Full robot-assisted gastrectomy with intracorporeal robot-sewn anastomosis produces satisfying outcomes

Figure 1 Flow diagram.

Figure 2 Placement of surgical ports. For A, B and E 8-mm ports were used. For C and D 12-mm ports were used. Port C was extended to 3 cm for specimen extraction from the abdominal cavity.

Figure 3 Lymphatic tissues are removed en bloc along the hepatic, splenic, left gastric artery and celiac trunk using an ultrasonic shear. The origins of these arteries are clearly identified and skeletonized, and the lymphatic tissue dissected away from the adventitia. The left gastric artery is then clipped or tied at its origin.

Figure 4 Distal subtotal gastrectomy with gastroduodenostomy (construction type of Billroth I). A, B: Robotic anastomosis for gastroduodenostomy; C: Continuous seromuscular suture; D, E: Continuous interlocking suture for posterior wall; F: Continuous interlocking suture for anterior wall; G: Interrupted sero-muscular suture; H: Complete anastomosis.

Figure 5 Proximal gastric resection with esophagogastrostomy. A: The terminal esophagus fully mobilized. Diaphragmatic crura are exposed and freed from the surrounding adipose and lymphatic tissue. The esophagus was stitched to the crura for better exposure; B-G: The remnant distal stomach was brought up just below the dissociated esophagus for end-to-end anastomosis; H: Complete anastomosis.

Figure 6 Total gastrectomy with esophagojejunostomy and Roux-en-Y reconstruction. A-E: The small bowel which is 15-20 cm away from the Treitz was brought up just below the dissociated esophagus for antecolic end-to-side anastomosis. Robotic anastomosis for esophagojejunostomy was performed in the same manner; F: The proximal jejunum 5 cm away from the esophagojejunal anastomotic stoma is transected by a 45-mm cartridge endostapler; G-I: The side-to-side jejunojejunostomy and jejunal stump were achieved using the hand-sewn technique in the same manner; J: Jejunal stump was achieved using the hand-sewn technique in the same manner; K, L: Sometimes, the esophagus was not transected until the posterior wall suturing of the esophagojejunostomy was finished.