Reduced-Port Robotic Distal Gastrectomy for Gastric Cancer: The Marionette Technique and Soft Coagulation Lymphadenectomy

Radical gastrectomy with meticulous lymph node dissection remains the definitive treatment for gastric cancer, and ongoing technical advances continue to focus on minimizing surgical trauma while preserving oncological safety. Robotic gastrectomy provides enhanced surgical precision through three-dimensional visualization and articulated instrumentation. Because a 3–4 cm umbilical incision is required for specimen extraction, maximizing the utility of this incision to reduce the need for additional ports represents a practical surgical strategy. Reduced-port and single-port approaches have therefore been introduced to decrease postoperative pain, improve cosmetic outcomes, and reduce port-related complications. Building on this concept, reduced-port robotic distal gastrectomy (rpRDG) utilizes a “4-arms in 3-ports” configuration that maximizes the utility of the umbilical incision while reducing surgical access trauma. A major technical consideration in rpRDG is the efficient use of robotic arms. In this video article, we demonstrate the marionette technique using endoclips to avoid dedicating a robotic arm exclusively to static traction. Briefly, the target tissue is grasped using an endoclip with a pre-tied suture, after which the free end of the suture is exteriorized through the abdominal wall and secured externally with a mosquito or Kelly clamp to provide stable, hands-free gastric retraction. Alternatively, the exteriorized suture can be weighted with heavy surgical instruments, such as long Kelly clamps, rather than fixed in place with a clamp. Additional instruments may then be added incrementally as dissection proceeds, allowing gravity-assisted traction with finely adjustable tension. This approach permits all robotic arms to remain available for active dissection, thereby improving operative ergonomics. We further present a strategic operative workflow in which bipolar dissection with soft coagulation using Maryland forceps is performed for precise lymphadenectomy around major vessels, whereas a vessel sealer is used along the greater curvature to reduce operative time. Through a representative case, we illustrate the fundamental procedural steps and technical principles of rpRDG.