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342
Fig. 41.28 Esophagojejunostomy (end-to-side) anastomosis
The exact location for esophagojejunostomy is now
marked on the jejunum; the circular stapler is introduced
with the help of lubricant. After insertion and correct
F. Berlth and H.-K. Yang
location, the jejunum is tighted to the stapler with the help
of a rubber band. This provides prevention of slipping
jejunum off the stapler and also from accidental closure of
the loop when firing the stapler (Fig. 41.27a–c). The stapler
goes into the umbilical incision; camera now comes in from
the right 12 mm trocar. The stapler is connected to the anvil,
and the esophagojejunostomy is performed. The jejunum’s
opening is closed with linear stapler (Fig. 41.28).
References
1. Park JM, Kim HI, Han SU, et al. Who may benefit from robotic
gastrectomy?: A subgroup analysis of multicenter prospective comparative study data on robotic versus laparoscopic gastrectomy. Eur
J Surg Oncol. 2016. https://doi.org/10.1016/j.ejso.2016.07.012.
2. Han D-S, Suh Y-S, Ahn HS, et al. Comparison of surgical outcomes
of robot-assisted and laparoscopy-assisted pylorus-preserving gastrectomy for gastric cancer: a propensity score matching analysis.
Ann Surg Oncol. 2015. https://doi.org/10.1245/s10434-014-4204-6.
Laparoscopic
Immunofluorescence-Guided
Lymphadenectomy in Gastric
Cancer Surgery
Woo Jin Hyung and In Gyu Kwon
42
Near-infrared (NIR) is an electromagnetic wave with a
range of 700–900 nm close to visible light in the infrared
light. Because NIR has a longer wavelength than visible
light, it can penetrate tissue several millimeters or centimeters. Therefore, we can see a deep target behind the normal
tissue. Moreover, NIR light does not interfere with the surgical field since it is invisible by the human eye.
Contrast agents are essential for NIR fluorescent
imaging. Methylene blue, indocyanine green (ICG),
5-aminolevulinic acid, etc., is used for NIR fluorescent
imaging. Among them, ICG is most commonly used.
NIR fluorescent imaging has recently emerged in various clinical conditions. It is applied for sentinel lymph node
mapping, direct tumor imaging, imaging of vital structures,
vascular perfusion, etc. [1–3].
42.1 Near-Infrared Fluorescent Imaging
for Gastric Cancer Surgery
In gastric cancer field, near-infrared fluorescent imaging has
been used mainly to identify the sentinel lymph nodes [4–6].
Intraoperative injection of ICG to a submucosal or subserosal
layer can visualize the draining lymph nodes by near-infrared fluorescent images. Although previous studies showed a
high detection rate of sentinel lymph nodes by using nearinfrared fluorescent imaging, there is a limitation for clinical
application of sentinel lymph node sampling as a routine procedure due to the complex lymphatic drainage system around
the stomach. So far, gastrectomy with D2 lymphadenectomy
is the standard for gastric cancer surgery [7, 8].
If the ICG is injected enough time before lymph node
dissection, it might visualize every draining lymph node
from the area of the primary tumor. ICG solution is prepared as a concentration of 1.25 mg/mL. One day before
surgery, ICG is injected 0.6 mL of the prepared solution
along with the submucosal layer at four points around the
primary tumor (Figs. 42.1a, b and 42.2). The total amount
of injected ICG solution was 2.4 ml (3 mg). NIR fluorescent image before lymph node dissection could distinguish
between lymphatics and normal tissue. This allows anatomical dissection to avoid normal tissue injury. NIR image
after lymphadenectomy could help to evaluate the completeness of lymph node dissection in real time. This allows
the improvement of surgical quality. Moreover, retrieval of
a lymph node from the resected specimen under the NIR
image could facilitate find tiny lymph nodes. This allows
more accurate diagnosis [9].
In case of NIR fluorescent image-guided gastrectomy,
there is no difference with default laparoscopic gastrectomy
with D2 lymphadenectomy. The steps for lymphadenectomy during minimally invasive gastrectomy are standardized (Fig. 42.3a–h).
Electronic supplementary material The online version of this
chapter (https://doi.org/10.1007/978-3-030-55176-6_42) contains
supplementary material, which is available to authorized users.
W. J. Hyung (*)
Department of Surgery, Yonsei University College of Medicine,
50-1 Yonsei-ro, Seodaemun-gu, Seoul 120-752, Republic of Korea
e-mail: wjhyung@yuhs.ac
I. G. Kwon
Department of Surgery, Gangnam Severance Hospital, Yonsei
University College of Medicine, Seoul, Republic of Korea
© 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_42
42.2 Description of the Surgical Procedure
(See Video 42.1)
Laparoscopic surgery has been expanded and applied for
gastric cancer. Laparoscopic gastrectomy with lymph node
dissection has already established as a standard for early
gastric cancer or stage I disease [7]. Several clinical studies about laparoscopic surgery for advanced gastric cancer
is currently ongoing and the results are being published one
by one [10–12].
