Laparoscopic Total Gastrectomy with D2 Lymphadenectomy in an Obese Patient with Intracorporeal Anastomosis

Leonardo Ferraz, MD, Thiago Boechat, MD, Marcio Balieiro, MD, Baltazar Fernandes, MD, Jose Ribamar S Azevedo, MD, PhD, FACS. Bonsucesso Federal Hospital / Rio de Janeiro – Brazil.

The aim of this video is to demonstrate the technique of Total Gastrectomy with D2 Lymphadenectomy with intracorporeal anastomosis in an obese patient . A 54-year-old woman patient, obese (IMC:33) and hypertensive, had 2-month history of epigastric pain and weight loss. Upper endoscopy demonstrated an 4x4cm ulcerated lesion located at the gastric incisura angularis. Biopsy revealed poorly differentiated adenocarcinoma (signet ring cell adenocarcinoma). Computer tomography showed localized disease with no clinical evidence of lymph node or peritoneal metastasis. Patient was submitted to minimally invasive approach in the supine position, using five trocars and a liver retractor. We perform a clockwise direction dissection. The initial step in the dissection is to divide the gastrocolic omentum to mobilize the greater curvature of the stomach and gain access to the lesser sac, perfoming lymphadenectomy of station 4sb and 4d. Then, we move foward dissection and ligation of right gastroepiploic vessels with station 6 lymphadenectomy. Afterward, stations 5, 12a and 8a are removed. Then, dissection and division of left gastric vessels and stations 7, 9 , 1 , 11p and 11d lymphadenectomy.
Division of short gastric vessels complete stations 4sa and 2 lymphadenectomy. Then, omentectomy is completed. Finally, esophagus and duodenum are stapled and a Roux and Y reconstruction is perfomed using a circular stapler for esophagojejunal anastomosis. In the end of procedure, specimen was removed from a 4 cm transverse incision in the optical port.
Post operative period was uneventful with patient discharged on post operative day 10. Final pathologic staging was pT1N0M0 and 61 harvested lymph nodes.