A comparison of postoperative outcomes between robotic-assisted and laparoscopic-assisted total gastrectomy: a comprehensive meta-analysis and systematic review

Abstract

Background

The application of robot-assisted technology in gastric cancer surgery is gradually gaining attention from surgeons. In this meta-analysis, our main objective was to assess whether robot-assisted techniques are more advantageous than laparoscopic-assisted technology in total gastrectomy.

Methods

We searched Pubmed, Embase, Web of Science, and Cochrane Library databases for clinical studies published before October 2023 comparing robotic-assisted total gastrectomy (RATG) and laparoscopic-assisted total gastrectomy (LATG) for gastric cancer. Non-clinical studies, data unavailability, or fewer than 50 included cases were excluded. The Newcastle-Ottawa Scale was used to assess the risk of bias by determining the quality of the observational studies. Statistical meta-analysis and drawing were performed using the Software Review Manager version 5.3 and Stata version 16.0. P < 0.05 was considered significant.

Results

Nine studies that included 1,864 patients with gastric cancer were included, published between 2012 and 2023. The results of the analysis showed that RATG has advantages in the following aspects: intraoperative blood loss was 17.69 ml lower in the RATG group than in the LATG group (WMD: -17.69,95% CI:-20.90 ∼ -14.49; P < 0.05); In terms of the number of resected lymph nodes, the RATG group had 2.65 more than the LATG group (WMD: 2.65,95% CI:0.88 ∼ -4.42); P < 0.05); the time to start liquid and postoperative hospital stays were 0.62 and 0.90 days shorter in the RATG group than in the LATG group, respectively (WMD: -0.62,95%CI: -1.06 ∼ -0.19; P < 0.05), (WMD: -0.90,95%CI: -1.43 ∼ -0.37; P < 0.05)); the incidence of major complications and pancreas fistula in the RATG group was 0.59% and 0.17% lower than in the LATG group, respectively (OR: 0.59,95% CI: 0.38 ∼ 0.93; P < 0.05), (OR: 0.17,95% CI: 0.03 ∼ 0.94; P < 0.05). However, the analysis showed that the operative time in the RATG group was 30.96 min longer than in the LATG group (WMD: 30.96,95% CI: 21.24 ∼ 40.69; P < 0.05).

Conclusions

Based on the results of this meta-analysis, we concluded that robotic-assisted technology may be a worthwhile technique to apply in the surgical treatment of total gastrectomy. However, this meta-analysis has the limitations that the included studies were all non-randomized controlled trials and published in Asian countries, and more high-quality randomized controlled trials are needed for further validation in the future.

The registered name and registration number

The study protocol for this meta-analysis is registered on the PROSPERO website under registration number CRD42024500512.

Introduction

As the fifth most prevalent malignant tumor, gastric cancer (GC) is also the fourth leading cause of cancer-related death in the world [1, 2]. Globally, there were more than 1 million new cases of stomach cancer in 2020 and 769,000 deaths due to stomach cancer [1]. Although GC is steadily declining globally, it is worth noting that the incidence of GC is increasing in young and middle-aged populations (age < 50 years) [1]. Therefore, GC remains a serious threat to human health. Radical gastrectomy remains the gold standard for treating resectable GC [3,4,5,6]. In recent years, minimally invasive techniques have developed rapidly in surgery. With the application of minimally invasive techniques, total gastrectomy have shown shorter hospital stays, lower incisional complication rates, and faster postoperative recovery for patients [7]. The laparoscopic technique is one of the first minimally invasive techniques widely used in various surgical procedures, among which laparoscopic gastrectomy (LG) is well-recognized by gastrointestinal surgeons.

However, with the widespread application of LG technology, its drawbacks have been gradually exposed, such as a two-dimensional field of view, limitation of instrumental movement, amplification of hand tremor, and extended learning curve, which puts more pressure on the surgeons than the open gastrectomy (OG) [8,9,10,11,12,13]. Furthermore, the above limitations have restricted the widespread use of D2 spleen-preserving laparoscopic-assisted total gastrectomy (LATG) [14, 15].

Robotic surgery, an emerging technology, has ushered in a new era of minimally invasive surgery. Robotic surgical systems are considered to overcome the technical shortcomings of traditional laparoscopic surgery and are widely used in general surgery and other surgical fields [16].

