Laparoscopy-assisted distal gastrectomy with D2 lymph node dissection and uncut Roux-en-Y reconstruction

作者群

U Ichiro

關鍵字

gastric cancer, treatment by laparoscopy, coelioscopie, cure cancer de l'estomac

媒體類型

期間

21'00''

刊物

2006-05

普通的

最愛

音訊

副標題

數位出版

WeBSurg.com, May 2006;6(05).
URL: http://www.websurg.com/doi-vd01en1960.htm

Laparoscopy-assisted distal gastrectomy with D2 lymph node dissection and uncut Roux-en-Y reconstruction

1. Patient and trocar placement 00'18''

We insert 6 ports as shown in the video.

2. Dissection of #14 lymph node 00'26''

We first show dissection of the number 14v lymph node. By dissecting the inferior pancreatic margin with dissecting forceps and LigaSure, we determine the superior margin of the number 14v lymph node and then expose the anterior surface of the superior mesenteric vein. The anterior surface of Henle’s gastrocolic trunk is exposed. Removing the fatty tissue in front of it, we expose the anterior surface of Henle’s gastrocolic trunk. This procedure enables us to determine the right margin in the vicinity of the number 14v lymph node. Moving to the root of the middle colic vein, we determine the left margin of the number 14v lymph node dissection. Finally, we remove the adipose tissue containing the number 14v lymph node. Here we can see the condition after the completion of the number 14v lymph node dissection.

3. Dissection of #6 lymph node 02'24''

Next, the dissection of the number 6 lymph node. We expose the anterior superior pancreaticoduodenal vein which indicates the inferior margin of the lymph node dissection. After separating the root of the right gastroepiploic vein, we place a clip only on the distal side and divide it using LigaSure. After dissecting lymph nodes existing on the surface of the pancreatic head and cranial to the anterior superior pancreaticoduodenal vein, we confirm the right gastroepiploic artery. We then encircle the right gastroepiploic artery and divide it after clipping. Finally, we dissect adipose tissue from the duodenum up to the pylorus. Here we see the condition after the completion of the number 6 lymph node dissection.

4. Transection of duodenum 04'17''

Then we divide the duodenum. After dividing the superior duodenal vessels, we transect the duodenum using an Endo-GIA.

5. Dissection of #8a lymph node 04'34''

Here we get started dissecting the number 8a lymph node. We divide the pancreatic capsule on the superior margin of the pancreas. Because fine blood vessels flow into this area, meticulous procedure is required to control bleeding. We separate the left gastric vein. After ligating only the distal side, we divide it using LigaSure. We separate the anterior surface of the common hepatic artery while elevating lymph nodes on this artery. Let’s move on to dissection of the number 12a and number 5 lymph nodes. We expose the outer surface of the proper hepatic artery. This maneuver must be performed with caution due to an abundance of nerve tissue in this area. We divide the separated tissue using LigaSure, and proceed with dissection of the number 12a lymph node. We then perform lymph node dissection proceeding in the direction from the anterior surface of the proper hepatic artery to the interior. We separate the root of the right gastric artery. We then divide the root of this artery and dissect the number 5 lymph node. The common hepatic artery is isolated by use of a vessel loop and by pulling the loop towards the abdominal wall the portal vein is separated and exposed on the superior margin of the pancreas.

6. Exposure of diaphragmatic crus 07'07''

We then separate the crus of the diaphragm. While exposing the right crus of the diaphragm, we make sure to separate it fully from the dorsal side of the esophagus. We then dissect the number 12a and number 8p lymph nodes. Caudal traction of the vessel loop facilitates separation of the number 12a and the number 8p lymph nodes from the left margin of the portal vein. You can see adequate dissection from the anterior surface of the portal vein to the left margin.

7. Dissection of #9 lymph node 07'54''

Now we dissect the right side of the number 9 lymph node. First, we design the division of the retroperitoneum as shown by the black arrows, and then we divide the retroperitoneum along the right side of the coeliac artery. The end point of the cut is the anterior surface of the crus of the diaphragm exposed earlier. We separate the adipose tissue from the right side of the coeliac artery and divide it using LigaSure. During this procedure, it is essential to confirm that the cut line is in the direction of the crus of the diaphragm. Then we continue dividing towards the head and proceed with the dissection crossing the lateral wall of the root of the celiac artery up to the anterior surface of the crus of the diaphragm. With this maneuver, dissection of the number 9 lymph node on the right side of the coeliac artery is completed. Let’s now move on to the dissection of the number 9 and number 11p lymph nodes. We start the dissection of the number 11p lymph node by exposure of the root of the splenic artery. The splenic artery is isolated by use of a vessel loop. By pulling this loop caudally, we can confirm the lymph nodes in the area on the left side of the coeliac artery and the area surrounded by the splenic artery.

