The world’s first pure single-port robotic radical total gastrectomy for advanced gastric cancer

To the Editor: Owing to developments in minimally invasive surgery, single-port (SP) robotic surgery is being increasingly performed.[1] Compared with traditional robotic and laparoscopic surgery, SP robotic surgery is advantageous in which the precision of surgery is improved owing to the flexibility of the robot; additionally, fewer and shorter incisions are made, leading to minimal trauma, barely visible scars, no “chopstick effect”, and faster recovery. In 2009, Kaouk et al[2] were the first to successfully perform radical prostatectomy and radical nephrectomy using the SP robotic surgical system, demonstrating the safety of the SP robotic system. Owing to the dissection of lymph nodes and the extent of surgery, the implementation of SP robotic surgery is limited to some extent. Dreifuss et al[3] reported SP robotic partial gastrectomy for gastrointestinal stromal tumors (GISTs). Cui et al[4] reported SP robotic total gastrectomy for advanced gastric cancer with extracorporeal Roux-en-Y anastomosis via a 7-cm long epigastric incision. Park et al[5] reported the safety and feasibility of reduced‑port robotic distal gastrectomy for gastric cancer using the da Vinci SP robotic system. However, the pure application of the SP robotic system in radical surgery for patients with advanced gastric cancer has not been reported thus far. Prof. Leping Li and Prof. Liang Shang in the Department of Gastrointestinal Surgery of Shandong Provincial Hospital, China, successfully performed the world’s first pure SP robotic radical total gastrectomy (SPRTG) for advanced gastric cancer using the Shurui SR-ENS-600 SP robotic system in July 2023 [Figure 1].Figure 1: The overview of the pure SPRTG with intracorporeal anastomosis for advanced gastric cancer. (A) Cutting the ligamenta gastrocolicum. (B) Dissection of No. 4 lymph nodes. (C) Exposing of the left gastric vein. (D) Exposing of the left gastric artery. (E) Dissection of No. 7 and No. 9 lymph nodes. (F) Dissection of No. 8a lymph nodes. (G) Dissection of No. 5 lymph nodes. (H) Exposing the fusion fascia between mesogastrium and transverse mesocolon. (I) Dissection of No. 6 lymph nodes. (J) Transecting the duodenum via an intracorporeal linear stapler. (K) Dissection of No. 8p and No. 12a lymph nodes. (L) Dissection of No. 3 lymph nodes. (M) Dissection of No. 1 lymph nodes. (N) Dissection of No. 11 lymph nodes. (O) Intracorporeal esophagojejunal anastomosis. (P) Intracorporeal Braun anastomosis. SPRTG: Single-port robotic radical total gastrectomy.Both patients involved in the study have signed the informed consent forms. The patient was a 49-year-old man who was found to have cardia cancer involving the lesser curvature of the gastric body via endoscopic examination. The preoperative stage was cT3N2M0 according to the 8th edition of the American Joint Committee on Cancer (AJCC) system. The tumor was completely resected through a single abdominal incision. A 3-cm incision was made around the umbilicus to establish a port for puncture, and the snake-like robotic arm was used for traction, leading to a complete exposure of the tissues around the stomach. The total gastrectomy and D2 lymph node dissection were successfully completed in 4 h, and intracorporeal esophagojejunal anastomosis and Braun anastomosis were subsequently performed. The surgical procedure was successful, and the intraoperative blood loss volume was only 10 mL. Only the electrocoagulation function of the robotic surgical system was used, and no additional energy equipment, such as an ultrasonic scalpel, was used. There were no reports of short-term postoperative complications or mortality. On the same day, SPRTG was also successfully performed on another 61-year-old female patient with locally advanced gastric cancer. More than 60 lymph nodes were found in these two patients. To date, these patients have been followed up for more than 1 year, and neither of them has reported any significant discomfort. No tumor recurrence has been observed. These findings indicate that pure SP robotic surgery has broad applications in the field of gastrointestinal surgery and that its applications in lymph node dissection and intracorporeal anastomosis are completely feasible and safe. According to the Chinese Expert Consensus on Robotic Gastric Cancer Surgery (2021 edition), the surgi­cal indications mainly include: (1) Tumor infiltration depth is ≤T4a. (2) Preoperative tumor staging is Stage I or II. (3) For gastric surgeons with extensive experience in gastric cancer surgery and proficiency in operating robotic surgical systems, robotic surgery can be applied for patients with preoperative tumor staging of Stage III or those requiring combined organ resection. The surgery should be performed by surgeons with an extensive experience in gastric cancer surgery. There is no expert consensus on the surgical indications for SP robots, and multicenter studies are needed in the future to provide evidence-based medical evidence. SP robotic surgery is mostly reported in small sample case reports, which preliminarily confirm the safety and effectiveness of SP robotic surgery for early gastric cancer. The initiation of SP robotic surgery for patients with advanced gastric cancer is an extension and expansion of the indications at the center. At present, robotic surgery is expensive, but it cannot be denied that robotic surgery, as a minimally invasive surgical method, has many advantages, such as minimal trauma, small scars, concealed incisions, and faster recovery. Owing to technological developments and support from medical insurance, patients can pay less for robotic surgery. With the increase in the incidence of gastric cancer and advancements in surgical techniques, patients are hoping for a new technique that provides good cosmetic outcomes, causes minimal trauma, and yields en bloc tumor resection. The SP robotic surgical system achieves en bloc tumor resection with minimal trauma and satisfactory cosmetic results. SPRTG can be beneficial for selected patients. Compared with traditional surgery, SPRTG can provide better cosmetic results, less pain, and a faster recovery. Additionally, more research is needed to compare the long-term outcomes of SPRTG with those of traditional surgery. Funding This paper was supported by grants from the National Natural Science Foundation of China (Nos. 82203854 and 82372772), Key Research and Development Program of Shandong Province (No. 2021CXGC011104), and Special Foundation for Taishan Scholars Program of Shandong Province (Nos. ts20190978 and tsqn202408363). Conflicts of interest None.