The safety and efficacy of robotic gastrectomy (RG) in early-stage GC patients have been gradually recognized [17,18,19]. Several studies [20,21,22,23,24,25,26] have reported surgical outcomes in RG and LG. However, no studies have systematically analyzed surgical outcomes in patients undergoing robotic-assisted total gastrectomy (RATG) and LATG. Therefore, the primary endpoint of this study was to compare which minimally invasive technique (RATG or LATG) is more advantageous in terms of surgical characteristics, postoperative recovery and postoperative complications. The secondary endpoint was to compare which minimally invasive technique had better postoperative quality of life.

Materials and methods

This study was carried out according to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) and AMSTAR (Assessing the methodological quality of systematic reviews) Guidelines [27, 28]. Because this study was a meta-analysis, Institutional Review Board (IRB) approval and patient consent were not required. The study protocol for this meta-analysis is registered on the PROSPERO website under registration number CRD42024500512.

Search strategy

We searched the Pubmed, Embase, Web of Science, and Cochrane Library databases for clinical studies published before October 2023 comparing RATG and LATG. We searched the literature using the “MeSH terms OR free-text terms” method, and the same formula was used to search across four databases. The search formula used in four databases was in Additional file 1.

Inclusion and exclusion criteria

The included studies must meet all the following criteria: (1) population: Adults (age ≥ 18 years) diagnosed with GC by postoperative pathologic biopsy; (2) intervention: The study reported postoperative outcomes of RATG versus LATG for GC; (3) outcomes: Postoperative outcomes reported in the study at least one of the following clinical data: operative time, intraoperative blood loss, retrieved lymph nodes, time to start liquid, postoperative hospital stays, postoperative complications, operative mortality, unplanned reoperation; The original data provides odds ratios (OR) values and 95% confidence intervals (95%CI) or the OR values and 95%CI can be calculated from the data; (4) study: the included studies should meet the criteria of being randomized controlled or non-randomized controlled trials published in English; If the same team or authors have published multiple related articles, we enrolled the latest or the more extensive scale number studies.

Studies that met the following criteria were excluded: (1) patients with esophagogastric junction cancer or residual GC; (2) the study data could not be extracted or were not available; (3) the number of cases was less than 50 in studies.

Study selection and data extraction

One reviewer (J.Z) imported literature from four database searches into EndNote X9 (Clarivate Analytics, Philadelphia, USA). The two reviewers (Y.P.Y and Z.M.Z) were independently and sequentially screened strictly by reading the title, abstract, and full text. Two reviewers discussed and resolved the issue in case of disagreements, with a third person if necessary (R.F.W). Clinical data from each of the included studies was extracted and transformed by two reviewers (Y.P.Y and Z.M.Z), including study author, date and country of publication, study design, number of study cases, age, sex ratio, body mass index (BMI), tumor diameter, scope of lymphadenectomy, operative time, intraoperative blood loss, number of retrieved lymph nodes, proximal margin, time to start liquid, postoperative hospital stays, overall complications, major complications (Clavien-Dindo classification ≥ IIIa) [29], etc. According to the Japanese gastric cancer treatment guidelines 2021 (6th edition) [30], D1 + lymph node dissection includes Nos. 1–7, 8a, 9, 11p; D2 lymph node dissection includes Nos. 1–7, 8a, 9, 11p, 11d, 12a. It needs to be clarified that we did not contact the authors of the included studies for missing data.

Quality assessment

We evaluated the quality of the research using the Newcastle-Ottawa scale (NOS) (http://www.ohri.ca/programs/clinical_epidemiology/oxford.asp). The NOS quality assessment criteria for a case-control study include Selection, Comparability, and Exposure, and the quality assessment criteria of the NOS for a cohort study include Selection, Comparability, and Outcome. It should be noted that for the “Was follow-up long enough for outcomes to occur” and “Adequacy of follow-up of cohorts” components of the “outcome” aspect, we required a follow-up time of ≥ 1 years and a follow-up failure rate ≤ 25% to receive 1 star, respectively. According to the NOS, two reviewers independently scored the research quality of each study. The NOS ranges from 0 to 9 stars, and ≥ six stars could be considered reliable for the quality of the study. Two reviewers (Y.P.Y and Z.M.Z) discussed and resolved the issue in case of disagreements, with a third person if necessary (R.F.W).

