A comprehensive review and meta-analysis comparing Robot-

assisted and 3D laparoscopic gastrectomy for Gastric cancer

§Qian-wen Wang1,2, §Jun Leng1,2, §Wei Li1, Jin Chen2

1
North Sichuan Medical college, Nanchong, Sichuan, China

2
Department of General Surgery, Mian Yang 404 Hospital, Sichuan

Province, China

Corresponding Author: Jin Chen

Email address: [email protected]

§ The contributions of these authors to this work are equal

Word count of the manuscript：2130words

Abstract

Objective: This review and meta-analysis evaluate the short-term

surgical results of robot-assisted gastrectomy compared to 3D

laparoscopic gastrectomy in individuals with gastric cancer.

Methods ： This research seeks to used scholarly articles from

PubMed, CNKI, Embase, and the Cochrane Library to gather relevant

studies on gastrectomy for gastric cancer published from the inception of

these databases up to July 15, 2024. The primary objective of the study is

to compare the therapeutic efficacy of robot-assisted gastrectomy (RG)

versus 3D laparoscopic gastrectomy (3D-LG). Similarly, the study will

strictly adhere to the inclusion and exclusion guidelines, focusing on

randomized controlled trials (RCTs) and cohort research.

Results ： A total of 1231 gastric cancer patients were involved in

incorporating seven retrospective cohort studies as the final analysis in

the study with 533 undergoing robot-assisted gastrectomy and 698

undergoing 3D-LG. The results showed that patients who received

robotic-assisted gastrectomy experienced superior outcomes regarding

EBL and time to first postoperative exhaust compared to those who

underwent 3D-LG. However, the robotic-assisted approach was

associated with a reduced number of LNY. Besides, there were

similarities between the two surgical techniques in relation to OT, LOHS,

and post-surgery complications.

Conclusion: In summary, robot-assisted gastrectomy is

acknowledged as a secure and efficient treatment option for individuals

with stomach cancer. This approach demonstrated notable benefits

compared to 3D-LG, particularly with regard to estimated intraoperative

blood loss and the timing of the first postoperative exhaust.

Keywords: Robot-assisted ； 3D laparoscopic ； gastrectomy ； gastric

cancer; meta-analysis

Introduction

Gastric cancer (GC) is among the most prevalent malignant tumors

of the digestive system, with its incidence ranking sixth and its mortality

third worldwide1. Surgery continues to be the primary approach for

treating gastric cancer2. Since Kitano3 et al. introduced laparoscopic distal

gastrectomy(DG) for GC, the use of laparoscopic techniques in GC

treatment has evolved significantly. Laparoscopic gastrectomy (LG)

provides significant immediate benefits compared to traditional open

surgery, such as less postoperative discomfort, reduced LOHS, and

improved gastrointestinal recovery. Additionally, minimally invasive

surgery has demonstrated comparable three-year disease-free survival

rates to laparotomy in terms of long-term outcomes 4. However,

laparoscopic techniques present challenges such as diminished visual

clarity, difficulties with hemostasis, and complications in Lymph node

yield (LNY). In 2014, Chinese researchers introduced 3D laparoscopic-

assisted radical gastrectomy for GC, advancing the application of 3D

technology in this field5. In contrast to conventional 2D laparoscopy, 3D

laparoscopy has demonstrated a notable decrease in EBL and the

frequency of severe bleeding6. Moreover, robotic surgical systems have

increasingly been adopted in gastrectomy with the introduction of the first

robotic radical gastrectomy by Hashizume et al. in 2002 7,8. The da Vinci

robotic system offers superior flexibility with its multi-angled robotic

arms and provides enhanced visual clarity with its 3D lens, making the

surgical process more ergonomically favorable9. Evidence suggests that

both 3D laparoscopy and robotic-assisted surgery confer advantages such

as reduced EBL and increased LNY compared to 2D laparoscopy6.

Nevertheless, studies comparing robot-assisted and 3D laparoscopic

approaches for GC remain limited. This research and meta-analysis aim

to evaluate and compare the short-term surgical outcomes of robot-

assisted gastrectomy (RG) versus 3D laparoscopic gastrectomy(3D-LG)

for GC.

