Laparoscopic total gastrectomy for pT2 N0 M0 adenocarcinoma of the lesser curvature of the stomach

Totally laparoscopic gastrectomy for cancer remains limited because of technical problems, expecially for lymphadenectomy. We present the case of a 75-year-old patient with no specific history in which an adenocarcinoma of the lesser curvature of the stomach was found. An endoscopic ultrasound had shown a UST3 N0 lesion. The CT-scan confirmed the absence of secondary lesion and a neoadjuvant chemotherapy was carried out. Following chemotherapy, a re-evaluation was performed and confirmed the 2 by 2cm lesion of the lesser curvature of the stomach without secondary lesion. The decision to perform a laparoscopic total gastrectomy was made.

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Laparoscopic total gastrectomy for pT2 N0 M0 adenocarcinoma of the lesser curvature of the stomach

Authors

B Dallemagne, F Costantino, J Marescaux

Abstract

Totally laparoscopic gastrectomy for cancer remains limited because of technical problems, expecially for lymphadenectomy. We present the case of a 75-year-old patient with no specific history in which an adenocarcinoma of the lesser curvature of the stomach was found. An endoscopic ultrasound had shown a UST3 N0 lesion. The CT-scan confirmed the absence of secondary lesion and a neoadjuvant chemotherapy was carried out. Following chemotherapy, a re-evaluation was performed and confirmed the 2 by 2cm lesion of the lesser curvature of the stomach without secondary lesion. The decision to perform a laparoscopic total gastrectomy was made.

Classification

basic techniques

Keywords

Laparoscopic total gastrectomy, pT2 N0 M0 adenocarcinoma, lesser curvature, stomach

Media type

Surgical video

Duration

16'26''

Publication

2009-11

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E-publication

WeBSurg.com, Nov 2009;9(11).
URL: http://www.websurg.com/doi-vd01en2756.htm

Laparoscopic total gastrectomy for pT2 N0 M0 adenocarcinoma of the lesser curvature of the stomach

1. Clinical case presentation 00'19''

This is the clinical case of a 75-year-old patient with no specific history in which an adenocarcinoma of the lesser curvature of the stomach was found following anemia in March 2009. An endoscopic ultrasound had shown a UST3 N0 lesion. The CT-scan confirmed the absence of secondary lesion and a neoadjuvant chemotherapy was carried out. Following chemotherapy, a re-evaluation was performed and gastroscopy confirmed the 2 by 2cm lesion of the lesser curvature of the stomach. Once again, the CT-scan did not show any secondary lesion. The decision is made to perform a laparoscopic total gastrectomy.

2. Abdominal cavity exploration 01'08''

We start with the exploration of the abdominal cavity using a videolaparoscopic approach. No secondary lesion is identified. The technique begins with a mobilization at the level of the gastro-omental ligament. Four operative ports are used. One 10-12mm optical port is placed at mid-distance between the xiphoid process and the umbilicus, and two 5mm ports are located in the right and left flank, and another 5mm port is placed at epigastric level.

3. Gastric mobilization 01'42''

The dissection starts as soon as the greater omentum is mobilized to the left. It is continued cephalad. In this case, the dissection is performed using the 5mm Ligasure device, which ensures a satisfactory hemostatic control. Faced with major vessels at the level of the gastrocolic omentum, we decide to place clips. The cranial dissection is continued until the short gastric vessels are mobilized at the level of the greater curvature of the stomach. The control of these vessels is achieved through coagulation with the 5mm Ligasure device. Dissection and mobilization of the stomach are carried on starting from the right portion of the greater omentum searching for the right gastro-omental artery. Such a mobilization helps us to achieve an extended D1 lymphadenectomy removing the lymph nodes at the level of the right and left gastro-omental arteries. We lift up the posterior surface of the stomach and take down the remaining attachments situated at the level of the gastric antrum. Such freeing and cranial retraction helps to identify the right gastro-omental artery, which will then be dissected over a 1cm length and clipped. Dissection and lymphadenectomy at the level of this artery is performed using the 5mm Ligasure device. 5mm clips are placed distally and proximally. Finally, the artery is completely divided and a lymph node dissection is achieved. The lymph node dissection is continued along the artery’s vascular supply and complete taking down of adhesions located on the posterior surface of the stomach at the antrum. We search for a retrogastric passage at the level of the second portion of the duodenum. A few remaining attachments render this maneuver technically demanding.

4. Duodenal division 04'53''

Once the first portion of the duodenum has been identified, a 60mm Endo-GIA linear stapler, white cartridge is applied in order to achieve a complete division at the level of the first portion of duodenum.

