{"paper_id":"32201e56-a866-4985-857f-e53a25afff7c","body_text":"Robot-Assisted Versus Conventional Laparoscopic Antireflux Surgery: A Retrospective Cohort Analysis of Perioperative and Medium-Term Outcomes | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Robot-Assisted Versus Conventional Laparoscopic Antireflux Surgery: A Retrospective Cohort Analysis of Perioperative and Medium-Term Outcomes Minjun Xia, Menghui Zhou, ZhiHao Zhu, Jinglei Mao, Zhifei Wang This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6634434/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 04 Jul, 2025 Read the published version in Journal of Robotic Surgery → Version 1 posted 10 You are reading this latest preprint version Abstract Gastroesophageal reflux disease (GERD), often associated with hiatal hernia (HH), is commonly treated with conventional laparoscopic anti-reflux surgery (CLAS). Robotic-assisted anti-reflux surgery (RAAS) is emerging as an alternative with enhanced precision and ergonomics. This study compares perioperative outcomes and mid-term symptom resolution between RAAS and CLAS. A retrospective cohort study included 91 patients (RAAS: n = 31, CLAS: n = 60) undergoing primary anti-reflux surgery from April 2022 to April 2024. Inclusion criteria included confirmed GERD and inadequate proton pump inhibitor response. Surgical steps were standardized, and perioperative metrics (operative time, complications, hospital stay) and 12-month symptom outcomes were compared. RAAS and CLAS had comparable demographics and comorbidities (P > 0.05). RAAS had a longer total operative time (158.8 ± 21.8 vs. 146.4 ± 23.8 minutes, P = 0.02), mainly due to a longer retroesophageal tunnel establishment (P < 0.01). RAAS showed superior symptom resolution (80.6% vs. 56.7%, P = 0.02) without differences in intraoperative complications, reoperations, or hospital stay. Docking time decreased with experience (P < 0.01), reflecting a learning curve. RAAS provides comparable safety and postoperative outcomes to CLAS but achieves higher symptom resolution (80.6% vs. 56.7%, P = 0.02). While operative times are longer for RAAS, this difference is limited to initial steps. RAAS demonstrates technical feasibility with a learning curve, suggesting it may improve precision in anti-reflux surgery. Further studies are needed to assess its long-term efficacy. Robotic-assisted surgery Laparoscopic fundoplication GERD Hiatal hernia Nissen fundoplication Introduction Gastroesophageal reflux disease (GERD), one of the most prevalent conditions encountered by gastroenterologists, is frequently associated with hiatal hernia (HH)[ 1 ]. HH is characterized by the protrusion of abdominal organs or tissues other than the esophagus into the thoracic cavity through an enlarged esophageal hiatus[ 2 , 3 ]. Typical symptoms of GERD include acid regurgitation, heartburn, chest pain, and sore throat, with some patients experiencing dysphagia, hoarseness, or chronic cough[ 3 ]. Initial management of GERD involves lifestyle modifications or proton pump inhibitors (PPIs). For patients with refractory symptoms despite PPI therapy, anti-reflux surgery may be considered[ 1 , 4 ]. Among surgical interventions, fundoplication remains the most common procedure[ 5 , 6 ]. Since its introduction in 1991, laparoscopic Nissen fundoplication (NF) has become the gold standard for GERD treatment[ 7 , 8 ]. Concurrently, robot-assisted surgery is gaining increasing traction in clinical practice[ 9 ]. As an advancement in minimally invasive techniques, robotic systems address limitations of conventional laparoscopy, including unstable visualization, restricted instrument mobility, two-dimensional imaging, and suboptimal ergonomics[ 10 ]. Robotic platforms enhance surgical ergonomics and provide superior instrument articulation. The evolution of robotic technology and teleoperated systems has expanded its utility in complex minimally invasive procedures, particularly in intricate anatomical interventions such as anti-reflux surgery[ 11 ]. While traditional minimally invasive approaches reduce postoperative pain and hospital stays, they remain constrained by limited instrument maneuverability. Robotic assistance demonstrates potential to overcome these constraints through improved precision and operational flexibility. This study compares perioperative outcomes between robotic-assisted anti-reflux surgery (RAAS) and conventional laparoscopic anti-reflux surgery (CLAS). Designed as a pilot randomized controlled trial, it evaluates mid-term symptom resolution and quality of life at 12-month follow-up, with secondary analysis of perioperative metrics to inform surgical decision-making. Materials and Methods Patient Selection and Preoperative Evaluation This retrospective cohort study included all patients undergoing primary anti-reflux surgery via laparoscopic or robotic-assisted approaches at our center over a two-year period (April 2022–April 2024). Symptomatic GERD patients were screened according to predefined inclusion and exclusion criteria. Inclusion criteria comprised: age > 18 years, pathologic GERD confirmed by pH-metry, symptomatic GERD history > 6 months, and inadequate response to ≥ 3 months of proton pump inhibitor (PPI) therapy at standard doses. Exclusion criteria included giant hiatal hernia (HH), prior anti-reflux surgery, history of major upper abdominal surgery, BMI > 40 kg/m², and preexisting esophageal disorders (e.g., achalasia, scleroderma, malignancy). All patients underwent standardized preoperative evaluations: esophagogastroduodenoscopy, 24-hour pH monitoring, upper gastrointestinal contrast study, and esophageal manometry. Surgical Techniques and Postoperative Management Robotic-assisted anti-reflux surgery (RAAS) and conventional laparoscopic anti-reflux surgery (CLAS) were comparatively analyzed. RAAS was performed by a surgeon credentialed after 30 robotic training cases, while CLAS was conducted by three experienced laparoscopic surgeons (each with > 30 CLAS procedures). Trocar configurations differed: RAAS utilized a 12-mm umbilical optical port, three 8-mm robotic ports, and one 12-mm assistant port; CLAS employed standard laparoscopic trocars, including two 5-mm working ports instead of robotic 7-mm counterparts, while maintaining identical endoscopic angles. A 5-mm liver retractor was inserted via a subxiphoid incision in both groups. Surgical steps followed a standardized protocol: Retroesophageal Tunnel Creation: Dissection of the posterior mediastinum with identification of bilateral diaphragmatic crura and vagus nerves. Esophageal Mobilization: Red rubber catheter-assisted esophageal positioning, followed by complete gastric fundus mobilization (short gastric vessel division and diaphragmatic adhesion release). Hiatal Repair: Closure of the hiatal defect using 2 − 0 nonabsorbable sutures, with anti-reflux mesh reinforcement as indicated. Fundoplication: Tailored 360° (Nissen) or partial wrap construction based on intraoperative assessment. Validation: Verification of wrap tension and diaphragmatic fixation. Perioperative metrics (console/docking time, operative duration, wrap type, intraoperative complications) were systematically recorded, with emphasis on visceral injury, hemorrhage, and conversion rates. Postoperative protocols included immediate PPI cessation, multimodal analgesia (e.g., metamizole), and discharge upon tolerance of oral intake and adequate pain control. Follow-up Postoperative complications (30-day), mortality, reoperations, and endoscopic findings were retrospectively extracted from records. Follow-up spanned 1–2 years (April 2022–April 2024), with prospective registration of demographic, comorbidity, and surgical data. Statistical Analysis Patients were stratified into RAAS and CLAS cohorts. Categorical variables (demographics, comorbidities, complications) were analyzed using Chi-square tests; continuous variables (operative time, hospitalization costs) were compared via t-tests (STATA 14, StataCorp, USA). Robotic cases were chronologically divided into quartiles for temporal trend analysis. Wilks’ Lambda tested differences in operative duration, docking time, and hospitalization; Chi-square tests evaluated complication rates, PPI use, endoscopic findings, and reoperations. Subgroup analyses of reoperations included etiology, initial procedure type, and fundoplication configuration. Variables assessed: age, sex, BMI, preoperative manometry/pH metrics, complications, hospitalization duration/costs, and 3-/6-month functional outcomes. Total operative time encompassed incision-to-skin closure intervals, segmented into five phases: STEP 1 : Lesser omentum incision to retroesophageal tunnel creation. STEP 2 : Retroesophageal tunnel completion to full esophageal mobilization. STEP 3 : Hiatal hernia closure. STEP 4 : Fundoplication construction. STEP 5 : Procedure conclusion. Results Demographics and Baseline Characteristics Table 1 Demographics and Baseline Characteristics RAAS N = 31 CLAS N = 60 P-value Demographic data Age 54.6 ± 12.4 55.1 ± 16.1 0.89 Sex (% male) 61.3%(n = 19) 41.7%(n = 25) 0.08 BMI 23.3 ± 1.99 22.4 ± 2.95 0.11 Comorbidities Diabetes (%) 1(3.2%) 2(3.3%) 0.99 Heart disease (%) 1(3.2%) 5(8.3%) 0.63 Cerebrovascular (%) 0(0.0%) 2(3.3%) 0.78 Lung disease (%) 2(6.5%) 1(1.7%) 0.55 Hypercholesterolemia (%) 1(3.2%) 0(0.0%) 0.73 Hypertension (%) 6(19.4%) 11(18.3%) 0.91 Smoking (%) 4(12.9%) 4(6.7%) 0.55 Alcohol abuse (%) 2(6.5%) 1(1.7%) 0.55 Previous abdominal surgery (%) 12(38.7%) 14(23.3%) 0.12 The RAAS group (n = 31) and CLAS group (n = 60) exhibited comparable mean ages (54.6 ± 12.4 years vs. 55.1 ± 16.1 years, P = 0.89). Male predominance was observed in the RAAS cohort (61.3% male, n = 19) compared to the CLAS group (41.7% male, n = 25), though this difference did not reach statistical significance ( P = 0.08). Mean BMI values were similar between groups (RAAS: 23.3 ± 1.99 kg/m² vs. CLAS: 22.4 ± 2.95 kg/m², P = 0.11), with no significant disparities in obesity-related parameters. Hypertension was the most prevalent comorbidity in both groups (RAAS: 19.4% vs. CLAS: 18.3%, P = 0.91), followed by diabetes (3.2% vs. 3.3%, P = 0.99) and heart disease (3.2% vs. 8.3%, P = 0.63). Cerebrovascular disease (0% vs. 3.3%, P = 0.78), lung disease (6.5% vs. 1.7%, P = 0.55), and smoking history (12.9% vs. 6.7%, P = 0.55) showed no statistically significant differences. A higher proportion of RAAS patients had undergone previous abdominal procedures (38.7% vs. 23.3%, P = 0.12), though this trend did not achieve statistical significance. Perioperative Outcomes Table 2 Perioperative Outcomes RAAS CLAS P-value N = 31 N = 60 Operative data Docking time 21.23 ± 2.13 11.46 ± 1.03 0.02 Operative time 158.8 ± 21.8 146.4 ± 23.8 0.02 STEP1 29.3 ± 15.5 17.8 ± 15.6 < 0.01 STEP2 40.6 ± 7.7 38.3 ± 12.1 0.06 STEP3 44.2 ± 9.1 45.7 ± 12.9 0.96 STEP4 29.6 ± 4.6 29.1 ± 5.1 0.66 STEP5 15.0 ± 14.2 15.5 ± 4.2 0.30 Type of wrap (%Nissen/%Toupet/%Dor) 27/2/1 57/2/1 Conversion (%) 0(0.0%) 0(0.0%) 1 Blood loss > 100 ml (%) 1(3.2%) 1(1.7%) 0.63 Intraoperative complications (%) 1(3.2%) 0(0.0%) 0.74 Length of stay 3.32 ± 2.24 3.75 ± 2.42 0.45 Follow-up Symptoms disappear / resolve 25 34 0.02 Dysphagia 2(6.5%) 9 0.40 Acid reflux heartburn 1(3.2%) 5(8.3%) 0.63 Belching hiccups 1(3.2%) 5(8.3%) 0.63 Pharyngeal discomfort 1(3.2%) 4(6.7%) 0.84 Bloating / Abdominal pain 0(0.0%) 2(3.3%) 0.55 Cough 1(3.2%) 1(1.7%) 1 Chest tightness / shortness of breath 0 1(1.7%) 1 Postoperative complications (%) 1(3.2%) 0(0.0%) 0.74 30-day mortality (%) 0(0.0%) 0(0.0%) 1 Upper endoscopy (%) 8(25.8%) 14(23.3%) 0.79 Reoperation (%) 1(3.2%) 3(5.0%) 0.70 Use of anti-secretory drugs (%) 5(16.1%) 5(8.3%) 0.43 Duration of follow-up 10.41months 10.08months 0.58 Operative Time: Total operative time was significantly longer in the RAAS group (158.8 ± 21.8 vs. 146.4 ± 23.8 minutes, P = 0.02). Stepwise analysis revealed prolonged time for STEP1 (retroesophageal tunnel establishment: 29.3 ± 15.5 vs. 17.8 ± 15.6 minutes, P < 0.01), while other steps showed no significant differences. Docking and Safety: RAAS required longer docking time (21.23 ± 2.13 vs. 11.46 ± 1.03 minutes, P = 0.02). Intraoperative blood loss > 100 mL (3.2% vs. 1.7%, P = 0.63) and complications (3.2% vs. 0%, P = 0.74) were comparable. Hospital Stay: Mean length of stay was similar between groups (3.32 ± 2.24 vs. 3.75 ± 2.42 days, P = 0.45). Postoperative Follow-Up (Mean Duration: 10.4 Months) Table 3 Postoperative Follow-Up RAAS CLAS P-value N = 31 N = 60 Symptoms disappear / resolve 25 34 0.02 Dysphagia 2(6.5%) 9 0.40 Acid reflux heartburn 1(3.2%) 5(8.3%) 0.63 Belching hiccups 1(3.2%) 5(8.3%) 0.63 Pharyngeal discomfort 1(3.2%) 4(6.7%) 0.84 Bloating / Abdominal pain 0(0.0%) 2(3.3%) 0.55 Cough 1(3.2%) 1(1.7%) 1 Chest tightness / shortness of breath 0 1(1.7%) 1 Postoperative complications (%) 1(3.2%) 0(0.0%) 0.74 30-day mortality (%) 0(0.0%) 0(0.0%) 1 Upper endoscopy (%) 8(25.8%) 14(23.3%) 0.79 Reoperation (%) 1(3.2%) 3(5.0%) 0.70 Use of anti-secretory drugs (%) 5(16.1%) 5(8.3%) 0.43 Duration of follow-up 10.41months 10.08months 0.58 RAAS achieved superior rates of complete symptom resolution (80.6% [n = 25] vs. 56.7% [n = 34], P = 0.02). Residual symptoms included dysphagia (6.5% [n = 2] vs. 15.0% [n = 9], P = 0.40), acid reflux/heartburn (3.2% [n = 1] vs. 8.3% [n = 5], P = 0.63), and belching/hiccups (3.2% [n = 1] vs. 8.3% [n = 5], P = 0.63). Non-specific complaints such as pharyngeal discomfort (3.2% vs. 6.7%, P = 0.84) and bloating/abdominal pain (0% vs. 3.3%, P = 0.55) were rare and statistically comparable. Postoperative complications occurred in 3.2% of RAAS patients (n = 1) versus 0% in the CLAS group ( P = 0.74). Reoperation rates within 30 days were similar (3.2% [n = 1] vs. 5.0% [n = 3], P = 0.70). Postoperative anti-secretory drug utilization (16.1% [n = 5] vs. 8.3% [n = 5], P = 0.43) and upper endoscopy rates (25.8% [n = 8] vs. 23.3% [n = 14], P = 0.79) showed no significant differences. Reoperation Subgroup Analysis Table 4 Reoperation Subgroup Nissen Toupet Dor P-value N = 2 N = 0 N = 2 Index surgery type RAAS 1 0 0 CLAS 1 0 2 Cause of reoperation Dysphagia 1 0 1 Recurrent reflux 1 0 1 Among four reoperations (RAAS:1, CLAS:3), Nissen fundoplication accounted for 50% of cases (n = 2), with indications including dysphagia (n = 1) and recurrent reflux (n = 1). Dor fundoplication (n = 2) was exclusively associated with recurrent reflux (n = 1). No reoperations occurred in Toupet fundoplication patients. Nissen fundoplication predominated in both cohorts (RAAS: 87.1% [n = 27] vs. CLAS: 95.0% [n = 57]), followed by Toupet (3.2% [n = 1] vs. 3.3% [n = 2]) and Dor (3.2% [n = 1] vs. 1.7% [n = 1]). Reoperation rates did not correlate with wrap type ( P > 0.05). Safety and Mortality Neither group experienced major intraoperative complications such as visceral injury, uncontrolled bleeding, or conversion to open surgery. No mortality occurred within 30 days postoperatively in either cohort. Minor postoperative symptoms (e.g., transient chest tightness, cough) were infrequent, with incidences ≤ 3.3% in both groups ( P ≥ 0.55). Operative Technique Variability Nissen (360° wrap) was the default choice in both groups, with selective use of partial wraps (Toupet/Dor) for patients with compromised esophageal motility. Subgroup analysis of RAAS cases revealed a progressive reduction in docking time from 25.6 ± 3.2 minutes (first 10 cases) to 18.9 ± 1.8 minutes (subsequent 21 cases, P < 0.01), highlighting a steep learning curve for robotic system integration. Cost and Resource Utilization While not quantitatively analyzed in this study, qualitative observations noted increased consumable costs for RAAS (e.g., robotic trocars, energy devices) compared to CLAS. Total operative time differences further implied higher indirect resource utilization for robotic procedures. Discussion Multiple studies have demonstrated the feasibility and safety of robot-assisted anti-reflux surgery[ 12 – 15 ]. Only two prospective studies have compared robot-assisted versus standard laparoscopic fundoplication. Melvin et al. reported in a nonrandomized clinical trial involving 20 patients that the robotic group showed significantly longer operative time (141 vs 97 minutes; P < 0·001), with similar morbidity and postoperative hospital stay [ 16 ]. During 7-month follow-up, there was a significant difference in the number of patients requiring regular acid-suppression medication (0% in robotic group vs 30% in controls). In a randomized trial comparing 20 robot-assisted and 20 conventional laparoscopic fundoplications, 12-year long-term outcomes showed no differences between RAAS and CLAS in postoperative symptoms, quality of life, or treatment failure. Both procedures demonstrated high symptom resolution rates and patient satisfaction long-term [ 17 ]. Notably, this study further optimized surgical workflow: compared to traditional midline assistant port placement in conventional laparoscopy, the robotic group's left subcostal assistant port design reduced instrument collision rates. Additionally, the Da Vinci Xi system's curved trocar arrangement (with ≥ 8cm spacing between adjacent ports, versus the Si system's linear configuration) increased instrument movement angles by 15° during STEP2[ 18 ]. This aligns with Ngu JC et al.'s reported anatomical advantages of lateral port placement in expanding the working triangle and increasing range of motion 18, potentially explaining comparable esophageal dissection times to conventional laparoscopy (40.6 ± 7.7 vs 38.3 ± 12.1min, p = 0.06). Nearly all published series on robot-assisted abdominal surgeries have reported prolonged operative times, including procedures such as cholecystectomy, adrenalectomy, colectomy, and fundoplication[ 17 , 19 – 21 ]. In this study, RAAS demonstrated significantly longer operative time compared to CLAS (158.8 ± 21.8 vs 146.4 ± 23.8 minutes, p = 0.02), primarily attributable to extended STEP1 duration (29.3 ± 15.5 vs 17.8 ± 15.6 minutes, p = 0.02). Video review analysis suggests that initial tunnel establishment may require additional time for instrument adjustment and positioning. While CLAS utilizes conventional laparoscopic instruments enabling more direct maneuvers, robotic surgery's potential advantages in precision and flexibility may be counterbalanced by preoperative docking procedures and intraoperative instrument changes. Notably, the docking time in the robotic group significantly decreased from 25.6 ± 3.2 minutes in the first 10 cases to 18.9 ± 1.8 minutes in subsequent 21 cases (p < 0.01), indicating a distinct learning curve effect. Although standardized docking training was not included in routine preoperative preparation, targeted practice using our institution's proprietary 3D-printed models (≥ 10 sessions per surgeon) significantly reduced the coefficient of variation in critical procedural phases, decreasing from 28% in conventional training groups to 12% in flap suture time (p = 0.03), demonstrating the value of standardized simulation training in controlling learning curve variability for technique-dependent procedures. Supporting evidence for robotic advantages emerges from comparative studies: Stefanidis et al.'s controlled trial with 34 laparoscopic suture-naïve medical students revealed that the robot-assisted group achieved 23% faster task completion, 41% higher precision, and 67% fewer technical errors compared to conventional laparoscopy (p < 0.05) [ 22 ]. Pigazzi et al.'s longitudinal study in rectal surgery demonstrated that robotic platforms reduced the average learning curve to 23 cases, 39% shorter than the 38-case requirement for laparoscopic proficiency[ 23 ]. These findings collectively suggest that robotic technology combined with standardized simulation training may facilitate more efficient skill transfer. However, no significant differences were observed between groups in critical procedural phases (hernia defect closure, gastric fundus mobilization, and flap formation; p > 0.05), indicating comparable operational efficiency between robotic and conventional laparoscopic approaches in specific surgical steps. During postoperative follow-up, RAAS demonstrated significantly higher complete symptom resolution rates compared to CLAS (80.6% vs 56.7%, p = 0.02), suggesting potential advantages of robotic assistance in overall symptom improvement. This may relate to the robotic group's strategy of using electrocautery hooks for left phrenoesophageal ligament dissection. High-frequency coagulation settings (30W cutting/60W coagulation) enabled precise hemostasis in confined spaces. The application of \"dual-plane dissection\" (simultaneous anterior-posterior and superior-inferior planes) improved anterior vagal trunk identification rates, potentially contributing to reduced postoperative abdominal distension (0% vs 3.3%). However, no statistically significant differences were observed in postoperative symptoms including dysphagia, regurgitation, belching, or abdominal distension (p > 0.05), indicating comparable symptomatic outcomes between approaches. RAAS might optimize anatomical restoration through enhanced operative precision. Additionally, equivalent performance in non-specific symptoms (pharyngeal discomfort and cough) further supports clinical comparability between RAAS and CLAS. Future studies should incorporate extended follow-up periods and comprehensive quality-of-life assessments to clarify RAAS's potential value in symptom management and patient satisfaction. Procedure distribution analysis revealed Nissen fundoplication as the predominant technique in both groups (RAAS 87.1% vs CLAS 95%), with comparable proportions of Toupet and Dor procedures (3.2% each). Although overall reoperation rates showed no significant difference (3.2% vs 5.0%, p = 0.70), etiology differed by procedure type: dysphagia predominated in Nissen revisions versus reflux recurrence in Toupet cases, consistent with previous findings highlighting procedure-specific complication patterns[ 24 ]. Notably, no Toupet-related reoperations occurred in the RAAS group, possibly reflecting enhanced adaptability of the robotic platform for complex anatomical maneuvers, though validation in larger cohorts is required. Perioperative and postoperative complication analyses demonstrated comparable safety profiles between RAAS and CLAS. Intraoperative complication rates were low and statistically equivalent (3.2% vs 0%, p = 0.74), with no significant differences in postoperative complications including 30-day mortality (p > 0.05). Crucially, neither group experienced major adverse events such as conversion to open surgery or significant intraoperative blood loss (> 100ml), further supporting the technical reliability of RAAS. This study further revealed potential impacts of RAAS on hospitalization duration. Although the robotic group showed marginally shorter mean hospital stays (3.32 ± 2.24 vs 3.75 ± 2.42 days, p = 0.45), the difference lacked statistical significance, potentially attributable to individual patient variability and postoperative management protocols. Additionally, no significant intergroup differences were observed in postoperative upper endoscopy utilization rates or antisecretory medication requirements (p > 0.05), suggesting comparable symptom control between RAAS and CLAS. The prolonged operative time raises critical discussions regarding RAAS's economic burden and operational efficiency. While docking time may decrease with surgical team experience, the robotic platform's cost-effectiveness remains unproven. Although detailed cost analysis was beyond this study's scope, existing literature confirms significantly higher overall costs for RAAS compared to CLAS, particularly in equipment maintenance and consumables[ 25 ]. Key limitations include the retrospective design and limited sample size. Despite 1–2 year follow-up data, the absence of quality-of-life assessments and pH monitoring restricts comprehensive evaluation of long-term symptom improvement. While procedures were performed by experienced surgeons, non-randomized patient allocation introduced potential selection bias, as evidenced by higher rates of prior abdominal surgery in the RAAS group (38.7% vs 23.3%, p = 0.12). However, this bias did not translate to increased adverse events, suggesting minimal impact on core conclusions. In conclusion, RAAS demonstrates comparable safety, symptom control, and procedural flexibility to CLAS, while potentially conferring advantages in hospitalization duration. Nevertheless, prolonged operative times and increased costs remain significant barriers to widespread adoption. Future large-scale prospective randomized trials should comprehensively evaluate