Reply to: 464-625: Re Role of robotic gastrectomy using da Vinci system compared with laparoscopic gastrectomy: initial experience of 20 consecutive cases

Abstract

To the Editor: We thank Dr. Hanisch and Dr. Ziogas [1] for their interest in our article regarding robotic surgery [2] and for their comments. The minimally invasive approach to surgery for gastric cancer has been debated since its first clinical application. At the same time, advanced technique brought the usage of medical robots to the surgical field, which induced another round of debates. The same issues debated for laparoscopic surgery have been debated for robotic gastrectomy including the problems of technical feasibility, long-term outcomes, and cost effectiveness. Among the numerous subjects to be discussed, we focused on rapid adaptation to robots by surgeons familiar with laparoscopic gastrectomy. Robotic surgery is not a new type of surgery but rather a form of advanced laparoscopic surgery because robotic surgery is laparoscopic surgery using instruments with seven degrees of freedom (Endo-wrist instrument, Intuitive Surgical, Sunnyvale, California, USA) but no tremors under a three-dimensional imaging system. Therefore, we focused our report on the da Vinci surgical system, the most advanced laparoscopic tool to date. Efficient operation of this robotic system can be demanding initially. However, the larger experience with robotic gastrectomies shows that initial robotic gastrectomies can be performed by experienced laparoscopic surgeons with satisfactory postoperative outcomes [3]. As exhibited by the results, the postoperative outcomes of initial robotic surgeries were comparable with those of laparoscopic surgeries performed after the learning curve period. The surgeon in the study had performed 177 laparoscopic gastrectomies before starting the robotic gastrectomy [2], which is many more than the 50 laparoscopic gastrectomies at least suggested to overcome the learning curve effect [4, 5]. Thus, we assumed that experienced laparoscopic surgeons could perform robotic gastrectomies with ‘‘a certain level of skill’’ even in an initial series. Although several recent reports have provided evidence that laparoscopic gastrectomy is safe for advanced cancers [6, 7], generally accepted indications for laparoscopic gastrectomy still are limited mostly to early gastric cancer. It is difficult to overcome the learning curve effect of laparoscopic gastrectomy in the West because early gastric cancer there is rare, as Hanisch and Ziogas [1] have described. However, many suggestions for reducing the learning curve effect for advanced laparoscopic procedures have been offered, such as formal training courses, cadaveric resection, close intraoperative supervision by experts, the assistance of experienced surgeons, and careful patient selection during the initial learning period, if possible [8]. With these strategies, surgeons in the West may reduce the learning curve period, although patients and surgeons may not be fully assured. A major concern regarding the application of robotic gastrectomy is whether its high cost will produce a greater benefit. Although several studies regarding this question have been published, no concrete conclusion has been reached [9–11]. Due to the high cost of robotic surgery, conducting a prospective randomized trial is almost impossible. Therefore, well-designed retrospective analyses need to be performed after the accumulation of experience. J. Song Department of Surgery, Kyungpook National University Hospital, Daegu, Korea e-mail: jyewon@gmail.com