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Fig. 33.44 Completion of
the seromuscular suture: after
completion of the serous
membrane suture. Close (a)
and schematic view (b)
Fig. 33.45 Cutting of all
layers: the incision surface is
tensed due to the SECUREA,
and it is possible to incise all
layers with the endoscope. Close
(a) and schematic view (b)
26933 Endoscopic and Minimally Invasive Surgical …
Fig. 33.46 Removal of the
specimen and SECUREA:
the resected specimen and the
SECUREA are collected using
the oral endoscopy. Close (a)
and schematic view (b)
Fig. 33.47 Endoscopic
examination (after 3 months):
during endoscopic
examination at 3 months after
the surgery, scar deformity
(a) after partial resection
of the vestibular area is
observed while food debris
and residual gastritis are not
present (b)
270 N. Inaki
References
1. Katai H, Sasako M, Fukuda H, et al., JCOG Gastric Cancer Surgical
Study Group. Safety and feasibility of laparoscopy-assisted distal
gastrectomy with suprapancreatic nodal dissection for clinical stage
I gastric cancer: a multicenter phase II trial (JCOG 0703). Gastric
Cancer. 2010;13(4):238–44.
2. Inaki N, Etoh T, Ohyama T, et al. A Multi-institutional, prospective,
phase II feasibility study of laparoscopy-assisted distal gastrectomy
with D2 lymph node dissection for locally advanced gastric cancer
(JLSSG0901). World J Surg. 2015;39(11):2734–41.
Suggested Reading
3. Matsuda T, Hiki N, Nunobe S, et al. Feasibility of laparoscopic and
endoscopic cooperative surgery for gastric submucosal tumors (with
video). Gastrointest Endosc. 2016;84:47–52.
4. Matsuda T, Nunobe S, Kosuga T, et al., Society for the Study of
Laparoscopy and Endoscopy Cooperative Surgery. Laparoscopic
and luminal endoscopic cooperative surgery can be a standard treatment for submucosal tumors of the stomach: a retrospective multicenter study. Endoscopy. 2017;49:476–83.
Laparoscopic Partial Gastrectomy for Gastric Cancer
Antonio Talvane Torres de Oliveira, Croider Franco Lacerda,
Paulo A. Bertulucci and Miguel A. Cuesta
34
34.1 Introduction
Gastrectomy, total or subtotal, with a proper lymphadenectomy after neoadjuvant therapy, if indicated, is the main
treatment for resectable gastric cancer. Many studies have
shown that Minimally Invasive Surgery (MIS) for other
gastrointestinal malignancies [1, 2], such as colorectal
and esophageal cancer, is oncologically safe and has several important short-term advantages in comparison with
the conventional open surgical techniques. These studies
showed favorable outcomes for MIS such as a less blood
loss, faster patient recovery, and fewer complications with
similar oncological outcomes. Concerning MI gastrectomy
for cancer, important advances include the use of neoadjuvant (and adjuvant) therapy [3] in advanced gastric cancer
and universal implementation of the principles of oncological resection including a proper lymphadenectomy based on
the Japanese guidelines [4]. Minimally invasive gastrectomy
may have the same advantages as its use in other digestive
cancers. Evidence for this MIS for gastric cancer is based
on European (Hulscher’s study, STOMACH, and LOGICA
trials) and South Korean (KLASS studies) and some metaanalysis [5–11]. They have shown that there are some shortterm advantages for partial gastrectomy whereas, for total
gastrectomy, they have shown similar short-term outcomes
while preserving oncological outcomes.
34.2 Clinical Staging and Surgical Plan
If gastric cancer is diagnosed by gastroscopy and biopsies,
clinical staging should be done by means of endoscopic
ultrasound, CT, and PET–CT scans (cTNM).
If the tumor seems resectable, depending on the clinical staging and location of the tumor, a surgical plan is
designed, concerning:
• Use of neoadjuvant therapy (stage II or higher)
• Type of resection: local, proximal, distal, or total gas-
trectomy. In advanced gastric cancer, the margin of
resection will be at least 5 cm.
• The type of lymphadenectomy, D1, D1 + , or D2.
We follow the Japanese Gastric Cancer treatment guidelines
2014 [4] and classified the lymph node stations in the surgical field according to it (Fig. 34.1).
34.3 Description of the Surgical Technique
(See Video 34.1)
The key steps to perform a laparoscopic partial or subtotal gastrectomy are:
1. Positioning of patient and placement of trocars.
Electronic supplementary material The online version of this
chapter (https://doi.org/10.1007/978-3-030-55176-6_34) contains
supplementary material, which is available to authorized users.
