regard to blood loss (299 vs 758 g) and postoperative hospitalization (19 vs 29 days). Conclusion  For properly selected patients, laparoscopically assisted total gastrectomy can be a curative and minimally invasive treatment for early gastric cancer.     

腹腔镜下早期胃癌节段切除术

目的探讨胃节段切除在分化型早期胃癌手术中的可行性。方法严格挑选2013年8月至2015年6月间4例中段早期胃癌病人,实施腹腔镜下胃节段切除并D1+或D2淋巴结清扫。观察淋巴结清扫数目、术后并发症等情况。结果在清扫小弯侧淋巴结过程中没有保留迷走神经。远端切缘距离幽门4 cm以上,平均淋巴结获取数目为18.5枚。在术后1年内均存在胃排空缓慢的症状和影像学征像,1年后得到缓解。结论经腹腔镜行早期胃癌节段切除在技术上安全可行,是否保留迷走神经有待于进一步的观察。     

Comparison of long-term outcomes of laparoscopy-assisted and open distal gastrectomy for early gastric cancer

Backgroud  Application of laparoscopy-assisted distal gastrectomy (LADG) for early gastric cancer (EGC) is still controversial because of scant evidence of long-term safety and feasibility. We evaluated the long-term outcome of LADG compared with conventional open distal gastrectomy (ODG) for EGC. Methods  Between March 1999 and July 2006, 106 patients underwent LADG and 105 patients underwent ODG for EGC. Clinicopathologic characteristics, postoperative outcomes, hospital course, postoperative morbidity, postoperative mortality, and long-term outcomes, including cancer recurrence and survival, were retrospectively compared between the two groups. Survival of all patients was confirmed with 55-month median follow-up. Results  Postoperative recovery was significantly faster in the LADG group; passing flatus occurred earlier, starting a liquid diet began sooner, and postoperative hospital stay was shorter (p < 0.05). Mean operation time was significantly longer in the LADG group. Postoperative complications in the LADG group occurred less frequently compared with in the ODG group (4.7% versus 13.3%, p = 0.046). Tumor recurrence occurred in two cases (0.9%) and death related to recurrence occurred in only one patient (0.5%). Overall 5-year survival rate (5-YSR) of all patients was 95.5%, while disease-specific 5-YSR was 98.8%. There was no significant difference in survival rates between the two groups; overall 5-YSR of the ODG and LADG groups was 94.9% and 95.9%, respectively. Conclusions  Our data suggest that LADG for EGC is feasible and safe. We expect the results of the present study to be confirmed by prospective randomized analysis. Dr. Lee and Dr. Yom contributed equally to the research and writing of the paper.     

A four-point fixation method for the resection of early gastric cancer,with particular reference to the analysis of cases of incomplete resection

We developed a four-point fixation method for the resection of gastric lesions. The aim of the present study was to compare the characteristics of early gastric cancer between the complete-resection group (56 patients) and the incomplete-resection group (10 patients). The results showed that the incomplete-resection group included a significantly higher proportion of patients with large lesions and patients in whom the lesion was located at the body or lesser curvature of the stomach. These results were similar to those previously reported for treatment with conventional strip biopsy. However, in contrast to conventional strip biopsy, relatively few patients with depressed-type gastric cancer were included in the incomplete-resection group. This is considered one of the most important features of the four-point fixation method. Received: 23 February 1996/Accepted: 28 May 1996     

Laparoscopically assisted total or distal gastrectomy with lymph node dissection for early gastric cancer

BACKGROUND: A secure lymphadenectomy in a laparoscopically assisted gastrectomy performed for gastric cancer is required because of the high prevalence of lymph node metastasis. A surgical technique for laparoscopic gastrectomy with lymph node dissection and reconstruction using a conventional circular stapler is reported. METHODS: Forty-nine laparoscopically assisted gastrectomies with lymphadenectomy (47 distal and two total gastrectomies) were performed using devices for retraction of the stomach and laparoscopic ligation of arteries, which were developed to ensure secure dissection of lymph nodes. Reconstruction by Billroth I or intestinal interposition using a conventional circular stapler was performed through a small incision through which the specimen was removed. When submucosal invasion was suspected (n = 16), the lymph nodes along with the common hepatic artery were also dissected through the same incision. RESULTS: The operations were performed without serious complication. None was converted to laparotomy, and there were no deaths. Metastatic lymph nodes were seen in perigastric nodes and nodes along the left gastric artery in five cases. In five of the 49 patients the macroscopic diagnosis of depth of invasion was underestimated. CONCLUSION: A technique of laparoscopic gastrectomy with lymph node dissection for early invasive gastric cancer is described. A definitive answer concerning the appropriate level of lymph node dissection and the role of laparoscopic gastrectomy in the treatment of more advanced gastric cancer remains to be defined.     

Comparison of laparoscopic and open gastrectomy for gastric cancer

BACKGROUND: The role of minimally invasive gastrectomy in the treatment of gastric cancer is not well defined. The aim of the current study was to compare the operative outcomes and adequacy of resection of laparoscopic gastrectomy compared to open gastrectomy for gastric cancer. METHODS: The clinical course of 15 consecutive patients who underwent minimally invasive gastrectomy or esophagogastrectomy for gastric cancer were compared with that of 21 patients who underwent open gastrectomy. Main outcome measures included operative time, blood loss, length of stay, morbidity, 30-day mortality, and adequacy of lymphadenectomy and resection margins. RESULTS: There was no conversion to laparotomy in the laparoscopic group. Intraoperative blood loss was significantly lower in the laparoscopic group (138 mL vs. 357 mL). There was no significant differences in the mean operative time (244 vs. 241 min.), transfusion rate (6% vs. 29%), median length of stay (6 vs. 7 days), morbidity (7% vs. 24%), or number of lymph nodes harvested (15 vs. 14 nodes) between the 2 groups. Resection margins were negative in all patients. There were no leaks and the 30-day mortality was 0 in both groups. Anastomotic strictures were higher in the laparoscopic patients. CONCLUSION: Laparoscopic gastrectomy is feasible and can be performed safely with adequate lymphadenectomy compared with open gastrectomy.     

Transgastrostomal endoscopic surgery for early gastric carcinoma and submucosal tumor

Background: Laparoscopic intraluminal surgery of the stomach is now widely used for a lesion on the posterior wall. However, this procedure has some technical limitation related to the intricate introduction of the surgical instruments into the gastric lumen. In this article, we report our newly developed technique of transgastrostomal endoscopic surgery that overcomes this limitation and is also suitable for full-thickness gastric wall resection of a lesion in the wall. Methods: After making a 4-cm-long temporary gastrostomy, a Buess-type endoscope is inserted into the gastric lumen through the gastrostomy. The operation is performed inside the gastric lumen under video camera guidance using electrocautery, scissors, and forceps. After resection, the wound in the mucosa or the wound after full-thickness resection is endoluminally sutured. Mucosal resection was performed in six cases of early gastric carcinoma, two cases of atypical epithelium, and one case of ectopic pancreas. Full-thickness wall resection was performed in four cases of a leiomyoma. Results: In all 13 cases, the lesion could be precisely located by the video camera. All lesions were then resected endoluminally. The mean duration of the operation was 148 min. The postoperative course in all cases was uneventful. Conclusions: Transgastrostomal endoscopic surgery is minimally invasive and an efficient tissue-preserving technique for the removal of early gastric carcinoma or submucosal tumor. Received: 7 September 1996/Accepted: 27 January 1997