A novel single‐port robot for total gastrectomy to treat gastric cancer: A case report (with video)

Multiport robots are now widely used for total gastrectomy for gastric cancer, while there is almost a void of research on whether single‐port (SP) robots can be used for total gastrectomy. Here, we report a case of a 75‐year‐old female patient who was diagnosed with gastric cardia adenocarcinoma by gastroscopy and underwent total gastrectomy assisted by the SHURUI SP robot. We successfully accomplished total gastrectomy and D2 lymph node dissection using the novel SP robotic platform. The patient was discharged from the hospital successfully with no complications during or after the surgery. Pathologic diagnosis showed adenocarcinoma of the gastric mucosa with partial signet‐ring cell carcinoma, and no metastasis was found in the 29 cleared lymph nodes. The use of the SHURUI SP robot for total gastrectomy in treating gastric cancer is both technically feasible and safe.


| INTRODUCTION
Gastric cancer ranks as the world's fifth most frequently occurring cancer and the third leading cause of cancerrelated death.Surgery remains the primary treatment option for gastric cancer.The use of robot-assisted surgery to treat gastric cancer has become widespread.However, single-port (SP) robots have been developed to achieve less surgical trauma and more aesthetically pleasing surgical incisions.Successful case reports of robotic total gastrectomy (RTG) for locally progressive gastric cancer using the da Vinci SP platform establish the feasibility of SP robotic application for total gastrectomy. 1The SHURUI SP surgical robot is a new robot platform.At present, the robot has only been approved for marketing by the National Medical Products Administration of China, and its safety and efficacy for radical prostatectomy have been proven. 2The purpose of this study is to describe the first clinical experience of this new SP robot system in RTG and to report its feasibility and safety.

| CASE PRESENTATION
A 75-year-old female patient presented to our hospital with abdominal pain.Gastroscopy confirmed adenocarcinoma This manuscript has not been published or submitted for publication elsewhere except as a short abstract in the proceedings of a scientific conference or symposium.
of the gastric cardia (Figure S1), and further examination confirmed that there was no distant metastasis of the lesion, so we planned to perform RTG.The patient's body mass index was 25.3 kg/m2 , and there was no history of previous abdominal surgery.Informed consent for surgery was obtained from the patient.This study was approved by the Ethics Committee of Wenzhou People's Hospital (Approval number: EC-20230506-02).
After anesthesia was completed, a 12-mm auxiliary operating port was placed in the patient's left anterior axillary line for suction and retraction of tissues and clamping of blood vessels, and a 3.5-cm incision around the umbilicus was made on the left side of the umbilicus to serve as the main operating port.The base of the SP robot was placed on the upper left side of the patient, and the first assistant was positioned on the left side of the patient (Figure 1).A multichannel trocar was inserted through an SP on the left side of the umbilicus.A 3D electronic endoscope was placed in the 12 o'clock position, and tissue grasping forceps, fenestrated bipolar forceps, and an electric hook were positioned in the 9, 6, and 3 o'clock positions, respectively.
Following the 5th edition of the Japanese Treatment Guidelines for Gastric Cancer, 3 we conducted a total gastrectomy and D2 lymph node dissection.Figure 2 and Figure S2 illustrate several significant stages of the operation, with Supporting Video 1 demonstrating the surgical procedure in brief.Then, surgeons made a 6-cm incision in the upper abdomen to extract the removed stomach from the abdominal cavity.Finally, a Roux-en-Y anastomosis was performed outside of the body.The jejunum  was cut 20 cm from the ligament of Treitz and then anastomosed side to side of the jejunum 60 cm distal to the severed end using a linear stapler.The body of the circular stapler (ETHICON CDH25A) was placed at the severed end of the jejunum and docked to the anvil placed in the esophageal stump, the anastomosis was excited, and, finally, the severed end of the jejunum was closed with a linear stapler.The 12-mm auxiliary incision was utilized to place an esophagojejunal anastomotic drain.
The total operation time was 411 minutes, including 39 minutes of docking time for assembling, connecting, and adjusting the robot and robotic arm, 238 min for dissection and 98 min for digestive tract reconstruction, and the remaining time for cleaning and placement of drains.There was 90 mL of bleeding during the operation, and the patient was transferred to the general surgical ward.On the fifth day postoperation, the patient was able to drink water, and was placed on a liquid diet on the seventh day post-operation, and then a soft diet on the 10th day postoperation.Pathologic diagnosis showed adenocarcinoma of the gastric mucosa with partial signet-ring cell carcinoma with pT3N0M0 staging.There were no indications of metastasis in any of the 29 cleared lymph nodes, and the tumor margins were negative.At the 3-month postoperative follow-up, the patient had no Clavian grade ≥3 surgical complications.Figure S3 depicts both the whole stomach specimen and the surgical incision.

