Gastric cancer is the fifth most common malignancy worldwide and the fourth leading cause
of cancer-related deaths. Surgical resection remains the primary treatment for the
radical management of gastric cancer. Laparoscopic-assisted gastrectomy (LG) has proven
to be a minimally invasive and safe approach for both early-stage and advanced gastric
cancer, offering significant advantages over open surgery. However, LG is still limited
by factors such as the restricted range of motion of straight forceps and the impact of
hand tremors on surgical precision. These challenges necessitate the development of more
advanced techniques. The Da Vinci robotic surgical system plays a critical role in
enhancing the precision of robotic surgeries. It provides a three-dimensional, ten-fold
magnified view of the surgical area, promotes natural hand-eye coordination, filters hand
tremors, and allows for greater freedom of movement with its articulated instruments. The
benefits of the Da Vinci system have been proved in complex procedures such as D2 lymph
node dissection for gastric cancer and lower mediastinal lymph node dissection. For
example, during lower mediastinal lymph node dissection in adenocarcinoma of the
gastroesophageal junction, the limited field of view of laparoscopic surgery restricts
the use of linear instruments, whereas the flexibility of robotic surgery offers an
advantage. Furthermore, peripancreatic lymph node clearance in radical gastric cancer
surgery presents a challenge. LG is prone to causing pancreatic injury during dissection
due to the fixed trocar positions and the rigidity of linear energy instruments, which
can result in complications such as postoperative pancreatic fistulas and abdominal
abscesses. The incidence of pancreatic fistulas after LG exceeds 5%, and higher amylase
levels in drainage fluid suggest potential subclinical pancreatic injury. In contrast,
robotic-assisted gastrectomy (RG) has evolved rapidly and offers advantages such as
reduced pancreatic compression during dissection and a lower risk of thermal injury
during lymph node removal. Retrospective studies suggest that RG is associated with less
blood loss, shorter hospital stays, and improved lymph node dissection compared to LG.
However, the evidence regarding the superiority of RG in terms of short-term outcomes
remains controversial, as some prospective studies and meta-analyses have not confirmed
its benefits. Prospective studies mainly focused on early gastric cancer, whereas the
safety, efficacy, and cost-effectiveness of RG in advanced gastric cancer are still
unclear.
Vascular coagulation is the key of minimally invasive surgery. In current robotic
procedures, ultrasonic energy devices have been widely used. However, they lack
flexibility and can generate high operating temperatures (up to 200°C), which risks
thermal damage to surrounding tissues. Park et al. demonstrated that LG using bipolar
energy devices resulted in lower postoperative C-reactive protein levels and reduced
blood loss compared to ultrasonic scalpel use. The bipolar vascular closure system
(Vessel Sealer Extend, VSE) is an advanced bipolar energy device with a fully articulated
wrist joint, enabling 540° rotation and multi-directional access to vessels and target
anatomical sites. The textured inner surface of the jaws enhances tissue grip, and it can
coagulate vessels up to 7 mm in diameter with lower energy, minimizing thermal damage to
adjacent structures. Retrospective studies have shown that robotic distal gastrectomy
using VSE has earlier resumption of a semi-liquid diet (4.0 vs. 4.2 days, p=0.03) and a
significantly lower incidence of postoperative intestinal obstruction (0% vs. 9.9%,
p=0.03) compared to conventional laparoscopic surgery. The VSE has also demonstrated
benefits in other surgical procedure. Yang et al. found that VSE use in robotic
thyroidectomy reduced the frequency of camera cleaning compared to the Harmonic energy
device (0.55 ± 0.51 vs. 1.93 ± 1.71, p<0.05). Additionally, a study comparing different
robotic instrument combinations for adrenalectomy found that the VSE in combination with
monopolar curved scissors offered the best performance. Based on these findings, the
investigators believe that the VSE energy device could optimize RG, improving both safety
and postoperative recovery.
There is a lack of prospective, multicenter, high-quality studies to verify the safety
and recovery benefits associated with reduced thermal damage using this novel energy
device. Therefore, the investigators propose a prospective, multicenter, observational
cohort study to evaluate the safety, feasibility, and potential benefits of RG with the
VSE energy device in the treatment of advanced gastric cancer. This study will assess
postoperative recovery, inflammatory response, and oncological outcomes.