Laparoscopic Totalgastrectomy and D2 Lymphadenectomy for Gastric Cancer and Intracorporeal Roux-En-Y Reconstruction Using Oro-Gastric Anvil, Over 120 Cases Experiences

Hitoshi Satodate, Dr, Haruhiro Inoue, Dr, Junichi Tanka, Dr, Shin-ei Kudo. Digestive Disease Cemter, Showa University Northern Yokohama Hospital

Introduction
Laparoscopic gastrectomy (LTG) for gastric cancer is becoming popular procedure in Japan. In our institution, 141 cases of the gastric cancer patients were operated last year and almost 90% of the patients were performed laparoscopic. One outstanding problem is intracorporeal esophago-jejunal anastomosis after LTG, because it’s technical difficulty. We introduced newly developed oro-gastric anvil (Orvil) for the anastomosis, and have experienced over 120 cases.

Method
A 12-mm trocar is placed through umbilical incision, and four additional trocars are placed. Our standard lymphadenectomy is modified D2 dissection. After thorough mobilization of the abdominal esophagus, it is taped and retracted. Then the esophagus is divided with stapler, and the tube attached to the Orvil is inserted per orally as a conventional naso-gastric tube. The tube is extracted from the esophageal stump. The tube is extracted outside from the trocar, and the anvil is loaded into the esophageal stump. Then the handpiece of EEA stapler is introduced from the umbilical port incision, after the EEA stapler passed and fixed into the opening of the jejunal limb. And the anastomosis is stapled also under the direct vision of the laparoscope.

Results
We have performed 128 cases of the LTG with this procedure, and have experienced only one anastomotic leakage and the case could be managed with conservative treatment. No other major problems had occurred. Mean operation time is 231min.

Conclusion
This technique is technically feasible, can be performed easily and securely. Two clear advantages can be raised with this method, compare with other techniques. First, this technique can be relatively easily applied for the cancer of the cardia, with necessity of lower esophageal resection. Second, open of the intestinal lumen into the abdominal cavity is minimal. This could be great benefit in view of avoiding peritoneal metastasis and surgical site infection. This technique could become the standard methods for reconstruction after LTG, facilitating the acceptance of LTG as a surgical option for patients with gastric cancer. We will show our clinical practice.