Background
Since the first case report of laparoscopic gastrectomy (LG) was reported in 1994, it has been used widely to treat gastric cancer due to the well-known short-term benefits, such as low rates of morbidities, decreased pain, shorter length of hospital stay, and less estimated blood loss [
1‐
4].
In general, LG can be divided into laparoscopy-assisted and totally laparoscopic techniques. With laparoscopy-assisted gastrectomy (LAG), lymph node dissection is performed laparoscopically, but the transection of the stomach and the anastomosis are performed through an epigastric mini-laparotomy. Therefore, it may be difficult to perform the anastomosis through a small incision on patients with obesity with thick abdominal walls or on patients with a small remnant stomach due to poor visualization. This reconstructive modality might lead to pain and increased injury from the forceful traction at the mini-laparotomy site. It is reported that intracorporeal anastomosis with totally laparoscopic gastrectomy (TLG) have the advantages of safer anastomosis under better visualization, less postoperative adhesion, faster postoperative recovery, and smaller scars [
5‐
7].
On the basis of our extensive laparoscopic experience gained from LAG, laparoscopic distal pancreatectomy, and other laparoscopic operations [
8‐
11], we started to develop TLG for the treatment of gastric cancer and we initially used staplers to make intracorporeal anastomosis. However, in our practice, we have found some disadvantages of using staplers, especially for intracorporeal esophagojejunostomy. Therefore, we were encouraged to use the intracorporeal hand-sewn technique, mainly used for esophagojejunostomy after total gastrectomy. We report herein our experiences with the various types of anastomosis after TLG and also an evaluation of the postoperative surgical outcomes according to the type of anastomosis to assess those technical feasibilities and discuss the advantages as well as our experience.
Discussion
The most popular version of LG is LAG, wherein the lymph node dissection is completed under the laparoscope. Then, the extracorporeal anastomosis with LAG was performed through a 50–70-mm small incision in the middle upper abdomen. Performing the anastomosis in this narrow and restricted space is often difficult, especially on obese patients with thick abdominal walls or on patients with a small remnant stomach. It should be noted that the inclusion of the auxiliary incision in LAG makes it divergent from the minimally invasive treatment concept pursued in laparoscopic surgery. Previous studies reported some advantages of TLG over LAG such as better cosmesis, less blood loss, and faster recovery. And as our essays issued before [
8], in practice, we have found that TLG is preferable to LAG for three additional reasons. First, TLG enables a tension-free anastomosis and thus avoids damage to the surrounding structures. Second, TLG is more suitable for a “no touch tumor” operation. Finally, TLG requires only a small incision and imparts more selectivity to the surgeon than LAG. However, until now, LAG is still the most commonly performed type of LG [
12]. The development of TLG has been limited because successful reconstruction of the digestive tract laparoscopically has been difficult to achieve, especially for intracorporeal esophagojejunostomy. Hence, there is a need to develop a more standardized methodology in reconstructing the digestive tract by the laparoscopic approach that is as simple and safe as possible.
The methods of gastrointestinal anastomosis after laparoscopic distal gastrectomy (LDG) are the same as those of standard laparotomy which include the Billroth I, Billroth II, and Roux-en-Y methods. All of the methods are safe and efficacious; however, there have been no statistically significant differences in the early postoperative outcomes among the three reconstruction methods [
13‐
15]. The ideal gastrointestinal reconstruction procedure should minimize postoperative morbidity and improve quality of life [
16]. Billroth I and Roux-en-Y procedures are the commonly used reconstruction techniques following resection of open distal gastrectomy (DG). Billroth I reconstruction has commonly been employed after DG for gastric cancer due to its simplicity, physiological advantage of allowing food to pass through the duodenum, and ease of postoperative endoscopy allowing access to the papilla of Vater [
17,
18]. However, there are three most common drawbacks of the Billroth I anastomosis, remnant gastritis, reflux esophagitis, and limitation in extent of resection.
Traditionally, Roux-en-Y reconstruction has been the reconstruction method of choice in total gastrectomy (TG) [
18] and is being increasingly used to prevent duodenogastric and gastroesophageal reflux in DG [
19‐
21]. However, Roux-en-Y gastrojejunostomies have their disadvantages as follows: ulcerogenic and Roux stasis syndrome [
22]. Moreover, it is complex, technically difficult, and time consuming, resulting in prolonged operative time under the totally laparoscopic intracorporeal procedure. And if not hand-sewn, the extensive use of endoscopic linear staplers can result in higher costs [
23]. Therefore, Roux-en-Y reconstruction is commonly performed extracorporeally through a mini-laparotomy incision in LAG.
Billroth II after DG is an alternative for reconstruction of the alimentary tract when Billroth I and Roux-en-Y reconstructions are difficult or unrealistic. The merits of Billroth II reconstruction compared to Billroth I are a lower food stasis rate and a larger extent of resection. If the tumor is located in the middle third of the stomach, it is difficult to perform Billroth I reconstruction because excessive tension might develop at the anastomosis site if a safety margin was included. And in China, the most gastric cancer cases are advanced stage, which need more radical resection. Based on the fact above, the most commonly used intracorporeal anastomosis method in DG in our center is Billroth II reconstruction. If Roux-en-Y reconstruction was used, we only choose the hand-sewn approach, which is more economical.