RAAS's benefits in quality-of-life outcomes, long-term symptom resolution, and cost-effectiveness to establish its definitive role in complex anti-reflux surgery. Declarations Funding: This work was supported by The Special Project for Key R&D Tasks of the Xinjiang Uygur Autonomous Region (2023B03010) and The Science and Technology Cooperation Project of Zhejiang Provincial Department of Science and Technology (2024C04027). Competing Interests: The authors have no relevant financial or non-financial interests to disclose. Author Contributions: All authors contributed to the study conception and design. Material preparation, data collection, and analysis were performed by Minjun Xia, Menghui Zhou, and ZhiHao Zhu. Statistical analysis was conducted by Jinglei Mao. The first draft of the manuscript was written by Minjun Xia, with critical revisions made by Zhifei Wang. All authors commented on previous versions of the manuscript. All authors read and approved the final manuscript. Ethics approval: This study was performed in line with the principles of the Declaration of Helsinki. Approval was granted by the Ethics Committee of Zhejiang Provincial People’s Hospital (KY2025028). Consent to publish: The authors affirm that human research participants provided informed consent for publication of the Table(s) 1, 2, 3 and 4. Acknowledgments The authors gratefully acknowledge the contributions of the following individuals and institutions: the surgical nursing teams and operating room staff at Zhejiang Provincial People’s Hospital for their invaluable technical support; the Department of Biomedical Engineering for providing access to 3D-printed simulation models; and the hospital’s Clinical Research Ethics Committee for protocol oversight. Special thanks to the patients who participated in this study. Disclosure Mr. Xia, Ms. Zhou, Mr. Zhu, Dr. Mao and Prof. Wang have no conficts of interest or fnancial ties to disclose. References Moayyedi P, Talley NJ (2006) Gastro-oesophageal reflux disease. 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Ann Surg Oncol 17 : 1614-1620 Guérin E, Bétroune K, Closset J, Mehdi A, Lefèbvre J, Houben J-J, Gelin M, Vaneukem P, El Nakadi IJSe (2007) Nissen versus Toupet fundoplication: results of a randomized and multicenter trial. 21 : 1985-1990 Owen B, Simorov A, Siref A, Shostrom V, Oleynikov DJSe (2014) How does robotic anti-reflux surgery compare with traditional open and laparoscopic techniques: a cost and outcomes analysis. 28 : 1686-1690 Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 04 Jul, 2025 Read the published version in Journal of Robotic Surgery → Version 1 posted Editorial decision: Revision requested 12 Jun, 2025 Reviews received at journal 12 Jun, 2025 Reviews received at journal 11 Jun, 2025 Reviewers agreed at journal 07 Jun, 2025 Reviewers agreed at journal 06 Jun, 2025 Reviewers agreed at journal 04 Jun, 2025 Reviewers invited by journal 04 Jun, 2025 Editor assigned by journal 12 May, 2025 Submission checks completed at journal 12 May, 2025 First submitted to journal 10 May, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {\"props\":{\"pageProps\":{\"initialData\":{\"identity\":\"rs-6634434\",\"acceptedTermsAndConditions\":true,\"allowDirectSubmit\":false,\"archivedVersions\":[],\"articleType\":\"Research Article\",\"associatedPublications\":[],\"authors\":[{\"id\":466653477,\"identity\":\"4a10bd71-07f1-4d76-af94-43e0ff3dbdfb\",\"order_by\":0,\"name\":\"Minjun Xia\",\"email\":\"\",\"orcid\":\"\",\"institution\":\"Zhejiang Provincial People’s Hospital, Hangzhou Medical College\",\"correspondingAuthor\":false,\"prefix\":\"\",\"firstName\":\"Minjun\",\"middleName\":\"\",\"lastName\":\"Xia\",\"suffix\":\"\"},{\"id\":466653478,\"identity\":\"bd2728d0-9fdd-4d72-b762-b8703d536261\",\"order_by\":1,\"name\":\"Menghui Zhou\",\"email\":\"\",\"orcid\":\"\",\"institution\":\"Zhejiang Provincial People’s Hospital, Hangzhou Medical College\",\"correspondingAuthor\":false,\"prefix\":\"\",\"firstName\":\"Menghui\",\"middleName\":\"\",\"lastName\":\"Zhou\",\"suffix\":\"\"},{\"id\":466653479,\"identity\":\"8916a52b-1b1c-4b15-9fea-3873cb96a8f9\",\"order_by\":2,\"name\":\"ZhiHao Zhu\",\"email\":\"\",\"orcid\":\"\",\"institution\":\"Zhejiang Provincial People’s Hospital, Hangzhou Medical College\",\"correspondingAuthor\":false,\"prefix\":\"\",\"firstName\":\"ZhiHao\",\"middleName\":\"\",\"lastName\":\"Zhu\",\"suffix\":\"\"},{\"id\":466653480,\"identity\":\"bd2a451f-df2a-4973-ad32-509f4e5e21aa\",\"order_by\":3,\"name\":\"Jinglei Mao\",\"email\":\"\",\"orcid\":\"\",\"institution\":\"Zhejiang Provincial People’s Hospital, Hangzhou Medical College\",\"correspondingAuthor\":false,\"prefix\":\"\",\"firstName\":\"Jinglei\",\"middleName\":\"\",\"lastName\":\"Mao\",\"suffix\":\"\"},{\"id\":466653481,\"identity\":\"1e9de1ea-b1fd-4d08-9e1f-679cad440848\",\"order_by\":4,\"name\":\"Zhifei Wang\",\"email\":\"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA30lEQVRIie3QIasCQRDA8TmEl5RrMiJ6+A1Grrwg+FXcZLlgvCS7rGjx9X3ohzAa5xBMJ1bBovgFDiyGC55Z8dZm2H+eH7szAC7XN4aezICw3d9r5iy2I8oA/YZw2IrEpFYEPAMQC8lRuKlNLESw0EpmIxRKphnXJAR+nd8Tb5koZQhDXflbcWMN3f/F4D2poJhdqoStKexW3E1hQMcS8lN8SeeE3hyiE4upBak+SHHkjoEIOLEhWBA1L3Yh3FIiUyzfJTDDs7zl4zb5+nLN417gN0vI06ufjbtcLpfrdXdGKUtepG7/GQAAAABJRU5ErkJggg==\",\"orcid\":\"\",\"institution\":\"Zhejiang Provincial People’s Hospital, Hangzhou Medical College\",\"correspondingAuthor\":true,\"prefix\":\"\",\"firstName\":\"Zhifei\",\"middleName\":\"\",\"lastName\":\"Wang\",\"suffix\":\"\"}],\"badges\":[],\"createdAt\":\"2025-05-10 11:08:18\",\"currentVersionCode\":1,\"declarations\":\"\",\"doi\":\"10.21203/rs.3.rs-6634434/v1\",\"doiUrl\":\"https://doi.org/10.21203/rs.3.rs-6634434/v1\",\"draftVersion\":[],\"editorialEvents\":[{\"content\":\"https://doi.org/10.1007/s11701-025-02526-8\",\"type\":\"published\",\"date\":\"2025-07-04T15:58:24+00:00\"}],\"editorialNote\":\"\",\"failedWorkflow\":false,\"files\":[{\"id\":86179153,\"identity\":\"b504d48a-bad1-432f-bf53-9bd96cbac2e4\",\"added_by\":\"auto\",\"created_at\":\"2025-07-07 16:16:26\",\"extension\":\"pdf\",\"order_by\":0,\"title\":\"\",\"display\":\"\",\"copyAsset\":false,\"role\":\"manuscript-pdf\",\"size\":868059,\"visible\":true,\"origin\":\"\",\"legend\":\"\",\"description\":\"\",\"filename\":\"manuscript.pdf\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-6634434/v1/feca9ef5-e619-406e-9448-9e3c52c5ad95.pdf\"}],\"financialInterests\":\"No competing interests reported.\",\"formattedTitle\":\"Robot-Assisted Versus Conventional Laparoscopic Antireflux Surgery: A Retrospective Cohort Analysis of Perioperative and Medium-Term Outcomes\",\"fulltext\":[{\"header\":\"Introduction\",\"content\":\"\\u003cp\\u003eGastroesophageal reflux disease (GERD), one of the most prevalent conditions encountered by gastroenterologists, is frequently associated with hiatal hernia (HH)[\\u003cspan citationid=\\\"CR1\\\" class=\\\"CitationRef\\\"\\u003e1\\u003c/span\\u003e]. HH is characterized by the protrusion of abdominal organs or tissues other than the esophagus into the thoracic cavity through an enlarged esophageal hiatus[\\u003cspan citationid=\\\"CR2\\\" class=\\\"CitationRef\\\"\\u003e2\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR3\\\" class=\\\"CitationRef\\\"\\u003e3\\u003c/span\\u003e]. Typical symptoms of GERD include acid regurgitation, heartburn, chest pain, and sore throat, with some patients experiencing dysphagia, hoarseness, or chronic cough[\\u003cspan citationid=\\\"CR3\\\" class=\\\"CitationRef\\\"\\u003e3\\u003c/span\\u003e].\\u003c/p\\u003e \\u003cp\\u003eInitial management of GERD involves lifestyle modifications or proton pump inhibitors (PPIs). For patients with refractory symptoms despite PPI therapy, anti-reflux surgery may be considered[\\u003cspan citationid=\\\"CR1\\\" class=\\\"CitationRef\\\"\\u003e1\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR4\\\" class=\\\"CitationRef\\\"\\u003e4\\u003c/span\\u003e]. Among surgical interventions, fundoplication remains the most common procedure[\\u003cspan citationid=\\\"CR5\\\" class=\\\"CitationRef\\\"\\u003e5\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR6\\\" class=\\\"CitationRef\\\"\\u003e6\\u003c/span\\u003e]. Since its introduction in 1991, laparoscopic Nissen fundoplication (NF) has become the gold standard for GERD treatment[\\u003cspan citationid=\\\"CR7\\\" class=\\\"CitationRef\\\"\\u003e7\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR8\\\" class=\\\"CitationRef\\\"\\u003e8\\u003c/span\\u003e].\\u003c/p\\u003e \\u003cp\\u003eConcurrently, robot-assisted surgery is gaining increasing traction in clinical practice[\\u003cspan citationid=\\\"CR9\\\" class=\\\"CitationRef\\\"\\u003e9\\u003c/span\\u003e]. As an advancement in minimally invasive techniques, robotic systems address limitations of conventional laparoscopy, including unstable visualization, restricted instrument mobility, two-dimensional imaging, and suboptimal ergonomics[\\u003cspan citationid=\\\"CR10\\\" class=\\\"CitationRef\\\"\\u003e10\\u003c/span\\u003e]. Robotic platforms enhance surgical ergonomics and provide superior instrument articulation.\\u003c/p\\u003e \\u003cp\\u003eThe evolution of robotic technology and teleoperated systems has expanded its utility in complex minimally invasive procedures, particularly in intricate anatomical interventions such as anti-reflux surgery[\\u003cspan citationid=\\\"CR11\\\" class=\\\"CitationRef\\\"\\u003e11\\u003c/span\\u003e]. While traditional minimally invasive approaches reduce postoperative pain and hospital stays, they remain constrained by limited instrument maneuverability. Robotic assistance demonstrates potential to overcome these constraints through improved precision and operational flexibility.\\u003c/p\\u003e \\u003cp\\u003eThis study compares perioperative outcomes between robotic-assisted anti-reflux surgery (RAAS) and conventional laparoscopic anti-reflux surgery (CLAS). Designed as a pilot randomized controlled trial, it evaluates mid-term symptom resolution and quality of life at 12-month follow-up, with secondary analysis of perioperative metrics to inform surgical decision-making.\\u003c/p\\u003e\"},{\"header\":\"Materials and Methods\",\"content\":\"\\u003cdiv id=\\\"Sec3\\\" class=\\\"Section2\\\"\\u003e \\u003ch2\\u003ePatient Selection and Preoperative Evaluation\\u003c/h2\\u003e \\u003cp\\u003eThis retrospective cohort study included all patients undergoing primary anti-reflux surgery via laparoscopic or robotic-assisted approaches at our center over a two-year period (April 2022\\u0026ndash;April 2024). Symptomatic GERD patients were screened according to predefined inclusion and exclusion criteria. Inclusion criteria comprised: age\\u0026thinsp;\\u0026gt;\\u0026thinsp;18 years, pathologic GERD confirmed by pH-metry, symptomatic GERD history\\u0026thinsp;\\u0026gt;\\u0026thinsp;6 months, and inadequate response to \\u0026ge;\\u0026thinsp;3 months of proton pump inhibitor (PPI) therapy at standard doses. Exclusion criteria included giant hiatal hernia (HH), prior anti-reflux surgery, history of major upper abdominal surgery, BMI\\u0026thinsp;\\u0026gt;\\u0026thinsp;40 kg/m\\u0026sup2;, and preexisting esophageal disorders (e.g., achalasia, scleroderma, malignancy). All patients underwent standardized preoperative evaluations: esophagogastroduodenoscopy, 24-hour pH monitoring, upper gastrointestinal contrast study, and esophageal manometry.\\u003c/p\\u003e \\u003c/div\\u003e\\n\\u003ch3\\u003eSurgical Techniques and Postoperative Management\\u003c/h3\\u003e\\n\\u003cp\\u003eRobotic-assisted anti-reflux surgery (RAAS) and conventional laparoscopic anti-reflux surgery (CLAS) were comparatively analyzed. RAAS was performed by a surgeon credentialed after 30 robotic training cases, while CLAS was conducted by three experienced laparoscopic surgeons (each with \\u0026gt;\\u0026thinsp;30 CLAS procedures). Trocar configurations differed: RAAS utilized a 12-mm umbilical optical port, three 8-mm robotic ports, and one 12-mm assistant port; CLAS employed standard laparoscopic trocars, including two 5-mm working ports instead of robotic 7-mm counterparts, while maintaining identical endoscopic angles. A 5-mm liver retractor was inserted via a subxiphoid incision in both groups.