5. D1 lymphadenectomy 05'07''

Dissection is continued all along the gastroduodenal artery in order to achieve a complete lymph node dissection. Following the route of the gastroduodenal artery, we then perform the lymph node dissection facing the proper hepatic artery. This lymph node dissection has the objective of completing the D1 lymphadenectomy. Here we can observe the proper hepatic artery along with the branch of the gastroduodenal artery. The lymph node dissection is continued at the level of the common hepatic artery. The lymph node dissection at the hepatic hilum will complete the D1 lymphadenectomy. Here the dissection is performed at the superior part of the lesser omentum (pars condensa). Dissection is carried out all along the common hepatic artery to achieve the lymph node dissection. The vascular control is achieved through the use of monopolar cautery and application of 5mm clips. The dissection is then continued towards the left gastric artery, which is dissected, hence completing the lymphadenectomy and the vascular control of the specimen. Dissection is further continued to remove the lymph nodes at the level of the coeliac trunk. The vascular division is always preceded by the application of clips in order to prevent any bleeding at this stage. Freeing is first performed anterior to the right crus: this helps us in obtaining a sufficient length of esophagus, hence facilitating the lowering of the distal portion of the esophagus.

6. Gastric fundus dissection 08'09''

We then turn our attention to the fundus of the greater curvature of the stomach. The posterior surface of the stomach is freed from its posterior attachments. This maneuver allows to identify the left crus of the diaphragm and to completely achieve the freeing of the specimen. This freeing allows to place caudal traction on the esophagus and control the vascular attachments posteriorly and the posterior gastric artery.

7. Dissection of the phreno-esophageal membrane 08'46''

Then the phreno-esophageal membrane is freed from the anterior surface of the stomach and of the distal esophagus. This freeing is completed to the right and to the left until attachments between the superior portion of the diaphragm and the esophagus are taken down completely. The vagus nerve is coagulated and divided using the 5mm Ligasure device. Here we can observe the retraction and the junction of the cardia along with the division of the posterior vagus nerve that allows the lowering of the esophagus.

8. Mediastinal dissection 09'37''

The mediastinal dissection will be carried out depending on the portion required to perform the anastomosis.

9. Proximal division 09'45''

Here you can see the proximal division line just at the distal part junction between the esophagus and the stomach leaving about 1cm of stomach at the level of the proximal division line. This will help us achieve the anastomosis and the restoration of bowel continuity. Once the resection has been completed, our objective is to restore the bowel continuity through a Roux-en-Y esophagojejunostomy.

10. Selecting the biliary loop 10'15''

The biliary loop is selected. It is fixed temporarily at the level of the left triangular ligament. This technique is used to perform a gastric bypass with a Roux-en-Y loop.

11. Measuring the alimentary loop 10'37''

Then the alimentary loop is measured. The anastomosis is performed at the foot of the loop between the duodenal loop that is tattooed and the intestinal loop to the left.

12. Jejunojejunal anastomosis 11'00''

Fixation is achieved thanks to a temporary stitch placed distally and an enterotomy is carried out using monopolar cautery always on the antimesenteric surface of the bowel. Once the enterotomy has been performed, an anisoperistaltic side-to-side anastomosis is achieved through the use of the 60mm Endo-GIA linear stapler, white cartridge. The anastomotic defect will be re-approximated using a re-absorbable monofilament PDS 3/0 running suture. The first running suture is placed at the inferior portion of the anastomosis and the second running suture is placed at the superior portion, thus linking up. Special attention must be paid to safely close the lowermost flexure of the jejunojejunal anastomosis. The temporary traction stitches are divided. Here we can observe how we close the mesenteric defect with application of a 2/0 absorbable monofilament suture. This closure is achieved through a running suture that is fixed by clip application.

13. Alimentary loop division 12'25''

Once the mesenteric closure has been achieved, the alimentary loop is divided just above the anastomosis at the foot of the loop. Once the division has been performed with the help of the Endo-GIA linear stapler, white cartridge, the vascular control is achieved at the level of the meso at approximately 3cm by following the terminal ileal artery. Therefore, a tension-free anastomosis is obtained at the level of the esophagus. Freeing of the temporary fixation is achieved and we search for the transmesocolic passage just above the duodenojejunal flexure. Once the avascular transmesocolic passage has been identified, the alimentary loop is placed in a supramesocolic position. The loop is passed through the mesenteric window and you can observe that there is no traction on the mounted loop at this moment.

14. Proximal anastomosis 13'25''

The alimentary loop is divided at its distal portion. This allows for the introduction of a PCEEA 25mm circular stapler. The proximal stump is then opened through monopolar cautery. A nasojejunal catheter had been introduced transorally. The anvil of a 25mm PCEEA mechanical circular stapler had been attached to the catheter. The trocar introduction site being enlarged at the left flank, the 25mm PCEEA circular stapler is introduced with a plastic wound protector through the abdominal wall. This circular stapler allows to perform the trans-sutural anastomosis, the extraction and transfixing. We make sure to avoid any twisting and check if the anastomotic doughnuts are appropriate. The blind loop is then divided through the use of an Endo-GIA 90. It is then taken out along with the specimen. We then turn our attention to the submesocolic area and we close the defect in the transmesocolic passage using PDS 3/0 suture material. A purse-string suture is achieved. The specimen will be extracted through a plastic wound protector. The PCEEA circular stapler’s introduction site will be used. A drain is placed at the level of the esophagojejunostomy. On postoperative day 5, the contrast swallow and follow-through investigation shows the total absence of contrast fluid leakage, without any anastomotic stricture. The patient resumed food intake from postoperative day 5 and was discharged on postoperative day 7.