# Balancing Surgical Innovation with Indications: A Multicenter Retrospective Comparison of Reduced-Port Distal Gastrectomy Using da Vinci SP Versus Multi-Port Robotic Platforms from the KLASS-13 Cohort

## TL;DR

This study compares single-port and multi-port robotic distal gastrectomy for gastric cancer, finding that the single-port method offers faster recovery without compromising safety in early-stage cases.

## Contribution

The study provides multicenter evidence on the safety and feasibility of single-port robotic distal gastrectomy for early-stage gastric cancer.

## Key findings

- Single-port robotic surgery had longer operative times and fewer retrieved lymph nodes but met cancer staging standards.
- Patients with single-port surgery had faster postoperative recovery and shorter hospital stays.
- Complication rates were comparable between the two approaches, supporting the safety of the single-port method.

## Abstract

Robotic gastrectomy is increasingly used for gastric cancer because it provides enhanced visualization and precise instrument control. As robotic systems have evolved, surgeons have developed reduced-port techniques to further minimize surgical trauma. More recently, a single-port robotic platform has enabled most surgical steps to be performed through a single main incision, with the goal of improving postoperative recovery. However, it is important to ensure that reducing the number of ports does not compromise cancer-related safety. We analyzed data from a multicenter registry of 820 patients who underwent reduced-port robotic distal gastrectomy, comparing outcomes between the single-port robotic system and the conventional multi-port platform. Although the single-port approach was associated with longer operative time and fewer retrieved lymph nodes, lymph node counts remained above internationally accepted standards for accurate cancer staging. Patients who underwent a single-port approach experienced faster postoperative recovery without an increase in short-term complications. These findings suggest that single-port robotic distal gastrectomy is safe and feasible in carefully selected patients, and its use should currently be limited to early-stage gastric cancer pending further long-term evidence.

Background: The da Vinci single-port reduced-port robotic distal gastrectomy (spRRDG) approach shows promise in enhancing surgical recovery while maintaining oncologic safety, but robust multicenter comparative data across diverse robotic platforms are lacking. We aimed to compare clinical outcomes between spRRDG and conventional RRDG (cRRDG) using Korean Laparoendoscopic Gastrointestinal Surgery Study-13 data. Methods: Clinicopathologic variables and perioperative outcomes concerning 820 patients who underwent curative RRDG with D1+ or D2 lymph node dissection (LND) (da Vinci spRRDG, n = 86; cRRDG, n = 734) were analyzed. We compared continuous variables using Student’s t- or Wilcoxon rank-sum tests, as appropriate, and categorical variables using χ2 or Fisher’s exact tests. Subgroup analyses were performed according to the extent of LND (D1+ vs. D2). Statistical significance was defined as p < 0.05. Results: spRRDG involved a longer operative time than cRRDG (227.06 ± 6.19 vs. 183.58 ± 2.18 min, p < 0.0001) and fewer retrieved LNs (rLNs) (36.38 ± 1.53 vs. 46.52 ± 0.66, p < 0.0001), but showed superior enhanced recovery after surgery (ERAS)-related outcomes, including shorter hospital stay (4.06 ± 0.23 vs. 5.95 ± 0.13 days), and earlier gas passage (postoperative day [POD] 2.24 ± 0.10 vs. 3.08 ± 0.04) and soft diet initiation (POD 1.59 ± 0.14 vs. 2.89 ± 0.07; all p < 0.0001). In subgroup analyses, the number of rLNs was lower in D1+ spRRDG (34.09 ± 1.58 vs. 44.36 ± 0.72, p < 0.0001), but remained above the oncologic threshold (≥16 LNs). In D2 dissections, no significant difference was observed (45.71 ± 3.69 vs. 53.30 ± 1.39, p = 0.1030). Faster postoperative recovery in spRRDG persisted after adjustment. Conclusion: spRRDG exhibited lower rLNs than cRRDG but remained within an oncologically acceptable range. Comparable complication rates and significantly improved ERAS outcomes suggest spRRDG is safe and feasible; however, its clinical application should remain limited to early gastric cancer until robust evidence from prospective studies emerges.