Laparoscopic distal gastrectomy followed by Roux-en-Y reconstruction in patients with gastric cancer

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摘要

This video presents a totally laparoscopic distal gastrectomy with roux-en-Y reconstruction for gastric cancer. Demonstrated is a technique to construct the anastomosis and avoid torsion of the jejunal limb.

分類

complex cases

關鍵字

gastric cancer, laparoscopic distal gastrectomy, roux-en-y

媒體類型

期間

14'00''

刊物

2006-10

普通的

最愛

音訊

副標題

數位出版

WeBSurg.com, Oct 2006;6(10).
URL: http://www.websurg.com/doi-vd01en2013.htm

Laparoscopic distal gastrectomy followed by Roux-en-Y reconstruction in patients with gastric cancer

1. Case presentation 00'18''

Roux-en-Y reconstruction after distal gastrectomy for patients with gastric cancer has been widely accepted by many institutions in Japan, in order to prevent post-gastrectomy remnant gastritis. Following laparoscopic distal gastrectomy, it was necessary to create a gastro-jejunostomy through a small incision if one does not have a technique to do the anastomosis under laparoscopic control. However, such a mini-laparotomy procedure often results in torsion of the Roux limb due to unsatisfactory handling and poor visualisation of the bowel. Hence, we have invented a laparoscopic technique to make a gastro-jejunostomy for Roux-en-Y reconstruction securely and safely. This new technique is quite convenient and our initial experiences show that the postoperative course is excellent, without significant morbidity or mortality.

2. Trocar placement 01'26''

Five trocars are inserted with a distance of the hand grip within each two so as to avoid interference of laparoscopic forceps.

3. Start of the procedure 01'59''

The liver is retracted upward with a Penrose drain which is stitched to the ventral wall. The gastrocolic ligament is divided with Autosonics or Ligasure. The operator stands between the legs of the patient. The left gastro-epiploic artery is divided. The right gastro-epiploic artery is divided. The duodenum is divided with the Endo-GIA stapler so that the stomach can be mobilised and superior pyloric lymph node can be easily dissected. The right gastric artery is divided. The left gastric vein is divided. The left gastric artery is cleared and divided. The upper body of the stomach is divided with the Endo-GIA staplers at the designated level. We usually have to fire 2 staplers consequently. The stomach specimen is retrieved in a plastic bag of Endo-catch 2 through the umbilical incision that may be widened for the passage of the bag.

4. Description of the gastro-entero anastomosis 08'26''

Now we show the new technique of Roux-en-Y reconstruction. Note that the jejunum is anastomosed through the gastric remnant before the division of the jejunum so that torsion of the bowel can be avoided. Following the side-to-side gastrojejunostomy, the jejunum is divided and simultaneously the opening for the first stapler is closed. A stab incision is made with the Autosonics at the stump of gastric remnant, greater curvature side for later incision of Endo-GIA. The upper jejunum, 50cm from the ligament of Treitz is grasped with atraumatic forceps and the mesentery is divided. Another stab incision for insertion of the Endo-GIA is made on the wall of the upper jejunum. The blade of the Endo-GIA is inserted into the jejunum through the stab incision. The anvil of the Endo-GIA is inserted into the gastric remnant. Thus the jejunum is anastomosed to the gastric remnant side-to-side. Confirm no bleeding from the staple line from the inner side of the anastomosis. A stay suture is placed intracorporeally so that the anterior staple line will be kept away from the posterior wall. Another Endo-GIA is used to close the stab incisions of the gastric remnant and jejunum. The jejunum is divided simultaneously and as a consequence, the gastrojejunostomy is completed. Make sure that the calibre of the anastomosis is satisfactory. Here we show knack and pitfalls during division of the intestinal mesentery. Put a gauze behind the jejunum mesentery while you are dividing the mesentery so that the tissue behind it can be protected. It is also important to utilise the so-called “flag motion” and to ensure nothing behind it is damaged. Now then, how far can we go without dividing the bowel before the anastomosis? Here we show esophageal jejunostomy after laparoscopic total gastrectomy by the same method. As you can see, even the esophagojejunostomy can be carried out nicely by the very same technique without prior division of the bowel. A stay suture is placed on the jejunum 30cm distal to the gastrojejunostomy. Another stay suture is made for the stump of the afferent loop. By pulling at these stay sutures through the umbilical incision, the jejunum segments are withdrawn extracorporeally, and the Roux-en-Y jejunostomy can be made either by hand stitches or stapling.

5. End of procedure 15'15''

Postoperative fluorography shows good passage through the gastrojejunostomy and smooth emptying of the gastric remnants.

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