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(3) Trimming: The greater omentum was trimmed up to
the point where the gastric corpus would be resected
(Fig. 33.6).
(4) Separation of the right side of the greater omentum:
The surgeon changed position to stand on the left side
of the patient. The assistant makes “matador-like”
traction and the surgeon used his left hand to create a
separated surface of the greater omentum and then proceeded to separate it progressively (Fig. 33.7).
(5) Pancreatic head lymph node dissection (No. 6 dissec-
tion): After the colon was moved aside, the anterosuperior pancreatoduodenal veins were exposed. (Foot-side
boundary of the No. 6 lymph node) (Fig. 33.8).
The assistant used his left hand to lift the veins and
arteries of the greater omentum on the right side of the
stomach, and his right hand to grasp and lift the posterior wall of the gastric antrum and he expanded the
backside of the pyloric ring (Fig. 33.9).
The layer outside the nerve (Outer-most layer)
of around the right gastroepiploic artery was secured,
while expanding the detachable layer between the veins
of the right gastroepiploic artery (Fig. 33.10).
The right gastroepiploic artery was clipped and
separated. Later, the adipose tissue, including the No. 6
lymph node that was at the time easily detachable, was
dissected while retaining the detachable layer of the
front surface of the pancreatic head, which had been
ensured (Fig. 33.11).
(6) Separation of the duodenum: Gauze was inserted into
the backside of the lesser curvature side of the duodenum; the gauze protruding from the abdomen side
was released as a guide, and the veins and arteries of
the upper duodenum were separated up to the point
where the gastroduodenal artery could be confirmed
(Fig. 33.12). The duodenum was transected with a linear stapler (Fig. 33.13).
(7) Release of the lesser omentum: The surgeon returned
to stand on the right side of the patient. The lesser
omentum was released near the root of the right gastric artery and separated up to the lesser curvature of
the stomach (Fig. 33.14). The serous membrane on
the anterior surface of the crura of the diaphragm was
incised with an electric scalpel (Fig. 33.15), and the
surface with which the myofascial layer would not be
damaged was determined and this layer was expanded.
Gauze for laparoscopic use was used to fill this fusion
fascia layer to create a dorsal and temporal side receptacle for the dissected superior margin of the pancreas
(Fig. 33.16).
25933 Endoscopic and Minimally Invasive Surgical …
Fig. 33.6 Trimming: the greater omentum was trimmed up
Fig. 33.7 Separation of the right side of the greater omentum. The
assistant makes “matador-like” traction
Fig. 33.8 Station 6 lymph node dissection. The anterosuperior pan-
creatoduodenal veins were exposed
260 N. Inaki
Fig. 33.9 Dissection at backside of the stomach. The assistant used
his left hand to lift the veins and arteries of the greater omentum on
the right side of the stomach
Fig. 33.12 The lesser curvature side of the duodenum. The gauze
protruding from the abdomen side was released as a guide, and the
veins and arteries of the upper duodenum were separated up to the
point where the gastroduodenal artery could be confirmed
Fig. 33.10 Outermost layer around the right gastroepiploic artery.
The layer outside the nerve (outermost layer) of around the right gastroepiploic artery was secured
Fig. 33.11 Separation of the right gastroepiploic artery. The right
gastroepiploic artery was clipped and separated
Fig. 33.13 Transection of the duodenum. The duodenum was tran-
sected with a linear stapler
Fig. 33.14 Release of the lesser omentum. The lesser omentum was
released near the root of the right gastric artery
26133 Endoscopic and Minimally Invasive Surgical …
Fig. 33.15 Incision of the serous membrane on the anterior surface
of the crura. The serous membrane on the anterior surface of the crura
of the diaphragm was incised with an electric scalpel
Fig. 33.16 Detection of the fusion fascia. Gauze for laparoscopic use
was inserted to the layer at the fusion fascia
(8) Handling of the right gastric artery: The assistant used
his right hand to grasp and lift the pedicle of the right
gastric artery and his left hand to grasp the surgical
sponge, Securea™ (Hogy Medical, Tokyo, Japan), and
he compressed the lower rim of the pancreas to turn the
pancreas over (Fig. 33.17). The root of the right gastric
artery was peeled back while enlarging the surface; the
root part was clip-separated (Fig. 33.18).