Regarding intracorporeal linear stapler side-to-side Billroth II reconstruction, we have summarized three points of experience as follows [
8]: First, anastomosis should be made at the posterior wall of the remnant stomach parallel to the greater curvature. Second is using a stapler to make position of the jejunum and gastric stump directly, instead of fixed by them using stitches before staples are applied. Third is using a manual continuous suture to close the common opening, instead of endoscopic linear staplers. It is reported that the delta-shaped anastomosis is a simple, easy, and safe method of intracorporeal gastroduodenostomy [
24]. We also used it for intracorporeal end-to-end Billroth I reconstruction and summarized three main points as follows: (1) Three stay sutures were placed to each end of the common opening and cutting edges of the stomach and duodenum to achieve a better involution. (2) The liner stapler is better to be vertical to the cutting edges of the stomach and duodenum. (3) Two steps are recommended during the closure of the common opening which is likely to avoid the anastomosis stricture.
For intracorporeal mechanical esophagojejunostomy in TG, the first 18 patients in our series used the conventional circular stapler-anvil method. Based on our experience, the esophagus was not cut off at first while the cardia was tightly tied with a band and then stretched down to well expose the esophagus. Purse-string suture was performed, and then, the anterior wall of the esophagus was cut with the Harmonic scalpel for a half-circle. After placement of the anvil, the suture line was tightened and the esophagus was finally cut off with the Harmonic scalpel. However, the circular stapler was inappropriate for placement during laparoscopic surgery due to its bigger size and absence of matching tube. The pneumoperitoneum was vulnerable to its placement, and the vision is unclear. The inserted anvil (OrVilTM; Covidien Mansfield, MA, USA) was introduced to simplify the procedure of anvil placement, which was reported safe and effective [
25]. However, because of its high cost, possibility of bacterial contamination in the abdominal cavity, and injury of the esophageal mucous, we did not use this method.
The linear stapler side-to-side method was simple in operation, and the anastomotic stoma was bigger, which can avoid the postoperative complications such as anastomotic stenosis. For position of the jejunum and esophageal stump, like linear stapler side-to-side Billroth II reconstruction, we used a stapler to make position directly. However, there are possible problems in this method, such as distortion of the Roux limb or mesenterium and slipping of the esophagojejunal anastomotic site into the lower mediastinum. The surgical margin is limited for longer esophageal stump should be reserved.
Hand-sewn end-to-side esophagojejunostomy overcomes the limitations caused by the mechanical method. This method completes the anastomosis after removal of the specimen. The anastomosis can be performed after intraoperative frozen section evaluation and confirmation of negative margins. And this method does not need longer esophageal stump. For patients with positive resection margin, the removal extent can be expanded appropriately to confirm negative resection margin. However, the hand-sewn method requires the operators with rich experience in laparoscopic suture skill, and it takes longer time. According to our experience, progressive practice can effectively shorten the learning curve. At the same time, the application of some new laparoscopic instruments can simplify the intracorporeal hand-sewn suture.
We recommend that the reconstruction method using a stapler should be selected on the basis of the location of the tumor. Our experience is that the side-to-side esophagojejunostomy using a linear stapler can be adopted for patients with lesions in the body and fundus of the stomach as well as the lower cardia. For patients with lesions in the upper and middle cardia, end-to-side esophagojejunostomy using a circular stapler is still chosen for enough surgical margins. Also, if the surgeon was well experienced with the laparoscopic hand-sewn technique, it can be used after TG regardless of tumor location.
The hand-sewn technique is quite difficult but not impossible. We are very willing to provide some experienced tips: First, knotless barbed sutures (V-LocTM; Covidien Mansfield, MA, USA) are recommended. It can shorten the time of anastomosis and can ensure the safety of anastomosis, with no need for permanent traction during the whole anastomosis process. Second, keep two long corner stay sutures respectively at the 3 o’clock and 9 o’clock positions of the anastomotic stoma when you are performing the posterior wall anastomosis, which is the most challenging step. This tip is able to maintain tension to provide a clear view of the posterior wall and allow more precise anastomosis. Maintaining the integrity of this anastomosis is important, and lessening the tension of the anastomosis is also a key point in preventing the occurrence of bile leakage. Moreover, interrupted sutures of the seromuscular layer are also helpful to reduce tension. The specially developed laparoscopic clamps play a crucial part in the success of the techniques. The clamps prevent fecal contamination of the abdominal cavity and facilitate the performance of the anastomosis.
Competing interests
The authors declare that they have no competing interests.
Authors’ contributions
KC designed the study and wrote the manuscript. JFY and DWC collected and analyzed the data. DW, YP, and JQC helped in the acquisition of the data and revised the article. HM polished the English language. YPM critically revised the manuscript for important intellectual content and gave the final approval. All authors read and approved the final manuscript.