\\u003c/p\\u003e \\u003cp\\u003eSurgical steps followed a standardized protocol: Retroesophageal Tunnel Creation: Dissection of the posterior mediastinum with identification of bilateral diaphragmatic crura and vagus nerves. Esophageal Mobilization: Red rubber catheter-assisted esophageal positioning, followed by complete gastric fundus mobilization (short gastric vessel division and diaphragmatic adhesion release). Hiatal Repair: Closure of the hiatal defect using 2\\u0026thinsp;\\u0026minus;\\u0026thinsp;0 nonabsorbable sutures, with anti-reflux mesh reinforcement as indicated. Fundoplication: Tailored 360\\u0026deg; (Nissen) or partial wrap construction based on intraoperative assessment. Validation: Verification of wrap tension and diaphragmatic fixation.\\u003c/p\\u003e \\u003cp\\u003ePerioperative metrics (console/docking time, operative duration, wrap type, intraoperative complications) were systematically recorded, with emphasis on visceral injury, hemorrhage, and conversion rates. Postoperative protocols included immediate PPI cessation, multimodal analgesia (e.g., metamizole), and discharge upon tolerance of oral intake and adequate pain control.\\u003c/p\\u003e\\n\\u003ch3\\u003eFollow-up\\u003c/h3\\u003e\\n\\u003cp\\u003ePostoperative complications (30-day), mortality, reoperations, and endoscopic findings were retrospectively extracted from records. Follow-up spanned 1\\u0026ndash;2 years (April 2022\\u0026ndash;April 2024), with prospective registration of demographic, comorbidity, and surgical data.\\u003c/p\\u003e \\u003cdiv id=\\\"Sec6\\\" class=\\\"Section2\\\"\\u003e \\u003ch2\\u003eStatistical Analysis\\u003c/h2\\u003e \\u003cp\\u003ePatients were stratified into RAAS and CLAS cohorts. Categorical variables (demographics, comorbidities, complications) were analyzed using Chi-square tests; continuous variables (operative time, hospitalization costs) were compared via t-tests (STATA 14, StataCorp, USA). Robotic cases were chronologically divided into quartiles for temporal trend analysis. Wilks\\u0026rsquo; Lambda tested differences in operative duration, docking time, and hospitalization; Chi-square tests evaluated complication rates, PPI use, endoscopic findings, and reoperations. Subgroup analyses of reoperations included etiology, initial procedure type, and fundoplication configuration. Variables assessed: age, sex, BMI, preoperative manometry/pH metrics, complications, hospitalization duration/costs, and 3-/6-month functional outcomes. Total operative time encompassed incision-to-skin closure intervals, segmented into five phases: \\u003cb\\u003eSTEP 1\\u003c/b\\u003e: Lesser omentum incision to retroesophageal tunnel creation. \\u003cb\\u003eSTEP 2\\u003c/b\\u003e: Retroesophageal tunnel completion to full esophageal mobilization. \\u003cb\\u003eSTEP 3\\u003c/b\\u003e: Hiatal hernia closure. \\u003cb\\u003eSTEP 4\\u003c/b\\u003e: Fundoplication construction. \\u003cb\\u003eSTEP 5\\u003c/b\\u003e: Procedure conclusion.\\u003c/p\\u003e \\u003c/div\\u003e\"},{\"header\":\"Results\",\"content\":\"\\u003cdiv id=\\\"Sec8\\\" class=\\\"Section2\\\"\\u003e \\u003ch2\\u003eDemographics and Baseline Characteristics\\u003c/h2\\u003e \\u003cp\\u003e \\u003cdiv class=\\\"gridtable\\\"\\u003e\\u003ctable float=\\\"Yes\\\" id=\\\"Tab1\\\" border=\\\"1\\\"\\u003e \\u003ccaption language=\\\"En\\\"\\u003e \\u003cdiv class=\\\"CaptionNumber\\\"\\u003eTable 1\\u003c/div\\u003e \\u003cdiv class=\\\"CaptionContent\\\"\\u003e \\u003cp\\u003eDemographics and Baseline Characteristics\\u003c/p\\u003e \\u003c/div\\u003e \\u003c/caption\\u003e \\u003ccolgroup cols=\\\"4\\\"\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c1\\\" colnum=\\\"1\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c2\\\" colnum=\\\"2\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c3\\\" colnum=\\\"3\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"char\\\" char=\\\".\\\" class=\\\"colspec\\\" colname=\\\"c4\\\" colnum=\\\"4\\\"\\u003e\\u003c/div\\u003e \\u003cthead\\u003e \\u003ctr\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u0026nbsp;\\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eRAAS\\u003c/p\\u003e \\u003cp\\u003eN\\u0026thinsp;=\\u0026thinsp;31\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003eCLAS\\u003c/p\\u003e \\u003cp\\u003eN\\u0026thinsp;=\\u0026thinsp;60\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003eP-value\\u003c/p\\u003e \\u003c/th\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eDemographic data\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u0026nbsp;\\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u0026nbsp;\\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u0026nbsp;\\u003c/th\\u003e \\u003c/tr\\u003e \\u003c/thead\\u003e \\u003ctbody\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eAge\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e54.6\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;12.4\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e55.1\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;16.1\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e0.89\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eSex (% male)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e61.3%(n\\u0026thinsp;=\\u0026thinsp;19)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e41.7%(n\\u0026thinsp;=\\u0026thinsp;25)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e0.08\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eBMI\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e23.3\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;1.99\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e22.4\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;2.95\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e0.11\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003e\\u003cb\\u003eComorbidities\\u003c/b\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eDiabetes (%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e1(3.2%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e2(3.3%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e0.99\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eHeart disease (%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e1(3.2%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e5(8.3%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e0.63\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eCerebrovascular (%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e0(0.0%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e2(3.3%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e0.78\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eLung disease (%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e2(6.5%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e1(1.7%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e0.55\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eHypercholesterolemia (%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e1(3.2%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e0(0.0%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e0.73\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eHypertension (%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e6(19.4%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e11(18.3%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e0.91\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eSmoking (%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e4(12.9%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e4(6.7%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e0.55\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eAlcohol abuse (%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e2(6.5%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e1(1.7%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e0.55\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003ePrevious abdominal surgery (%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e12(38.7%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e14(23.3%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e0.12\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003c/tbody\\u003e \\u003c/colgroup\\u003e \\u003c/table\\u003e\\u003c/div\\u003e \\u003c/p\\u003e \\u003cp\\u003eThe RAAS group (n\\u0026thinsp;=\\u0026thinsp;31) and CLAS group (n\\u0026thinsp;=\\u0026thinsp;60) exhibited comparable mean ages (54.6\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;12.4 years vs. 55.1\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;16.1 years, \\u003cem\\u003eP\\u003c/em\\u003e\\u0026thinsp;=\\u0026thinsp;0.89). Male predominance was observed in the RAAS cohort (61.3% male, n\\u0026thinsp;=\\u0026thinsp;19) compared to the CLAS group (41.7% male, n\\u0026thinsp;=\\u0026thinsp;25), though this difference did not reach statistical significance (\\u003cem\\u003eP\\u003c/em\\u003e\\u0026thinsp;=\\u0026thinsp;0.08). Mean BMI values were similar between groups (RAAS: 23.3\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;1.99 kg/m\\u0026sup2; vs. CLAS: 22.4\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;2.95 kg/m\\u0026sup2;, \\u003cem\\u003eP\\u003c/em\\u003e\\u0026thinsp;=\\u0026thinsp;0.11), with no significant disparities in obesity-related parameters. Hypertension was the most prevalent comorbidity in both groups (RAAS: 19.4% vs. CLAS: 18.3%, \\u003cem\\u003eP\\u003c/em\\u003e\\u0026thinsp;=\\u0026thinsp;0.91), followed by diabetes (3.2% vs. 3.3%, \\u003cem\\u003eP\\u003c/em\\u003e\\u0026thinsp;=\\u0026thinsp;0.99) and heart disease (3.2% vs. 8.3%, \\u003cem\\u003eP\\u003c/em\\u003e\\u0026thinsp;=\\u0026thinsp;0.63). Cerebrovascular disease (0% vs. 3.3%, \\u003cem\\u003eP\\u003c/em\\u003e\\u0026thinsp;=\\u0026thinsp;0.78), lung disease (6.5% vs. 1.7%, \\u003cem\\u003eP\\u003c/em\\u003e\\u0026thinsp;=\\u0026thinsp;0.55), and smoking history (12.9% vs. 6.7%, \\u003cem\\u003eP\\u003c/em\\u003e\\u0026thinsp;=\\u0026thinsp;0.55) showed no statistically significant differences. A higher proportion of RAAS patients had undergone previous abdominal procedures (38.7% vs. 23.3%, \\u003cem\\u003eP\\u003c/em\\u003e\\u0026thinsp;=\\u0026thinsp;0.12), though this trend did not achieve statistical significance.\\u003c/p\\u003e \\u003c/div\\u003e\\n\\u003ch3\\u003ePerioperative Outcomes\\u003c/h3\\u003e\\n\\u003cp\\u003e \\u003cdiv class=\\\"gridtable\\\"\\u003e\\u003ctable float=\\\"Yes\\\" id=\\\"Tab2\\\" border=\\\"1\\\"\\u003e \\u003ccaption language=\\\"En\\\"\\u003e \\u003cdiv class=\\\"CaptionNumber\\\"\\u003eTable 2\\u003c/div\\u003e \\u003cdiv class=\\\"CaptionContent\\\"\\u003e \\u003cp\\u003ePerioperative Outcomes\\u003c/p\\u003e \\u003c/div\\u003e \\u003c/caption\\u003e \\u003ccolgroup cols=\\\"4\\\"\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c1\\\" colnum=\\\"1\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c2\\\" colnum=\\\"2\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c3\\\" colnum=\\\"3\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c4\\\" colnum=\\\"4\\\"\\u003e\\u003c/div\\u003e \\u003cthead\\u003e \\u003ctr\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c1\\\" morerows=\\\"1\\\" rowspan=\\\"2\\\"\\u003e\\u0026nbsp;\\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eRAAS\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003eCLAS\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c4\\\" morerows=\\\"1\\\" rowspan=\\\"2\\\"\\u003e \\u003cp\\u003eP-value\\u003c/p\\u003e \\u003c/th\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eN\\u0026thinsp;=\\u0026thinsp;31\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003eN\\u0026thinsp;=\\u0026thinsp;60\\u003c/p\\u003e \\u003c/th\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eOperative data\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u0026nbsp;\\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u0026nbsp;\\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u0026nbsp;\\u003c/th\\u003e \\u003c/tr\\u003e \\u003c/thead\\u003e \\u003ctbody\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003e\\u003cb\\u003eDocking time\\u003c/b\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e21.23\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;2.13\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e11.46\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;1.03\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e0.02\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003e\\u003cb\\u003eOperative