Standardization of robot-assisted total gastrectomy with D2 lymph node dissection after neoadjuvant chemotherapy: Description of the technique and outcomes of 96 procedures

Background. Robot-assisted surgery is becoming an independent option for minimally invasive treatment of stomach cancer due to stable 3D visualization, high instrument mobility, and capability of controlled multivector traction in anatomically complex areas. However, quality of this intervention depends, among other things, on the level of technique standardization. Complexity of surgery increases after neoadjuvant chemotherapy, and reproducibility of the results in large extent depends on organization of the operational block, port configuration, D2 lymph node dissection technique, and reconstructive strategy. Aim. To describe a standardized technique of robot-assisted total gastrectomy with D2 lymph node dissection after neoadjuvant chemotherapy and to evaluate short-term surgical and oncological outcomes of 96 procedures. Materials and methods. We performed a descriptive analysis of data from 96 patients with locally advanced stomach cancer who underwent robotassisted total gastrectomies after neoadjuvant chemotherapy. All interventions were carried out at a single high-volume center between 2021 and January 2026 using the da Vinci model Si robotic surgical system. Operative time, blood loss volume, lymph node yield, rates of conversions, intraoperative complications, R0 resections, severe postoperative complications, esophagojejunostomy leakage, clinically relevant postoperative pancreatic fistula, and postoperative mortality were assessed. Exact 95 % confidence intervals (95 % CI) for binary outcomes were calculated using the Clopper–Pearson method. Statistical analysis was descriptive; intergroup hypothesis testing was not performed due to the absence of internal comparison group. Results. Mean operative time was 221 min and mean blood loss volume was 120 ± 55 mL (95 % CI 108.9–131.1 mL). Mean lymph node yield was 32.1 (range 21–67). No conversions or intraoperative complications occurred – rate 0 % (95 % CI 0–3.8 %). R0 resection was achieved in all patients – rate 100 % (95 % CI 96.2–100 %). Clavien–Dindo grade III–V complications developed in 7 of 96 patients – 7.3 % (95 % CI 3.0–14.4 %). Esophagojejunostomy leakage occurred in 2.1 % (95 % CI 0.3–7.3 %), duodenal stump leakage in 1.0 % (95 % CI 0.03–5.70 %), and clinically relevant grade B postoperative pancreatic fistula in 3.1 % (95 % CI 0.6–8.9 %). Postoperative mortality was 1.0 % (95 % CI 0.03–5.70 %). Conclusion. High level of technical feasibility, absence of conversions, acceptable rate of severe complications and adequate characteristics of surgical radicality of standardized robot-assisted total gastrectomy after neoadjuvant chemotherapy were demonstrated. The data should be interpreted as a result of evaluation of reproducibility and safety of the technique and not as evidence of superiority of robot-assisted access. Comparison to other approaches requires controlled studies with analysis of long-tern oncological outcomes.