Laparoscopic total gastrectomy with D2 lymphadenectomy

The procedure begins with marking the trocar positions on the abdominal wall. After inserting the Veress needle and pressure-controlled CO2 insufflation, the following trocars are placed in a semicircular arrangement:

• T1 = 10 mm optic trocar
• T2 = 10 mm working trocar
• T3 = 5 mm working trocar (later 12 mm for CEEA stapler and extension incision for specimen retrieval)
• T4 = 12 mm working trocar
• T5 = 5 mm working trocar

The resection phase begins with the opening of the omental bursa by incision of the gastrocolic ligament. For this, the greater omentum is folded cranially, and the ligament is successively transected at the upper edge of the transverse colon using the Thunderbeat® device.

The preparation is continued at the gastroduodenal junction. Mobilization of the duodenum is also performed using the Thunderbeat® device and is carried out up to approximately 2 cm distal to the pylorus. After lifting the stomach, the right gastric artery is located and transected near its origin from the proper hepatic artery.

Note: Special care is required for the dorsal preparation of the duodenum. Injuries to the pancreatic capsule should be avoided as much as possible, as otherwise pancreatic fistulas, local inflammatory reactions, and insufficiency of the duodenal stump may result.

After exposing the common hepatic artery, the lesser omentum is transected near the liver. The postpyloric transection of the duodenum is performed using a 60 mm Endo-GIA stapler device.