Pure single-incision laparoscopic D2 lymphadenectomy for gastric cancer: Novel approach to 11p lymph node dissection (Mid-pancreas mobilization)

Sang-Hoon Ahn, MD, Sang-Yong Son, MD, Do Hyun Jung, MD, Do Joong Park, MD, PhD, Hyung-Ho Kim, MD, PhD. Department of Surgery, Seoul National University Bundang Hospital.

Purpose: We sought to evaluate the usefulness of a novel mid-pancreas mobilization for 11p lymph node dissection (LND) to accomplish D2 lymph node dissection in pure single-incision laparoscopic distal gastrectomy (SIDG) for gastric cancer.

Methods: Briefly, in pure SIDG, after the completion of 7, 8a/12a, 9 LND among the suprapancreatic portion, 11p LND was started from the mid-pancreas mobilization. After the whole mid-pancreas mobilization from the white line of Toldt, two gauzes were inserted behind the pancreas. This maneuver facilitated to expose the splenic vein because of the tilting of the pancreas and the complete detachment of soft tissue including 11p lymph node from the white line of Toldt. The dissection plane along the splenic artery and vein for 11p lymph node dissection could be visualized just by the control of the operator’s grasper without an assistant.

Results: The procedure was completed in 10 patients without intraoperative events; conversion to conventional laparoscopy; and surgery-related complications, including postoperative pancreatic fistula. In all 10 patients, the standards of D2 lymph node dissection were satisfied by exposing the splenic vein. The mean numbers of retrieved lymph node and 11p lymph node were 60.6 +-14.3 and 4.3 +- 2.3, respectively.

Conclusion: Mid-pancreas mobilization for 11p LND in pure SIDG seems feasible and embryologically ideal and may be applicable to conventional laparoscopic gastrectomy.

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