Introduction: This video will detail the relevant steps in laparoscopic total gastrectomy and D2 lymphadenectomy with a hand-sewn esophago-jejunal anastomosis.
Method and Patient: A 53 year-old male presented with weight loss and significant familiar history for gastric cancer (Both parents and sister). An upper GI endoscopy revealed a 10 mm gastric ulcer between the body and the anthrum; and a mucosal deformity in the body. Both lesions where biopsed and histology was positive for signet-ring cell adenocarcinoma. Muscularis propia was not involved on endoscopic ultrasound. Laboratory work was normal and a chest-abdomen-pelvis CT did showed signs of disemination. Although a small lesion a total gastrectomy was decided due to familiar history and hystology.
Surgical technique : Tha patient was placed in supine position. The surgeon worked from the right of the patient at a higher level. Five trocars were used: three 10-12mm, and 2 of 5mm. The greater omentum was dissected with the gastrocolic ligament as we entered the lesser sac using the harmonic scalpel. Lymph-nodes groups 5 and 6 were dissected with the first portion of the duodenumm was transected with a 45mm blue linear stapler. The dissection is then continued proximally. The hepato-duodenal ligament is dissected with the lymph nodes and the hepatic artery is dissected along to the celiac trunk. The left gastric artery is dissected with the lymph-nodes and transected between hemostatic clips. The splenic artery is dissected retreiving the lymph nodes. The dissection continues up to the diaprhagmatic pillars and groups 1 and 2 are diseccted. The esophago-gastric junction is dissected. We complete the dissection along the greater curve dissecting the short gastric vessels and lymph-nodes of the splenic ileus. A Roux-en-Y is performed, and the roux limb is ascended in an antecolic fashion. The distal esophagus is transected using the harmonic scalpel and an esophago-jejunal end-to-side hand-sewn anastomosis is performed in a one layer continous 3-0 vycril. A negative blue dye test was carried. The surgical specimen was extracted in a plastic bag. Two drainages was placed near the anastomosis. No conversion was required.
Operative time was 180 minutes. The patient was discharged on postoperative day 5 with no complication.
Definitive histology confirmed signet-ring cell adenocarcinoma with several focus around the ulcer. The tumor involved no further lamina propia, without vascular or perineural permeation. The surgical borders were negatives. Two positive lymph-nodes were found in groups 3 and 5. Postoperative stage was T1N1M0 and the patient was scheduled for adjuvant radio-quimiotherapy.
Conclusion: The laparoscopic total gastrectomy with hand-sewn esofago-jejunal anastomosis is a feasible option for reconstruction with good reults.
Session: Podium Video Presentation
Program Number: V044
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