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van den Berg et al. Mini-invasive Surg 2019;3:23 I http://dx.doi.org/10.20517/2574-1225.2019.07 Page 7 of 9

Jejunal pouch
The most common reconstruction technique after a total gastrectomy is the oesophago-jejunostomy Roux-
en-Y reconstruction. However, this technique is associated with complaints like reflux, weight loss, and
[43]
dumping syndrome . One of the techniques performed to potentially improve long-term outcome is the
[44]
formation of a jejunal pouch . A recent meta-analysis which includes 25 studies comparing reconstruction
with or without a pouch, mainly in patients who underwent open surgery, showed a reduction of the risk
[45]
of dumping syndrome , reduced heartburn and oesophagitis, as well as a significantly higher body mass
2
2
index (22.2 kg/m vs. 20.9 kg/m ; WMD 1.28; 95%CI: 0.61-1.94). However, minimal reports of jejunal pouch
[46]
reconstruction in a laparoscopic approach have been published so far .
NOVEL TECHNIQUES
Robotic gastrectomy
Robotic surgery for gastric cancer remains experimental and controversial, in part due to the lack of RCTs.
However, several Western and Asian centres have reported their series of robotic surgery in gastric cancer
patients. A meta-analysis comparing LG to robotic gastrectomy included three non-randomised controlled
[47]
studies . Robotic gastrectomy was associated with a longer operation time but reduced intra-operative
blood loss. No differences were found in lymph node yield, morbidity, mortality, and LOS. The authors
therefore concluded that a robotic approach is safe and feasible, however, that further research is warranted
to investigate the effect on long-term oncological outcomes. More recently, a meta-analysis which included
19 studies comparing LG with robotic gastrectomy again showed that robotic gastrectomy was associated
[48]
with a prolonged operation time (WMD - 49.05 min; P < 0.01) . In addition, reduced intraoperative blood
loss (WMD - 24.38 mL; P < 0.01) as well as higher costs were observed (WMD - 3944.8 USD; P < 0.01).
Again, there were no differences in morbidity, mortality, LOS, and lymph node yield. In general, robotic
gastrectomy is as safe as LG. However, as the robotic approach is associated with longer operation times
and higher costs, without any significant advantages over LG, the laparoscopic approach for gastric cancer
is generally preferred.

CONCLUSION
Minimally invasive gastrectomy is feasible and safe in eastern and western countries. It has benefits for
both early and advanced gastric cancer, as well as total and subtotal gastrectomy. The increasing worldwide
trend for centralisation of gastric cancer treatment facilitates the use of a laparoscopic approach. These
both aspects will increase treatment with neo-adjuvant and adjuvant chemotherapy, whilst LG also
improves tolerance of adjuvant chemotherapy. Short term benefits include less blood loss, decreased LOS
and lower postoperative morbidity and mortality. Quality of surgery markers such as lymph node yield
and resection margin status appear to be comparable to open surgery. Long term survival data available
currently indicate overall and disease-free survival is not inferior to open surgery, however the results from
ongoing RCTs are awaited.

DECLARATIONS
Authors’ contributions
All authors had equal contribution in the writing process of this article.

Availability of data and materials
Not applicable.

Financial support and sponsorship
None.