Statistical analysis

The software of RevMan 5.3 (The Cochrane Collaboration, Oxford, England) and Stata 16.0 (StataCorp LP, Texas, United States) were used to perform statistical meta-analysis and drawing. This statistical analysis used the OR value to assess the count data and weighted mean difference (WMD) for continuous variables. The effect size was calculated with a 95%CI for each meta-data set. Heterogeneity was assessed utilizing the I-squared (I²) tests. If the I² statistic was greater than or equal to 50%, we considered that there was high heterogeneity in the results. We use a fixed-effects model in the presence of low heterogeneity (< 50%) as well as a random-effects model in the case of high heterogeneity (> 50%). The Stata 16.0 software was used to perform subgroup analyses, sensitivity analyses, and publication bias analyses for this study. Sensitivity analysis was performed by sequentially removing each study. We have chosen an outcome that includes all studies for publication bias analysis. The funnel plot was utilized to show and assess the publication of bias, and the Begg’s and Egger tests were utilized to evaluate the degree of bias. When the P-value < 0.05, the difference in the analyzed results was statistically significant.

Results

Study selection

Based on the above-mentioned search strategies, 1534 related studies were searched from the four databases, including 479 in PubMed, 477 in Embase, 63 in the Cochrane Library, and 515 in Web of Science. After rigorous selection and careful discussion by two reviewers, nine studies [31,32,33,34,35,36,37,38,39] were finally selected. Of the nine included studies, one was a case-control study, and the remaining eight were cohort studies. The screening flow diagram is shown in Fig. 1.

Fig. 1

PRISMA diagram showing the meta-analysis comparing the outcomes of robotic-assisted total gastrectomy and laparoscopic-assisted total gastrectomy; EGJC, esophagogastric junction cancer

Study characteristics and quality assessment

The nine studies published between 2012 and 2023, came from three countries: China, Japan, and Korea, which included one prospective study and the remaining eight were retrospective. Our study included 1864 participants with GC, 706 of whom had undergone RATG, and 1158 with LATG. General information about the participants in this meta-analysis is summarized in Table 1. We assessed the quality of research for each study according to the NOS. The details of the quality evaluation in the included studies are presented in Table 2.

Table 1 Characteristics and quality scores of included studies

Table 2 Results of quality assessment using the Newcastle-Ottawa scale for included studies

Meta analysis

We performed the statistical meta-analysis and graphing of the clinical data. The results of all the analyses are summarized in Table 3.

Table 3 Meta analysis of clinical outcomes between LATG and RATG

Surgical outcomes

Operative time

All nine included studies reported information on operative time, and a total of 1864 patients (RATG:706, LATG:1158) were included. Due to the significant heterogeneity among the studies (I² = 78%; P < 0.05), the result was analyzed using a random effects model. The results demonstrated that the operative time in the RATG group was 30.96 min longer than in the LATG group (WMD: 30.96,95% CI:21.24 ∼ 40.69;P<0.05) (Fig. 2a).

Fig. 2

Forest plot of the included studies for Surgical outcomes: (a) operative time; (b) intraoperative blood loss

Intraoperative blood loss

Eight studies provided results in intraoperative blood loss, and a total of 1763 patients (RATG:670, LATG:1093) were included. We analyzed the results using a fixed-effects model. The analysis of the results showed intraoperative blood loss was 17.69 ml lower in the RATG group than in the LATG group (WMD: -17.69,95% CI:-20.90∼-14.49;P<0.05) (Fig. 2b).

Oncological outcomes

Retrieved lymph nodes

Eight articles showed the results on the number of lymph node resections, including 655 and 1100 cases in the RATG and LATG groups, separately. In terms of the number of resected lymph nodes, the RATG group had 2.65 more than the LATG group (WMD: 2.65,95% CI:0.88 ∼ 4.42;P<0.05) (Fig. 3a).

Fig. 3

Forest plot of the included studies for Oncological outcomes: (a) retrieved lymph nodes; (b) proximal margin

Proximal margin

Three articles showed the results of the proximal margin, including 161 cases and 197 cases in the RATG and LATG groups, separately. The outcome of the proximal margin showed no significant differences between the RATG and LATG groups (WMD: -0.08,95% CI:-0.54 ∼ 0.38;P>0.05) (Fig. 3b).

Postoperative recovery

Time to start the liquid

Regarding the time to start the liquid, four studies reported data, and 1116 patients (RATG: 361, LATG: 755) were included. The result was analyzed using a random-effects model (I² = 86%; P < 0.05). The results indicated that the time to start liquid and postoperative hospital stays were 0.62 days shorter in the RATG group than in the LATG group (WMD: -0.62,95% CI:-1.06∼-0.19;P<0.05) (Fig. 4a).

