First-in–New Zealand: robotic subtotal D2 gastrectomy

We report the successful completion of the first robotic subtotal gastrectomy performed in New Zealand, representing a significant milestone in the evolution of minimally invasive upper gastrointestinal surgery nationally. Laparoscopic subtotal gastrectomy remains technically demanding, particularly because of the complexity of D2 lymphadenectomy and Roux-en-Y reconstruction, and carries a risk of peri-operative morbidity. The adoption of robotic platforms offers the potential to enhance technical precision and improve peri-operative outcomes in this setting.

A 47-year-old woman with poorly cohesive adenocarcinoma containing signet ring cells arising within a 15mm gastric ulcer proximal to the incisura received neoadjuvant fluorouracil, leucovorin, oxaliplatin and docetaxel (FLOT) chemotherapy. Staging laparoscopy and pre-operative computed tomography demonstrated no evidence of metastatic disease. She subsequently underwent robotic subtotal gastrectomy with D2 lymphadenectomy and Roux-en-Y reconstruction. Intraoperative gastroscopy was used to confirm a 5cm macroscopic margin, and frozen section analysis demonstrated clear resection margins. The Roux-en-Y reconstruction was completed intracorporeally, with closure of mesenteric defects using a 0 V-Loc™ suture. Anastomotic integrity was confirmed with a negative methylene blue leak test. Total operative time was 300 minutes, including frozen section analysis, and blood loss was minimal. The post-operative course was uncomplicated, with management according to an enhanced recovery pathway and discharge on post-operative day 4. Final histopathology demonstrated ypT1aN0 disease with no nodal metastases identified (0/18 lymph nodes). The patient subsequently completed adjuvant chemotherapy.

This case underscores the ongoing evolution of minimally invasive surgery in the management of upper gastrointestinal malignancy and builds upon the progressive development of our institutional robotic programme, within which we recently reported the first robot-assisted oesophagectomy in New Zealand.¹ The robotic platform provides high-definition three-dimensional visualisation and improved surgeon ergonomics, facilitating meticulous suprapancreatic and coeliac axis lymphadenectomy. Enhanced instrument articulation and improved access are particularly advantageous during intracorporeal reconstruction, including hand-sewn gastrojejunostomy, jejunojejunostomy and mesenteric defect closure. Furthermore, robotics may reduce inadvertent pancreatic trauma, minimise blood loss and improve technical consistency in patients with elevated body mass index or anatomically challenging upper abdominal pathology.² Potential challenges include access and exposure in multi-quadrant surgery, increased setup requirements and dependence on institutional experience and workflow familiarity.

Accumulating evidence suggests superior short-term post-operative outcomes in robotic gastrectomy compared with conventional laparoscopic gastrectomy. Meta-analysis of randomised trials and propensity-matched studies show the overall complication rate was 18% lower in the robotic group, with on average 29mls less blood loss, which translates to a 40% lower blood transfusion rate, a 62% lower conversion rate, 0.69 days shorter length of stay and 3.25 more lymph nodes harvested.³ Despite these peri-operative advantages, current evidence indicates equivalent oncological and long-term survival outcomes between robotic and laparoscopic approaches.^4,5

The successful execution of this case demonstrates the feasibility and safety of robotic subtotal gastrectomy within New Zealand and establishes a foundation for a wider application in complex upper gastrointestinal oncology. Prospective data collection and outcome analysis are required to monitor and evaluate peri-operative outcomes, oncologic efficacy and cost effectiveness in our setting. Nevertheless, broader implementation may remain challenging given the low procedural volumes across many centres and the resource limitations within the New Zealand healthcare system.