Robotic distal subtotal gastrectomy with D2 lymphadenectomy for gastric cancer patients with high body mass index: comparison with conventional laparoscopic distal subtotal gastrectomy with D2 lymphadenectomy

Background: Minimally invasive surgery (MIS) has emerged as a treatment of choice for early-stage gastric cancer. However, applying MIS to gastric patients with high body mass index (BMI) is technically challenging, especially when performing D2 lymphadenectomy. Recently, robotic systems have been adopted to overcome the technical limitations of conventional laparoscopic surgery. Nevertheless, studies on the impact of the use of robotic systems to perform D2 lymphadenectomy in high BMI patients are lacking. Accordingly, this study was designed to compare the quality of lymphadenectomy, together with surgical outcomes, by robotic distal subtotal gastrectomy with D2 lymphadenectomy (RDGD2) to those by laparoscopic distal subtotal gastrectomy with D2 lymphadenectomy (LDGD2) in patients of different BMI status. Methods: Retrospective review of a prospectively collected database identified 400 gastric cancer patients who underwent either RDGD2 (n = 133) or LDGD2 (n = 267) between 2003 and 2010. Patients were categorized according to surgical approach and BMI. We compared clinicopathologic characteristics, as well as short-term and long-term outcomes, between surgery and BMI groups. Results: Regardless of BMI, RDGD2 required significantly longer operation time than LDGD2 (p = 0.001); meanwhile, RDGD2 showed significantly less blood loss than LDGD2 (p = 0.005). Between BMI groups, RDGD2 showed no significant difference in the rate of retrieving more than 25 lymph nodes (p = 0.181); however, LDGD2 was associated with a significantly lower rate of retrieving more than 25 lymph nodes in high BMI patients (p = 0.006). In high BMI patients, complications did not significantly differ between surgical approaches. As well, RDGD2 and LDGD2 demonstrated no statistically significant survival difference according to BMI status. Conclusions: The benefits of a robotic approach were more evident in high BMI patients than in normal BMI patients when performing distal subtotal gastrectomy with D2 lymphadenectomy, particularly in terms of blood loss and consistent quality of lymphadenectomy. Robotic surgery could be an effective alternative to conventional laparoscopic surgery in treating gastric cancer patients with high BMI.