Fig. 4

Forest plot of the included studies for Postoperative recovery: (a) time to start liquid; (b) postoperative hospital stays

Postoperative hospital stays

Seven studies presented outcomes of postoperative hospital stays, and a total of 1669 patients (RATG: 634, LATG: 1035) were included. The postoperative hospital stays were 0.90 days shorter in the RATG group than in the LATG group (WMD: -0.90,95% CI:-1.43∼-0.37;P<0.05) (Fig. 4b).

Postoperative complications

Overall complications

Seven studies provided precise data on overall complications and a total of 1570 patients (RATG: 570, LATG: 1000) were included. There was no significant difference in the occurrence of overall complications between the two groups (OR: 0.92,95% CI:0.70 ∼ 1.22;P > 0.05) (Fig. 5a).

Fig. 5

Forest plot of the included studies for Postoperative complications: (a) overall complications; (b) major complications; (c) pancreas fistula; (d) wound problem; (e) intra-abdominal abscess; (f) anastomotic leakage; (g) intestinal obstruction; (h) intra-abdominal bleeding; (i) operative mortality; (j) unplanned reoperation

Major complications

The occurrence of major complications was demonstrated in eight studies (RATG: 607, LATG: 1043). The analysis presented that the occurrence of major complications in the RATG group was 0.59% lower than in the LATG group (OR: 0.59,95% CI:0.38 ∼ 0.93;P<0.05) (Fig. 5b).

Pancreas fistula

Eight articles reported the results of the pancreatic fistula, separately including 632 and 1084 cases in the RATG and LATG groups. The analyzed result was statistically different between the two groups, and the incidence of pancreas fistula in the RATG group was 0.17% lower than in the LATG group (OR: 0.17,95% CI:0.03 ∼ 0.94;P<0.05) (Fig. 5c).

Other postoperative complications

The results of other postoperative complication rates showed no significant differences between the two groups, including wound problem (Fig. 5d), intra-abdominal abscess (Fig. 5e), anastomotic leakage (Fig. 5f), intestinal obstruction (Fig. 5g), intra-abdominal bleeding (Fig. 5h), operative mortality (Fig. 5i) and unplanned reoperation (Fig. 5j).

Subgroup analyses

Operative time

Country-specific subgroup analyses of the operative time were conducted (Fig. 6), The studies of China and Japan demonstrated significantly longer operative times in the RATG than LATG, which showed low heterogeneity (I² = 0.0%, I² = 0.0%). Similarly, the same results were shown in the Korean study.The operative times were also significantly longer in the RATG group than in the LATG group, but showed high heterogeneity (I² = 77.1%).

Fig. 6

Country-specific subgroup analyses of the operative time

Retrieved lymph nodes

Country-specific and lymphadenectomy-specific subgroup analyses of the retrieved lymph nodes were conducted (Fig. 7a and b), The studies of China have shown RATG to be significantly superior to LATG in retrieved lymph nodes (I² = 28.6%). There was no significant difference between RATG and LATG in the studies of Japan and Korea (I² = 63.2%, I² = 67.1%). The studies of D2 lymphadenectomy have shown RATG to be significantly superior to LATG (I² = 28.6%). There was no significant difference between RATG and LATG in the studies of D1+/D2 lymphadenectomy (I² = 58.7%). Our analysis for sources of high heterogeneity revealed that when the ROh studies were excluded the results showed that RATG was significantly superior to LATG in retrieved lymph nodes, and the results showed low heterogeneity. We read the full study and found that the number of lymph node resections was significantly different between pre-propensity score matching and post-propensity score matching, which may be related to the high heterogeneity of the results of the retrieved lymph nodes.

Fig. 7

(a) Country-specific subgroup analyses of the retrieved lymph nodes. (b) Lymphadenectomy-specific subgroup analyses of the retrieved lymph nodes

Time to start liquid

Country-specific subgroup analyses of the time to start liquid were conducted (Fig. 8). The studies of China have shown RATG to be significantly shorter than LATG in time to start liquid (I² = 90.6%). We found that each study did not detail the criteria by which the first postoperative liquid diet could be given, which may be the source of high heterogeneity.

Fig. 8

Country-specific subgroup analyses of the time to start liquid

Major complications

Country-specific subgroup analyses of the major complications were conducted (Fig. 9). There was no significant difference between RATG and LATG in the studies of China and Japan (I² = 0%, I² = 0%). However, the studies of Korea have shown RATG to be significantly less than LATG in the incidence of major complications(I² = 0%).

