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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_536_Библиотеки_им_академика_М_И_Перельмана.pdf
Modified Billroth-I DeltaShaped Anastomosis After Distal
Gastrectomy
Takahiro Kinoshita
35
35.1 Introduction
Laparoscopic distal gastrectomy is increasingly implemented worldwide according to the positive outcomes
of some randomized studies. In terms of reconstruction,
several methods have been attempted such as Billroth-I,
Billroth-II, or Roux-en-Y. Each method has pros and cons,
and probably decisions are made according to the individual patient’s conditions, surgeon’s preference, or regional
trends. Advantages of Billroth-I are simplicity, save of
time, and physiological passage of foods. In our center, we
choose Billroth-I when meeting the following criteria; (i)
large enough size of a remnant stomach, (ii) no duodenal
invasion, and (iii) no reflux esophagitis or hiatus hernia.
Therefore, in general, localized tumors at the antrum or
lower stomach body seem to be suitable candidates. As an
intracorporeal Billroth-I reconstruction, delta-shaped anastomosis only using a linear stapler is broadly accepted [1],
which was originated from the concept of functional endto-end anastomosis.
35.2 Description of the Surgical Technique (See Video 35.1)
The key steps to perform a Billroth I Delta-shaped anastomosis are:
Electronic supplementary material The online version of this
chapter (https://doi.org/10.1007/978-3-030-55176-6_35) contains
supplementary material, which is available to authorized users.
T. Kinoshita (*)
Gastric Surgery Division, National Cancer Center Hospital East,
6-5-1 Kashiwanoha, Kashiwa 277-8577, Japan
e-mail: takkinos@east.ncc.go.jp
1. Port placement and patient’s position
The patient is positioned in supine and legs apart with
head-up tilt. Five ports are used and the operator stands at
the right side of the patient (Fig. 35.1). The first assistant
stands at the left side of the patient and the camera assistant between the legs (Fig. 35.2). Lateral segment of the
liver should be retracted in either method to attain sufficient
operative space (Fig. 35.3).
Technical steps
2. Transection of the duodenum
After infrapyloric lymphadenectomy, dissection of the station No. 6 according to the Japanese Classification [2], the
duodenal bulb is skeletonized for consequent transection.
Therefore, the duodenum should be normally divided just
beneath the pyloric ring in anterior–posterior direction as
much as possible using a 60-mm linear stapler advanced
from a left lower port.
3. Resection of the stomach
After suprapancreatic and lesser curvature site lymphadenectomy (No. 1 and No. 3), the stomach is resected. If the
tumor is invisible from the serosal surface, intraoperative
peroral endoscopy is employed to confirm the tumor location. Recently, indocyanine green (ICG) injection is also
conducted for this purpose. Resection line should be dyed
on the stomach wall (Fig. 35.4), and usually requiring twice
firing of a 60-mm stapler (Fig. 35.5). The resected specimen
is placed in an extraction bag.
4. Testing the tension
After resection of the stomach, simulation should be done
to test whether the tension is adequate between the remnant
stomach and the duodenum. Both the remnant stomach and
the duodenum stump are moved medially to be overlapped
(Fig. 35.6). If the tension seems too tight, relevant adhesion
© 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_35
279
280 T. Kinoshita
Fig. 35.1 Placement
of ports. Close (a) and
schematic view (b)
Fig. 35.2 Position of patient
and surgical team (a, b)
Fig. 35.3 Liver retraction
should be lysed or switch to another method should be
considered.
5. Creating entry holes for stapler insertion
First, the edge at the greater curvature site of the stomach
stump is hold by forceps to be cut in 1 cm in length, being
adjusted for stapler’s caliber (Fig. 35.7). A suction device is
put into the remnant stomach through this hole to withdraw
contents. Then, the edge of the posterior side of the duodenal stump is held to be cut in a similar way (Fig. 35.8).
6. Gastroduodenostomy using a linear stapler
A 45-mm stapler is introduced from the left lower port and
a cartridge site is inserted into the stomach (Fig. 35.9). The
stapler is temporarily clamped at the posterior wall site and
moved toward the duodenal stump. The duodenal stump is
Fig. 35.4 Gastric resection
line dyed. Close (a) and
schematic view (b)
28135 Modified Billroth-I Delta-Shaped Anastomosis …
Fig. 35.5 Stomach is divided by linear stapler. Close (a, b) and schematic view (c)
grasped by forceps to be lifted up and moved a little medially. Temporary clamp is released and an anvil fork of the
stapler is gently inserted into the duodenum (Fig. 35.10).
The remnant stomach is a slightly twisted to keep a certain
distance between the stomach stump and the anastomotic
line aiming no ischemic area. Regarding the duodenum,
such a twisting is not required because the stump will be
resected together when closing the common entry hole by
stapler. After verifying that both intestinal walls are fastened in 40–45 mm in length with no gap, the stapler can be
fired (Fig. 35.11). After removal of the stapler, hemostasis
on the staple line should be proved using the suction device.