8. Dissection of #7 lymph node 10'17''

We proceed with dissection of the number 7 lymph node. We separate the root of the left gastric artery; the right side of this artery has more abundant nerve tissue than the left side making separation difficult. But it is possible to expose the artery root by meticulous separation and division using LigaSure. After the root is separated, it is clipped and cut using LigaSure, and the number 7 lymph node is dissected. We return to the dissection of the number 9 and number 11p lymph nodes. We use dissecting forceps to separate meticulously the area around the lymph nodes in the earlier confirmed area surrounded by the coeliac artery and the root of the splenic artery, and divide using LigaSure and scissors. This action exposes the anterior surface of the splenic vein and we then proceed to separate meticulously the anterior surface of the vein. Subsequently, after using dissecting forceps to separate adipose tissue around the splenic artery and the anterior surface of the splenic vein, we dissect the number 11p lymph node in a distal direction using LigaSure and scissors. Care must be taken at this time not to damage the splenic vein. We then proceed with separation and dissection between the splenic vein and the retroperitoneum. After this, we keep dividing in a continuous line from the tissue that has been dissected ‘en bloc’ to the lesser curvature of the esophagogastric junction. We cut to ensure a clear demarcation between the number 1 lymph node and the number 2 lymph node. Here we see the condition after the completion of the number 9 and number 11p lymph node dissection. Finally, we dissect the number 1 and number 3 lymph nodes. We dissect adipose tissue in the lesser curvature in the direction from the proximal side towards the distal side of the stomach. First, we cut along the anterior side of the visceral peritoneum; the thick blood vessels that enter into the wall of the stomach are thoroughly divided using LigaSure. Then, we cut along the posterior side of the visceral peritoneum; for the posterior side, we divide the blood vessels in the direction from the distal side towards the proximal side. Because of limitations imposed by the trocar angle, this is a more natural maneuver. We then skeletonize the lesser curvature in a posterior to anterior direction. The cut layer is made continuous with the earlier cut anterior side. This maneuver completes dissection of the number 1 and number 3 lymph nodes. Let’s now show a video of the condition of the completion of the D2 lymph node dissection. We believe that the same level of lymph node dissection has been achieved as with conventional open surgery.

9. Transection of stomach 15'15''

Let’s now move on to the transection of the stomach. A small transverse incision of 4 centimetres is made in the upper abdomen, and a wound protector is applied. Then the detached stomach and dissected adipose tissue are drawn out of the abdominal cavity through the small incision. The site of the lesion is confirmed and the stomach is transected on the proximal side.

10. Reconstruction 15'44''

We present the uncut Roux-en-Y reconstruction method. As shown in the schema of the reconstruction, we prefer a variant form of B2. The afferent loop lumen is occluded with a stapler. A Brown’s anastomosis is made at the length of 30 centimeters in the afferent loop. First, in the presence of pneumoperitoneum, the 25 centimetre point from the ligament of Treitz is located on the jejunum, and it is drawn out of the small incision. Support sutures are placed in two locations at the presumptive gastrojejunostomy site. A small hole is made in the mesenterium of the proximal afferent loop 5 centimetres from the presumptive gastrojejunostomy site. The lumen is then occluded using an SGIA™ knifeless stapler. The staple line is oversewn with seromuscular layer suturing. We use a 30 cm thread to determine the 30 cm point along the afferent loop and mark it with pigment. Then, we create a Brown’s anastomosis in the form of a side-to-side anastomosis using Endo-GIA. At this time, we suture closed the previously created entry hole using 4/0 absorbable sutures. All of the above maneuvers for creating anastomosis are performed extracorporeally except for gastrojejunostomy. We open a small hole at the presumptive gastrojejunostomy site and return the jejunum to the abdominal cavity. Laparoscopically, we observe the anastomosis created extracorporeally to confirm that there are no abnormalities. The forks of the Endo-GIA are inserted into the small hole created in the jejunum and in the stump of the greater curvature of the remnant stomach. Then the device is closed and fired. This creates a side-to-side anastomosis connecting the remnant stomach and the jejunum. Finally, the entry holes are closed laparoscopically by a hand-suture technique. As a rule, suturing is done with Gambe stitch using interrupted sutures. Ligation is done using the Roeder knot, a form of extracorporeal knot split. This is a simple and very useful method of ligation. If the remnant stomach is large, it is possible to perform conventional suturing from the small incision. However, in cases where the remnant stomach is small or the patient is obese, it is often necessary to suture laparoscopically. It is therefore important for the laparoscopic surgeon to learn the fundamentals of conventional suturing and knot-tying performed through an endoscopic method. Finally, the anastomosis is completed with an addition of seromuscular layer suturing.

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