Background: In gastric cancer, complete mesogastric excision may decrease tumor disruption during lymphadenectomy. This technique requires enbloc excision of blood vessels, lymphatics, and fatty tissues along embryologic planes connecting the stomach to the retroperitoneum. We present a robotic total gastrectomy and D2 lymphadenectomy with complete mesogastric excision for a 41 year-old woman with a BMI of 34, CDH1 mutation, and cT4aN1M0 gastric cancer after neoadjuvant chemotherapy.

Methods: Using the Xi robot, the procedure begins with division of the gastrocolic ligament. Dissection follows the inferior border of the pancreas clearing the left gastroepipolic mesogastrium, with ligation of left gastroepiploic and short gastric vessels. Dissection proceeds medially towards the pancreatic head, clearing the right gastroepiploic mesogastrium and ligation of its vessels. The right gastric artery ligation is followed by clearance along the proper and common hepatic arteries. Enbloc clearance of the left gastric mesogastrium follows the superior pancreatic boarder, separating fatty tissues from the splenic vessels and the celiac artery. Nodal stations 1,2,3,4,5,6,7,8a,9,11,12a are retrieved. The duodenum and distal esophagus are divided, and a stapled Roux-en-Y reconstruction is performed.

Results: Operative time was 328 minutes, estimated blood loss was 300 mL, and hospital stay was 5 days. Pathology was ypT4aN0 with 33 lymph nodes. The patient initiated adjuvant chemotherapy 32 days post-operatively.

Conclusions: We report the first robotic total gastrectomy with D2 lymphadenectomy and complete mesogastric excision in the United States. This technique facilitates successful completion of D2 lymphadenectomy and may become an important procedure for adequate resection of gastric cancer.