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Laparoscopic subtotal gastrectomy and D1 extended lymphadenectomy for gastric cancer

Laparoscopic gastrectomy for cancer is feasible. However, an extensive D2 or D3 lymphadenectomy by laparoscopy is very demanding and yet to be accepted as standard procedure. In this video, we show the stepwise technique of a D1 extended gastrectomy in a patient with a cT2N0M0 gastric tumor.

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Laparoscopic subtotal gastrectomy and D1 extended lymphadenectomy for gastric cancer

作者群

J Torres Bermúdez, S del Valle Ruiz , M Montoya Tabares, E Garcia Abril , J Lopez Espejo, G Sánchez de la Villa

摘要

Laparoscopic gastrectomy for cancer is feasible. However, an extensive D2 or D3 lymphadenectomy by laparoscopy is very demanding and yet to be accepted as standard procedure. In this video, we show the stepwise technique of a D1 extended gastrectomy in a patient with a cT2N0M0 gastric tumor.

關鍵字

Laparoscopic subtotal gastrectomy, D1 extended lymphadenectomy, gastric cancer

媒體類型

手術影片

期間

14'54''

刊物

2011-10

普通的

最愛

Favorites Media

音訊

副標題

數位出版

WeBSurg.com, Oct 2011;11(10).
URL: http://www.websurg.com/doi-vd01en3408.htm

Laparoscopic subtotal gastrectomy and D1 extended lymphadenectomy for gastric cancer

1. Operative technique; team and patient position 00'30''

The patient was addressed to the operating room for laparoscopic subtotal gastrectomy. The patient was placed in a modified lithotomy position with the arms at a right angle and legs apart. The surgeon stands between the legs of the patient, the camera assistant and the second assistant sit down on the right and left side of the patient, respectively.

2. Trocar position 00'50''

We used a five trocar technique. A close pneumoperitoneum is insufflated up to 12mmHg. One 11mm trocar for the 30-degree optic is inserted 1cm right and below the umbilicus. Two 12mm trocars for the operator’s instruments are introduced on the right and left mid-clavicular line level the umbilicus. A 5mm trocar is introduced on the left mid-axillary line for the assistant’s instrument and another 5mm trocar below the xiphoid process for the liver retractor.

3. Laparoscopic exploration 01'26''

After a laparoscopic exploration, no further evidence of intra-abdominal disease or liver metastases was observed. The tumor was confirmed to be in the lower stomach no extending to the serosa.

4. Omentectomy and dissection of number 4sb and 4d lymph nodes 01'39''

The first step of the operation is the total resection of the gastrocolic ligament along with the lymph nodes surrounding the left gastro-epiploic vessels (number 4sb) and the number 4d lymph nodes station adjacent to the right gastro-epiploic vessels. The dissection begins to the left in order to clear the insertion of the omentum in the transverse colon by using a 10mm Ligasure™. Since there are fewer adhesions, the lesser sac is easier to open. The adhesions between the stomach and the anterior surface of the pancreas are divided by lifting the stomach. The dissection finished on the greater curvature after the division of the left gastro-epiploic vessels using the Ligasure™. The operation is now carried on to the right. Care must be taken as there is a possibility of heat colon perforation because of its proximity to the duodenum.

5. Division of the right gastro-epiploic vessels and number 6 lymph nodes dissection 02'47''

The infra-pyloric (number 6) lymph nodes station along the right gastro-epiploic vessels will be dissected as a result of the division of these vessels. First, the right superior colic vein (RSCV) has to be found in order to identify the root of the right gastro-epiploic vein (RGEV), which is separated by means of the Ligasure™ device at the very location from which the vein arises on Henle’s gastrocolic trunk. The right gastro-epiploic artery is exposed and divided at its origin on the gastro-duodenal artery (GDA) using the Ligasure™. The fat tissue on the surface of the pancreatic head is completely dissected. A retrogastric passage is made at the level of the pylorus. The gastro-duodenal artery is exposed.

6. Dissection of the number 5 lymph nodes 03'55''

The dissection will now take place from above. The peritoneal membrane over the hepato-duodenal ligament is open. The root of the right gastric artery (RGA) on the proper hepatic artery and the supra-pyloric number 5 lymph nodes are dissected and divided using the Ligasure™.

7. Transection of the duodenum 04'55''

The pylorus and the duodenum are free from the surrounding fat tissue. The duodenum is transected 1cm below the pylorus using an Endo-GIA® linear stapler (6cm blue cartridge) Endo-GIA®. We prefer to do this through the trocar inserted on the right side to have a tension-free duodenal stump, since the angle of the instrument allows the stump to have more symmetry between the anterior and posterior duodenal walls.