Literature search

This research follows recognized framework for conducting

systematic reviews and meta-analyses as established in the PROSPERO

database (CRD42024574328). More importantly, the literatures in the

database were reviewed by WQW and LJ as researchers to find out if the

study met the criteria. A thorough computerized study was performed

across PubMed, CNKI, Embase, and the Cochrane Library from the

inception of these databases up to July 15, 2024, using English and

Chinese publications. The keywords such as "Robot-assisted,"

"Laparoscopic," "Gastrectomy," and "Gastric Cancer," were employed as

search strategy. Similarly, subject headings and free-text terms were used

across the four databases. In addition to a manual review of relevant

literature, a secondary citation search was conducted to identify and

include additional pertinent studies for detailed analysis.

The Inclusion and Exclusion Strategy

Inclusion Strategy: This strategy only used and diagnosed adult

patients with GC who had undergone surgical treatment. Further, adult

patients who had undergone RG were used as intervention group while

the control group consisted of patients who underwent 3D-LG. The main

outcome measures were EBL, time to first postoperative flatus, and

operative time (OT). Secondary outcome measures included the number

of LNY, LOHS, and postoperative complications. Notably, RCTs and

cohort studies were part of inclusion strategy. On the other hand, the

exclusion strategy failed to recognized any data, single-arm studies,

conference abstracts, and case reports that was lacking primary outcome.

Conducting analysis and extracting information

The inclusion and exclusion criteria were predefined by two

researchers who independently conducted literature screening and studies.

Initially, they assessed the eligibility of the research by reviewing titles

and abstracts. Subsequently, the researchers consulted third parties

whenever there were discrepancies or disagreement during the screening

process for purposes of resolving conflicts and reaching consensus. The

final studies incorporated in this analysis provided vital data on the main

author, publication year, patient count, age range, gender ratio, and tumor

dimensions, as well as primary and secondary outcomes.

Statistical analysis
 The Review Manager 5.4.1 application will be tasked by conducting

the statistical analysis of the data from the study. Continuous variables

will be presented as weighted mean differences (WMDs), Categorical

variables will be presented as odds ratios (ORs), with each accompanied

by 95% confidence intervals. Additionally, data will be converted to

means and standard deviations (SDs) for studies providing only median,

quartiles, or extreme values using the method outlined by Shi 10 et al.

Binary variables will be analyzed using the Cochran-Mantel-Haenszel

method, while continuous variables will be analyzed using the inverse

variance method. Heterogeneity among the included studies will be

evaluated with the I² statistic, considering I² values ≥ 50% indicative of

significant heterogeneity. Since p-value < 0.05 will be deemed

statistically significant, a random-effects model will be employed for all

analyses due to the potential for significant between-trial variability. The

quality of the included studies will be evaluated using the ROBINS-I

tool. Sensitivity analyses will be conducted by systematically excluding

individual studies to evaluate the robustness and reliability of the results

and to identify potential destabilizing factors. Given that fewer than ten

studies are included, the power of the statistical tests may be limited, and

thus, an analysis of publication bias will not be performed11,12.

Result

Primary characteristics

The strategy used in this study adheres to the inclusion and

exclusion criteria, identified seven retrospective studies for final

inclusion13–19. Table 1 provides a summary of the specific features and

results of these studies. The analysis encompassed a total of 1231

patients, with 698 undergoing RG and 533 undergoing 3D-LG. All

studies were conducted by researchers from China. Figure 1 depicts the

PRISMA flowchart outlining the procedure of selecting studies. Initial

data analysis (Table 2) showed no notable differences between the two

groups in terms of age (P = 0.26), BMI (P = 0.29), percentage of males (P

= 0.33), and tumor size (P = 0.80), indicating that the groups were highly

comparable.

Assessment of quality

This review included seven retrospective cohort studies that we

assessed using the ROBINS-I instrument. The evaluation indicated that

Cong13 and Liu16 had a 'low' overall risk of bias, Li15 was deemed 'critical,'

and the other four studies were rated as having a 'moderate' risk. Figure 2

provides a comprehensive overview of the quality evaluation outcomes.