Fig. 9

Country-specific subgroup analyses of the Major complications

Sensitivity analysis

We performed sensitivity analyses for each outcome indicator using a one-by-one exclusion method. After analysis, we found that the statistical significance changed in the retrieved lymph nodes and major complications, indicating a lack of stability in the original results. The sensitivity analyses of the remaining outcome indicators did not show significant differences from the original results, which demonstrated the stability of the initial results, such as the operative time (Figure S1) and the time to start the liquid (Figure S2).

When we excluded studies by Jia et al. and Ye et al., respectively, the recalculations indicated that the lymph nodes retrieved did not show any notable differences between the RATG and LATG group (WMD: 2.00,95% CI:-0.15 ∼ 4.15;P=0.07, I² = 50%); (WMD:2.09, 95% CI:-0.43 ∼ 4.61; P:0.10, I²:55%) (Fig. 10a), which was inconsistent with our original result (WMD:2.65, 95% CI:0.88 ∼ 4.42; P<0.05, I²:50%). Combined with the results of the previous subgroup analyses, we did not incorporate the results after the sensitivity analyses because we considered that the instability of the original result could have originated from surgical treatment by different surgeons.

After excluding studies by Hikage et al. and Shibasaki et al., respectively, the analyses demonstrated that there was no notable difference in the occurrence of major complications between the two groups (OR: 0.66, 95% CI:0.41 ∼ 1.04;P=0.07, I²:9%); (OR:0.71, 95% CI:0.44 ∼ 1.16; P:0.17, I² = 0%) (Fig. 10b). The original result contradicted this observation (OR:0.59, 95% CI:0.38 ∼ 0.93; P<0.05, I²:18%). The previous subgroup analysis indicated that the instability of this outcome may be related to different countries. Furthermore, there was no remarkable heterogeneity in the initial outcome, and we decided not to exclude these two studies.

Fig. 10

(a) sensitivity analysis for the retrieved lymph nodes using a one-by-one exclusion method; (b) sensitivity analysis for the major complications using a one-by-one exclusion method

Publication bias

By observing the funnel plot of the anastomotic leakage (Fig. 11) and using Begg and Egger tests (Begg’s test: P = 0.251; Egger’s test: P = 0.323), we found no significant publication bias in this analysis.

Fig. 11

Funnel plot of the anastomotic leakage

Discussion

With the rapid development of minimally invasive surgery (MIS), robotic-assisted techniques have been gradually applied in gastric cancer surgery. The performance of robotic surgery in TG, the most challenging procedure in GC surgery, has attracted considerable attention [40]. However, we have yet to find a systematic meta-analysis of the postoperative outcomes of RATG and LATG. This meta-analysis aimed to investigate whether RATG is a valuable option for patients with GC.

Operative time is one of the most critical surgical factors when comparing two minimally invasive techniques, as it is an essential factor in assessing the quality and accessibility of the procedure [41, 42]. Some studies [41, 43,44,45,46] have suggested that the longer time for robotic surgery is mainly related to two aspects: (1) the need for additional robotic arm docking and equipment commissioning before the formal operation of robotic surgery. (2) the inexperience of surgeons in using robotic surgical systems. Related studies by Jia et al. and Chen et al. [39, 47] demonstrated no meaningful difference between RATG and LATG regarding the robot/laparoscopy time (the actual time of entry into the abdominal cavity for operative procedures). In addition, the relevant literature reports that robotic surgery time can be reduced by improving surgical experience after a sufficient learning curve [19, 42, 48, 49]. Notably, for experienced surgeons who have performed LG, the learning curve for RG was shorter than LG [18, 50,51,52]. Thus, the standardization of early commissioning operations and the increased surgeon experience may contribute to similar results for both technical approaches [53, 54].

Surgical blood loss is also one of the most significant surgical indicators in assessing the outcomes of radical gastrectomy. Less intraoperative bleeding is associated with a better short-term clinical course [55, 56], and more importantly, reduces the chance of postoperative blood transfusion in patients. According to the relevant literature, perioperative blood transfusion increases the risk of cancer recurrence and is negatively associated with long-term survival after radical gastrectomy [57,58,59,60]. Compared to laparoscopic procedures, robotic surgery has the advantages of tremor filtering, high definition 3D image, high degree of freedom and comfortable remote console [21, 51, 52, 61,62,63,64,65,66], which are more favorable for manipulation by the surgeons, such as separation and ligation of blood vessels and tissues. Especially for TG, a marathon surgery that requires precise vascular ionization and lymph node dissection, these advantages of robotic manipulation are crucial.