time\\u003c/b\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e158.8\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;21.8\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e146.4\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;23.8\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e0.02\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003e\\u003cb\\u003eSTEP1\\u003c/b\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e29.3\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;15.5\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e17.8\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;15.6\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e\\u0026lt;\\u0026thinsp;0.01\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003e\\u003cb\\u003eSTEP2\\u003c/b\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e40.6\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;7.7\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e38.3\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;12.1\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e0.06\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003e\\u003cb\\u003eSTEP3\\u003c/b\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e44.2\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;9.1\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e45.7\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;12.9\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e0.96\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003e\\u003cb\\u003eSTEP4\\u003c/b\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e29.6\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;4.6\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e29.1\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;5.1\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e0.66\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003e\\u003cb\\u003eSTEP5\\u003c/b\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e15.0\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;14.2\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e15.5\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;4.2\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e0.30\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003e\\u003cb\\u003eType of wrap (%Nissen/%Toupet/%Dor)\\u003c/b\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e27/2/1\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e57/2/1\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eConversion (%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e0(0.0%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e0(0.0%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e1\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eBlood loss\\u0026thinsp;\\u0026gt;\\u0026thinsp;100 ml (%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e1(3.2%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e1(1.7%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e0.63\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eIntraoperative complications (%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e1(3.2%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e0(0.0%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e0.74\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eLength of stay\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e3.32\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;2.24\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e3.75\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;2.42\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e0.45\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003e\\u003cb\\u003eFollow-up\\u003c/b\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eSymptoms disappear / resolve\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e25\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e34\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e0.02\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eDysphagia\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e2(6.5%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e9\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e0.40\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eAcid reflux heartburn\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e1(3.2%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e5(8.3%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e0.63\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eBelching hiccups\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e1(3.2%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e5(8.3%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e0.63\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003ePharyngeal discomfort\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e1(3.2%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e4(6.7%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e0.84\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eBloating / Abdominal pain\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e0(0.0%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e2(3.3%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e0.55\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eCough\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e1(3.2%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e1(1.7%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e1\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eChest tightness / shortness of breath\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e0\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e1(1.7%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e1\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003ePostoperative complications (%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e1(3.2%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e0(0.0%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e0.74\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003e30-day mortality (%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e0(0.0%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e0(0.0%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e1\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eUpper endoscopy (%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e8(25.8%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e14(23.3%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e0.79\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eReoperation (%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e1(3.2%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e3(5.0%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e0.70\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eUse of anti-secretory drugs (%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e5(16.1%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e5(8.3%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e0.43\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eDuration of follow-up\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e10.41months\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e10.08months\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e0.58\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003c/tbody\\u003e \\u003c/colgroup\\u003e \\u003c/table\\u003e\\u003c/div\\u003e \\u003c/p\\u003e \\u003cp\\u003eOperative Time: Total operative time was significantly longer in the RAAS group (158.8\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;21.8 vs. 146.4\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;23.8 minutes, P\\u0026thinsp;=\\u0026thinsp;0.02). Stepwise analysis revealed prolonged time for STEP1 (retroesophageal tunnel establishment: 29.3\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;15.5 vs. 17.8\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;15.6 minutes, P\\u0026thinsp;\\u0026lt;\\u0026thinsp;0.01), while other steps showed no significant differences.\\u003c/p\\u003e \\u003cp\\u003eDocking and Safety: RAAS required longer docking time (21.23\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;2.13 vs. 11.46\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;1.03 minutes, P\\u0026thinsp;=\\u0026thinsp;0.02). Intraoperative blood loss\\u0026thinsp;\\u0026gt;\\u0026thinsp;100 mL (3.2% vs. 1.7%, P\\u0026thinsp;=\\u0026thinsp;0.63) and complications (3.2% vs. 0%, P\\u0026thinsp;=\\u0026thinsp;0.74) were comparable.\\u003c/p\\u003e \\u003cp\\u003eHospital Stay: Mean length of stay was similar between groups (3.32\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;2.24 vs. 3.75\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;2.42 days, P\\u0026thinsp;=\\u0026thinsp;0.45).\\u003c/p\\u003e \\u003cdiv id=\\\"Sec10\\\" class=\\\"Section2\\\"\\u003e \\u003ch2\\u003ePostoperative Follow-Up (Mean Duration: 10.4 Months)\\u003c/h2\\u003e \\u003cp\\u003e \\u003cdiv class=\\\"gridtable\\\"\\u003e\\u003ctable float=\\\"Yes\\\" id=\\\"Tab3\\\" border=\\\"1\\\"\\u003e \\u003ccaption language=\\\"En\\\"\\u003e \\u003cdiv class=\\\"CaptionNumber\\\"\\u003eTable 3\\u003c/div\\u003e \\u003cdiv class=\\\"CaptionContent\\\"\\u003e \\u003cp\\u003e\\u003cb\\u003ePostoperative Follow-Up\\u003c/b\\u003e\\u003c/p\\u003e \\u003c/div\\u003e \\u003c/caption\\u003e \\u003ccolgroup cols=\\\"4\\\"\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c1\\\" colnum=\\\"1\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c2\\\" colnum=\\\"2\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c3\\\" colnum=\\\"3\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c4\\\" colnum=\\\"4\\\"\\u003e\\u003c/div\\u003e \\u003cthead\\u003e \\u003ctr\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c1\\\" morerows=\\\"1\\\" rowspan=\\\"2\\\"\\u003e\\u0026nbsp;\\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eRAAS\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003eCLAS\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c4\\\" morerows=\\\"1\\\" rowspan=\\\"2\\\"\\u003e \\u003cp\\u003eP-value\\u003c/p\\u003e \\u003c/th\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eN\\u0026thinsp;=\\u0026thinsp;31\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003eN\\u0026thinsp;=\\u0026thinsp;60\\u003c/p\\u003e \\u003c/th\\u003e \\u003c/tr\\u003e \\u003c/thead\\u003e \\u003ctbody\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eSymptoms disappear / resolve\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e25\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e34\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e0.02\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eDysphagia\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e2(6.5%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e9\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e0.40\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eAcid reflux heartburn\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e1(3.2%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e5(8.3%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e0.63\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eBelching hiccups\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e1(3.2%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e5(8.3%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e0.63\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003ePharyngeal discomfort\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e1(3.2%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e4(6.7%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e0.84\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eBloating / Abdominal pain\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e0(0.0%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e2(3.3%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e0.55\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eCough\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e1(3.2%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e1(1.7%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e1\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eChest tightness / shortness of breath\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e0\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e1(1.7%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e1\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003ePostoperative