Robotic spleen-preserving splenic hilar lymphadenectomy for advanced proximal gastric cancer: A feasible and simplified procedure

Background: Robotic systems recently have been introduced to overcome technical limitations of conventional laparoscopic gastrectomy, especially for complex procedures [1]. We developed a set of procedural operation steps for robotic spleen-preserving splenic hilar lymphadenectomy, which is difficult and recommended in D2 lymph node (LN) dissection during total gastrectomy [2-4]. Methods: The robotic operative procedures of splenic hilar lymphadenectomy using the da Vinci (R) Si system were demonstrated in a step-by-step manner, with technical tips for each step, in the video clip. The above procedures were performed on 40 consecutive patients with stage cT2-3 proximal gastric cancer between July 2016 and September 2017. The learning curve was analyzed based on the cumulative sum method (CUSUM). Results: The mean age and body mass index of patients were 55.3 +/- 10.4 years (range 29-78) and 23.0 +/- 2.7 kg/m(2) (range 15.4-28.4), respectively. All spleen-preserving surgeries were successfully performed without open or laparoscopy conversion. Mean operation time of splenic hilar lymphadenectomy was 20.3 +/- 6.4 min (range 13.3-46.3); mean blood loss was 13.7 +/- 5.3 ml (range 8.0-40.0). The overall average of 38.8 +/- 13.1 LNs (range 19-81) was retrieved, including a mean 3.3 +/- 1.4 (range 0-8) splenic hilar area LNs, with a 10% (4/40) metastatic rate. No immediate postoperative mortality was observed. 6 patients (15.0%) experienced a complication after surgery; the operation-related complications consisted of one wound complications, one abdominal infection, and one anastomosis leakage. At a median follow-up of 12 months, one patient had experienced lung metastasis. According to the CUSUM, the cut-off point of splenic hilar LN dissection time and blood loss were 15th and 20th cases, respectively. Conclusion: Robotic surgery can improve the quality of surgery and promote the D2 LN dissection. This procedure is feasible and simplifies complicated splenic hilar lymphadenectomy.