Fully Laparoscopic Total Gastrectomy with Double Staple Anastomosis

Contributor: Joseph Kim

This video demonstrates a fully laparoscopic total gastrectomy using a double-staple technique that facilitates the safe and effective creation of an esophagojejunal anastomosis. Fully laparoscopic total gastrectomy provides distinct advantages over the open laparotomy technique. An elderly gentleman was found to be anemic on routine bloodwork exam. Subsequent upper endoscopy revealed gastric cancer of the cardia, necessitating complete gastric resection. This video demonstrates a fully laparoscopic total gastrectomy using a double staple technique that facilitates the safe and effective creation of an esophagojejunal anastomosis.

DOI: http://dx.doi.org/10.17797/i3nfwwigio

Editor Recruited By: Jeffrey B. Matthews, MD

The following major steps serve as an outline for this surgery. 1. Entrance into the lesser sac. 2. Mobilization of the stomach along the greater curvature up to the left crus, including division of the short gastric vessels. 3. Ligation of the right gastroepiploic vessels. 4. Transection of the duodenum distal to the pylorus with a linear stapler. 5. Ligation of the right gastric artery. 6. Division of the gastrohepatic ligament up to the level of the right crus. 7. Skeletonization of the left gastric vessels. 8. Transection of the distal esophagus. 9. Division of proximal jejunum approximately 10-15 cm distal to the ligament of Treitz. 10. The end-to-end anastomosis (EEA) stapler is inserted into the opening of the blind end of the Roux limb. 11. The pin is fired and mated with the anvil to create the esophagojejunal anastomosis. 12. The blind end of the Roux limb is closed. 13. The jejunojejunostomy is created approximately 45 cm from the esophagojejunal anastomosis.
The double staple technique is a safe and effective technique to create the esophagojejunal anastomosis in laparoscopic or robotic total gastrectomy procedures.
There are no absolute contraindications to using the double staple technique. However, should the technique fail or be unsafe to perform, conversion to open gastrectomy with a hand-sewn anastomosis may be indicated.
Following induction of general anesthesia, the patient is placed in a supine 15-30 degree reverse Trendelenburg position. A Veress needle technique or Hasson technique is used to enter the abdomen. Five ports (two 5-mm and three 10/12-mm) are placed in a semicircular arrangement surrounding the umbilicus. The right lateral 5-mm port may be used for a fixed liver retractor. The remaining ports are used interchangeably for dissection or transection.
We obtain laboratory work including a complete blood cell count, chemistry profile, and liver function tests. The liver function tests are important when a replaced or an accessory left hepatic artery must be divided. Chest x-ray and abdominal computed tomography with intravenous contrast are obtained.
Avascular plane. Left crus. Right gastroepiploic vessels. Right gastric artery. Left gastric artery. Right crus. Coronary vein. Vein of mayo.
The OrVil device allows for safe and effective creation of an esophagojejunal anastomosis in the laparoscopic or robotic setting. However, if the OrVil device fails to create a sufficient anastomosis, open conversion is almost always mandated with a hand-sewn anastomosis.
The major risk is an anastomotic leak.
No conflicts.
Special thanks to Martin Vaughan for video narration.
Kachikwu, E.L, Trisal, V., Kim, J., Pigazzi, A., Ellenhorn, J.D.I. Minimally Invasive Total Gastrectomy for Gastric Cancer: A Pilot Series. J Gastrointest Surg (2011) 15:81-86 Kim, H.H., Baik, Y.H., Yun, Y.H., et al., Improved Quality of Life Outcomes After Laparoscopy-assisted Distal Gastrectomy for Early Gastric Cancer: Results of a Prospective Randomized Clinical Trial. Ann Surg. 2008. 248(5): p. 721-7 Shinohara, T., Kanaya, S., Taniguchi, K., et al., Laparoscopic Total Gastrectomy with D2 Lymph Node Dissection for Gastric Caner. Arch Surg, 2009. 144(12): P.113-42

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