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Shimada et al. Mini-invasive Surg 2019;3:7 I http://dx.doi.org/10.20517/2574-1225.2018.78 Page 9 of 11

experts that the use of a surgical robot may be beneficial for more complicated procedures, including more
[36]
advanced cancer disease . Although a number of robot-assisted gastrectomy (RAG) are rapidly increasing
since RAG has been covered by insurance in April 2018 in some limited institutes, several issues remain
to be solved regarding clinical indication, short- and long-term outcomes, cost- effectiveness, and stress
[40]
of surgeons [37-39] . Recently, Li et al. reported a retrospective PSM analysis that the overall postoperative
complication rate was 13.4% and 11.6% in the RAG and LG groups, with no significant difference, and the
3-year OS and recurrence rates of the RAG and LG groups were also comparable (78.6% vs. 74.1%; 18.8% vs.
21.4%; respectively). Moreover, multicenter prospective study of RAG vs. LG for gastric cancer including
AGC has been published in 2016, which demonstrated no significant differences between groups were
noted in overall complication and mortality rates, estimated blood loss, rates of open conversion, diet
[41]
build-up, or length of hospital stay, except for operative time and total costs .

Thus, although RAG has evident benefits, it is difficult to assess and compare some advantages at the
moment with respect to traditional surgery. Larger randomized prospective trials, well-designed cost-
effectiveness analysis, and high-quality comparative-effectiveness research are needed before robotic
resection can be considered an acceptable alternative for patients with AGC. Probably, the main indication
for RAG is when it serves as an adjunct to laparoscopic resection in selected patients with local advanced
tumors requiring a D2 LND.

CONCLUSION
LG with D2 lymph node dissection by expert surgeons under the cautious indications could be acceptable
treatment for locally AGC. On the other hand, we should keep searching for solutions to the technical or
oncological issues, and long-term outcome of phase III study should be warranted for standard treatment.

DECLARATIONS
Authors’ contributions
Retrieved the data and cited literatures: Shimada M
Provided technical and clinical advices for Shimada M: Amaya S, Munemoto Y, Mitsui T
Read and approved the final manuscript: All authors

Availability of data and materials
Not applicable.

Financial support and sponsorship
None.

Conflicts of interest
All authors declared that there are no conflicts of interest.

Ethical approval and consent to participate
Not applicable.

Consent for publication
Not applicable.

Copyright
© The Author(s) 2019.