8. Reinforcement of the duodenal stump 05'21''

To prevent leakage, the suture line is reinforced using a 2/0 PDS™ seromuscular running suture.

9. Dissection of the number 8 lymph nodes 05'39''

To remove the number 8 node station around the common hepatic artery, we clear all the fat tissue above the pancreas starting from the gastro-duodenal artery to the left by using monopolar coagulation. As we perform a lymphadenectomy of number 7, 8 and 9 lymph node groups without the dissection of number 12, 11 and 10 nodes, a D1 extended lymphadenectomy could be assigned. It is assumed that the patient has a T2 tumor as it is not extending to the serosa. In such tumors (T2), the estimated incidence of group 3 lymph node invasion is about 2%. Although the dissection of lymph nodes number 12 and 11p are considered steps of D2 lymphadenectomy, these stations belong to level 3 (N3) of cancer invasion. On the other hand, the complete dissection of number 12 lymph nodes is made around vital structures and could increase the operative morbidity and mortality.

10. Dissection of number 9 lymph nodes 07'36''

The dissection is now carried on to the left to remove the number 9 node station around the celiac trunk. To make the dissection of the number 9 celiac trunk and 7 left gastric artery lymph nodes easier, we open the peritoneal membrane from the celiac trunk up to the right crus in both sides. The dissection of the proximal peri-splenic lymph nodes number 11p is very difficult as the artery sometimes runs behind the pancreas with a high risk of injury. This should be specially kept in mind because the blood of the gastric remnant will be supplied only for the terminal branches of the splenic artery, the short gastric vessels. In addition, the invasion of theses nodes is considered as distant metastasis.

11. Dissection of number 7 lymph nodes and division of the left gastric vessels 08'22''

The fat tissue and number 7 node station along the left gastric vessels and over the trifurcation of the celiac trunk are swept upwards. The vein and the artery could be independently divided using clips but we prefer the division with a vascular stapler.

12. Dissection of number 1 lymph nodes 10'28''

The right peri-esophageal and paracardial fat tissue with number 1 nodes are dissected using the Ligasure™ from the proximal to the distal side of the stomach. 09:57 This image shows the final view after completion of dissection of number 8, 9, 7 and 1 node stations.

13. Skeletonization of the lesser curvature 10'49''

Finally, we skeletonize the lesser curvature in a distal to proximal direction by cutting the adipose tissue with proximal 3 lymph nodes.

14. Gastric transection 11'09''

The proximal level of the gastric transection must be far enough from the tumor to get clean resection margin. The stomach is transected in this case using one 6 cm linear stapler with green cartridge and two with blue cartridge through the trocar inserted on the right. Now, the specimen is placed in a large Endobag (Endocath™, Covidien). The Endobag is pulled out through a 15mm trocar to be tied offside without extraction. Then, it is reintroduced again in the abdominal cavity to avoid loss of pneumoperitoneum during the next steps of the operation.

15. Extraction of the specimen 14'10''

A single close suction drain is left at the operating area. The specimen is removed from the abdominal cavity through a 4cm minilaparotomy on the left site. Total operative time was 240 min. Liquid oral intake was on the 1st postoperative day. The total postoperative stay was 7 days. The microscopic histological examination established a stage II (pT2a N1 Mx) differentiated adenocarcinoma. From 24 harvested lymph nodes, only one on the greater curvature was affected. The patient was sent to adjuvant radio-chemotherapy.

16. Gastrointestinal reconstruction 12'29''

The jejunum is pushed upwards through a window opened in the transverse mesocolon. It is placed in isoperistaltic position. An opening is made on the anterior wall of the jejunum and another one on the posterior wall of the greater curvature of the stomach. Then, a 60 mm blue cartridge is inserted to create a side-to side isoperistaltic gastro-jejunum anastomosis. The nasogastric tube is repositioned and the insertion openings are closed with intracorporeal PDS™ 2/0 extramucosal running suture.

17. Closure of Petersen’s and mesenteric defect 13'20''

The Petersen’s defect located between the mesentery of the alimentary loop and the transverse mesocolon as well as the mesenteric defect created by the Roux-en-Y reconstruction are closed intracorporeally with a purse-string of silk 2/0.

18. Extraction of the specimen 14'10''

A single close suction drain is left at the operating area. The specimen is removed from the abdominal cavity through a 4cm minilaparotomy on the left site. Total operative time was 240 min. Liquid oral intake was on the 1st postoperative day. The total postoperative stay was 7 days. The microscopic histological examination established a stage II (pT2a N1 Mx) differentiated adenocarcinoma. From 24 harvested lymph nodes, only one on the greater curvature was affected. The patient was sent to adjuvant radio-chemotherapy.