Surgery · Medical Literature
Perioperative outcomes of a novel laparoscopic-like "3-arm + 2-port" model in robot-assisted distal gastrectomy in patients with resectable, non-metastatic gastric cancer: a randomized controlled trial.
Abstract
To compare the perioperative outcomes of a novel laparoscopic-like 3-arm + 2-port and traditional 4-arm + 1-port models in robot-assisted distal gastrectomy with Billroth II reconstruction in patients with resectable, non-metastatic gastric cancer. This randomized controlled trial included patients with resectable, non-metastatic gastric cancer who underwent robot-assisted distal gastrectomy with Billroth II reconstruction with Braun anastomosis and D2 lymphadenectomy. Patients were randomly allocated into two groups based on trocar port placement: traditional 4 + 1 and novel laparoscopic-like 3 + 2 models, using a computer-generated stratified blocked randomization sequence. Outcome measures included operative times, intraoperative blood loss, lymph node yield, postoperative outcomes, and operating room costs. A total of 195 patients were included: 98 in the 3 + 2 group and 97 in the 4 + 1 group. The total operative time was significantly shorter in the 3 + 2 group than in the 4 + 1 group (207.14 ± 22.214 vs. 221.38 ± 26.689 min, p < 0.001). Subsequently, significant reductions in the regional and non-operative times, including omentectomy, stations 4sb, 6, 5/12, 11p/8a/7/9, and 1/3 lymph node dissection, robotic arm docking and switching, and target organ exposure times were also demonstrated in the 3 + 2 group. Significantly more lymph nodes were harvested from station 4sb in the 3 + 2 group (5.26 ± 1.431 vs. 4.70 ± 1.393, p = 0.007). Operating room costs were also significantly lower in the 3 + 2 group (CNY 15,140.56 ± 2,712.21 vs. CNY 18,650.03 ± 1,497.41, p < 0.001). This novel 3 + 2 laparoscopic-like model represents a technically viable and economically advantageous alternative to robot-assisted distal gastrectomy for patients with gastric cancer.
Clinical relevance
Robot-assisted distal gastrectomy (RADG) with D2 lymphadenectomy is an established but costly and time-intensive approach for resectable, non-metastatic gastric cancer; the traditional 4-arm + 1-port configuration imposes non-trivial operative and economic burdens. This RCT addresses the gap in evidence for optimized trocar-port configurations that could reduce operative time and OR costs without compromising oncologic adequacy. Given gastric cancer's global incidence burden and the expanding adoption of robotic platforms, surgical teams performing RADG should be aware of alternative port models that may improve efficiency and cost-effectiveness.
Key findings
1. Total operative time was significantly shorter in the 3+2 group versus the 4+1 group (207.14 ± 22.21 min vs. 221.38 ± 26.69 min; p < 0.001), representing a mean reduction of approximately 14 minutes. 2. Multiple regional and non-operative sub-times were significantly reduced in the 3+2 group, including omentectomy, lymph node dissection at stations 4sb, 6, 5/12, 11p/8a/7/9, and 1/3, as well as robotic arm docking and switching, and target organ exposure times (p values not individually specified in abstract). 3. Lymph node yield at station 4sb (greater omentum/short gastric territory) was significantly higher in the 3+2 group (5.26 ± 1.43 vs. 4.70 ± 1.39 nodes; p = 0.007), suggesting non-inferior—and potentially superior—oncologic dissection at this station. 4. Operating room costs were significantly lower in the 3+2 group (CNY 15,140.56 ± 2,712.21 vs. CNY 18,650.03 ± 1,497.41; p < 0.001), representing a mean cost reduction of approximately CNY 3,509 (~18.8%) per case. 5. The trial enrolled 195 patients across two arms (3+2: n = 98; 4+1: n = 97) using computer-generated stratified blocked randomization, providing adequate power for perioperative outcome comparisons. 6. No statistically significant between-group differences in intraoperative blood loss or postoperative outcomes were reported in the abstract, supporting equivalent safety of the 3+2 configuration (specific values and p-values for these endpoints not detailed in the abstract).
Practice implications
Surgical teams performing RADG with Billroth II reconstruction and D2 lymphadenectomy should consider adopting the 3-arm + 2-port laparoscopic-like configuration, as it significantly reduces total operative time (~14 min) and OR costs (~18.8%) while maintaining or improving lymph node yield at station 4sb without apparent compromise of postoperative safety. This model may be particularly advantageous in high-volume robotic gastric cancer programs where cumulative time and cost savings are clinically and institutionally meaningful. Surgeons transitioning to this configuration should note that the 2-port assistant access may require proficiency in laparoscopic-style instrument handling, and outcomes should be monitored prospectively during the adoption phase, particularly for stations where lymph node yield differences were not statistically significant.