Gastric cancer surgery has traveled an extraordinary distance since Theodor Billroth performed the first successful gastric resections in the nineteenth century. What was once a brutal open operation, carried out in traditional operating theaters with limited visualization and high morbidity, has become a field defined by keyhole incisions, high-definition cameras, robotic arms, and increasingly, artificial intelligence. A new review published in Annals of Gastroenterological Surgery traces this transformation through what researchers call the early minimally invasive era, roughly the two decades from the mid-1990s to the mid-2010s, and maps out where the next revolution will come from. The story is not simply one of gadgets. It is a story of how surgeons in East Asia, working with extraordinary case volumes and an unusual willingness to subject their own techniques to randomized trials, turned a controversial idea into a global standard of care.
The conceptual foundations were laid long before the first camera entered an abdomen. Surgeons such as Kajitani, Okajima, and Maruyama validated D2 lymphadenectomy, the systematic removal of the lymph node stations around the stomach, establishing both the oncologic logic and the therapeutic value of extended nodal dissection. Then came a crucial corrective. Sasako’s landmark randomized trial demonstrated that adding prophylactic para-aortic nodal dissection to D2 surgery did not improve patient survival, a result that shifted the field’s focus toward survival balanced with quality of life and laid the groundwork for the modern, evidence-based approach to deciding how much surgery is enough. That principle, that more extensive is not universally better, now underpins nearly every innovation in the field.
The minimally invasive era began in earnest in 1994, when Kitano reported the first laparoscopic gastrectomy for gastric cancer. Skepticism was intense. Critics questioned whether a two-dimensional video view could ever match the tactile feedback and direct exposure of open surgery, particularly for a cancer operation requiring meticulous lymph node dissection. In 2002, Hashizume performed the first robotic gastrectomy, opening a second technological front. What followed was a systematic, two-decade process of evaluation, refinement, and gradual integration, driven primarily by high-volume centers in Japan, Korea, and China. A single-center pilot study of 164 patients demonstrated the safety of laparoscopic gastrectomy for early gastric cancer and revealed unexpected improvements in postoperative quality of life. A subsequent multicenter phase 2 trial across eight centers extended the approach to more advanced disease, creating the foundation for the definitive randomized trials that would follow.
Those trials have transformed practice. Korea’s KLASS-01 study showed in 2019 that laparoscopic distal gastrectomy was noninferior to open surgery for early gastric cancer in five-year disease-free survival. KLASS-02 extended the finding to locally advanced disease, confirming comparable relapse-free survival with laparoscopic D2 lymphadenectomy and fewer complications. Japan’s JCOG0912 trial established noninferiority for laparoscopy-assisted distal gastrectomy in stage I disease, and the JLSSG0901 trial replicated the result for advanced cancer in 2023. China’s CLASS-01 and CLASS-02 trials contributed complementary evidence for distal and total gastrectomy. Taken together, these studies converted laparoscopic gastrectomy from an experimental technique into an evidence-based standard. Robotic surgery, by contrast, remains at an earlier stage of proof. Comparative studies show the robot is feasible, with reduced blood loss and similar lymph node harvests, but large-scale randomized evidence is still limited, and ongoing East Asian trials are expected to clarify its place in treatment guidelines.
Behind the trial results lies a distinctive culture of collaboration and knowledge sharing. Japanese, Korean, and Chinese surgical groups have long exchanged operative videos, built consensus documents, and performed live demonstration surgeries for international audiences. When Uyama shared detailed videos of laparoscopic D2 dissections, the clarity and sophistication of the technique astonished viewers and accelerated global understanding of what minimally invasive cancer surgery could achieve. International teleconferences and live surgical transmissions, including real-time dialogue between operating surgeons and remote experts, have proven educational even for highly experienced operators. The review argues that this openness is not incidental but essential: meaningful innovation in surgery depends on institutions and countries actively sharing what works, what fails, and how standards can be harmonized across centers with very different case volumes and resources.
The review also emphasizes that surgeons themselves should drive the technology, not merely adopt it. The author describes identifying the limitations of conventional two-dimensional endoscopic visualization, particularly in depth perception and structural recognition, and then collaborating with engineering teams to develop three-dimensional laparoscopic endoscopes that improved precision in dissection and reconstruction. This surgeon-inventor model, the argument goes, should be cultivated from the earliest stages of surgical education, because only clinicians embedded in daily operative reality can identify the design flaws that matter for safety and outcomes. The same philosophy extends to how new techniques spread. Simple publication is not enough. The safest dissemination strategy embeds innovation within clinical trials that include structured quality assurance: objective assessment of surgical proficiency, standardized operative guidelines, procedure manuals, educational videos, and validated evaluation forms.
As standard procedures mature, attention has turned to optimization and personalization. Reconstruction after proximal gastrectomy has become a fertile arena for innovation. The SPADE technique uses double-suture anchoring between the posterior wall of the esophagus and the anterior wall of the stomach to create a flap and pseudo-fornix, improving anti-reflux function and reducing complications. The OFFROAD technique reinforces anastomoses and dissected areas with remaining omental tissue, and preliminary studies suggest it does not significantly increase operative time or complication rates while potentially mitigating the severity of leaks. The ongoing ADDICT trial is asking a more fundamental question: whether D1+ or D2 dissection is the appropriate extent for advanced gastric cancer. Meanwhile, function-preserving approaches are challenging the assumption that every early cancer needs the same resection as advanced disease. Middle segmental gastrectomy, an evolution of pylorus-preserving gastrectomy, aims to maintain gastric function for tumors in the middle third of the stomach, and sentinel node navigation surgery, inspired by melanoma trials and refined by the SENORITA group, may allow less extensive resections in carefully selected patients based on biologic information from mapped lymphatic basins.