7. Closure of the common entry hole
Using a 3-0 suture material, three or four stay sutures are
placed in advance. These sutures should be stitched at the
Fig. 35.6 After resection of the stomach, simulation should be done
to test whether the tension is adequate between the remnant stomach
and the duodenum
stomach and duodenal walls to expand a V-shape of the
anastomotic stapling line (Fig. 35.12). Closure of the entry
hole is made by twice firing of linear staplers. As a first
282 T. Kinoshita
Fig. 35.7 Opening in the
gastric stump. Close (a) and
schematic view (b)
Fig. 35.8 Opening in the
duodenal stump. Close (a)
and schematic view (b)
Fig. 35.9 A 45-mm stapler
is introduced from the left
lower port and a cartridge site
is inserted into the stomach.
Close (a) and schematic view (b)
Fig. 35.10 The other
cartridge site is introduced
into the duodenum. Close (a)
and schematic view (b)
Fig. 35.11 The stapler can be fired
28335 Modified Billroth-I Delta-Shaped Anastomosis …
stapling, the 45-mm stapler is used. Only 30-mm length is
utilized very close to the edge of the hole to avoid anastomotic stricture. Stretching the entry hole in straight line
by retracting the stay sutures is mandatory. As a second
stapling, the 60-mm stapler is used. In this stapling, the
duodenal stump is resected at the same time so that the
operator should control the position of it. The stapler must
be clamped and released several times to find the best stapling position (Fig. 35.13).
8. After finishing the anastomosis, a nasogastric tube
is introduced into the stomach and air-tight test is
employed to confirm the integrity (Fig. 35.14).
Fig. 35.12 Using a 3-0 suture material, three or four stay sutures are placed in advance. These sutures should be stitched at the stomach and
duodenal walls to expand a V-shape of the anastomotic stapling line. Close (a, b) and schematic view (c)
Fig. 35.13 Closure of the
entry hole is made by twice
firing of linear staplers. As
the first stapling, the 45-mm
stapler is used. Only 30-mm
length is utilized very close to
the edge of the hole to avoid
anastomotic stricture. Close
(a) and schematic view (b)
284 T. Kinoshita
References
1. Kanaya S, Gomi T, Momoi H, et al. Delta-shaped anastomo-
sis in totally laparoscopic Billroth I gastrectomy: new technique of intraabdominal gastroduodenostomy. J Am Coll Surg.
2002;195:284–7.
2. Japanese Gastric Cancer Association. Japanese classifica-
tion of gastric carcinoma: 3rd English edition. Gastric Cancer.
2011;14(2):101–12.
Fig. 35.14 Final aspect of the anastomosis
Robotic Distal Gastrectomy for Gastric Cancer
Young-Woo Kim and Won Ho Han
36
36.1 Introduction
Gastrectomy with extended lymph node dissection is the
only standard curative treatment for locally advanced gastric cancer. The development of laparoscopic surgery has
changed much in gastric cancer surgery over recent decades, and robotic technology tried to overcome the limitations of laparoscopic surgery [1, 2]. However, basic
principle of robotic gastrectomy is same as open gastrectomy. Then, what is standard gastrectomy? The answer for
this question is not simple because the standard D2 gastrectomy has evolved over 60 years. Currently, it is believed
important to keep “surgical plane based on embryological
origin” to perform an en bloc dissection of mesogastrium.
The difficulty comes from the fact that pancreas is in the
middle of the mesogastrium and should be saved with
major vessels like common hepatic artery, splenic artery,
and splenic vein. Suprapancreatic nodal dissection must be
the most challenging part of the surgery with laparoscopic
approach due to the technological limitation. Robotic surgery could have a role in this technological challenge of
laparoscopic gastric surgery [3].
Robotic gastrectomy has several advantages over laparoscopic gastrectomy including flexibility of instruments,
a three-dimensional view, correction of hand tremors, and
improved ergonomics. These advantages are favorable for
lymph node dissection while avoiding vessel injury and minimizing damage to adjacent organs [4–6] However, robotic
Electronic supplementary material The online version of this
chapter (https://doi.org/10.1007/978-3-030-55176-6_36) contains
supplementary material, which is available to authorized users.
Y.-W. Kim (*) · W. H. Han
Department of Cancer Control and Population Health, National
Cancer Center Graduate School of Cancer Science and Policy &
Center for Gastric Cancer, National Cancer Center, 323 Ilsan-ro,
Ilsandonggu, Goyang 10408, Republic of Korea
e-mail: youngwookim082@gmail.com
gastrectomy has limitations in lack of tactile sense, longer
duration of operating time due to the additional time for the
robotic arms comparing with laparoscopic gastrectomy.
36.2 Indication
Robotic subtotal gastrectomy is indicated in the presence
of malignancy. Although it has been widely accepted as an
appropriate treatment in early gastric cancer, performing the
operation in advanced gastric cancer is still controversial
similar to laparoscopic subtotal gastrectomy.
36.3 Description of the Surgical Steps (See Video 36.1)
The key steps to perform a robotic distal gastrectomy are:
1. General preparation of the patient, surgical team,
and placement of trocars
After induction of general anesthesia, the patient is placed
in supine position. The skin of the lower chest and upper
abdomen is prepared in a routine manner.
