Total laparoscopic gastrectomy with D2 lymphadenectomy - general and visceral surgery

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  • Trocar positioning

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    Start the procedure by marking the trocar positions on the abdominal wall. After inserting the Veress needle and pressure-controlled CO2 insufflation, place the following trocars in a semicircle:

      • T1 = camera trocar (10 mm)
      • T2 = working trocar(10 mm)
      • T3 = working trocar 5 mm (later 12 mm for CEEA stapler and extension of incision for specimen retrieval)
      • T4 = working trocar (12 mm)
      • T5 = working trocar (5 mm)
  • Incising the gastrocolic ligament and resecting the omentum (LN 4)

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    Start the resection phase by opening the lesser peritoneal sac and incising the gastrocolic ligament. To do this, fold over the greater omentum craniad and divide the ligament step by step along the superior aspect of the transverse colon with the Thunderbeat® device.

  • Dissecting the duodenum (LN 11) and transecting the right gastric artery

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    Continue the dissection at the gastroduodenal junction. Mobilize the duodenum likewise with the Thunderbeat® device to around 2 cm distal to the pylorus. After lifting the stomach, locate the right gastric artery and divide it close to its origin at the proper hepatic artery.

    Note: Pay particular attention when dissecting the posterior aspect of the duodenum. Make every attempt not to injure the pancreatic capsule as this could result in pancreatic fistula, local inflammatory reaction, and leakage from the duodenal remnant.

  • Dissecting the common hepatic artery, resecting the lesser omentum and transecting the duodenum

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    After exposing the common hepatic artery, divide the lesser omentum close to the liver. Transect the postpyloric duodenum with a 60 mm Endo-GIA stapler.

  • Exposing the celiac trunk (LN 8), dissecting and dividing the left gastric artery

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    Next, dissect the suprapancreatic lymph nodes along the common hepatic artery to the celiac trunk, such that the lymph nodes remain attached to the specimen. Expose the left gastric artery and divide it between metal clips.

  • Dissecting the splenic hilum (LN 10)

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    While preserving the spleen, divide the gastrosplenic ligament close to the spleen.

  • Dissecting the esophageal hiatus, including lymphadenectomy down to the aorta (LN 1 and 2)

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    This step involves the cardioesophageal dissection and lymphadenectomy in the lower mediastinum. To that effect, mobilize both diaphragmatic crura and the terminal esophagus, while resecting also the paracardial lymph nodes. Divide both vagal trunks.

  • Temporarily anchoring the jejunum on the stomach, Roux-en-Y jejunostomy

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    Restore passage with the esophagus in end-to-side technique with the circular EEA stapler by introducing it into the open end of the Roux limb (“shepherd’s crook”). Prepare the jejunojejunostomy by locating a jejunal limb about 30 cm distad of the duodenojejunal flexure (ligament of Treitz), pull it up loosely to the stomach anterior to the colon, and temporarily anchor it with a suture at the gastric fundus. Follow the efferent limb of this anchored loop for another 50–60 cm and then position it such that both limbs parallel each other. After punctate antimesenteric opening of both intestinal lumens with the electrocautery hook, fashion the side-to-side anastomosis with a 60 mm Endo-GIA stapler. Close the insertion site of the stapler halves with a running suture Vicryl 3/0.

    Note: The reconstruction presented here is an established surgical technique used in bariatric laparoscopic gastric bypass.

  • Opening the esophagus and placing the CEEA anvil through the mouth

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    First, insert via the mouth a nasogastric tube mounted on the anvil of a 21 mm CEEA stapler (nasogastric tubes with pre-mounted anvils are available as ready-made medical products in sizes 21–25 mm from the medical industry). Next, open the esophagus by semicircular transection of its anterior wall just above the cardia. Once the tip of the gastric tube appears in the incised esophagus, pull it through into the abdominal cavity Now arm the semicircular opening in the esophagus with a monofilament purse string suture (nonabsorbable, size 0). Next, complete the esophageal transection, pull through the anvil into the distal esophagus and secure it with the purse string suture. Finally, detach the nasogastric tube from the anvil and withdraw it from the abdominal cavity.

  • End-to-side esophagojejunostomy

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    Remove the suture anchoring the jejunum at the gastric fundus. Transect the pulled-up first jejunal limb 10–15 cm distad of the side-to-side jejunojejunostomy. After extending the trocar incision in the left upper quadrant (T3), insert the 21 mm CEEA stapler first into the abdominal cavity and then into the opened intestinal lumen. Pull up the limb to the esophagus anterior to the colon, perforate the intestinal wall at the antimesenteric border with the spiked shank and then insert the extended spike into the anvil shaft. When closing the stapler, it became evident that the esophageal wall was not properly centered due to inadequate tension. Therefore, this had to be corrected by a second purse string suture (V-Loc 2/0) which was tightened step by step. Problem-free mechanical fashioning of the esophagojejunostomy was now possible.

  • Completing the Roux-en-Y anastomosis with jejunal segment resection

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  • Oversewing esophagojejunostomy suture line failure

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  • Retrieving the resected gastric specimen, drainage

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  • Resected gastric specimen

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