Laparoscopic proximal gastrectomy with double tract reconstruction by intracorporeal anastomoses

Nobuhiro Takiguchi, PhD, MD, M Nagata, MD, Y Nabeya, MD, A Ikeda, MD, O Kainuma, MD, A Soda, MD, A Cho, MD, Y Muto, MD, S Parku, MD, H Arimitsu, MD, E Ishigami, MD, M Sato, MD, H Yamamoto, MD

Division of Gasroenterological Surgey, Chiba Cancer Center, Chiba, Japan

Background: In laparoscopic proximal gastrectomy (LPG), reconstruction methods are various, for example, esohago-gastrostomy, jejunal interposition, and double tract reconstruction. We adopt LPG with double tract reconstruction from the viewpoint of functional superiority and avoiding severe complications. We demonstrate this procedure by intracorporeal anastomoses.

Method: Double tract reconstruction is composed of Roux en Y reconstruction and gastro- jejunostomy. Indication for the LPG, the preoperative examination shows early gastric cancer located at the upper part of stomach without lymph node swelling. Under laparoscopy, lymph node dissections, exposure of abdominal esophagus and clearing the gastric wall of resection line are performed. Resection line of stomach is cut by linear stapler. Taping is performed jejunum at 25cm distal from Treitz ligament. Mini-laparotomy is performed with an incision about 4.5cm at left subcostal port and anvil head of a 25mm circular stapler is introduced into the abdominal cavity. The surgical glove was attached to the wound retractor to maintain the pneumoperitoneum. After half cutting esophagus, anvil head is inserted and hand-sewn purse-string suture along the cut end of esophagus using 2-0 monofilament is done. A monofilament pretied loop is applied to reinforce the ligation.
Resected sample is removed and Y limb anastomosis is sutured by handsewn.
Esophagojejunosotomy is performed by antecolic route. The body of the circular stapler was introduced through a surgical grove. The circular stapler is inserted into the distal limb of the jejunum. Intracorporeal circular stapling is done under laparoscopy. The jejunal stump is closed by linear stapling.
Anterior wall of remnant stomach and jejunum about 15cm distal from esopagojejunosotomy are cut and linear stapler is inserted. After stapling, the insert hole is closed by linear stapler.

Results: Six patients underwent this procedure. Operation records showed 270 min in operation time, and 30.8ml in blood loss, respectively. Median hospital stay was 10 days. There were no anastomotic insufficiency and surgical site infections. No cases with the reflux symptom were found, and all cases had good diet intake.

Conclusion: Laparoscopic proximal gastrectomy with double tract reconstruction by intracorporeal anastomoses is minimal invasive. The new double tract reconstruction after proximal gastrectomy that we designed seems to be excellent from the clinical outcomes.

Session: Poster Presentation

Program Number: P208

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