Primary Outcome Measures

The meta-analysis results showed that RG had notable advantages

over 3D-LG in several key metrics. Notably, it correlated with a markedly

reduced estimated blood loss ([WMD] -10.97, 95% Confidence Interval

[CI] -15.74 to -6.20; p < 0.00001) (refer to Figure 3-A) and a quicker

onset of the time to first postoperative flatus (WMD -0.43, 95% CI -0.64
to -0.21; p < 0.0001) (refer to Figure 3-B). However, the two surgical

methods showed no statistically distinction in the OT (WMD -1.04, 95%

CI -6.47 to 4.39; p = 0.71) (refer to Figure 3-C).

Secondary Outcome Measures

The meta-analysis revealed that RG had a notably reduced LNY

count in comparison to 3D-LG ( [WMD] -3.64, 95% Confidence Interval

[CI] -5.33 to -1.95; p < 0.001) (refer to Figure 4-A). Conversely, the two

methods showed no notable statistical differences regarding LOHS

(WMD -0.57, 95% CI -2.38 to 1.25; p = 0.54) (refer to Figure 4-B) and

postoperative complications ( [OR] 0.92, 95% CI 0.67 to 1.26; p = 0.60)

(refer to Figure 4-C).

Sensibility analysis

The meta-analysis revealed substantial heterogeneity in some

outcomes, with I² values reaching 78% for time to first postoperative

flatus and up to 95% for LOHS. Further, we conducted sensitivity

analyses by sequentially excluding each study with the objective of

exploring the sources of this heterogeneity. However, despite these

exclusions, neither the degree of heterogeneity nor the overall

conclusions of the meta-analysis were significantly altered, thereby

reinforcing the robustness and stability of our results.

Discussion

Results from the meta-analysis of seven studies revealed that RG

outperforms 3D-LG in terms of EBL. Robotic surgical systems are noted

for their high-definition, magnified 3D imaging and the flexibility and

stability of their robotic arms. These features enable surgeons to better

delineate anatomical structures and conduct more precise dissections,

particularly in challenging anatomical regions such as the subpyloric area

and the superior edge of the pancreas. Consequently, this precision

contributes to a significant reduction in intraoperative bleeding 20.

Furthermore, the robotic platform's capability to operate three robotic

arms and one camera arm simultaneously lessens the dependency on

assistant collaboration, unlike 3D laparoscopy. This reduction in reliance

improves efficiency in urgent situations, such as intraoperative bleeding,

by minimizing delays caused by communication issues and facilitating

rapid hemostasis. Additionally, robotic systems offer enhanced

intraoperative bleeding control compared to 3D laparoscopy, employing

advanced techniques like ultrasonic scalpels and vascular clips alongside

other technical measures for effective hemostatic management.

The meta-analysis of seven studies demonstrated that RG leads to a

shorter time to the first postoperative flatus compared to 3D-LG.

Specifically, Song (2023) reported a first postoperative flatus time of 2.70

± 0.79 days in the 3D-LG and 2.43 ± 0.61 days in the RG. This indicates

that robotic surgery may be more advantageous for the recovery of

gastrointestinal function postoperatively, aligning with the results of

Kim21 et al. One potential reason for this benefit is that the robotic
surgical system's three robotic arms are entirely controlled by the

surgeon, which minimizes the need for assistance-related manipulation of

non-surgical areas (such as the jejunoileum and transverse colon). This

reduction in external traction and compression likely decreases

gastrointestinal interference and promotes quicker recovery of

gastrointestinal function after surgery. Improved gastrointestinal recovery

can reduce the incidence of postoperative complications, accelerate the

resumption of normal eating, shorten LOHS, and potentially lower

overall patient hospital costs.

The comprehensive review found no notable disparity in OT

between RG and 3D-LG. This conclusion aligns with Song 17, who

documented OT of 171.96 ± 47.31 minutes for 3D-LG and 167.22 ±

45.70 minutes for RG, with no statistically significant difference (p =

0.289). Several factors contribute to the longer OT in robotic distal and

total gastrectomy procedures, including the setup time for the robotic
arms and the varying levels of proficiency among the operating team. As

robotic surgical systems continue to advance and as coordination among

surgeons, assistants, and surgical staff improves, it is anticipated that the

OT for RG will further decrease.