343
344 W. J. Hyung and I. G. Kwon
Here, the following procedure note will describe laparoscopic distal gastrectomy with D2 lymphadenectomy,
which is the standard extent of lymph node dissection. And,
the different points for total gastrectomy and robotic gastrectomy also will be described subsequently.
The key steps to perform a laparoscopic distal gastrectomy with D2 lymph node dissection under infrared fluorescent imaging guidance are:
1. Trocar insertion and position
Five trocars are used usually. A 12 mm trocar is placed
at the midline just below the umbilicus. After CO
2
pneumoperitoneum of 12 mmHg is achieved, the operation table is placed in 15–30° of reverse-Trendelenburg
position to fall down the transverse colon and small
intestine by gravity. Four additional trocars are inserted
under direct visualization: two 12-mm and two 5-mm
trocars. Specifically, a 5-mm diameter trocar is placed
just below the costal margin and right side of the falciform ligament, as cephalic as possible on the patient’s
right side. Then, a 12-mm trocar is inserted on the
Fig. 42.2 Peritumoral injection of ICG by gastroscopy a day before
surgery
mid-clavicular line of the mid-abdomen. This trocar is
mainly used with advanced energy devices for the core
procedure of lymphadenectomy by coagulation and dissection. Therefore, the upper position of the trocar is
advantageous for dissection of the suprapancreatic area.
Other 5- and 12-mm trocars for an assistant are inserted
on the left side. The port placement for minimally invasive gastrectomy and robot-assisted gastrectomy are in
our department standardized (Fig. 42.4a–c).
2. Liver retraction
Pars flaccida is divided after the exposure of the
hepatogastric ligament by pushing the liver upward.
Puncture of the abdominal wall on both sides of the
falciform ligament and subcostal margin by a straight
needle with thread. The mid-portion of the thread is
anchored to pars condensa. The thread of V shape is
effectively retracted liver upward [13] (Fig. 42.5).
3. Partial omentectomy (total omentectomy)
If there is no evidence of serosa invasion by the tumor
on laparoscopic exploration (Fig. 42.6a, b), partial
omentectomy could be performed. Pushing stomach
superiorly and anteriorly from the assistant will make
it easy to find the thin layer by tenting the omentum.
Left-side dissection and greater curvature mobilization begin by dividing the omentum more than 3 cm
far from gastroepiploic vessels of the greater curvature
side. Left-side dissection of omentum proceeds toward
the lower pole of the spleen (Fig. 42.7).
4. Ligation of left gastroepiploic vessels
The root of the left gastroepiploic vessel is identified
and ligated using clips. When the partial omentectomy
is performed, the omental branch of the left gastroepiploic vessel should be preserved for the prevention of
remnant omentum ischemia (Fig. 42.8).
5. Clearance of soft tissue along the greater curvature
Fig. 42.1 a, b Primary
tumor
34542 Laparoscopic Immunofluorescence-Guided Lymphadenectomy …
Fig. 42.3 a–h Steps for lymphadenectomy during minimally invasive gastrectomy. Left-side dissection for #4sb around LGEV (a). Right-side
dissection for #6 lymph nodes above the páncreas (b). For #5 and #8a, RGA is exposed and soft tissues around the CHA are dissected (c). Soft
tissues medial to the PV and PHA are dissected for proper #12a dissection in D2 lymphadenectomy (d). LGA is exposed above the celiac trunk
(e). For #11p dissection, SV and SA are exposed and all soft tissues are cleaned along these vessels (f). Lesser curvature is cleaned to remove
#1 lymph nodes (g). Final view of lymph node dissection (h). Abbreviations: LGEV: left gastroepiploic vessels, ASPDV: anterior superior pancreaticoduodenal vein, RCV: right colic vein, MCV: middle colic vein, MCA: middle colic artery, RGA: right gastric artery, PHA: proper hepatic
artery, CHA: common hepatic artery, PV: portal vein, LGA: left gastric artery, LGV: left gastric vein, SV: splenic vein, SA: splenic artery, LC:
lesser curvature, AHA: accessory hepatic artery arising from LGA
The short gastric vessels are usually preserved for a
distal gastrectomy; however, if the tumor is located in a
high body, one or two short gastric arteries can be sacrificed to obtain proper resection margins and to create
enough space for the anastomosis. All of the soft tissue along the greater curvature area should be removed
from the stomach by dissecting the pylorus to complete
the #4sb and #4d lymph node harvest (Fig. 42.9a, b).
6. Ligation of right gastroepiploic vein
Right side and infra-pyloric dissection are performed
by incising the soft tissue from the colonic vessels
to the root of the superior mesenteric vessels while
exposing the head of the pancreas (Fig. 42.10a, b). The
gastrocolic trunk is identified as it drains into the superior mesenteric vein and station #6 lymph nodes are
dissected. The right gastroepiploic vein is isolated and
divided while preserving the venous drainage from the
head of the pancreas (anterior superior pancreaticoduodenal vein) and colon.
