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Laparoscopic total gastrectomy and D2 lymphadenectomy for gastric cancer of the lesser curvature

Laparoscopic gastrectomy is recognized to be a less invasive operation for early gastric cancer. This video shows a totally laparoscopic total gastrectomy with D2 lymph node dissection for a cancer of the lesser curve with a clear demonstration of each surgical step.

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Laparoscopic total gastrectomy and D2 lymphadenectomy for gastric cancer of the lesser curvature

作者群

G Dapri, J Himpens, GB Cadière

摘要

Laparoscopic gastrectomy is recognized to be a less invasive operation for early gastric cancer. This video shows a totally laparoscopic total gastrectomy with D2 lymph node dissection for a cancer of the lesser curve with a clear demonstration of each surgical step.

分類

complex cases

關鍵字

Laparoscopic total gastrectomy, D2 lymphadenectomy, gastric cancer, lesser curvature

媒體類型

手術影片

期間

11'06''

刊物

2009-06

普通的

最愛

Favorites Media

音訊

副標題

數位出版

WeBSurg.com, Jun 2009;9(06).
URL: http://www.websurg.com/doi-vd01en2668.htm

Laparoscopic total gastrectomy and D2 lymphadenectomy for gastric cancer of the lesser curvature

1. Introduction 00'17''

This is the case of a 51-year-old woman with a tumor at the lesser curvature qualified for surgical exploration because she had no metastatic disease. Laparoscopy was started using 5 trocars.

2. Omentectomy 00'31''

An omentectomy was performed by clearing station #4.

3. Right gastric artery and dissection of lymph node station 5 00'39''

Subsequently the right gastric artery was dissected and lymph nodes of station #5 were cleared. Dissection was then taken cephalad and to the left with incision of the pars condensa and the pars flaccida of the gastrohepatic ligament.

4. Celiac trunk dissection 01'04''

The celiac axis has been identified.

5. Dissection of lymph node station 8 01'09''

The hepatic artery was first dissected and all lymphoglandular tissue was dissected off the vessel, here by clearing station #8 anteriorly and posteriorly. Dissection was then taken again cephalad and all lymphoglandular tissue overlying the splenic artery and the root of the celiac axis were dissected off. Care was taken that the specimen was preserved in one piece in order to avoid dissemination. The hepatic artery and the splenic artery come into view, and hook dissection allows for a very meticulous freeing of all the structures. Eventually the left gastric artery and pedicle are dissected.

6. Left gastric vein division 02'38''

The left gastric vein is clipped and divided exactly at the superior surface of the pancreas and right on top of the splenic artery. All lymphoglandular tissue around the left gastric artery at the root of the celiac axis is dissected and the suspicious lymph node comes into view, which is dissected and left with the specimen.

7. Left gastric artery division 03'31''

The artery itself is again properly skeletonized by hook dissection and clipped as well as the left gastric vein.

8. Dissection of lymph node stations 1 and 2 04'02''

Dissection is now continued with the ultrasonic scissors going superiorly, right anteriorly to the aorta here by clearing all lymphoglandular tissue between the aorta and the esophagus and the stomach. The hiatus comes into view and the hiatal fibres are incised in order to freely dissect stations #1 and #2. Partial resection of the hiatus’s muscles will allow for a more straightforward anastomosis towards the end of the procedure.

9. Dissection of lymph node station 10 05'15''

Attention is now drawn towards the splenic hilum and station #10 is completely dissected free and all lymphoglandular tissue of that area is swept towards the specimen.

10. Dissection of lymph node station 11 05'55''

Dissection is now taken to the right and station #11 is cleared as well.

11. Duodenal and esophageal division 06'14''

After clearance of all the tributary stations, the esophagus and the duodenum will now be divided, first the duodenum using a blue load 60mm cartridge covered by Seamguard whereas the esophagus is transected sharply by scissors. The anvil of the circular stapler is put inside the esophageal lumen before complete transection of the esophagus is performed. A purse-string suture of Prolene 2/0 is now fashioned around the stem of the anvil and tied extracorporeally. The angle of Treitz is located and a loop of small bowel is selected, which can be easily lifted towards the esophageal region.

12. End-to-side esophagojejunal anastomosis and Roux-en-Y reconstruction 07'26''

A circular anastomosis is performed end-to-side between the esophagus and the selected loop of small bowel using a 25 circular stapler covered by plastic sheet. Local bleedings as here at the splenic hilum can be dealt with by selective ligation using a preformed knot (Endoloop). The blind end of the Roux limb is now transected using a white load, and a 60cm alimentary loop is fashioned with re-anastomosis with the biliary loop using a 60mm white cartridge of the linear stapler. A conventional jejuno-jejunostomy is performed. Closure of the insertion opening is initiated while the stapler is still in place, which will allow for a very symmetrical closure of the opening. The stapler is withdrawn and two converging running sutures PDS 3/0 will close the insertion opening.

13. Mesenteric and Petersen\'s defect closure 09'55''

The mesenteric defect that was created by the Roux-en-Y construction is now closed with a purse-string of Polypropylene 1, the purse-string being tied by an extracorporeal knotting technique. The Petersen’s defect, which is located between the mesentery of the alimentary loop and the transverse mesocolon is closed in a similar fashion, that with a purse-string of Polypropylene 1 in order to avoid internal herniation. The alimentary loop is anchored to the right pillar of the hiatus in order to reduce traction and a drain is left close to the esophagogastrostomy.