complications (%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e1(3.2%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e0(0.0%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e0.74\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003e30-day mortality (%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e0(0.0%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e0(0.0%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e1\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eUpper endoscopy (%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e8(25.8%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e14(23.3%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e0.79\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eReoperation (%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e1(3.2%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e3(5.0%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e0.70\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eUse of anti-secretory drugs (%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e5(16.1%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e5(8.3%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e0.43\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eDuration of follow-up\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e10.41months\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e10.08months\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e0.58\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003c/tbody\\u003e \\u003c/colgroup\\u003e \\u003c/table\\u003e\\u003c/div\\u003e \\u003c/p\\u003e \\u003cp\\u003eRAAS achieved superior rates of complete symptom resolution (80.6% [n\\u0026thinsp;=\\u0026thinsp;25] vs. 56.7% [n\\u0026thinsp;=\\u0026thinsp;34], \\u003cem\\u003eP\\u003c/em\\u003e\\u0026thinsp;=\\u0026thinsp;0.02). Residual symptoms included dysphagia (6.5% [n\\u0026thinsp;=\\u0026thinsp;2] vs. 15.0% [n\\u0026thinsp;=\\u0026thinsp;9], \\u003cem\\u003eP\\u003c/em\\u003e\\u0026thinsp;=\\u0026thinsp;0.40), acid reflux/heartburn (3.2% [n\\u0026thinsp;=\\u0026thinsp;1] vs. 8.3% [n\\u0026thinsp;=\\u0026thinsp;5], \\u003cem\\u003eP\\u003c/em\\u003e\\u0026thinsp;=\\u0026thinsp;0.63), and belching/hiccups (3.2% [n\\u0026thinsp;=\\u0026thinsp;1] vs. 8.3% [n\\u0026thinsp;=\\u0026thinsp;5], \\u003cem\\u003eP\\u003c/em\\u003e\\u0026thinsp;=\\u0026thinsp;0.63). Non-specific complaints such as pharyngeal discomfort (3.2% vs. 6.7%, \\u003cem\\u003eP\\u003c/em\\u003e\\u0026thinsp;=\\u0026thinsp;0.84) and bloating/abdominal pain (0% vs. 3.3%, \\u003cem\\u003eP\\u003c/em\\u003e\\u0026thinsp;=\\u0026thinsp;0.55) were rare and statistically comparable. Postoperative complications occurred in 3.2% of RAAS patients (n\\u0026thinsp;=\\u0026thinsp;1) versus 0% in the CLAS group (\\u003cem\\u003eP\\u003c/em\\u003e\\u0026thinsp;=\\u0026thinsp;0.74). Reoperation rates within 30 days were similar (3.2% [n\\u0026thinsp;=\\u0026thinsp;1] vs. 5.0% [n\\u0026thinsp;=\\u0026thinsp;3], \\u003cem\\u003eP\\u003c/em\\u003e\\u0026thinsp;=\\u0026thinsp;0.70). Postoperative anti-secretory drug utilization (16.1% [n\\u0026thinsp;=\\u0026thinsp;5] vs. 8.3% [n\\u0026thinsp;=\\u0026thinsp;5], P\\u0026thinsp;=\\u0026thinsp;0.43) and upper endoscopy rates (25.8% [n\\u0026thinsp;=\\u0026thinsp;8] vs. 23.3% [n\\u0026thinsp;=\\u0026thinsp;14], P\\u0026thinsp;=\\u0026thinsp;0.79) showed no significant differences.\\u003c/p\\u003e \\u003c/div\\u003e \\u003cdiv id=\\\"Sec11\\\" class=\\\"Section2\\\"\\u003e \\u003ch2\\u003eReoperation Subgroup Analysis\\u003c/h2\\u003e \\u003cp\\u003e \\u003cdiv class=\\\"gridtable\\\"\\u003e\\u003ctable float=\\\"Yes\\\" id=\\\"Tab4\\\" border=\\\"1\\\"\\u003e \\u003ccaption language=\\\"En\\\"\\u003e \\u003cdiv class=\\\"CaptionNumber\\\"\\u003eTable 4\\u003c/div\\u003e \\u003cdiv class=\\\"CaptionContent\\\"\\u003e \\u003cp\\u003eReoperation Subgroup\\u003c/p\\u003e \\u003c/div\\u003e \\u003c/caption\\u003e \\u003ccolgroup cols=\\\"5\\\"\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c1\\\" colnum=\\\"1\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"char\\\" char=\\\".\\\" class=\\\"colspec\\\" colname=\\\"c2\\\" colnum=\\\"2\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"char\\\" char=\\\".\\\" class=\\\"colspec\\\" colname=\\\"c3\\\" colnum=\\\"3\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"char\\\" char=\\\".\\\" class=\\\"colspec\\\" colname=\\\"c4\\\" colnum=\\\"4\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c5\\\" colnum=\\\"5\\\"\\u003e\\u003c/div\\u003e \\u003cthead\\u003e \\u003ctr\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c1\\\" morerows=\\\"1\\\" rowspan=\\\"2\\\"\\u003e\\u0026nbsp;\\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eNissen\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003eToupet\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003eDor\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c5\\\" morerows=\\\"1\\\" rowspan=\\\"2\\\"\\u003e \\u003cp\\u003eP-value\\u003c/p\\u003e \\u003c/th\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eN\\u0026thinsp;=\\u0026thinsp;2\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003eN\\u0026thinsp;=\\u0026thinsp;0\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003eN\\u0026thinsp;=\\u0026thinsp;2\\u003c/p\\u003e \\u003c/th\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eIndex surgery type\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u0026nbsp;\\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u0026nbsp;\\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u0026nbsp;\\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c5\\\"\\u003e\\u0026nbsp;\\u003c/th\\u003e \\u003c/tr\\u003e \\u003c/thead\\u003e \\u003ctbody\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eRAAS\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e1\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e0\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e0\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eCLAS\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e1\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e0\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e2\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003e\\u003cb\\u003eCause of reoperation\\u003c/b\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eDysphagia\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e1\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e0\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e1\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eRecurrent reflux\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e1\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e0\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e1\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003c/tr\\u003e \\u003c/tbody\\u003e \\u003c/colgroup\\u003e \\u003c/table\\u003e\\u003c/div\\u003e \\u003c/p\\u003e \\u003cp\\u003eAmong four reoperations (RAAS:1, CLAS:3), Nissen fundoplication accounted for 50% of cases (n\\u0026thinsp;=\\u0026thinsp;2), with indications including dysphagia (n\\u0026thinsp;=\\u0026thinsp;1) and recurrent reflux (n\\u0026thinsp;=\\u0026thinsp;1). Dor fundoplication (n\\u0026thinsp;=\\u0026thinsp;2) was exclusively associated with recurrent reflux (n\\u0026thinsp;=\\u0026thinsp;1). No reoperations occurred in Toupet fundoplication patients. Nissen fundoplication predominated in both cohorts (RAAS: 87.1% [n\\u0026thinsp;=\\u0026thinsp;27] vs. CLAS: 95.0% [n\\u0026thinsp;=\\u0026thinsp;57]), followed by Toupet (3.2% [n\\u0026thinsp;=\\u0026thinsp;1] vs. 3.3% [n\\u0026thinsp;=\\u0026thinsp;2]) and Dor (3.2% [n\\u0026thinsp;=\\u0026thinsp;1] vs. 1.7% [n\\u0026thinsp;=\\u0026thinsp;1]). Reoperation rates did not correlate with wrap type (\\u003cem\\u003eP\\u003c/em\\u003e\\u0026thinsp;\\u0026gt;\\u0026thinsp;0.05).\\u003c/p\\u003e \\u003c/div\\u003e \\u003cdiv id=\\\"Sec12\\\" class=\\\"Section2\\\"\\u003e \\u003ch2\\u003eSafety and Mortality\\u003c/h2\\u003e \\u003cp\\u003eNeither group experienced major intraoperative complications such as visceral injury, uncontrolled bleeding, or conversion to open surgery. No mortality occurred within 30 days postoperatively in either cohort. Minor postoperative symptoms (e.g., transient chest tightness, cough) were infrequent, with incidences\\u0026thinsp;\\u0026le;\\u0026thinsp;3.3% in both groups (\\u003cem\\u003eP\\u003c/em\\u003e\\u0026thinsp;\\u0026ge;\\u0026thinsp;0.55).\\u003c/p\\u003e \\u003c/div\\u003e \\u003cdiv id=\\\"Sec13\\\" class=\\\"Section2\\\"\\u003e \\u003ch2\\u003eOperative Technique Variability\\u003c/h2\\u003e \\u003cp\\u003eNissen (360\\u0026deg; wrap) was the default choice in both groups, with selective use of partial wraps (Toupet/Dor) for patients with compromised esophageal motility. Subgroup analysis of RAAS cases revealed a progressive reduction in docking time from 25.6\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;3.2 minutes (first 10 cases) to 18.9\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;1.8 minutes (subsequent 21 cases, \\u003cem\\u003eP\\u003c/em\\u003e\\u0026thinsp;\\u0026lt;\\u0026thinsp;0.01), highlighting a steep learning curve for robotic system integration.\\u003c/p\\u003e \\u003c/div\\u003e \\u003cdiv id=\\\"Sec14\\\" class=\\\"Section2\\\"\\u003e \\u003ch2\\u003eCost and Resource Utilization\\u003c/h2\\u003e \\u003cp\\u003eWhile not quantitatively analyzed in this study, qualitative observations noted increased consumable costs for RAAS (e.g., robotic trocars, energy devices) compared to CLAS. Total operative time differences further implied higher indirect resource utilization for robotic procedures.\\u003c/p\\u003e \\u003c/div\\u003e\"},{\"header\":\"Discussion\",\"content\":\"\\u003cp\\u003eMultiple studies have demonstrated the feasibility and safety of robot-assisted anti-reflux surgery[\\u003cspan additionalcitationids=\\\"CR13 CR14\\\" citationid=\\\"CR12\\\" class=\\\"CitationRef\\\"\\u003e12\\u003c/span\\u003e\\u0026ndash;\\u003cspan citationid=\\\"CR15\\\" class=\\\"CitationRef\\\"\\u003e15\\u003c/span\\u003e]. Only two prospective studies have compared robot-assisted versus standard laparoscopic fundoplication. Melvin et al. reported in a nonrandomized clinical trial involving 20 patients that the robotic group showed significantly longer operative time (141 vs 97 minutes; P\\u0026thinsp;\\u0026lt;\\u0026thinsp;0\\u0026middot;001), with similar morbidity and postoperative hospital stay [\\u003cspan citationid=\\\"CR16\\\" class=\\\"CitationRef\\\"\\u003e16\\u003c/span\\u003e]. During 7-month follow-up, there was a significant difference in the number of patients requiring regular acid-suppression medication (0% in robotic group vs 30% in controls). In a randomized trial comparing 20 robot-assisted and 20 conventional laparoscopic fundoplications, 12-year long-term outcomes showed no differences between RAAS and CLAS in postoperative symptoms, quality of life, or treatment failure. Both procedures demonstrated high symptom resolution rates and patient satisfaction long-term [\\u003cspan citationid=\\\"CR17\\\" class=\\\"CitationRef\\\"\\u003e17\\u003c/span\\u003e]. Notably, this study further optimized surgical workflow: compared to traditional midline assistant port placement in conventional laparoscopy, the robotic group's left subcostal assistant port design reduced instrument collision rates. Additionally, the Da Vinci Xi system's curved trocar arrangement (with \\u0026ge;\\u0026thinsp;8cm spacing between adjacent ports, versus the Si system's linear configuration) increased instrument movement angles by 15\\u0026deg; during STEP2[\\u003cspan citationid=\\\"CR18\\\" class=\\\"CitationRef\\\"\\u003e18\\u003c/span\\u003e]. This aligns with Ngu JC et al.'s reported anatomical advantages of lateral port placement in expanding the working triangle and increasing range of motion 18, potentially explaining comparable esophageal dissection times to conventional laparoscopy (40.6\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;7.7 vs 38.3\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;12.1min, p\\u0026thinsp;=\\u0026thinsp;0.06).