BackgroundThe robotic platform offers distinct advantages for total gastrectomy, particularly through effective use of the fourth robotic arm 1 .When used deliberately, the fourth arm enables stable counter-traction, single-surgeon control, and creation of a consistent surgical workspace, facilitating precise dissection and safe reconstruction 2 . MethodsWe present a video of robotic total gastrectomy performed for a patient with gastric adenocarcinoma.Key technical elements include port placement optimized for fourth-arm engagement (Figure 1) 3 , external liver retraction using a Penrose drain, and indocyanine green injection proximal to the tumor to confirm the esophageal transection level 4 .The fourth arm was used strategically to elevate vascular pedicles and lymph node basins during D2 lymphadenectomy 5 , including infrapyloric, suprapancreatic, and left gastric artery dissections.Reconstruction included creation of a retrocolic Roux limb, hand-sewn esophagojejunostomy, jejunojejunostomy, and meticulous closure of all mesenteric and hiatal defects. ResultsThe fourth arm provided consistent counter-traction during lymphadenectomy, improved visualization of critical vascular anatomy, and enabled precise, tension-controlled suturing during esophagojejunostomy and jejunojejunostomy.Operative time was 5 hours and 17 minutes with estimated blood loss <100 mL.Final pathology demonstrated pT4aN3a poorly differentiated gastric adenocarcinoma with adequate lymph node harvest.The patient recovered uneventfully and was discharged on postoperative day 4. Conclusion J o u r n a l P r e -p r o o fThoughtful, dynamic use of the fourth robotic arm enhances exposure, ergonomics, and precision during robotic total gastrectomy.Mastery of fourth-arm techniques is critical for safe D2 lymphadenectomy, tension-free reconstruction, and reproducible outcomes in complex gastric surgery.
Hierl et al. (Wed,) studied this question.