(9) Dissection of the suprapancreatic lymph node: The
assistant used his right hand to firmly grasp (activate
the ratchet) and lift the gastropancreatic fold (pedicle
of the left gastric artery), and with his left hand, turned
the pancreas over by compressing the lower margin of
the pancreas with a surgical sponge, Securea™ ((Hogy
Medical, Tokyo, Japan) (Fig. 33.19). Detachment was
performed in one continuous motion from the anterior
surface of the common hepatic artery to the anterior
Fig. 33.17 Handling of the right gastric artery. The assistant grasped
and lifted the pedicle of the right gastric artery and compressed the
lower rim of the pancreas to turn the pancreas over
Fig. 33.18 Separation of right gastric artery. The root of right gastric
artery was clip separated
Fig. 33.19 Suprapancreatic lymph node dissection. The assistant
lifted the gastropancreatic fold (pedicle of the left gastric artery) and
turned the pancreas over by compressing the lower margin of the pancreas with a surgical sponge
262 N. Inaki
surface of the splenic artery. The so-called “ω-line”
was ensured. The detachable layer outside the nerve
on the left side of the left gastric artery was separated
(Fig. 33.20). Both lateral sides of the left gastric artery
were detached as much as possible to the backside.
To prevent damage to the pancreatic parenchyma and
pancreatic artery, the positions where they were ascertained (Fig. 33.21). The periphery of the left gastric
artery was clipped and separated (Fig. 33.22).
The base on the right side of the lymph nodes on
the superior margin of the pancreas (near the boundary between No. 8a, 9, and 8p) was adequately sealed
using the laparoscopic coagulating shears and separated (Fig. 33.23). The posterior wall of the lesser cur-
Fig. 33.20 Outermost layer of the left gastric artery. The outermost
layer of the left gastric artery was separated
vature of the stomach was separated. At this point, if
the vagus nerve was intact, it would have been cut out
(Fig. 33.24).
Fig. 33.21 The left side of the lymph nodes around celiac artery. The
left side of the lymph nodes on the superior margin of the pancreas
was cut out
Fig. 33.22 Separation of the left gastric artery. The periphery of the
left gastric artery was clipped and separated
Fig. 33.23 The right side of the lymph nodes around celiac artery.
The right side of the lymph nodes around celiac artery was adequately
sealed and separated
Fig. 33.24 Dissection at the posterior wall of the lesser curvature.
The posterior wall of the lesser curvature of the stomach was separated
(10) Trimming of the lesser curvature of the stomach (No.
1 and No. 3 lymph node dissection): The assistant
lifted the lesser omentum with two hands in the manner of a matador and separated the lesser omentum
from the gastric corpus from the backside of the lesser
curvature of the stomach (Fig. 33.25). Next, the stom-
ach was returned to its normal position, and the lesser
omentum was separated from the gastric corpus on the
abdominal side (Fig. 33.26).
(11) Separation of the gastric corpus: The gastric corpus is
separated into two rounds (Fig. 33.27).
(12) Extraction of the extracted stomach and reinsufflation:
The extracted stomach was stored in a plastic bag (to
prevent tumor dispersion and wound contamination)
and extracted from the navel opening. The wound was
extracted only large enough to perform the extraction.
After extraction, a wound protector was inserted, a
silicone cap was used as a cover, the camera port previously mentioned was inserted, and the stomach was
26333 Endoscopic and Minimally Invasive Surgical …
Fig. 33.27 Separation of the gastric corpus. The gastric corpus is
separated by linear stapler in two rounds
reinsufflated (Fig. 33.28). When all procedure of lymphadenectomy is finished, dissection area was checked
(Fig. 33.29).
Fig. 33.25 Trimming of the lesser curvature. The lesser omentum
was separated from the gastric corpus from the backside of the lesser
curvature of the stomach
Fig. 33.26 Trimming of the lesser curvature (anterior). The lesser
omentum was separated from the gastric corpus on the abdominal side
4. Roux-en-Y reconstruction
A small hole was made in the jejunal mesentery, at a part
that was approximately 25 cm from the ligament of Treitz,
and the jejunum was separated with the linear stapler. The
mesentery was only slightly separated (separation of the
arteries and veins at the margin) (Fig. 33.30).