A 12-mm port is placed by open technique above the
umbilicus, and a pneumoperitoneum to 12 mmHg is established. Under direct vision, three 8-mm robotic trocars are
placed, two ports in the upper abdomen at the midclavicular
line on the left (robotic arm No. 1) and on the right (robotic
arm no. 2) and one port at the right anterior axillary line
(robotic arm No. 3). In addition, a 12-mm port for the assistant is placed between the left robotic port and the camera
port. Each trocar requires a distance of at least 7–8 cm for
the motion (Fig. 36.1).
2. Liver retraction
Straight needle 2-0 monofilament thread is inserted through
the left side of subcostal margin. Then the needle punctured
© 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_36
285
286 Y.-W. Kim and W. H. Han
mesocolon should be dissected to avoid damage to the
transverse mesocolon (Fig. 36.3).
4. Left gastroepiploic vessel ligation and No. 4sb
Lymph node dissection
The partial omentectomy is performed in the direction of
the spleen lower pole, the spleen lower pole and distal pancreas are identified. When the dissected omentum is lifted
up, the contour of the left gastroepiploic vessel branching
from the splenic artery and vein appears. After branching the left gastroepiploic vessel from the splenic vessels,
there are vessels to the greater omentum. Vessel ligature
should be made at its proximal part, so that it is preserved
(Fig. 36.4).
When operator lifts the greater omentum including No.
4sb and No. 4d lymph node, the boundary between greater
curvature of stomach and omentum appears, which is easier to separate by ultrasonic device. Unlike conventional
laparoscopic gastrectomy, articulated movement can easily
dissect it without adjusting the angle of the surgical plane
Fig. 36.1 Position of the trocars
(Fig. 36.5).
out at the inferior of the right subcostal margin. After cutting the needle, phrenoesophageal ligament is clipped with
thread together (Fig. 36.2). Then the thread is pulled and
tied.
3. Left partial omentectomy
Left partial omentectomy is performed at a distance of
3–4 cm from the gastroepiploic vessel arcade. Operator
holds the stomach anterior wall and lifts it up, it is easy
to observe the vessel going to the greater omentum. The
physiologic plane between greater omentum and transverse
Fig. 36.2 Phrenoesophageal
ligament is clipped with
thread together
5. Right partial omentectomy and Right gastroepiploic
vessel ligation and No. 6 and No. 14v Lymph node
dissection
Partial omentectomy is performed toward right side on
starting site of the left partial omentectomy. After dissection along the physiology plane between greater omentum
and transvers mesocolon, the head of pancreas is identified.
By lifting the right gastroepiploic vessel, operator can occasionally vertically erect or tilt it to identify and expose the
surrounding major structures. First, physiologic adhesion
of posterior wall of stomach and pancreas body should be
divided to identify gastroduodenal artery (Fig. 36.6). Then,
Fig. 36.3 The physiological
plane between greater
omentum and transverse
mesocolon should be
dissected to avoid damage to
the transverse mesocolon
Fig. 36.4 After branching
the left gastroepiploic vessel
from the splenic vessels,
there are vessels to the
greater omentum. Vessel
ligature should be made at
its proximal part, so that it is
preserved
28736 Robotic Distal Gastrectomy for Gastric Cancer
Fig. 36.5 Unlike
conventional laparoscopic
gastrectomy, articulated
movement can easily dissect
it without adjusting the angle
of the surgical plane
288 Y.-W. Kim and W. H. Han
Fig. 36.6 First, physiologic
adhesion of posterior wall of
stomach and pancreas body
should be divided to identify
gastroduodenal artery
Fig. 36.7 To identify the
duodenum and pancreas
head, the transverse
mesocolon can be easily
separated by following the
physiologic plane
to identify the duodenum and pancreas head, the transvers
mesocolon can be easily separated by following the physiologic plane (Fig. 36.7).
The border of the No. 6 lymph node is separated from
the upper margin of the anterior superior pancreaticoduodenal vein (ASPDV) (Fig. 36.8). After identifying and ligat-
ing the right gastroepiploic vein branching from proximal
of ASPDV and right accessory colic vein, ligate the right
gastroepiploic artery from the posterior right gastroepiploic
vein (Figs. 36.9 and 36.10). Infrapyloric vessels should be
ligated because hemostasis is not easy by ultrasonic device
(Fig. 36.11).
6. Rt. Gastric vessels ligation, No. 5 Lymph node dis-
section, and duodenal resection
After No. 6 lymph node dissection, Put the gauze between
the duodenum and the pancreas and Let the assistant pull
the duodenum downward. Then supraduodenal vessels are
exposed (Fig. 36.12).
Common hepatic artery, proper hepatic artery, and right
gastric artery should be identified and then ligated the origin of right gastric artery with No. 5 lymph node dissection
simultaneously (Fig. 36.13). Duodenal resection is per-
formed by stapler through assistant port (Fig. 36.14).