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How Many Cases of Laparoscopic and Robotic Distal Gastrectomy Are Required to Achieve Proficiency? A Systematic Review

Authors
Kai Siang CHAN1,2, Aung Myint OO1,2,3

Affiliations

  1. Department of General Surgery, Tan Tock Seng Hospital, Singapore
  2. Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore
  3. Yong Loo Lin School of Medicine, National University of Singapore, Singapore

Introduction
Minimally-invasive distal gastrectomy (MIDG) has non-inferior oncological outcomes compared to open distal gastrectomy for gastric cancer. Robotic distal gastrectomy (RDG) may have a higher lymph node (LN) harvest compared to laparoscopic distal gastrectomy (LDG). This study aims to evaluate the number of cases required to surmount the LC (i.e. NLC) in MIDG.

Methods
A systematic review on PubMed, Embase, Scopus and the Cochrane Library from inception till August 2022 was performed for studies reporting LC in LDG and/or RDG. NLC on reduced-port / single-port MIDG only were separately analysed. Studies reporting various extents of gastrectomy were included if there were ≥75% of cases with MIDG. Poisson means (95% confidence interval (CI)) was used to determine NLC. Negative binomial regression was used for comparative analysis.

Results
A total of 45 articles with 71 data sets (LDG n=45, RDG n=24) were analysed. There were 7776 patients in total (LDG n=5516, RDG n=2260). Majority of studies were conducted in East Asia (n=68/71). Majority (76.1%) of data sets used non-arbitrary methods of analyses. The overall NLC for RDG (excluding single/reduced-port MIDG) was significantly lower compared to LDG (RDG 22.4 (95% CI: 20.4-24.5); LDG 46.7 (95% CI: 44.1-49.4); incidence rate ratio 0.48, p<0.001). The overall NLC for reduced-port LDG and single-port LDG were 25.7 (n=3 data sets, 95% CI: 20.3-32.1) and 32.0 (n=2 data sets, 95% CI: 24.6-40.9) respectively. The median number of laparoscopic gastrectomy (LG) cases prior was 0 (interquartile range (IQR) 0-105) for LDG and 159 (IQR 101-305.3) for RDG. Meta-regression analysis did not show a significant impact prior experience in LG, extent of lymphadenectomy and intracorporeal vs extracorporeal anastomosis had on overall NLC for LDG and RDG.

Conclusion
NLC for RDG is shorter compared to LDG, but this may be due to prior experience in LG and ergonomic advantages of RDG.