All studies reported the duration of the postoperative hospital stay, and data of only 1 study could not be used to calculate the WMD (Fig. 7). The meta-analysis revealed significant heterogeneity between the RAG group and the LAG group (I2 = 84%), with the similar hospital stay after RAG and LAG [WMD -0.65 (95% CI -1.53 to 0.23) days; P = .15]. As the potential influencing factors of postoperative hospital stay, the days of oral intake and first flatus were analyzed, respectively. There was no difference between the 2 groups in either one of them (Supplemental Figure 1, 2, http://links.lww.com/MD/B971).
The funnel plot for the primary outcome of postoperative complications was relatively symmetrical between the 2 groups, suggesting that publication biases were not serious. All studies remained inside the limits of the 95% CI (Fig. 9).
As prognostic factors of surgical therapy for tumors, the number of retrieved lymph nodes and resection margin cannot be ignored. This analysis showed that there was no obvious difference in the total number of lymph nodes resected between RAG and LAG. Robot-assisted surgery is based on laparoscopic surgery, and the operative steps of lymph node dissection are generally the same as those in LAG. In addition to the above reasons, so many gastric cancer patients showed stage I clinicopathology in our meta-analysis, and the number of metastatic lymph nodes among different tiers was correspondingly reduced. These findings may not reflect the advantages of the robotic surgical system. Some of the selected studies[16–19] precisely reported the tumor resection margin. The length of the proximal and distal resection margin was undifferentiated between the groups overall. This finding showed RAG could accomplish the range of radical resection in LAG, and we still believe the distance from the resection margin to the lesion is of great significance for surgeons.
The duration of the postoperative hospital stay for patients accepting RAG was the same as that of patients undergoing LAG. Although the average length of hospital stay was reduced by nearly a day when comparing the 2 groups, the difference did not reach statistical significance. Time to diet, mobilization, first flatus, and drainage are potential factors that should have an important impact on postoperative recovery. However, not all the factors were precisely described in all the selected studies. Finally, we chose 6 selected articles,[14,17–19,21,23] which contained sufficient data to analyze the days of oral intake and first flatus respectively, and found these 2 potential factors could not induce the different postoperative hospital stay between the 2 groups. We considered that patients receiving RAG might not recover faster than those undergoing LAG only depending on more advanced surgical techniques.
As an important assessment indicator, the patients’ financial burden should not be ignored. We found that the cost of RAG is higher than LAG in some studies.[22,35,36] It is an apparent obstacle to encourage surgeons to use the robotic system in surgeries. But this could be overcome by the generalization of robots and financial supplements from the national health insurance system in the future.
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