Optimization now begins well before the operating room. The review highlights anemia as one of the most important modifiable preoperative factors, since suboptimal hemoglobin worsens recovery, raises complication rates, and harms long-term outcomes. A seven-year multicenter trial demonstrated that intravenous ferric carboxymaltose significantly improves hemoglobin levels and reduces transfusion needs in surgical patients. In parallel, patient blood management, endorsed by the World Health Organization, promotes evidence-based transfusion thresholds, meticulous intraoperative hemostasis, and preservation of the patient’s own blood, with benefits including faster recovery, shorter hospital stays, and fewer transfusion-related risks. These strategies reflect a broader shift toward holistic, patient-centered care in which surgical technique, perioperative medicine, and long-term survivorship are planned together rather than treated as separate phases.
The most consequential frontier, however, is artificial intelligence. Deep-learning systems for endoscopy have already demonstrated improved detection rates of early gastric cancer lesions, reducing operator-dependent variability and potentially enabling earlier diagnosis. Computer vision models are being trained to recognize surgical phases, identify critical structures such as lymph node stations, major vessels, and dissection planes, and provide real-time feedback during laparoscopic and robotic gastrectomy. Machine learning algorithms integrating clinical, laboratory, and imaging data show promise for predicting survival and postoperative complications, supporting individualized prehabilitation and risk stratification. Yet the review is candid about the obstacles. Many AI applications rest on small, single-center datasets with limited external validation, and concerns about data privacy, algorithmic interpretability, medico-legal responsibility, and workflow integration remain unresolved. Autonomous robotic systems, despite demonstrating remarkable precision in experimental tasks, remain far from safe independent deployment in complex oncologic surgery, where judgment and ethical responsibility remain fundamentally human.
The future envisioned is collaborative rather than substitutive. Flexible robotic platforms such as K-Flex, holographic and three-dimensional printed preoperative modeling, and the coming flood of genomic, proteomic, and radiomic data will give surgeons tools of unprecedented power, but translating that data into actionable treatment decisions, from the choice and extent of surgery to perioperative therapy and surveillance, will require clinicians who are curious, data-driven, and committed to patient safety. In the model the review proposes, AI assists with case selection, operative planning, intraoperative guidance, and postoperative monitoring, while surgeons interpret the unexpected, weigh patient values, and take responsibility for nuanced decisions. Global capacity-building through tele-mentoring, simulation, and structured fellowships is meant to ensure these advances reach patients far beyond the high-volume East Asian centers where they were born. The transformation of gastric cancer surgery, from Billroth’s open incisions to intelligent operating rooms, is ultimately a story about surgeons who refused to stop asking whether the operation could be done better, and who built the evidence, the tools, and the networks to find out.
Subject of Research: Evolution and future of minimally invasive gastric cancer surgery, including randomized trial evidence, surgical innovation, and artificial intelligence applications
Article Title: Innovations in Gastric Cancer Surgery During Early Minimally Invasive Era and Future Perspectives
Article References: El‐On, R., & Kim, Y.-W. (2026). Innovations in Gastric Cancer Surgery During Early Minimally Invasive Era and Future Perspectives. Annals of Gastroenterological Surgery, 10(5), 1382-1387. https://doi.org/10.1002/ags3.70234
Image Credits: AI Generated
DOI: 10.1002/ags3.70234
Keywords: gastric cancer, laparoscopic gastrectomy, D2 lymphadenectomy, robotic surgery, randomized controlled trials, artificial intelligence, sentinel node navigation, function-preserving surgery, patient blood management, surgical innovation, minimally invasive surgery, East Asia
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Ophelia Keating. (September 24, 2026). From Open Incisions to Intelligent Machines: The Radical Reinvention of Gastric Cancer Surgery. Scienmag. https://scienmag.com/from-open-incisions-to-intelligent-machines-the-radical-reinvention-of-gastric-cancer-surgery/
Ophelia Keating. “From Open Incisions to Intelligent Machines: The Radical Reinvention of Gastric Cancer Surgery.” Scienmag, 24 September 2026, https://scienmag.com/from-open-incisions-to-intelligent-machines-the-radical-reinvention-of-gastric-cancer-surgery/. Accessed 24 September 2026.
Ophelia Keating. “From Open Incisions to Intelligent Machines: The Radical Reinvention of Gastric Cancer Surgery.” Scienmag. September 24, 2026. https://scienmag.com/from-open-incisions-to-intelligent-machines-the-radical-reinvention-of-gastric-cancer-surgery/
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Tags: advances in surgical visualizationArtificial Intelligenceartificial intelligence in surgeryD2 lymphadenectomyD2 lymphadenectomy validationEast AsiaEast Asian gastric cancer treatmentfunction-preserving surgeryfuture of gastric cancer treatmentgastric cancerhistory of gastric cancer surgerylaparoscopic gastrectomyMinimally invasive surgerypatient blood managementrandomized clinical trials in surgeryrandomized controlled trialsrobotic gastric resectionRobotic surgerysentinel node navigationsurgical innovationsurgical innovation in oncology