A. T. T. de Oliveira · C. F. Lacerda · P. A. Bertulucci
Department of Upper GI Surgery, Americas Medical City
Hospital, Rio de Janeiro, Brazil
e-mail: contato@drantoniotalvane.com.br
M. A. Cuesta (*)
Department of Surgery. Amsterdam UMC, Amsterdam,
The Netherlands
e-mail: ma.cuesta@amsterdamumc.nl
© Springer Nature Switzerland AG 2021
M. Asunción Acosta et al. (eds.), Atlas of Minimally Invasive Techniques in Upper Gastrointestinal Surgery,
https://doi.org/10.1007/978-3-030-55176-6_34
Patient is placed in lithotomy position. Surgeon stands
between the legs of the patient (Fig. 34.2). 5 trocars of
5/12 mm are placed in the upper abdomen. Assistance incision is placed on the left side (trocar site) or Pfannenstiel
incision (Fig. 34.3).
2. Omentectomy. Omentectomy will be started from the
middle to the left. Omental bursa is opened (Fig. 34.4a–
c). In partial gastrectomy omentectomy will end at the
level of the gastric resection.
271
272 A. T. T. de Oliveira et al.
3. Lymphadenectomy of station 6 (right gastroepiploic
vessels), followed bydivision of the right gastroepiploic
vessels with clips at the level of the head of the pancreas
(Fig. 34.5a, b).
4. The supraduodenal window is created (Fig. 34.6a,
b). Opening hepatoduodenal ligament with division
of pars flaccida along the liver edge, up to the right
crus (Fig. 34.7a–c). Division of the right gastric artery
(Fig. 34.7d). Lymphadenectomy of stations 8a and 12a,
(Fig. 34.7e–g).
5. Dissection of the superior part of the duodenum
(supraduodenal window) and division of the proximal
Fig. 34.1 Operative field with lymph node stations
duodenum by stapler (Fig. 34.8a, b).
6. Dissection and lymphadenectomy of the celiac trunk
(stations 9, 7, and 11p) (Fig. 34.9a–c). Division of the
left gastric vessels between clips (Fig. 34.9d).
After partial gastrectomy, reconstruction can be made by a
Roux Y gastrojejunostomy anastomosis or a Billroth I Delta
anastomosis. In this chapter, we present the first type of
anastomosis. Dr. Kinoshita’s Delta anastomosis will be presented in the next chapter (see Chap. 35).
Fig. 34.2 Position of patient and surgeons during laparoscopic
gastrectomy
Fig. 34.3 Placement of
trocars (a) and help incision
(b)
34.4 Description of the Surgical Technique of
Roux Y gastrojejunostomy anastomosis
The key steps to perform a reconstruction after partial
gastrectomy [] by a Roux Y gastrojejunostomy anastomosis
are:
7. Before division of the stomach, resection of stations
1 and 3 along the small curvature is done (between the
esophagogastric junction and the level of resection on
the small curvature. These tissues should be included
with the specimen (Fig. 34.10a, b).
Fig. 34.4 Start with omentectomy until the place of the gastrectomy. Close (a, b) and schematic view (c)
27334 Laparoscopic Partial Gastrectomy for Gastric Cancer
Fig. 34.5 Dissection and division of the gastroepiploic vessels and lymphadenectomy (station 6). Close (a, b) and schematic view (c)
Fig. 34.6 Dissect the
supraduodenal window. Close
(a) and schematic view (b)
8. Division of proximal stomach is performed at the chosen level by means of linear stapler including the lymph
node stations 1 and 3 (Fig. 34.11a–c).
9. A hole is made in the transverse mesocolon and the jejunal loop able for the anastomosis is prepared and divided
by staplers (Fig. 34.12).
10. The distal jejunal loop is ascended through the opening of the mesocolon, to the stump of the stomach in the
supramesocolic space (Fig. 34.13a–c).
11. A side-to-side gastrojejunal anastomosis is performed
with the linear stapler. The anastomosis is located in
the posterior wall of the gastric remnant a couple of cm
from the stapled line (Fig. 34.14a, b). The gastrojejunal
defect (used to introduce the stapler) is closed by running suture (Fig. 34.14c, d).
12. A side-to-side jejunojejunostomy is performed by
means of linear stapler (Fig. 34.15a, b), follow by clo-
sure of mesenteric defects. Final view of the anastomosis
(Fig. 34.16).
13. Specimen is retrieved through a well-protected incision
®
using the Alexis device
.