A small hole was made at the site approximately 25 cm
from the tip of the lifted jejunum and at the tip of the afferent loop jejunum (Fig. 33.31), and the linear stapler was
used to perform side-to-side anastomosis (Fig. 33.32). The
insertion holes of the stapler were suture closed in a continuous single layer using 3–0 absorbent thread. The needle
was handled from the far end of the visual field toward the
near end of the visual field. As a trick for handling the needle, try to firmly stitch at the seromuscular layer and only
slightly at the membrane surface (Fig. 33.33).
A small hole was made at the jejunum of Roux limb
(Fig. 33.34).
Anastomosis of the residual stomach and jejunum: The
residual stomach and jejunum were anastomosed in an isoperistaltic manner. A small hole was made in the anal side
approximately 60 mm from the tip of the lifted jejunum and
in the tip of the lesser curvature side of the staple line of the
residual stomach and anastomosis was performed using the
linear stapler (Fig. 33.35). The insertion holes of the stapler
were suture closed using almost the same procedure as for
the Y limb (Fig. 33.36).
Closure of Petersen’s space: A 3-0 nonabsorbent thread
was used to continuously suture close Petersen’s space.
When doing this, the needle was handled from the front of
the visual field to the back (from the leg side to the head
264 N. Inaki
Fig. 33.28 Retrieval of the
specimen and reinsufflation.
The resected specimen was
stored in a plastic bag and
extracted from umbilicus (a).
Wound protector and silicone
cap were attached and the
stomach was reinsufflated (b)
Fig. 33.29 Completion
of lymph node dissection:
suprapancreatic region (a)
and pancreatic head (b)
Fig. 33.30 Transection of jejunum. A small hole was made in the
jejunal mesentery, at a part that was approximately 25 cm from the
ligament of Treitz
Fig. 33.31 Preparation of Y limb. A small hole was made at the site
approximately 25 cm from the tip of the lifted jejunum and at the tip
of the afferent loop jejunum
26533 Endoscopic and Minimally Invasive Surgical …
Fig. 33.32 Side-to-side anastomosis. The linear stapler was used to
perform side-to-side anastomosis
Fig. 33.33 Closure of entry hole of stapler. The insertion holes of
the stapler were suture closed in a continuous single layer using 3-0
absorbent thread
Fig. 33.35 Gastrojejunostomy. Gastrojejunostomy was performed
using the linear stapler
Fig. 33.36 Closure of entry hole of stapler. The insertion holes of the
stapler were suture closed
Fig. 33.34 Preparation of Roux limb. A small hole was made on the
anal side approximately 60 mm from the tip of the lifted jejunum
Fig. 33.37 Completion of reconstruction. The rout of reconstruction
was inspected
266 N. Inaki
side), and the space was suture closed up to near the colon.
In patients in whom the greater omentum was conserved,
the greater omentum would be gathered into the hands to
perform stitching and the bottom rim would then be cut.
Closure of the Y limb mesentery: The gap of the mesentery of the Y limb was continuously suture closed using
nonabsorbent thread. During this, the needle was handled
so that the staple line of the resection stump of the jejunum was immersed under the mesentery as much as possible. This can be expected to prevent adhesion to the surface
where the staples were exposed.
After the completion of reconstruction, the rout of reconstruction was inspected (Fig. 33.37).
Depending on the circumstances, a 19 Fr closure-type
drain should be placed from the right-upper 5-mm port to
the lower surface of the liver, but at our facility, drain placement is not performed for D1 + dissection gastrectomies.
33.1.3 Postoperative Management
The patient may begin drinking water 2 days after the operation. From day 3, soup is allowed; whole porridge and soft
foods can be added, each at 2-day intervals. The patient can
be discharged 8 days after the operation.
33.1.4 Tips, Tricks, and Pitfalls
When performing a dissection, close attention should
be paid to keeping the visual field expansion and operative field dry. In addition to standardizing expansion, the
electronic devices normally used to perform surgery are
laparoscopic coagulating shears, Bipolar Maryland dissectors, and suction and water delivery devices with a button
electrode.
With regard to reconstruction, the Y limb can usually
be created from the small laparotomy surface in the navel.