It is worth highlighting that lymph node dissection is crucial in radical gastrectomy. The condition of lymph node dissection and surgical margin are frequently used as an indicator to assess oncological safety [43]. Related studies have reported that independent risk factors for early relapse in patients with radical gastrectomy include lymphovascular infiltration [67], lymph node metastasis and tumor stage. Standard lymph node dissection not only improves the precision of the patient’s pathological stage and provides the clinical basis for further treatment, but also reduces the incidence of cancer recurrence and metastasis [68]. The use of conventional laparoscopic forceps to expose and manipulate deep vessels and areas can be particularly difficult, especially when performing lymph node dissection around the hepatic, splenic hilar, and splenic arteries [61]. Conversely, operators can more easily expose and dissect lymph nodes with the assistance of the robotic system, even in particularly narrow and complex areas [69]. Surgical margins are strongly associated with postoperative survival and local recurrence rates [70]. This study demonstrated that the condition of the proximal margin was not significant between the RATG and LATG groups. Due to insufficient data, the results of the positive margin and the distal cut-off margin were not included in this study. In general, RATG had a similar margin profile and adequate lymph node dissection outcome compared to LATG.

Rapid postoperative recovery is known to be a significant advantage of MIS. This meta-analysis demonstrated that the RATG group had a shorter time to first postoperative fluid intake and postoperative hospitalization than the LATG group. The flexible stability of the robotic arm avoids excessive pulling on the intestinal tract, thus benefiting the recovery of bowel function [64]. Early food intake also speeds up patient recovery and shortens postoperative hospitalization.

The occurrence of postoperative complications is an invaluable indicator for evaluating the short-term prognosis and the safety and feasibility of the procedure [48, 70]. The main complications are the most demanding in terms of clinical care, cost, prognosis, and quality of life, and place additional burdens on clinical treatment and patients [61]. Therefore, the incidence of major complications allows an accurate assessment of surgical outcomes and reduces subjectivity. Pancreatic fistulas have been associated with parenchymal manoeuvers when performing lymph node dissection [3]. The high degree of freedom and stability of the robotic arm minimizes pulling on the pancreas during lymph node dissection or other operations, thus reducing substantial injury [42, 50, 53]. Furthermore, there were no significant differences in the rates of surgical mortality and unplanned reoperation between the RATG and LATG groups. Based on these outcomes, we consider RATG to be safe and acceptable.

The high cost is a crucial issue that prevents the widespread use of robotics in gastric cancer surgery. Several studies have revealed that RG costs are significantly higher than LG [42, 61, 71, 72]. Studies also show that the advantages of robotic surgery can compensate for its higher cost, such as fewer postoperative complications and length of hospitalization [73, 74]. However, the higher cost of the robotic system was deemed insufficient by the researchers involved to justify the theoretical advantages of the technology [75]. If robotic surgery leads to a better prognosis for patients with gastric cancer, then we believe its high cost is acceptable. Due to the low number of included studies reporting on the cost aspect of surgery, we were unable to perform a meta-analysis on this aspect. Therefore, future studies are needed to prove whether the high cost of GC therapy is consistent with the potential strength of RATG.

This study is the first meta-analysis to compare RATG with LATG in terms of efficacy, safety, and feasibility. However, some of the limitations of this study must be considered when utilizing its outcomes: (1) all included studies were retrospective, except for one prospective study. The absence of high-quality randomized controlled trials (RCT) may lead to publication bias; (2) all included studies were published by Asian countries, and the applicability and generalizability of these results are limited, thus the results of these analyses must be treated with caution; (3) due to the few number of included studies, data on some variables could not be meta-analyzed, such as distal margins, drain amylase levels, and nutritional status; (4) most of the included studies did not perform survival analyses or had a short follow-up period, and long-term postoperative prognosis needs to be further analyzed, such as postoperative quality of life, 5-year recurrence rate and survival rate; (5) there was significant heterogeneity in the analyzed outcome in terms of operative time, retrieved lymph nodes, and time to start liquid, and the outcome of sensitivity analyses suggested a lack of stability in the outcome of retrieved lymph nodes and major complications. Therefore, we need to refer to these results with caution.

Conclusion

RATG showed better outcomes in terms of intraoperative bleeding, lymph node dissection, postoperative recovery, and relevant surgical complications. Although the long duration and high cost of surgery remain a concern, RATG may be a promising and valuable technique for the treatment of GC. Due to certain limitations of this meta-analysis, the systematic meta-analysis of multiple high-quality, multicenter RCTs is still needed to validate the advantages of RATG in future studies.