Laparoscopic and Robotic Procedures Combined Surgery (LARCS): A Novel Approach to Trainee Participation in Robotic Gastrectomy

Abstract

Background

Robotic gastrectomy (RG) for gastric cancer reduces morbidity and achieves long-term outcomes comparable to laparoscopy. However, RG is typically a solo-surgeon procedure performed by expert console surgeons, limiting trainees' operative experience. To address this issue, we developed Laparoscopic and Robotic procedures Combined Surgery (LARCS), in which the patient-side surgeon (PSS) performs selected surgical maneuvers, including dissection, clipping, and stapling, using laparoscopic instruments under the supervision of the console surgeon.

Methods

We retrospectively analyzed 96 patients who underwent robotic distal or subtotal gastrectomy at Kitasato University Hospital between January 2019 and December 2023. Patients were divided into a conventional RG group (CRG; n = 60) and a LARCS group (n = 36). Propensity scores were estimated based on age, sex, body mass index, American Society of Anesthesiologists status, and clinical T and N categories. Cardinality matching within a 0.2-standard-deviation caliper of the logit of the propensity score yielded 23 matched pairs, with all absolute standardized mean differences for the matching covariates < 0.1. Perioperative outcomes and PSS participation were compared.

Results

After matching, adequate balance was achieved for all matching covariates, with absolute standardized mean differences ranging from 0 to 0.062. Operative time was 406 min in the LARCS group and 373 min in the CRG group (p = 0.110). Estimated blood loss tended to be greater with LARCS (51 vs. 6 mL, p = 0.070). Any postoperative complication occurred in 6 and 5 patients, respectively (p = 1.000), and major complications occurred in 2 and 0 patients, respectively (p = 0.500). Median PSS operative time was 108 min, corresponding to 26.6% of the total operative time in LARCS, versus 0 min in CRG (p < 0.001).

Conclusions

LARCS provided patient-side trainees with supervised, instrument-based first-operator participation for approximately one-quarter of the operative time, supporting its feasibility as a complementary approach to trainee participation during robotic gastrectomy. Further prospective studies incorporating objective competency-based assessments are required to determine its educational effectiveness and safety.