14. Trocars are retrieved, closing the defects in the abdominal wall.
274 A. T. T. de Oliveira et al.
Fig. 34.7 Open the hepatoduodenal and hepatogastric ligament: close (a, b, c) and schematic view (d). Ligation of right gastric artery: close (e)
and schematic view (f). Lymphadenectomy of the hepatoduodenal (stations 8a and 12a) along the portal vein (g, h, i)
Fig. 34.8 Duodenum
division by staplers. Close (a,
b) and schematic view (c, d)
27534 Laparoscopic Partial Gastrectomy for Gastric Cancer
Fig. 34.9 Lymphadenectomy of stations 9, 7, and 11p. Close (a, b, c) and schematic view (d). Ligation of the left gastric artery by clips (e).
General view of the lymphadenectomy (8a, 12a, 7, 9, and 11p) (f)
Fig. 34.10 Lymphadenectomy stations 1 and 3. Close (a, b) and schematic view (c)
276 A. T. T. de Oliveira et al.
Fig. 34.11 Division of the
proximal stomach by linear
stapler: close (a, b) and
schematic view (c). View of
the proximal gastric stump (d)
Fig. 34.12 Opening the
transverse mesocolon. Close
(a) and schematic view (b)
Fig. 34.13 Division of the jejunal loop (a) and ascending the loop through the mesocolon (b). Gastric stump and jejunal loop alongside (c)
Fig. 34.14 Gastrojejunal
side-to-side anastomosis:
close (a) and schematic view
(b). Closure of the defect:
close (c) and schematic view (d)
27734 Laparoscopic Partial Gastrectomy for Gastric Cancer
Fig. 34.15 Side-to-side
gastrojejunal anastomosis. Close
(a) and schematic view (b)
278 A. T. T. de Oliveira et al.
4. Japanese Gastric Cancer Association. Japanese gastric can-
cer treatment guidelines 2014 (ver. 4). Gastric Cancer
2017;20(1):1–19.
5. Beyer K, Baukloh AK, Kamphues C, et al. Laparoscopic versus
open gastrectomy for locally advanced gastric cancer: a systematic
review and meta-analysis of randomized controlled studies. World
J Surg Oncol. 2019;17(1):68.
6. van der Wielen N, Straatman J, Cuesta MA, et al. Short-term
outcomes in minimally invasive versus open gastrectomy: the
differences between East and West. A systematic review of the literature. Gastric Cancer 2018;21(1):19–30.
7. Haverkamp L, Weijs TJ, van der Sluis PC, et al. Laparoscopic total
gastrectomy versus open total gastrectomy for cancer: a systematic
review and meta-analysis. Surg Endosc. 2013;27:1509–20.
8. Kim W, Kim HH, Han SU, et al. Decreased morbidity of lapa-
roscopic distal gastrectomy compared with open distal gastrectomy for stage I gastric cancer: short-term outcomes from a
multicenter randomized controlled trial (KLASS-01). Ann Surg.
2016;263(1):28–35.
9. Lee HJ, Hyung WJ, Yang HK, et al. Short-term outcomes of a
multicenter randomized controlled trial comparing laparoscopic
distal gastrectomy with D2 lymphadenectomy to open distal gas-
Fig. 34.16 Final view of the reconstruction
References
1. Bonjer HJ, Deijen CL, Haglind E, et al. A randomized trial of
laparoscopic versus open surgery for rectal cancer. N Engl J Med.
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2. Straatman J, van der Wielen N, Cuesta MA, et al. Minimally invasive versus open esophageal resection: three-year follow-up of the
previously reported randomized controlled trial: the TIME trial.
Ann Surg. 2017;266(2):232–6.
3. Al Batran SE, Homann N, Pauligk C et al. Perioperative chemotherapy with fluouracil plus leucovorin, oxaliplatin, and docetaxel
versus fluouracil or capecitabine plus cisplatin and epirubicin for
locally advanced, resectable gastric cancer or gastro-oesophageal
junction adenocarcinoma (FLOT 4): a randomized, phase 2/3
trial. Lancet 2019; 393: 1948–1957.
trectomy for locally advanced gastric cancer (KLASS-02-RCT).
Ann Surg. 2019;270(6):983–91.
10. Straatman J, van der Wielen N, Cuesta MA, et al. Surgical techniques, open versus minimally invasive total gastrectomy after
chemotherapy (STOMACH trial): study protocol for a randomized
controlled trial. Trials. 2015;16:123.
11. Haverkamp L, Brenkman HJF, Seesing MFJ, et al. Laparoscopic
versus open gastrectomy for gastric cancer, a multicenter prospectively randomized controlled trial (LOGICA-trial). BMC Cancer.
2015;15:556.