Laparoscopic hand-sewn esophagojejunal anastomosis after laparoscopic total gastrectomy for gastric cancer

Abstract

Aims: Laparoscopic distal gastrectomy for gastric cancer is a common practice in Japan. However, laparoscopic total gastrectomy (LTG) is still not widely accepted because of the difficulty of reconstruction after total gastrectomy. In particular, successfully performing esophagojejunal anastomosis under laparoscopy is very challenging, even with mechanical anastomosis using staplers. Therefore, a hand-sewn laparoscopic esophagojejunal anastomosis technique was developed without the use of staplers. Twenty laparoscopic hand-sewn esophagojejunal anastomoses have been performed in Roux en Y reconstructions. The aim of this study was to describe the technical aspects of the novel technique by video presentation. Method(s): Twenty patients diagnosed with early gastric cancer were underwent laparoscopic total gastrectomy by a single surgeon at this institution. The surgeon completed radical lymph node dissection, and the abdominal esophagus was mobilized and transected with an endolinear stapler. The specimens were retrieved from an umbilical port extended to 3 cm. Pneumoperitoneum was established, and reconstruction was made in the Roux en Y manner under laparoscopy. First, the jejunojejunostomy was made laparoscopically with an endolinear stapler combined with hand suturing. The cut end of the abdominal esophagus was opened with laparoscopic coagulating shears (LCS), and a 2.5 cm hole was made at the antimesenteric side of the jejunum of Roux limb for anastomosis using the LCS. Finally, an end-to-side esophagojejunal anastomosis was made with hand-sewn single layer interrupted sutures using 3-0 absorbable sutures. A leak test was performed for all patients after completion of the anastomosis. The mesenteric defect, transverse colon defect and Petersen's defect were closed by non absorbable sutures to prevent internal hernia. Result(s): Twenty totally laparoscopic Roux en Y reconstructions with hand-sewn esophagojejunostomies were performed successfully in all of the patients. There were no cases that had to be converted to open surgery. The median suturing time for the hand-sewn esophagojejunal anastomosis was 44.5 min, and the median number of stitches was 15. No anastomotic leakage occurred. All patients were discharged within 2 weeks without any perioperative complications. Conclusion(s): Laparoscopic hand-sewn esophagojejunal anastomosis during laparoscopic total gastrectomy for early gastric cancer was therefore found to be a feasible and safe surgical procedure.