Laparoscopic total gastrectomy for adenocarcinoma

This is a video demonstrating laparoscopic total gastrectomy for adenocarcinoma. Mobilization of the greater omentum and stomach are presented in detail, together with vascular and lymph node dissection according to the Japanese gastric cancer classification. Finally, a stapled esophago-jejunostomy is performed for restoration of gastro-intestinal continuity. This is another case where Dr. Dallemagne, MD demonstrates how a complex resection can be undertaken laparoscopically using a stepwise approach.

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Laparoscopic total gastrectomy for adenocarcinoma

Authors

Abstract

This is a video demonstrating laparoscopic total gastrectomy for adenocarcinoma. Mobilization of the greater omentum and stomach are presented in detail, together with vascular and lymph node dissection according to the Japanese gastric cancer classification. Finally, a stapled esophago-jejunostomy is performed for restoration of gastro-intestinal continuity. This is another case where Dr. Dallemagne, MD demonstrates how a complex resection can be undertaken laparoscopically using a stepwise approach.

Classification

complex cases

Keywords

laparoscopic total gastrectomy, gastric adenocarcinoma

Media type

Surgical video

Duration

14'00''

Publication

2007-01

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E-publication

WeBSurg.com, Jan 2007;7(01).
URL: http://www.websurg.com/doi-vd01en2058.htm

Laparoscopic total gastrectomy for adenocarcinoma

1. Dissection of greater omentum 00'15''

This is a case of a PT3N2M0 adenocarcinoma of the stomach in a 52-year-old male. The patient is placed in reverse Trendelenburg position with legs apart. The surgeon stands between the legs. 4 to 5 ports can be used. 3 to 10mm ports are placed across the upper abdomen as shown with additional 5mm ports in the left subcostal and epigastric area for retraction. Surgery starts with division of the gastro-colic ligament. The greater omentum is resected completely by dividing the attachments to the transverse colon. This is continued downwards to the interior leaf of the mesocolon and towards the right until the proximal duodenum is visualised. The omentum must be retracted superiorly in order to display the correct plane.

2. Right gastro-epiploic vessel and station 6 lymph node dissection 02'01''

The first important vascular step is the dissection of the right gastro-epiploic vessels. Again, here it is necessary to apply good superior traction of the stomach and omentum in order to visualise clearly first the right gastro-epiploic vein, followed by the artery. At this time also, it is possible to excise the infra-pyloric lymph nodes, which correspond to station 6 according to the Japanese Gastric Cancer Association. Once the right gastro-epiploic vessels are taken, the pylorus and proximal duodenum are dissected posteriorly. The right gastric artery is visible at the distal end of this tunnel.

3. Division of gastro-hepatic and hepatoduodenal ligaments 03'15''

However, we do not divide it yet until we release the gastro-hepatic and hepatoduodenal ligaments from above.

4. Dissection of common hepatic artery and station 5 and 12 lymph nodes 03'53''

After incising the gastro-hepatic ligament and the hepatoduodenal ligament, the hepatic artery is identified. Lymph nodes in this region, corresponding to station 12, are cleared during the exposure of this vessel. By dissecting the right gastric artery completely, we also remove the station 5, or supra-pyloric lymph nodes.

5. Division of right gastric artery and duodenum 04'55''

Next, we divide the right gastric artery between clips coming posteriorly from behind the pylorus. Once a good tunnel is created behind the pylorus, the proximal duodenum is divided using a linear intestinal stapler. This is an important step in order to retract the distal stomach and expose the common hepatic artery.

6. Dissection of station 8 lymph nodes 06'25''

A sling is placed around the artery and retracted superiorly to facilitate the dissection of the lymph nodes along these vessels, corresponding to station 8. Unfortunately, in this case, the working space is not very comfortable to proceed with the lymphadenectomy proximally along the common hepatic artery to the coeliac axis.

7. Division of left gastric artery 08'10''

Therefore, we proceeded with gastric mobilisation first. In order to dissect the left gastric artery, the fundus of the stomach is mobilised posteriorly. Next, the lesser curvature of the stomach is dissected to free the left gastric vessels. Then, strong superior traction is placed on the stomach and the left gastric artery is divided between clips.

8. Division of gastrosplenic ligament 09'14''

Following this, the gastrosplenic ligament is divided. It is important to dissect this carefully using either an energy device or clips to ligate and divide the short gastric vessels that pass between the splenic hilum and the greater curvature of the stomach.

9. Dissection of diaphragmatic hiatus and mobilization of esophagus 09'54''

For the final part of gastric mobilisation, we turn our attention to the diaphragmatic hiatus. The pars condensa of the lesser omentum is divided and the right crus of the diaphragm is identified. Once this is seen clearly, the phreno-oesophageal ligament is released superiorly and traced to the left crus of the diaphragm. Then, the remaining gastrophrenic attachments are dissected from below the oesophagus. In the process, the abdominal oesophagus is completely mobilised.

10. Completion of station 7, 8 and 9 lymphadenectomy 11'15''

With the main bulk of the stomach now out of the way, we turn our attention to the lymphadenectomy of common hepatic, left gastric and coeliac axis lymph nodes. These correspond with lymph node stations 7, 8 and 9 according to the Japanese classification. It is preferable to perform this dissection en bloc with the gastric specimen. However, in this case the working space was not comfortable earlier, when the stomach was in situ. With gentle traction of the fatty tissue surrounding these arteries, the lymphadenectomy can be performed with a hook as shown. Japanese surgeons have demonstrated that radical D2 gastrectomy confers 30-40% 5-year survival for patients with stage 3 gastric cancer.

11. Esophageal transection 13'10''

A marking suture is placed on the distal oesophagus to orientate it for subsequent anastomosis. Then it is divided with a linear stapler.

12. Roux-en-Y retrocolic esophago-jejunostomy 13'40''

Gastro-intestinal continuity is restored with a standard retro-colic Roux-en-Y oesophago-jejunostomy. The jejunal loop is first measured. A marking suture is then placed.