Retrospective Study
Copyright ©The Author(s) 2017. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Gastroenterol. Apr 7, 2017; 23(13): 2376-2384
Published online Apr 7, 2017. doi: 10.3748/wjg.v23.i13.2376
Minimally invasive surgery for gastric cancer: A comparison between robotic, laparoscopic and open surgery
Amilcare Parisi, Daniel Reim, Felice Borghi, Ninh T Nguyen, Feng Qi, Andrea Coratti, Fabio Cianchi, Maurizio Cesari, Francesca Bazzocchi, Orhan Alimoglu, Johan Gagnière, Graziano Pernazza, Simone D’Imporzano, Yan-Bing Zhou, Juan-Santiago Azagra, Olivier Facy, Steven T Brower, Zhi-Wei Jiang, Lu Zang, Arda Isik, Alessandro Gemini, Stefano Trastulli, Alexander Novotny, Alessandra Marano, Tong Liu, Mario Annecchiarico, Benedetta Badii, Giacomo Arcuri, Andrea Avanzolini, Metin Leblebici, Denis Pezet, Shou-Gen Cao, Martine Goergen, Shu Zhang, Giorgio Palazzini, Vito D’Andrea, Jacopo Desiderio
Amilcare Parisi, Alessandro Gemini, Stefano Trastulli, Jacopo Desiderio, Department of Digestive Surgery, St. Mary’s Hospital, University of Perugia, 05100 Terni, Italy
Daniel Reim, Alexander Novotny, Klinik und Poliklinik fuer Chirurgie, Klinikum Rechts der Isar, Technical University Munich, 81675 Munich, Germany
Felice Borghi, Alessandra Marano, Department of Surgery, General and Oncologic Surgery Unit, Santa Croce e Carle Hospital, 12100 Cuneo, Italy
Ninh T Nguyen, Department of Surgery, Division of Gastrointestinal Surgery, University of California, Irvine Medical Center, Orange, CA 92868, United States
Feng Qi, Tong Liu, Gastrointestinal Surgery, Tianjin Medical University General Hospital, Tianjin 300052, China
Andrea Coratti, Mario Annecchiarico, Division of Oncological and Robotic Surgery, Department of Oncology, Careggi University Hospital, 50134 Florence, Italy
Fabio Cianchi, Benedetta Badii, Unit of general and endocrine surgery, Center of oncologic minimally invasive surgery (COMIS), Careggi University Hospital, 50134 Florence, Italy
Maurizio Cesari, Giacomo Arcuri, Department of General Surgery, Hospital of Città di Castello, USL1 Umbria, 06012 Città di Castello, Italy
Francesca Bazzocchi, Andrea Avanzolini, Department of General Surgery, Division of General, Gastroenterologic and Minimally Invasive Surgery, G.B. Morgagni Hospital, 47121 Forlì, Italy
Orhan Alimoglu, Metin Leblebici, Department of General Surgery, School of Medicine, Istanbul Medeniyet University, 34000 Istanbul, Turkey
Johan Gagnière, Denis Pezet, Department of Digestive and Hepatobiliary Surgery, Estaing University Hospital, 63000 Clermont-Ferrand, France
Graziano Pernazza, Department of Surgery, Robotic General Surgery Unit, San Giovanni Addolorata Hospital, 00184 Rome, Italy
Simone D’Imporzano, Esophageal Surgery Unit, Tuscany Regional Referral Center for the Diagnosis and Treatment of Esophageal Disease, Medical University of Pisa, 56124 Pisa, Italy
Yan-Bing Zhou, Shou-Gen Cao, Department of General Surgery, The Affiliated Hospital of Qingdao University, Qingdao 266003, Shandong Province, China
Juan-Santiago Azagra, Martine Goergen, Unité des Maladies de l’Appareil Digestif et Endocrine, Centre Hospitalier de Luxembourg, 1210 Luxembourg, Luxembourg
Olivier Facy, Service de Chirurgie Digestive et Cancérologique CHU Bocage, 21000 Dijon, France
Steven T Brower, Department of Surgical Oncology and HPB Surgery, Englewood Hospital and Medical Center, Englewood, NJ 07631, United States
Zhi-Wei Jiang, Shu Zhang, Department of General Surgery, Jinling Hospital, Medical School, Nanjing University, Nanjing 210002, Jiangsu Province, China
Lu Zang, Department of Surgery, Ruijin Hospital, Shanghai Jiaotong University, School of Medicine, Shanghai 200020, China
Arda Isik, Department of General Surgery, Erzincan University, School of Medicine, 24100 Erzincan, Turkey
Giorgio Palazzini, Vito D’Andrea, Department of Surgical Science, “La Sapienza” University, 00161 Rome, Italy
Jacopo Desiderio, Department of Digestive Surgery, St. Mary’s Hospital of Terni - University of Perugia, 05100 Terni, Italy
Author contributions: Parisi A and Desiderio J were involved in study conception and design; Parisi A, Reim D, Borghi F, Nguyen NT, Qi F, Coratti A, Cianchi F, Cesari M, Bazzocchi F, Alimoglu O, Gagnière J, Pernazza G, D’Imporzano S, Zhou YB, Azagra JS, Facy O, Brower ST, Jiang ZW, Zang L, Isik A, Gemini A, Trastulli S, Novotny A, Marano A, Liu T, Annecchiarico M, Badii B, Arcuri G, Avanzolini A, Leblebici M, Pezet D, Cao SG, Goergen M, Zhang S, Palazzini G, D’Andrea V and Desiderio J collected data and were involved in critical revision and drafting of the final manuscript.
Supported by CARIT Foundation (Fondazione Cassa di Risparmio di Terni e Narni), No. 0024137.
Institutional review board statement: The study was approved by the ethics Committee of CEAS Umbria.
Conflict-of-interest statement: No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article.
Data sharing statement: Technical appendix, statistical code, and dataset available from the corresponding author at
Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See:
Correspondence to: Jacopo Desiderio, MD, Department of Digestive Surgery, St. Mary’s Hospital of Terni - University of Perugia, Via Tristano di Joannuccio 1, 05100 Terni, Italy.
Telephone: +39-349-7531121 Fax: +39-744-205078
Received: December 12, 2016
Peer-review started: December 26, 2016
First decision: January 10, 2017
Revised: January 23, 2017
Accepted: March 15, 2017
Article in press: March 15, 2017
Published online: April 7, 2017