\\u003c/p\\u003e \\u003cp\\u003eNearly all published series on robot-assisted abdominal surgeries have reported prolonged operative times, including procedures such as cholecystectomy, adrenalectomy, colectomy, and fundoplication[\\u003cspan citationid=\\\"CR17\\\" class=\\\"CitationRef\\\"\\u003e17\\u003c/span\\u003e, \\u003cspan additionalcitationids=\\\"CR20\\\" citationid=\\\"CR19\\\" class=\\\"CitationRef\\\"\\u003e19\\u003c/span\\u003e\\u0026ndash;\\u003cspan citationid=\\\"CR21\\\" class=\\\"CitationRef\\\"\\u003e21\\u003c/span\\u003e]. In this study, RAAS demonstrated significantly longer operative time compared to CLAS (158.8\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;21.8 vs 146.4\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;23.8 minutes, p\\u0026thinsp;=\\u0026thinsp;0.02), primarily attributable to extended STEP1 duration (29.3\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;15.5 vs 17.8\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;15.6 minutes, p\\u0026thinsp;=\\u0026thinsp;0.02). Video review analysis suggests that initial tunnel establishment may require additional time for instrument adjustment and positioning. While CLAS utilizes conventional laparoscopic instruments enabling more direct maneuvers, robotic surgery's potential advantages in precision and flexibility may be counterbalanced by preoperative docking procedures and intraoperative instrument changes. Notably, the docking time in the robotic group significantly decreased from 25.6\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;3.2 minutes in the first 10 cases to 18.9\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;1.8 minutes in subsequent 21 cases (p\\u0026thinsp;\\u0026lt;\\u0026thinsp;0.01), indicating a distinct learning curve effect. Although standardized docking training was not included in routine preoperative preparation, targeted practice using our institution's proprietary 3D-printed models (\\u0026ge;\\u0026thinsp;10 sessions per surgeon) significantly reduced the coefficient of variation in critical procedural phases, decreasing from 28% in conventional training groups to 12% in flap suture time (p\\u0026thinsp;=\\u0026thinsp;0.03), demonstrating the value of standardized simulation training in controlling learning curve variability for technique-dependent procedures.\\u003c/p\\u003e \\u003cp\\u003eSupporting evidence for robotic advantages emerges from comparative studies: Stefanidis et al.'s controlled trial with 34 laparoscopic suture-na\\u0026iuml;ve medical students revealed that the robot-assisted group achieved 23% faster task completion, 41% higher precision, and 67% fewer technical errors compared to conventional laparoscopy (p\\u0026thinsp;\\u0026lt;\\u0026thinsp;0.05) [\\u003cspan citationid=\\\"CR22\\\" class=\\\"CitationRef\\\"\\u003e22\\u003c/span\\u003e]. Pigazzi et al.'s longitudinal study in rectal surgery demonstrated that robotic platforms reduced the average learning curve to 23 cases, 39% shorter than the 38-case requirement for laparoscopic proficiency[\\u003cspan citationid=\\\"CR23\\\" class=\\\"CitationRef\\\"\\u003e23\\u003c/span\\u003e]. These findings collectively suggest that robotic technology combined with standardized simulation training may facilitate more efficient skill transfer. However, no significant differences were observed between groups in critical procedural phases (hernia defect closure, gastric fundus mobilization, and flap formation; p\\u0026thinsp;\\u0026gt;\\u0026thinsp;0.05), indicating comparable operational efficiency between robotic and conventional laparoscopic approaches in specific surgical steps.\\u003c/p\\u003e \\u003cp\\u003eDuring postoperative follow-up, RAAS demonstrated significantly higher complete symptom resolution rates compared to CLAS (80.6% vs 56.7%, p\\u0026thinsp;=\\u0026thinsp;0.02), suggesting potential advantages of robotic assistance in overall symptom improvement. This may relate to the robotic group's strategy of using electrocautery hooks for left phrenoesophageal ligament dissection. High-frequency coagulation settings (30W cutting/60W coagulation) enabled precise hemostasis in confined spaces. The application of \\\"dual-plane dissection\\\" (simultaneous anterior-posterior and superior-inferior planes) improved anterior vagal trunk identification rates, potentially contributing to reduced postoperative abdominal distension (0% vs 3.3%). However, no statistically significant differences were observed in postoperative symptoms including dysphagia, regurgitation, belching, or abdominal distension (p\\u0026thinsp;\\u0026gt;\\u0026thinsp;0.05), indicating comparable symptomatic outcomes between approaches. RAAS might optimize anatomical restoration through enhanced operative precision. Additionally, equivalent performance in non-specific symptoms (pharyngeal discomfort and cough) further supports clinical comparability between RAAS and CLAS. Future studies should incorporate extended follow-up periods and comprehensive quality-of-life assessments to clarify RAAS's potential value in symptom management and patient satisfaction.\\u003c/p\\u003e \\u003cp\\u003eProcedure distribution analysis revealed Nissen fundoplication as the predominant technique in both groups (RAAS 87.1% vs CLAS 95%), with comparable proportions of Toupet and Dor procedures (3.2% each). Although overall reoperation rates showed no significant difference (3.2% vs 5.0%, p\\u0026thinsp;=\\u0026thinsp;0.70), etiology differed by procedure type: dysphagia predominated in Nissen revisions versus reflux recurrence in Toupet cases, consistent with previous findings highlighting procedure-specific complication patterns[\\u003cspan citationid=\\\"CR24\\\" class=\\\"CitationRef\\\"\\u003e24\\u003c/span\\u003e]. Notably, no Toupet-related reoperations occurred in the RAAS group, possibly reflecting enhanced adaptability of the robotic platform for complex anatomical maneuvers, though validation in larger cohorts is required.\\u003c/p\\u003e \\u003cp\\u003ePerioperative and postoperative complication analyses demonstrated comparable safety profiles between RAAS and CLAS. Intraoperative complication rates were low and statistically equivalent (3.2% vs 0%, p\\u0026thinsp;=\\u0026thinsp;0.74), with no significant differences in postoperative complications including 30-day mortality (p\\u0026thinsp;\\u0026gt;\\u0026thinsp;0.05). Crucially, neither group experienced major adverse events such as conversion to open surgery or significant intraoperative blood loss (\\u0026gt;\\u0026thinsp;100ml), further supporting the technical reliability of RAAS.\\u003c/p\\u003e \\u003cp\\u003eThis study further revealed potential impacts of RAAS on hospitalization duration. Although the robotic group showed marginally shorter mean hospital stays (3.32\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;2.24 vs 3.75\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;2.42 days, p\\u0026thinsp;=\\u0026thinsp;0.45), the difference lacked statistical significance, potentially attributable to individual patient variability and postoperative management protocols. Additionally, no significant intergroup differences were observed in postoperative upper endoscopy utilization rates or antisecretory medication requirements (p\\u0026thinsp;\\u0026gt;\\u0026thinsp;0.05), suggesting comparable symptom control between RAAS and CLAS.\\u003c/p\\u003e \\u003cp\\u003eThe prolonged operative time raises critical discussions regarding RAAS's economic burden and operational efficiency. While docking time may decrease with surgical team experience, the robotic platform's cost-effectiveness remains unproven. Although detailed cost analysis was beyond this study's scope, existing literature confirms significantly higher overall costs for RAAS compared to CLAS, particularly in equipment maintenance and consumables[\\u003cspan citationid=\\\"CR25\\\" class=\\\"CitationRef\\\"\\u003e25\\u003c/span\\u003e].\\u003c/p\\u003e \\u003cp\\u003eKey limitations include the retrospective design and limited sample size. Despite 1\\u0026ndash;2 year follow-up data, the absence of quality-of-life assessments and pH monitoring restricts comprehensive evaluation of long-term symptom improvement. While procedures were performed by experienced surgeons, non-randomized patient allocation introduced potential selection bias, as evidenced by higher rates of prior abdominal surgery in the RAAS group (38.7% vs 23.3%, p\\u0026thinsp;=\\u0026thinsp;0.12). However, this bias did not translate to increased adverse events, suggesting minimal impact on core conclusions.\\u003c/p\\u003e \\u003cp\\u003eIn conclusion, RAAS demonstrates comparable safety, symptom control, and procedural flexibility to CLAS, while potentially conferring advantages in hospitalization duration. Nevertheless, prolonged operative times and increased costs remain significant barriers to widespread adoption. Future large-scale prospective randomized trials should comprehensively evaluate RAAS's benefits in quality-of-life outcomes, long-term symptom resolution, and cost-effectiveness to establish its definitive role in complex anti-reflux surgery.\\u003c/p\\u003e\"},{\"header\":\"Declarations\",\"content\":\"\\u003cp\\u003e\\u003cstrong\\u003eFunding:\\u0026nbsp;\\u003c/strong\\u003eThis work was supported by The Special Project for Key R\\u0026amp;D Tasks of the Xinjiang Uygur Autonomous Region (2023B03010) and The Science and Technology Cooperation Project of Zhejiang Provincial Department of Science and Technology (2024C04027).\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eCompeting Interests:\\u0026nbsp;\\u003c/strong\\u003eThe authors have no relevant financial or non-financial interests to disclose.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eAuthor Contributions:\\u0026nbsp;\\u003c/strong\\u003eAll authors contributed to the study conception and design. Material preparation, data collection, and analysis were performed by Minjun Xia, Menghui Zhou, and ZhiHao Zhu. \\u0026nbsp;Statistical analysis was conducted by Jinglei Mao. The first draft of the manuscript was written by Minjun Xia, with critical revisions made by Zhifei Wang. All authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eEthics approval:\\u0026nbsp;\\u003c/strong\\u003eThis study was performed in line with the principles of the Declaration of Helsinki.\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003eApproval was granted by the Ethics Committee of Zhejiang Provincial People\\u0026rsquo;s Hospital (KY2025028).\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eConsent to publish:\\u0026nbsp;\\u003c/strong\\u003eThe authors affirm that human research participants provided informed consent for publication of the Table(s) 1, 2, 3 and 4.\\u003c/p\\u003e\\n\\u003cstrong\\u003eAcknowledgments\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eThe authors gratefully acknowledge the contributions of the following individuals and institutions: the surgical nursing teams and operating room staff at Zhejiang Provincial People\\u0026rsquo;s Hospital for their invaluable technical support; the Department of Biomedical Engineering for providing access to 3D-printed simulation models; and the hospital\\u0026rsquo;s Clinical Research Ethics Committee for protocol oversight. Special thanks to the patients who participated in this study.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u0026nbsp;\\u003cstrong\\u003eDisclosure\\u003c/strong\\u003e Mr. Xia, Ms. Zhou, Mr. Zhu, Dr. Mao and Prof. Wang have no conficts of interest or fnancial ties to disclose.\\u003c/p\\u003e\"},{\"header\":\"References\",\"content\":\"\\u003col\\u003e\\n \\u003cli\\u003eMoayyedi P, Talley NJ (2006) Gastro-oesophageal reflux disease. Lancet 367\\u003cstrong\\u003e:\\u003c/strong\\u003e2086-2100\\u003c/li\\u003e\\n \\u003cli\\u003eKahrilas PJ, Kim HC, Pandolfino JE (2008) Approaches to the diagnosis and grading of hiatal hernia. Best Pract Res Clin Gastroenterol 22\\u003cstrong\\u003e:\\u003c/strong\\u003e601-616\\u003c/li\\u003e\\n \\u003cli\\u003eNurko S (2017) Pathophysiology of Gastroesophageal Reflux Disease. Gastroesophageal Reflux in Children, pp 15-25\\u003c/li\\u003e\\n \\u003cli\\u003eKatz PO, Gerson LB, Vela MF (2013) Guidelines for the diagnosis and management of gastroesophageal reflux disease. Am J Gastroenterol 108\\u003c/li\\u003e\\n \\u003cli\\u003eStefanidis D, Hope WW, Kohn GP, Reardon PR, Richardson WS, Fanelli RD, endoscopy SGCJS (2010) Guidelines for surgical treatment of gastroesophageal reflux disease. 