Robotic versus open distal gastrectomy for gastric cancer

Background: Gastrectomy with D2 lymphadenectomy is the gold standard for locally advanced gastric cancer (GC). While robotic surgery is established for early-stage GC, its oncological equivalence to open surgery in advanced stages remains debated in Western cohorts. This study compares perioperative safety and long-term outcomes between robotic distal gastrectomy (RDG) and open distal gastrectomy (ODG). Methods: This bicentric, retrospective study included 100 patients (RDG, n = 50; ODG, n = 50) treated between 2016 and 2024. The primary endpoint was overall survival (OS) at 1, 3, and 5 years. Secondary endpoints included perioperative outcomes, lymph node yield, postoperative complications, and length of hospital stay. Results: RDG had longer operative times (277.5 vs. 237.5 minutes, P < 0.001) but significantly lower blood loss (50 vs. 365 mL, P < 0.001) and transfusion rates (6.0% vs. 24.0%, P = 0.023). Oncological radicality was comparable: R0 rates (96.0% vs. 94.0%, P = 0.678) and lymph node yield (24.5 vs. 25.0, P = 0.809) showed no significant differences. RDG demonstrated shorter hospital stays (8 vs. 11 days, P < 0.001) and lower morbidity (26.0% vs. 50.0%, P = 0.023). Multivariate analysis showed that the surgical approach did not independently predict major complications (respiratory complications or duodenal stump leakage [DSL]). Age >75, Charlson Comorbidity Index ≥6, American Society of Anesthesiologists ≥3, and tumor, node, metastasis stage ≥III were identified as independent predictors for DSL. Long-term analysis revealed no significant difference in median OS (37.0 vs. 39.0 months, log-rank P = 0.820) or recurrence rates (24.0% vs. 28.0%). Conclusions: RDG is oncologically equivalent to ODG across all stages. Despite longer operative times, RDG offers lower morbidity and faster recovery, confirming it as a safe and effective therapeutic option. Our findings support adopting robotic surgery even for locally advanced GC in high-complexity Hub institutions.