To investigate the role of minimally invasive surgery for gastric cancer and determine surgical, clinical, and oncological outcomes.


This is a propensity score-matched case-control study, comparing three treatment arms: robotic gastrectomy (RG), laparoscopic gastrectomy (LG), open gastrectomy (OG). Data collection started after sharing a specific study protocol. Data were recorded through a tailored and protected web-based system. Primary outcomes: harvested lymph nodes, estimated blood loss, hospital stay, complications rate. Among the secondary outcomes, there are: operative time, R0 resections, POD of mobilization, POD of starting liquid diet and soft solid diet. The analysis includes the evaluation of type and grade of postoperative complications. Detailed information of anastomotic leakages is also provided.


The present analysis was carried out of 1026 gastrectomies. To guarantee homogenous distribution of cases, patients in the RG, LG and OG groups were 1:1:2 matched using a propensity score analysis with a caliper = 0.2. The successful matching resulted in a total sample of 604 patients (RG = 151; LG = 151; OG = 302). The three groups showed no differences in all baseline patients characteristics, type of surgery (P = 0.42) and stage of the disease (P = 0.16). Intraoperative blood loss was significantly lower in the LG (95.93 ± 119.22) and RG (117.91 ± 68.11) groups compared to the OG (127.26 ± 79.50, P = 0.002). The mean number of retrieved lymph nodes was similar between the RG (27.78 ± 11.45), LG (24.58 ± 13.56) and OG (25.82 ± 12.07) approach. A benefit in favor of the minimally invasive approaches was found in the length of hospital stay (P < 0.0001). A similar complications rate was found (P = 0.13). The leakage rate was not different (P = 0.78) between groups.


Laparoscopic and robotic surgery can be safely performed and proposed as possible alternative to open surgery. The main highlighted benefit is a faster postoperative functional recovery.

Keywords: Gastric cancer, Gastrectomy, Minimally invasive surgery, Robotic, Robot-assisted, Laparoscopy

Core tip: The IMIGASTRIC project is a multi-institutional study on gastric cancer developed to collect information on the surgical, clinical, and oncological features of patients undergoing gastrectomy with a robotic, laparoscopic, or open approach. A research group was first established in 2014 and after sharing a specific study protocol, data collection officially started at the end of 2015. A tailored Web-based software was developed to standardize information, facilitate the process of data collection in a unified multi-institutional database, and guarantee the proper storage of patient’s data. The purpose was to create an international registry with a high methodological quality.