Total laparoscopic gastrectomy with D2 lymphadenectomy - general and visceral surgery
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Trocar positioning
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)
Dissecting the duodenum (LN 11) and transecting the right gastric artery
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
Exposing the celiac trunk (LN 8), dissecting and dividing the left gastric artery
Dissecting the splenic hilum (LN 10)
Dissecting the esophageal hiatus, including lymphadenectomy down to the aorta (LN 1 and 2)
Temporarily anchoring the jejunum on the stomach, Roux-en-Y jejunostomy
Opening the esophagus and placing the CEEA anvil through the mouth
End-to-side esophagojejunostomy
Completing the Roux-en-Y anastomosis with jejunal segment resection
Oversewing esophagojejunostomy suture line failure
Retrieving the resected gastric specimen, drainage
Resected gastric specimen
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