Discussion
postoperative pain, colorectal and gynecologic surgery, trauma, cancer, hernia, low transverse abdominal wounds, bipolar, gastric cancer
POSTOPERATIVE COMPLICATIONS, CANCER, EVENTS, ADVERSE EFFECTS, SCARRING, COMPLICATIONS, GASTRIC CANCER
In this study, we reported da Vinci SPRDG could be safely performed without major complications in patients with gastric cancer. All 19 patients were discharged within 4 days after surgery. Among them, fourteen patients completed their hospital stay within 3 days, and no patients had an unscheduled hospital visit within 30 days postsurgery.We selected the Pfannenstiel incision for multichannel cannula insertion and specimen retrieval. Classically, the Pfannenstiel incision is favored for colorectal and gynecologic surgery because it has lower incisional hernia incidence and less postoperative painSchematic illustration of robotic gastrectomy. (The camera of the da Vinci SP robotic system is multijointed and includes an elbow joint, so that the surgical area in the upper abdomen is sufficiently accessed and visualized through the Pfannenstiel approach (Fig. Since the introduction of minimally invasive surgery, surgeons have been trying to perform surgically and oncologically safe operations with less trauma. Instruments and imaging systems have been developed to enable comparable or even better dissection quality than conventional surgery with a smaller incision. If surgery can be conducted safely with fewer trocars, then the use of fewer trocars would reduce surgical trauma and consequent adverse effects. Indeed, this phase I/II clinical trial demonstrated that SPRDG through a Pfannenstiel incision using the da Vinci SP system could be a feasible and safe option for gastric cancer surgery.Single-incision surgery and natural orifice transluminal endoscopic surgery are attractive not only because of lower surgical trauma but also because of reduced scarring. Of course, surgical and oncological safety must first be established. So, if the safety of the operation is qualified, the cosmetic satisfaction from small scars could be valuable for selective patients. This study’s patients had low transverse abdominal wounds that can be covered by underwear. Thus, SPRDG is expected to be a safe surgical option for patients for whom cosmesis is an important factor.To the best of our knowledge, this study is the first report on the clinical experience of the da Vinci SP system with SPRDG. There was no conversion to other surgical techniques, additional trocar insertion, or grade III or higher major postoperative complications or readmission events in the 19 patients, demonstrating the feasibility and safety of the SP robotic system for distal gastrectomy. However, the use of the Pfannenstiel incision might affect early recovery and good cosmesis. Our procedure could be a valid option for selected patients with the potential for less postoperative pain, lower possibility of incisional hernia, and better cosmesis than standard surgical techniques.There are several limitations to this study. First, as this was a single-arm study, we could not compare SPRDG with conventional robotic distal gastrectomy or laparoscopic distal gastrectomy, so comparative studies should be conducted to determine if SPRDG has advantages in terms of incisional hernia incidence, postoperative pain or cosmesis satisfaction. Second, we did not assess long-term patient outcomes in this study, which will be important to measure, considering that the most critical factor in radical cancer surgery is oncological safety. Third, although our study was prospective, the primary purpose was to confirm the safety of SPRDG, so there might be selection bias. Additional real-world studies may be needed in patients with challenging conditions such as high body mass index or advanced gastric cancer. Additionally, this study was conducted by a single expert surgeon with various experiences in laparoscopic and robotic gastrectomy. Whether this is generally accepted requires further research. Last, SPRDG procedure described in this manuscript was developed for initial cases, and methods are continuously evolving and undergoing modifications. For instance, we recently used bipolar dissectors in both hands rather than monopolar scissors in the left hand and a bipolar dissector in the right hand. The pursuit of optimizing surgical techniques is ongoing, and the surgical details discussed here may change with increased use of SPRDG.