We report a successful simultaneous total robotic curative resection for synchronous advanced GC and RC. Although there are some reports on simultaneous laparoscopic surgery for synchronous GC and CRC [8,9,10,11], this is the first report on simultaneous total robotic curative resection for synchronous advanced GCs and RCs. Byoung et al. first reported simultaneous robotic surgery for GC and right colon cancer [12]. Although both GC and CRC were advanced cancers in this case, robotic surgery had advantages for both peripancreatic lymph node dissection for GC surgery [13, 14] and pelvic manipulation (especially to reduce neuropathy and urinary retention) for RC surgery [4, 15] and was therefore selected to reduce postoperative complications and allow for a smooth introduction of postoperative chemotherapy for GC. In addition, simultaneous surgery may have many advantages, such as small skin incisions, reduced postoperative pain, and early mobility, resulting in decreased inflammatory cytokines and postoperative bowel obstruction [16, 17].
However, there are limitations to simultaneous robotic surgery. First, GC and RC are treated within different surgical fields, involving the upper and lower abdomen, respectively. In this case, we preoperatively examined the details of the port setting, position of the small incision, and arrangement of the operating room including the robot, anesthesia machine, nurse, and position of the patient. In a real room, we simulated the machine and the patient among surgeons, anesthesiologists, scrub nurses, and medical engineers. Additionally, the number of ports can be reduced by sharing the left and right mid-abdominal ports. We also discussed whether the gastric cancer or the rectal cancer should be resected first, and we decided to begin with the gastric cancer for the following reasons. (1) The depth of the gastric cancer was submucosal, so there was a low probability that robotic surgery would be impossible. On the other hand, the rectal cancer had the potential for extra-serosal invasion, and there was a higher probability of conversion to open LAR by incision of only the lower abdomen. (2) By performing gastric cancer surgery first, it was possible to mobilize the left side of the colon for reconstruction of the rectal cancer surgery. (3) Robotic gastrectomy and intracorporeal gastroduodenostomy (delta-shaped anastomosis) did not require mini-laparotomy. It was possible to make a small incision in favor of rectal cancer surgery. Second, the operative time was long. In previous reports, the operative time of the simultaneous robotic surgery for GC and RC was 640 min [12], and in this case, it was 648 min. Between 2013 and 2018, there were five cases of simultaneous surgery for GC and RC at our institution; two cases were open surgery, and three cases were laparoscopic surgery. The median operating time of the five cases was 631 (383–931) min, the median blood loss was 346 (0–1084) mL, and the median postoperative hospital stay was 14 (9–22) days. Among them, postoperative intestinal obstruction of grade 2 was observed in one open surgery case as a postoperative complication. Compared with these cases, the case we are comparable in postoperative short-term results. However, further analysis is required to confirm the oncological safety and feasibility of simultaneous robotic resection for synchronous advanced GCs and RCs.
We believe that simultaneous robotic surgery for synchronous advanced GC and RC may be a feasible option if these limitations can be solved by team skill and careful preoperative planning.