7. Ligation of right gastroepiploic artery
Further dissection along the surface of the pancreas
head exposes the right gastroepiploic artery and it is
divided at its origin (Fig. 42.11a, b).
8. Creation of a window for duodenal transection
346 W. J. Hyung and I. G. Kwon
Fig. 42.3 undefined
Fig. 42.4 a, b, c Port
placement for minimally
invasive gastrectomy. 6-port
(a) or 5-port (b) surgery can
be used for laparoscopic
gastrectomy. Place for ports
in robotic gastrectomy (c).
Abbreviations: C: Camera,
S: Surgeon, A: Assistant, R:
Retractor
Fig. 42.5 Liver retraction
Fig. 42.6 a, b Laparoscopic
view of the adenocarcinoma
with serosal involvement
(lower body, anterior wall)
(a) and infrared imaging (b)
34742 Laparoscopic Immunofluorescence-Guided Lymphadenectomy …
The duodenum is mobilized from the pancreas along
the gastroduodenal artery, and dissection continues to
the bifurcation of the proper hepatic artery. In preparation for the duodenal transaction, the area above the
pancreas and the duodenum are dissected. Placing a
gauze on top of the pancreas and underneath the duodenum helps create the supraduodenal dissection plane
and prevent injury to the pancreas. Next, the supraduodenal vessels are divided and dissection continues
along the gastroduodenal artery until the right gastric
vessels are exposed (Fig. 42.12a, b).
9. Duodenal transection
An endo-linear stapler is introduced through the right
lower port or the assistant port (left lower), and the
duodenum is transected (Fig. 42.13a, b).
348 W. J. Hyung and I. G. Kwon
Fig. 42.7 Omentectomy to
the left
Fig. 42.8 Ligation of the
left gastroepiploic vessels
10. Ligation of the right gastric artery
Retraction of the liver upward by the assistant allows
for easier dissection of the anterior portion of the hepatoduodenal ligament. Then, the right gastric artery is
identified and ligated at its origin (Fig. 42.14a–c).
11. Division of the lesser omentum up to the right side
of the esophageal hiatus
Soft tissue and posterior attachments are dissected
along the gastrohepatic ligament toward the left side of
the esophageal hiatus.
12. Dissection of lymph node station 12a
The soft tissues around the common hepatic artery and
proper hepatic artery are dissected to remove lymph
nodes #8a and #12a. To expose of the portal vein,
grasp the tissues around the common hepatic artery the
retraction laterally (Fig. 42.15a, b).
13. Dissection of lymph node station 8 and 9
Dissection is then continued along the common hepatic
artery to harvest station #9 lymph nodes. Since the
location and draining vein of the left gastric vein is various, precise dissection is required (Figs. 42.16a–c and
42.17a, b).
14. Dissection of lymph node station 7 and ligation of
left gastric artery
The left gastric artery is then identified and skeletonized; the camera angle can be rotated to reveal the
posterior side of the left gastric artery in the oblique
view (Fig. 42.18a–c). The artery is then clipped and
Fig. 42.9 a, b General view
after omentectomy (a) and
infrared imaging (b)
34942 Laparoscopic Immunofluorescence-Guided Lymphadenectomy …
ligated, which facilitates exposure for #11p lymph
nodes. Dissection of lymph node station 11p.
The pancreas should be pulled toward the caudal direction to exposure splenic artery or vein (Fig. 42.19a–c).
15. Clearance of soft tissues along the lesser curvature
Dissection of soft tissue is performed along the lesser
curvature from the esophageal hiatus down to the transaction line of the stomach (Fig. 42.20a-c).
16. Gastric transection and different types of anastomo-
sis (Figs. 42.21a, b and 42.22a–f).
17. Pathology outcome of the presented case
(Fig. 42.23a–c)
Adenocarcinoma, poorly differenced, type diffuse
(Lauren) that invades proper muscle (pT2). Lymph nodes
metastasis in 5 out of 53 lymph nodes (Fluorescent
nodes: 5/33 and Non-Fluorescent nodes: 0/20).
42.3 Laparoscopic Total Gastrectomy with D2 Lymph Node Dissection
After left gastroepiploic vessel ligation, lymph node dissection continues to the direction of upward for ligating short
gastric artery (station 4sa) and separation of gastrosplenic
ligament up to the left side of the esophageal hiatus. After
350 W. J. Hyung and I. G. Kwon
Fig. 42.10 a, b Fusion
of the mesocolon and the
right gastroepiploic vessels
is dissected (a). Infrared
imaging (b)
Fig. 42.11 a, b After
lymphadenectomy of station
6, right gastroepiploic vessels
are divided (a, b)
35142 Laparoscopic Immunofluorescence-Guided Lymphadenectomy …