Surgical team configuration, technical errors, and workload in robotic distal gastrectomy.

BACKGROUND

Robotic distal gastrectomy requires coordinated task allocation between the console surgeon and bedside assistant. Whether a laparoscopic-like "3-arm+2-port" configuration is associated with better technical performance and lower surgical workload compared with the conventional "4-arm+1-port" configuration remains unclear.

METHODS

This single-center prospective cohort study included 84 patients undergoing robotic distal gastrectomy from September 2025 to March 2026. After variable-ratio propensity score matching, 45 patients in the "3-arm+2-port" group and 22 in the "4-arm+1-port" group were analyzed. Technical errors were assessed from operative videos using Observational Clinical Human Reliability Analysis. Workload was evaluated separately for primary surgeons and assistants.

RESULTS

After matching, covariate balance was substantially improved. The "3-arm+2-port" group had fewer total technical errors than the "4-arm+1-port" group (42.6 (7.2) vs. 52.8 (6.9); P < .001), with significant differences in phase 3 (11.4 (3.5) vs. 15.7 (4.1); adjusted P < .001) and phase 6 (9.0 (2.7) vs. 14.1 (3.0); adjusted P < .001). Grade 2 bleeding, tissue slippage, heat burn, and Hem-o-lok slippage were also less frequent. Overall workload scores were lower for primary surgeons (8 (7-9) vs. 12 (9-13); P < .001) and assistants (6 (5-8) vs. 10 (8.25-11); P < .001). Operative time, docking time, blood loss, and short-term recovery outcomes were more favorable, whereas console time, time-adjusted technical error rate, lymph node harvest, and complications did not differ significantly.

CONCLUSIONS

In robotic distal gastrectomy, the laparoscopic-like "3-arm+2-port" configuration was associated with fewer technical errors, lower team workload, and more favorable short-term recovery, although the time-adjusted technical error rate did not differ significantly. These findings suggest that surgical team configuration is a potentially modifiable factor associated with intraoperative performance and teamwork efficiency.