| DISCUSSION
It has been two decades since Hashizume and Sugimachi initially documented the utilization of robots for gastric cancer surgery. 4At present, the safety of robot-assisted total gastrectomy with D2 lymph node dissection for gastric cancer is unquestionable, and it tends to gradually replace laparoscopic total gastrectomy for gastric cancer.On the contrary, there are few studies on total gastrectomy for gastric cancer using SP robots.The intraoperative blood loss, in this case, was 90 mL, which is lower than the mean value of the group that underwent multiport robotic surgery (154.37 ± 89.68 mL), as reported by Yang et al. 5 Several studies have reported the advantage of robotic gastrectomy in reducing intraoperative bleeding over laparoscopic surgery. 6However, whether SP robotic surgery is more advantageous than multiport robotic surgery in reducing intraoperative bleeding remains to be determined by studies with larger sample sizes.In addition, our operative time was longer than that of a conventional robot performing a similar procedure.However, we must recognize that this is the first time we have used an SP robotic platform for modified surgery at our center.As we become more familiar with the docking of the platform and the surgical procedure, we will be able to significantly reduce the operative time.
Adequate lymph node clearance is essential for patient prognosis and staging accuracy. 7,8And Ye et al. found that the removal of more than 30 lymph nodes was an independent risk factor for bleeding after total gastrectomy.This may be because adequate lymph node dissection may damage blood vessels and increase the risk of postoperative intra-abdominal hemorrhage. 6Whereas a total of 29 lymph nodes were cleared in the present case, less intraoperative bleeding and the absence of serious postoperative complications may be associated with this.It is worth mentioning that since the SP robot lacks the ultrasonic knife for lymph node dissection, its increased difficulty in lymph node dissection and risk of bleeding may be a major reason limiting the application of the SP robot for radical gastric cancer surgery.
In addition, there are some observations that need to be added in the course of this case study.First, the mechanical arm of the SP robot with a serpentine arm has some flexibility and low strength compared with the inflexible robotic arm of the multiport robot.The electric hook causes the serpentine arm and even the surgical field to tremble when cutting off tissues with significant tension, necessitating the surgeon in charge to exercise caution to prevent damage to the surrounding tissues and blood vessels.Second, the SP robot's camera and robotic arm are integrated into one entrance point, enabling the whole surgical field to move as a singular unit pivoting on the entrance of the abdominal wall while reducing potential conflicts between the robotic arms.However, this leads to a narrower field of view compared with multiport robotic and laparoscopic surgery.Additionally, the movement of the robotic arm can obstruct the field of view and adjustment of the endoscope's orientation is often necessary, resulting in increased surgical time and difficulty.Finally, the new SP robot, similar to the da Vinci SP robotic platform, lacks an ultrasonic knife and suction device due to port limitations.Hopefully, it will be improved in the future in subsequent models.Overall, the study provides evidence that supports the safety and effectiveness of using an SP robotic system for total gastrectomy in gastric cancer patients.

AUTHOR CONTRIBUTIONS
Yuncheng Luo: Manuscript writing.Yiren Hu: Operating surgeon, manuscript writer, and editor.Zhangwei Yang, Pengwei Wang: Attending physicians of the presented patient.Min Li, Bo Wu: Data curation.Huachao Zheng: Video preparation.Dandan Bao: Manuscript revision and preparation of materials.All authors contributed to the article and approved the submitted version.
Working position of the SP robotic platform at the time of the operation.(B) The SHURUI SP robotic system in an undeployed state.
F I G U R E 2 Surgical procedure for total gastrectomy using the SHURUI SP robotic system.(A) Ligation of the left gastric artery.(B) Severed duodenum.