Standard-Based Port-Sharing Workflow for Simultaneous Robot-Assisted Distal Gastrectomy and Right-Sided Colectomy: A Case Report.

INTRODUCTION: Synchronous gastric and colorectal cancers occur in approximately 4% of patients. Although simultaneous resection is common in laparoscopic surgery, robot-assisted simultaneous procedures are less frequently reported because of logistical constraints in multi-quadrant targeting and port geometry. Herein, we describe a standardized and reproducible workflow using the da Vinci Xi system (Intuitive Surgical, Sunnyvale, CA, USA) that focuses on strategic port sharing and planned redocking.

CASE PRESENTATION: An 86-year-old man presented with gastric cancer (cT3N0M0, Stage II), ascending colon cancer (cT2N0M0, Stage I), and symptomatic cholelithiasis. The procedure was performed using a da Vinci Xi system with single-direction docking from the patient's left side. A 5-cm mini-laparotomy and 6 robotic ports were used. To enhance reproducibility, the integrated layout was designed to align with our institutional standard setups (National Hospital Organization Disaster Medical Center) for isolated distal gastrectomy and right-sided colon resection. Most ports were shared, with only the R1 working arm relocated between phases to optimize the triangulation for each target. The surgical sequence was strategically planned to minimize table-tilt transitions, starting with right-sided colectomy in the Trendelenburg position, followed by a single transition to the reverse Trendelenburg position for D3 lymphadenectomy and the subsequent gastric phase. After distal gastrectomy, cholecystectomy was performed during optimal upper abdominal exposure. The surgery was successfully completed by a small team of 1 console surgeon and 1 bedside assistant. The operative and console times were 390 and 350 min, respectively, with 20 mL of blood loss. Final pathology showed R0 resection for both cancers (gastric: pT2N1M0; colon: pT1N0M0). The patient's postoperative course was favorable despite a Clavien-Dindo grade II serous leakage, which was resolved with antibiotics.

CONCLUSIONS: A standardized workflow featuring fixed docking, planned targeting, and port sharing may facilitate robot-assisted simultaneous resection in selected patients. By combining standard institutional setups, the approach may help streamline dual-quadrant logistics while preserving ergonomic triangulation; however, further case accumulation is needed.