Introduction: Complications after gastrectomy for gastric adenocarcinoma frequently prevent the return to intended oncologic therapy (RIOT), and RIOT is essential to optimize survival outcomes. Anastomotic leak is reported in 1.5–14.4% of cases. A robotic gastrectomy technique achieving no leaks and 100% RIOT in 35 consecutive patients is presented.
Methods:
Methods: Patients were positioned supine.
Trocar Placement: Robotic and assistant 8 mm trocars were placed (Fig 1). The gastrocolic omentum was divided and the distal stomach mobilized.
Duodenal Mobilization and Division: The proximal duodenum was mobilized off the pancreas to the right of the gastroduodenal artery. The right gastroepiploic and gastric vessels were divided, and the duodenum transected with a 60 mm blue load stapler on SeamGuard.
Gastric Mobilization and Lymphadenectomy: Endoscopy confirmed tumor location and extent of resection. The stomach was mobilized proximally with D2 lymphadenectomy. The left gastric vessels were divided.
Esophageal Division: After confirming Z-line, the esophagus was divided proximally with a 60 mm stapler; prior to division, esophageal edges were anchored to the crura to prevent retraction.
Jejunal Division and Reconstruction: The jejunum was divided 40–50 cm distal to the ligament of Treitz with division of the mesentery. A stapled jejunojejunostomy was constructed with Roux-limb length of 70-80 cm, and the enterotomy closed with continuous single-layer in Connell and simple running fashion. Crotch stitches were placed.
Esophagojejunostomy: A 25 mm Orvil anvil was introduced orally, exteriorized, and connected to the EEA stapler via a mini-gel port. The “candy-cane” was divided and the jejunojejunal mesentery was closed with 2-0 silk. Saline immersion leak test confirmed anastomotic integrity.
Specimen Extraction: The specimen was removed via a Pfannenstiel incision.
Results: All patients underwent postoperative contrast study. Diet was advanced from bariatric clear to full liquids as bowel function returned. Median length of stay was 4 days (IQR 3–6). Among 35 patients with biopsy-proven gastric adenocarcinoma: R0 resection was achieved in 34/35, anastomotic leak in 0/35, major complications in 6/35, 30-day readmission in 5/35, and 30-day mortality in 0/35. Of 30 eligible patients, all (100%) did RIOT.
Conclusions: This video highlights a reproducible robotic technique for gastrectomy that eliminates anastomotic leak and ensures return to intended oncologic therapy. Standardization of key steps may significantly enhance postoperative recovery and optimize oncologic outcomes.
Learning Objectives:
Recognizing the tips and tricks of duodenal division and esophageal division.
Cannulating the biliopancreatic limb and Roux-limb length with division of the jejunal mesentery, especially in total gastrectomy, to decrease the risk of anastomotic complications.
Understanding the technical considerations and advantages of jejunojejunal mesenteric closure.
