Robotic esophageal reconstruction with a diagonal stapling technique: technical description and early outcomes from a single-center series.

[BACKGROUND] Esophageal reconstruction after total or proximal gastrectomy is technically demanding. Robotic platforms provide enhanced dexterity, yet anastomotic protocols vary widely. We developed a unified, geometry-driven robotic technique-applicable to both total and proximal gastrectomy-that creates a wide V-shaped anastomosis by extending and rotating a right-anterior esophageal flap to maximize perfusion and minimize axial tension.

[METHODS] Between March 2021 and May 2025, 41 patients underwent robotic gastrectomy using our "diagonal V-geometry" reconstruction: 18 proximal gastrectomies with esophagogastrostomy and 23 total gastrectomies with esophagojejunostomy. A multi-arm surgical robot with 3D visualization and articulating instruments was used. The muscularis was divided directly; the mucosa was incised over a nasogastric tube to avoid contralateral injury. Traction sutures rotated the flap posteriorly, widening the staple line interface. A powered linear stapler created a 40-45-mm V-shaped anastomosis to either the gastric remnant or Roux limb. The enterotomy was closed with a 60-mm staple line. In proximal gastrectomy, a partial Toupet fundoplication was added. Leak tests confirmed integrity. Barbed sutures secured fixation.

[RESULTS] Median age was 73 years (proximal) and 77 years (total); median BMI was 21.6 and 21.2 kg/m. D2 lymphadenectomy was performed in most patients (88.9% in PG; 100% in TG). Median operative time was 428 min (proximal) and 400 min (total). Blood loss was minimal (median 0 mL). One non-anastomotic complication occurred (5.6%) in the proximal group; none in the total group. Critically, no anastomotic leaks, strictures, or reoperations occurred. Imaging confirmed wide lumens; patients resumed oral intake without dysphagia. Three-month follow-up showed no reflux.

[CONCLUSIONS] Our unified robotic diagonal V-geometry technique yielded zero leaks or strictures in 41 gastrectomies. By rotating the right-anterior flap to create a broad V-shaped staple line, perfusion is preserved and tension minimized. Larger multicenter studies are needed to confirm these promising outcomes.