24\\u003cstrong\\u003e:\\u003c/strong\\u003e2647-2669\\u003c/li\\u003e\\n \\u003cli\\u003eHorgan S, Pellegrini CAJSCoNA (1997) Surgical treatment of gastroesophageal reflux disease. 77\\u003cstrong\\u003e:\\u003c/strong\\u003e1063-1082\\u003c/li\\u003e\\n \\u003cli\\u003eDallemagne B, Weerts J, Jehaes C, Markiewicz S, Lombard RJSLE, Techniques P (1991) Laparoscopic Nissen fundoplication: preliminary report. LWW, pp 138-143\\u003c/li\\u003e\\n \\u003cli\\u003eMcKinley SK, Dirks RC, Walsh D, Hollands C, Arthur LE, Rodriguez N, Jhang J, Abou-Setta A, Pryor A, Stefanidis DJSe (2021) Surgical treatment of GERD: systematic review and meta-analysis. 35\\u003cstrong\\u003e:\\u003c/strong\\u003e4095-4123\\u003c/li\\u003e\\n \\u003cli\\u003eMoore M, Afaneh C, Benhuri D, Antonacci C, Abelson J, Zarnegar RJWjogs (2016) Gastroesophageal reflux disease: a review of surgical decision making. 8\\u003cstrong\\u003e:\\u003c/strong\\u003e77\\u003c/li\\u003e\\n \\u003cli\\u003eArcerito M, Changchien E, Falcon M, Parga MA, Bernal O, Moon JTJTAS (2018) Robotic fundoplication for gastroesophageal reflux disease and hiatal hernia: initial experience and outcome. 84\\u003cstrong\\u003e:\\u003c/strong\\u003e1945-1950\\u003c/li\\u003e\\n \\u003cli\\u003eMi J, Kang Y, Chen X, Wang B, Wang ZJSe (2010) Whether robot-assisted laparoscopic fundoplication is better for gastroesophageal reflux disease in adults: a systematic review and meta-analysis. 24\\u003cstrong\\u003e:\\u003c/strong\\u003e1803-1814\\u003c/li\\u003e\\n \\u003cli\\u003eTalamini M, Campbell K, Stanfield CJJol, techniques as (2002) Robotic gastrointestinal surgery: early experience and system description. 12\\u003cstrong\\u003e:\\u003c/strong\\u003e225-232\\u003c/li\\u003e\\n \\u003cli\\u003eWykypiel H, Wetscher G, Klaus A, Schmid T, Gadenstaetter M, Bodner J, Bodner EJLsAoS (2003) Robot-assisted laparoscopic partial posterior fundoplication with the DaVinci system: initial experiences and technical aspects. 387\\u003cstrong\\u003e:\\u003c/strong\\u003e411-416\\u003c/li\\u003e\\n \\u003cli\\u003eMelvin W, Needleman B, Krause K, Schneider C, Wolf R, Michler R, Ellison EJSE, Techniques OI (2002) Computer-enhanced robotic telesurgery. 16\\u003cstrong\\u003e:\\u003c/strong\\u003e1790-1792\\u003c/li\\u003e\\n \\u003cli\\u003eOzawa S, Furukawa T, Ohgami M, Wakabayashi G, Kitajima MJSE (2001) Robot-assisted laparoscopic anti-reflux surgery. 15\\u003cstrong\\u003e:\\u003c/strong\\u003eS152\\u003c/li\\u003e\\n \\u003cli\\u003eGould JC, Melvin WSJSC (2003) Telerobotic foregut and esophageal surgery. 83\\u003cstrong\\u003e:\\u003c/strong\\u003e1421-1427\\u003c/li\\u003e\\n \\u003cli\\u003eLang F, Huber A, Kowalewski K, Kenngott H, Billmann F, Billeter A, Fischer L, Bintintan V, Gutt C, Müller-Stich BJSe (2022) Randomized controlled trial of robotic-assisted versus conventional laparoscopic fundoplication: 12 years follow-up. 36\\u003cstrong\\u003e:\\u003c/strong\\u003e5627-5634\\u003c/li\\u003e\\n \\u003cli\\u003eNgu JC-Y, Tsang CB-S, Koh DC-S (2017) The da Vinci Xi: a review of its capabilities, versatility, and potential role in robotic colorectal surgery. Robot Surg 4\\u003cstrong\\u003e:\\u003c/strong\\u003e77-85\\u003c/li\\u003e\\n \\u003cli\\u003eNio D, Bemelman W, Busch O, Vrouenraets B, Gouma DJSE, Techniques OI (2004) Robot-assisted laparoscopic cholecystectomy versus conventional laparoscopic cholecystectomy: a comparative study. 18\\u003cstrong\\u003e:\\u003c/strong\\u003e379-382\\u003c/li\\u003e\\n \\u003cli\\u003eMorino M, Beninca G, Giraudo G, Del Genio G, Rebecchi F, Garrone CJSe (2004) Robot-assisted vs laparoscopic adrenalectomy: a prospective randomized controlled trial. 18\\u003cstrong\\u003e:\\u003c/strong\\u003e1742-1746\\u003c/li\\u003e\\n \\u003cli\\u003ePark J, Choi G, Park S, Kim H, Ryuk JJJoBS (2012) Randomized clinical trial of robot-assisted versus standard laparoscopic right colectomy. 99\\u003cstrong\\u003e:\\u003c/strong\\u003e1219-1226\\u003c/li\\u003e\\n \\u003cli\\u003eStefanidis D, Wang F, Korndorffer JR, Dunne JB, Scott DJ (2010) Robotic assistance improves intracorporeal suturing performance and safety in the operating room while decreasing operator workload. Surgical endoscopy 24\\u003cstrong\\u003e:\\u003c/strong\\u003e377-382\\u003c/li\\u003e\\n \\u003cli\\u003ePigazzi A, Luca F, Patriti A, Valvo M, Ceccarelli G, Casciola L, Biffi R, Garcia-Aguilar J, Baek J-H (2010) Multicentric study on robotic tumor-specific mesorectal excision for the treatment of rectal cancer. Ann Surg Oncol 17\\u003cstrong\\u003e:\\u003c/strong\\u003e1614-1620\\u003c/li\\u003e\\n \\u003cli\\u003eGuérin E, Bétroune K, Closset J, Mehdi A, Lefèbvre J, Houben J-J, Gelin M, Vaneukem P, El Nakadi IJSe (2007) Nissen versus Toupet fundoplication: results of a randomized and multicenter trial. 21\\u003cstrong\\u003e:\\u003c/strong\\u003e1985-1990\\u003c/li\\u003e\\n \\u003cli\\u003eOwen B, Simorov A, Siref A, Shostrom V, Oleynikov DJSe (2014) How does robotic anti-reflux surgery compare with traditional open and laparoscopic techniques: a cost and outcomes analysis. 28\\u003cstrong\\u003e:\\u003c/strong\\u003e1686-1690\\u003c/li\\u003e\\n\\u003c/ol\\u003e\"}],\"fulltextSource\":\"\",\"fullText\":\"\",\"funders\":[],\"hasAdminPriorityOnWorkflow\":false,\"hasManuscriptDocX\":true,\"hasOptedInToPreprint\":true,\"hasPassedJournalQc\":\"\",\"hasAnyPriority\":false,\"hideJournal\":false,\"highlight\":\"\",\"institution\":\"\",\"isAcceptedByJournal\":true,\"isAuthorSuppliedPdf\":false,\"isDeskRejected\":\"\",\"isHiddenFromSearch\":false,\"isInQc\":false,\"isInWorkflow\":false,\"isPdf\":false,\"isPdfUpToDate\":true,\"isWithdrawnOrRetracted\":false,\"journal\":{\"display\":true,\"email\":\"info@researchsquare.com\",\"identity\":\"journal-of-robotic-surgery\",\"isNatureJournal\":false,\"hasQc\":true,\"allowDirectSubmit\":false,\"externalIdentity\":\"jors\",\"sideBox\":\"Learn more about [Journal of Robotic Surgery](http://link.springer.com/journal/11701)\",\"snPcode\":\"11701\",\"submissionUrl\":\"https://submission.nature.com/new-submission/11701/3\",\"title\":\"Journal of Robotic Surgery\",\"twitterHandle\":\"\",\"acdcEnabled\":true,\"dfaEnabled\":true,\"editorialSystem\":\"em\",\"reportingPortfolio\":\"Springer Hybrid\",\"inReviewEnabled\":true,\"inReviewRevisionsEnabled\":false},\"keywords\":\"Robotic-assisted surgery, Laparoscopic fundoplication, GERD, Hiatal hernia, Nissen fundoplication\",\"lastPublishedDoi\":\"10.21203/rs.3.rs-6634434/v1\",\"lastPublishedDoiUrl\":\"https://doi.org/10.21203/rs.3.rs-6634434/v1\",\"license\":{\"name\":\"CC BY 4.0\",\"url\":\"https://creativecommons.org/licenses/by/4.0/\"},\"manuscriptAbstract\":\"\\u003cp\\u003eGastroesophageal reflux disease (GERD), often associated with hiatal hernia (HH), is commonly treated with conventional laparoscopic anti-reflux surgery (CLAS). Robotic-assisted anti-reflux surgery (RAAS) is emerging as an alternative with enhanced precision and ergonomics. This study compares perioperative outcomes and mid-term symptom resolution between RAAS and CLAS. A retrospective cohort study included 91 patients (RAAS: n\\u0026thinsp;=\\u0026thinsp;31, CLAS: n\\u0026thinsp;=\\u0026thinsp;60) undergoing primary anti-reflux surgery from April 2022 to April 2024. Inclusion criteria included confirmed GERD and inadequate proton pump inhibitor response. Surgical steps were standardized, and perioperative metrics (operative time, complications, hospital stay) and 12-month symptom outcomes were compared. RAAS and CLAS had comparable demographics and comorbidities (P\\u0026thinsp;\\u0026gt;\\u0026thinsp;0.05). RAAS had a longer total operative time (158.8\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;21.8 vs. 146.4\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;23.8 minutes, P\\u0026thinsp;=\\u0026thinsp;0.02), mainly due to a longer retroesophageal tunnel establishment (P\\u0026thinsp;\\u0026lt;\\u0026thinsp;0.01). RAAS showed superior symptom resolution (80.6% vs. 56.7%, P\\u0026thinsp;=\\u0026thinsp;0.02) without differences in intraoperative complications, reoperations, or hospital stay. Docking time decreased with experience (P\\u0026thinsp;\\u0026lt;\\u0026thinsp;0.01), reflecting a learning curve. RAAS provides comparable safety and postoperative outcomes to CLAS but achieves higher symptom resolution (80.6% vs. 56.7%, P\\u0026thinsp;=\\u0026thinsp;0.02). While operative times are longer for RAAS, this difference is limited to initial steps. RAAS demonstrates technical feasibility with a learning curve, suggesting it may improve precision in anti-reflux surgery. Further studies are needed to assess its long-term efficacy.\\u003c/p\\u003e\",\"manuscriptTitle\":\"Robot-Assisted Versus Conventional Laparoscopic Antireflux Surgery: A Retrospective Cohort Analysis of Perioperative and Medium-Term Outcomes\",\"msid\":\"\",\"msnumber\":\"\",\"nonDraftVersions\":[{\"code\":1,\"date\":\"2025-06-06 16:27:30\",\"doi\":\"10.21203/rs.3.rs-6634434/v1\",\"editorialEvents\":[{\"type\":\"communityComments\",\"content\":0},{\"type\":\"decision\",\"content\":\"Revision requested\",\"date\":\"2025-06-12T11:11:45+00:00\",\"index\":\"\",\"fulltext\":\"\"},{\"type\":\"editorInvitedReview\",\"content\":\"\",\"date\":\"2025-06-12T10:06:34+00:00\",\"index\":\"hide\",\"fulltext\":\"\"},{\"type\":\"editorInvitedReview\",\"content\":\"\",\"date\":\"2025-06-11T19:11:21+00:00\",\"index\":\"hide\",\"fulltext\":\"\"},{\"type\":\"reviewerAgreed\",\"content\":\"133533924320343333527985572189346513176\",\"date\":\"2025-06-07T12:11:54+00:00\",\"index\":\"hide\",\"fulltext\":\"\"},{\"type\":\"reviewerAgreed\",\"content\":\"319568075308999242486802555597535005157\",\"date\":\"2025-06-06T20:37:21+00:00\",\"index\":\"hide\",\"fulltext\":\"\"},{\"type\":\"reviewerAgreed\",\"content\":\"89191122656847129689022299663023247112\",\"date\":\"2025-06-04T21:35:03+00:00\",\"index\":\"hide\",\"fulltext\":\"\"},{\"type\":\"reviewersInvited\",\"content\":\"\",\"date\":\"2025-06-04T15:42:29+00:00\",\"index\":\"\",\"fulltext\":\"\"},{\"type\":\"editorAssigned\",\"content\":\"\",\"date\":\"2025-05-12T15:38:03+00:00\",\"index\":\"\",\"fulltext\":\"\"},{\"type\":\"checksComplete\",\"content\":\"\",\"date\":\"2025-05-12T14:39:22+00:00\",\"index\":\"\",\"fulltext\":\"\"},{\"type\":\"submitted\",\"content\":\"Journal of Robotic Surgery\",\"date\":\"2025-05-10T11:01:38+00:00\",\"index\":\"\",\"fulltext\":\"\"}],\"status\":\"published\",\"journal\":{\"display\":true,\"email\":\"info@researchsquare.com\",\"identity\":\"journal-of-robotic-surgery\",\"isNatureJournal\":false,\"hasQc\":true,\"allowDirectSubmit\":false,\"externalIdentity\":\"jors\",\"sideBox\":\"Learn more about [Journal of Robotic Surgery](http://link.springer.com/journal/11701)\",\"snPcode\":\"11701\",\"submissionUrl\":\"https://submission.nature.com/new-submission/11701/3\",\"title\":\"Journal of Robotic Surgery\",\"twitterHandle\":\"\",\"acdcEnabled\":true,\"dfaEnabled\":true,\"editorialSystem\":\"em\",\"reportingPortfolio\":\"Springer Hybrid\",\"inReviewEnabled\":true,\"inReviewRevisionsEnabled\":false}}],\"origin\":\"\",\"ownerIdentity\":\"664a9f03-1e64-4980-9433-fb2888b13e66\",\"owner\":[],\"postedDate\":\"June 6th, 2025\",\"published\":true,\"recentEditorialEvents\":[],\"rejectedJournal\":[],\"revision\":\"\",\"amendment\":\"\",\"status\":\"published-in-journal\",\"subjectAreas\":[],\"tags\":[],\"updatedAt\":\"2025-07-07T16:06:19+00:00\",\"versionOfRecord\":{\"articleIdentity\":\"rs-6634434\",\"link\":\"https://doi.org/10.1007/s11701-025-02526-8\",\"journal\":{\"identity\":\"journal-of-robotic-surgery\",\"isVorOnly\":false,\"title\":\"Journal of Robotic Surgery\"},\"publishedOn\":\"2025-07-04 15:58:24\",\"publishedOnDateReadable\":\"July 4th, 2025\"},\"versionCreatedAt\":\"2025-06-06 16:27:30\",\"video\":\"\",\"vorDoi\":\"10.1007/s11701-025-02526-8\",\"vorDoiUrl\":\"https://doi.org/10.1007/s11701-025-02526-8\",\"workflowStages\":[]},\"version\":\"v1\",\"identity\":\"rs-6634434\",\"journalConfig\":\"researchsquare\"},\"__N_SSP\":true},\"page\":\"/article/[identity]/[[...version]]\",\"query\":{\"redirect\":\"/article/rs-6634434\",\"identity\":\"rs-6634434\",\"version\":[\"v1\"]},\"buildId\":\"8U1c8b4HqxoKbykW_rLl7\",\"isFallback\":false,\"isExperimentalCompile\":false,\"dynamicIds\":[84888],\"gssp\":true,\"scriptLoader\":[]}","source_license":"CC-BY-4.0","license_restricted":false}