Depending on the capabilities of the surgeon, the abilities
of the team, and the level of familiarity, when it is possible
to do from the small laparotomy, it is recommended to be
performed under direct visual guidance.
33.2 Laparoscopy and Endoscopy
Cooperative Surgery for Early Gastric
Cancer with Sentinel Lymph Node
Biopsy
Laparoscopic gastric resection for gastric submucosal tumors (SMTs) is a minimally invasive procedure
developed to resect these early gastric cancers. But its
Fig. 33.38 Setup and
port placement. In addition
to the preparation for
the laparoscopic distal
gastrectomy, endoscope scope
set is prepared and placed.
Port setup corresponds
to the laparoscopic distal
gastrectomy
26733 Endoscopic and Minimally Invasive Surgical …
problem is to determine the exact extent of the tumor
borders, and this is essential to perform an adequate radical resection. In order to accomplish this, a combination
of laparoscopic and luminal endoscopic intervention, the
so-called laparoscopic and endoscopic cooperative surgery (LECS) technique has been developed to perform
a proper resection. The procedure entails a laparoscopic
gastric resection assisted by an endoscopic submucosal
dissection.
Intervention can be used for SMTs in all gastric locations including the esophagogastric junction. In the case
of technical problems, intervention should be converted to
open surgery.
The procedure is safe and feasible for resection of gastric SMTs tumors.
Fig. 33.39 Dot marking
and a local injection of
the indocyanine green:
dot marking is performed
around the tumor and a local
injection of the indocyanine
green in subserosal area is
performed. Close (a) and
schematic view (b)
33.2.1 Description of the Operative Technique (See Video 33.1)
The key steps to perform a LECS procedure are:
1. Setup and port placement: In addition to the prepara-
tion for the laparoscopic distal gastrectomy, endoscope
scope set is prepared and placed. Port setup corresponds to the laparoscopic distal gastrectomy (five trocars placed in the upper abdomen). Surgeon operates
between the legs of the patient (Fig. 33.38).
2. Dot marking and a local injection of the indocyanine
green: Dot marking is performed around the tumor and
a local injection of the indocyanine green in subserosal
area is performed (Fig. 33.39).
3. Lymph flow by the indocyanine green: Lymph flow is
observed by the indocyanine green, and the lymphatic
basin, including the sentinel node, is dissected (Fig. 33.40).
Fig. 33.40 Normal vision.
a Lymph flow by the
indocyanine green b Lymph
flow is observed by the
indocyanine green, and the
lymphatic basin, including
the sentinel node, is dissected
268 N. Inaki
Fig. 33.41 Circumferential
dissection of mucosal and
submucosal layer: mucous
membrane and submucosal layer
are circumferentially dissected
during endoscopy. Close (a) and
schematic view (b)
Fig. 33.42 Marking at
serosal surface: marking with
pyocyanine is performed
from the serosal surface
during laparoscopy. Close (a)
and schematic view (b)
Fig. 33.43 Suture of serosal
layer using SECREA: serosal
surfaces are sutured so that
the SECUREA is buried
in the serosal surface of
the tumor. Close (a) and
schematic view (b)
4. Circumferential dissection of mucosal and submucosal
layer: Mucous membrane and submucosal layer are circumferentially dissected during endoscopy (Fig. 33.41).
5. Marking at serosal surface: Marking with pyocyanine
is performed from the serosal surface during laparoscopy (Fig. 33.42).
6. Suture of serosal layer using SECUREA: Serosal surfaces are sutured so that the SECUREA is buried in the
serosal surface of the tumor (Fig. 33.43).
7. Completion of the seromuscular suture: After completion of the serous membrane suture (Fig. 33.44).
8. Cutting of all layers: The incision surface is tensed due
to the SECUREA, and it is possible to incise all layers
with the endoscope (Fig. 33.45).
9. Removal of the specimen and SECUREA: The resected
specimen and the SECUREA are collected using the
oral endoscopy (Fig. 33.46).
10. Endoscopic examination (after 3 months): During
endoscopic examination at 3 months after the surgery,
scar deformity after partial resection of the vestibular
area is observed while food debris and residual gastritis
are not present (Fig. 33.47).