# Combined splenectomy and robotic subtotal gastrectomy with short gastric vessel salvation for gastric cancer with SANT of the spleen: A case report

## TL;DR

This case report describes a successful combined surgical approach for gastric cancer with a splenic mass, using advanced imaging and robotic techniques to preserve blood flow and digestive function.

## Contribution

The paper introduces a novel surgical method combining splenectomy and subtotal gastrectomy with vessel preservation using RUS™ and indocyanine green.

## Key findings

- Combined splenectomy and subtotal gastrectomy can be safely performed with proper vessel preservation.
- RUS™ software provides real-time guidance for vascular anatomy during surgery.
- Indocyanine green confirms adequate blood flow to the remnant stomach.

## Abstract

Surgical methods to treat gastric cancer are quite straightforward. However, in rare cases of gastric cancer accompanied by a splenic mass that requires splenectomy, treatment options become much more complicated. Splenectomy can effectively treat splenic masses, but without adequate salvation of vessels, could increase the risk of ischemic necrosis if simultaneously performed with distal subtotal gastrectomy.

The patient is a 40-year-old male diagnosed with cancer at the stomach angle. Abdominal CT also confirmed a huge mass in the spleen, suspected to be sclerosing angiomatoid nodular transformation (SANT). 3-dimensional CT angiography and RUS™ software were used to visualize the patient's intraabdominal anatomy before and throughout surgery. The robotic approach was used to incorporate said technologies while intricately preserving the short gastric vessels. Indocyanine green was injected intravenously to confirm adequate perfusion to the remnant stomach.

Subtotal gastrectomy can be performed concurrently with splenectomy if the splenic and vascular anatomies allow for a safe splenectomy and preservation of the short gastric vessels. The feasibility of the operation should be confirmed by meticulous exploration of the patient's specific anatomy before and during surgery.

This report demonstrates a successful method to perform subtotal gastrectomy with splenectomy. Despite its complexity and time-consuming nature, this procedure can greatly benefit patients by allowing safe resections and maximal preservation of digestive functions, nutrition, and quality of life. As a result, we recommend that it be more readily considered when treating complex cases like this.

•Combined splenectomy and subtotal gastrectomy increases risk of ischemic necrosis.•RUS™ can provide intraoperative real-time guide of patient-specific vascular anatomy.•RUS™ can help assess feasibility of combined splenectomy and subtotal gastrectomy.•Indocyanine green injection should be used to confirm adequate perfusion.

Combined splenectomy and subtotal gastrectomy increases risk of ischemic necrosis.

RUS™ can provide intraoperative real-time guide of patient-specific vascular anatomy.

RUS™ can help assess feasibility of combined splenectomy and subtotal gastrectomy.

Indocyanine green injection should be used to confirm adequate perfusion.