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toward each landmark of surgical scenes, while we try to prevent the organ injury by delicate manipulation.
For non-touch isolation of the tumor, gauze is frequently used to retract or lift up stomach, and to absorb
bleeding or lymphatic fluid, which can make dry field.

FUTURE PERSPECTIVE
Ongoing prospective studies
To provide answers to the extent of laparoscopic LND in AGC, phase III trials to confirm the non-
inferiority of this procedure to open are ongoing. In Japan, the short-term outcome of the randomized
controlled trial to evaluate laparoscopic vs. open surgery for AGC (JLSSG0901) has been published in the
30th annual meeting of the Japan Society for Endoscopic Surgery in December 2017, which demonstrated
no significant differences in grade 3 and higher postoperative complications between two groups (3.1%
[28]
vs. 4.7%) . In China, CLASS-01 (NCT01609309) has been conducted and the short-term outcomes were
[3]
already published, demonstrating no difference between LG and OG (15.2% vs. 12.9%) in morbidity rate .
The final outcomes, namely 3-year DFS, are awaited the publication before long. In Korea, the short-term
[4]
outcomes of KLASS-02 (NCT01456598) were disclosed in ASCO 2016 meeting , which demonstrated less
complication rate (16.4% vs. 24.3%), less use of analgesics, and faster recovery in LG group. Its primary
endpoint, or 3-year relapse free survival, will be analyzed also anytime soon. We should wait for the final
results of these three phase-III trials. Especially, not only long-term survival rate but also difference of
recurrence pattern should be carefully checked the specific feature in recurrences after LG. Concerning
LTG, a Korean group has launched multicenter randomized controlled trial for application of LTG with
LND for gastric cancer (KLASS-06; NCT03385018) in 2018. However, some researchers suggested that LTG
for AGC should be carried out on a trial basis until the definitive results are available, and surgeons should
be particularly attentive to No.10 or 11d LND without lessening the quality of LND compared with open
[29]
total gastrectomy . The data from these studies are expected to decide future directions for the indication
of LG for AGC.

Neo adjuvant chemotherapy
A few phase III trials and retrospective studies have provided supportive evidence that NAC results in
high compliance, as well as other favorable factors such as high rate of R0 resection and tumor regression,
which lead to a better prognosis [17,30,31] . There have been many RCT comparing LG with OG as mentioned
above. However, very few on the comparison between LG + NAC and OG + NAC. Recently, a phase II trial
to which evaluate the safety and efficacy of LG after NAC for distal advanced gastric cancer and which
provide theoretical basis for conducting a multicenter phase III verification clinical trial conducted in
[32]
China . Long term follow up and piling up the cases will be necessary in the future.
Conversion surgery
The term “conversion therapy” describes a therapeutic concept in which the treatment strategy is converted
by chemotherapy to curative surgery through an oncosurgical approach. The terms “conversion surgery”
[33]
or “adjuvant surgery” can be applied to the operations performed for conversion therapy. Yoshida et al.
proposed that the indications for conversion therapy include patients with marginally resectable metastasis,
some patients who are incurable and unresectable except certain circumstances of local palliation needs,
and patients with noncurable metastasis in whom an R0 resection can be expected after a satisfactory
response to chemotherapy. There were long-term survivors who underwent conversion surgery for such
patients. The median survival time of the patients who underwent surgical resection was 30.5 months, as
[34]
opposed to those who received chemotherapy alone at 11.3 months . If the feasibility of this concept will
be estimated in the near future by large-scale retrospective and prospective cohort studies, laparoscopic
approach may be applied to treatment for minimal invasive surgery.

Robotic surgery
Robotic surgical instruments seem to have potential to cover disadvantages of LG, such as insufficiency
[35]
of forceps’ degree of freedom or surgeons’ physiological tremor at the tip of device . It is suggested by