Assessing quality in minimally invasive D2 lymphadenectomy: from technical difficulty to AI-enabled audit

Abstract

Minimally invasive D2 lymphadenectomy for gastric cancer is technically demanding, and its quality varies across patients, surgeons, platforms, and institutions. Conventional endpoints, including lymph node yield, margin status, operative time, blood loss, postoperative morbidity, and survival, remain essential but do not consistently capture intraoperative procedural fidelity, safety-critical deviations, or case complexity. This narrative framework review synthesized evidence from MEDLINE, Embase, and Web of Science from inception to May 10, 2026, focusing on technical difficulty, surgical quality assessment, pathology-centered oncologic adequacy, risk-adjusted outcomes, and artificial intelligence (AI)-enabled audit. Technical difficulty was conceptualized as a case- and context-dependent risk-adjustment layer shaped by anatomical complexity, vascular variation, therapy-altered tissue planes, visceral adiposity, operative platform, team workflow, and learning stage. Surgical quality was defined as a multidomain construct integrating process metrics, pathology metrics, and risk-adjusted clinical outcomes. The proposed framework provides audit-oriented guidance for identifying a simplified minimum dataset, prioritizing high-risk D2 segments for selective process review, and interpreting process, pathology, and outcome indicators together after adjustment for technical difficulty. AI may support scalable audit through video indexing, phase and step recognition, extraction of high-risk operative segments, assisted event logging, and structured feedback. However, AI outputs should be treated as candidate measurement signals requiring human confirmation, expert surgical review, pathology-based assessment, external validation, governance, and post-deployment monitoring. Future validation should proceed stepwise, from feasibility testing and inter-rater reliability assessment to prospective workflow evaluation and multicenter assessment of audit efficiency, benchmarking validity, and process- or patient-level outcomes. Quality assessment in minimally invasive D2 lymphadenectomy should shift from isolated surrogate endpoints toward an auditable, difficulty-adjusted framework that makes “D2 achieved” more measurable, reviewable, and clinically meaningful.