Current research generally indicates that RG is superior in the

number of LNY compared to 2D laparoscopic gastrectomy, particularly

for lymph nodes in Groups 6, 7, 10, 11p, and 14v 22,23. However, our meta-

analysis found that RG was associated with fewer LNY compared to 3D-

LG. Similarly, Liu16 reported that the 3D-LG had a significantly higher

number of LNY than the RG (29.33 ± 13.02 vs. 24.82 ± 9.50, p = 0.002).

This discrepancy may be attributed to the superior depth perception

offered by 3D-LG, which enhances the surgeon's ability to perform

dissection in complex areas. Additionally, the absence of tactile feedback

with robotic systems might prompt surgeons to use a more conservative

dissection approach to ensure safety during complex lymph node

dissections. The number of LNY is crucial as it correlates with the

pathological stage and prognosis of GC. Studies suggest that dissecting at

least 16 lymph nodes in patients with stages II to III significantly

improves prognosis24. The eighth edition of the AJCC guidelines

recommends dissecting a minimum of 16 regional lymph nodes 25. Despite

our findings that RG resulted in fewer LNY compared to 3D-LG, both

techniques successfully achieved the target of dissecting more than 16

lymph nodes, demonstrating their effectiveness and safety in lymph node

dissection.

Our comprehensive review of seven research papers found no

notable variation in the rate of post-surgery complications between RG

and 3D-LG. Gong26 et al. The meta-analysis similarly found no notable

difference in post-surgery complications between robotic and

laparoscopic methods. According to Liu16, there was no meaningful

statistical disparity in the total complication rates (12.9% for 3D-LG

compared to 17.1% for RG) or in the rates of major complications (0.7%

versus 4.3%) between the groups. Similarly, Cui 14 observed an overall

complication rate of 10.8% (37/344) in the 3D-LG compared to 12.8%

(24/187) in the RG, with no statistical significance (P = 0.473). These

findings suggest that both 3D laparoscopic and robotic systems offer

comparable safety and efficacy regarding postoperative complications in

GC.

Limitations

This meta-analysis represents the first attempt to compare the

efficacy of RG with 3D-LG for GC. Nonetheless, several significant

limitations need to be acknowledged. First, the analysis included only

seven case-control studies with relatively small sample sizes, which

contributed to a low study quality and exhibited moderate to high

heterogeneity. Additionally, all included studies were conducted within

China, which may introduce regional bias. Due to data constraints, this
meta-analysis was unable to conduct further subgroup analyses (e.g.,

separating distal gastrectomy from total gastrectomy) to explore sources

of heterogeneity and could not evaluate data on postoperative

anastomotic leakage or survival outcomes. Therefore, additional well-

designed RCTs are necessary to confirm and build on these results.

Conclusions

This meta-analysis of seven cohort studies demonstrates that RG is

both safe and feasible for treating GC. The procedure shows notable

advantages over 3D-LG, particularly in reducing EBL and shortening the

time to the first postoperative flatus. Nonetheless, further multicenter

randomized double-blind controlled trials are necessary to confirm

additional potential benefits and assess the long-term effects of RG.

Declaration of Interest Statement

All authors disclosed no relevant relationships.

Author Contributions
 Each author contributed to the study's conceptualization and design.

Data gathering and analysis were carried out by WQW and LJ. However,

processing of data and images was managed by WQW. On the other hand,

the drafting of the initial manuscript was done by LW, which was

reviewed and enhanced by CJ to improve its intellectual content.

Therefore, the authors made great contributions towards the study.

Data Availability Statement

For any contributions and additions, one can directly contact the

authors. However, the study also includes the original contributions

discussed in the article.

Funding： Mian Yang Health Commission 2020 Scientific Research

Project Encouragement Project（202024）

Acknowledgments: None

Ethics declarations: Not applicable.

 Consent for publication: Not applicable.

Competing interests: The writers affirm that they possess no

conflicting interests.

Figure legend

Fig. 1: The PRISMA Flowchart

Fig. 2: Quality Evaluation Chart using ROBINS-I Tool

Fig. 3: A - Forest Plots of the EBL; B - Forest Plots of the time to

first postoperative flatus; C - Forest Plots of OT

Fig. 4: A - Forest Plots of LNY; B - Forest Plots of LOHS; C -

Forest Plots of postoperative complications

Table

Table 1: Studied characteristics and outcome measures

Table 2 displays the demographic information of the research

projects.

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