Three-step method for systematic lymphadenectomy in gastric cancer surgery using the ‘curettage and aspiration dissection technique’ with Peng’s multifunctional operative dissector

Step one consisted of the Kocher maneuver and the dissection of the greater omentum together with the anterior sheet of the mesocolon. The right Gerota’s membrane and perirenal fat were lifted to reveal the right renal blood vessels and the right testicular or ovarian blood vessels. Next, a Kocher maneuver was performed to expose the duodenum, the head of the pancreas, and the inferior vena cava to exclude undetected metastases at station number 13 (Figure 5). The dissection was initiated at the duodenal membrane after the Kocher maneuver was completed. Subsequently, the greater omentum and the anterior sheet of the mesocolon and pancreatic capsule were dissected from right to left (Figure 6). The transverse colon was pulled caudally by the first assistant, and the surgeon lifted the greater omentum with the left hand so that the anterior sheet could be easily dissected from the underlying tissue between the hepatic flexure and the splenic flexure using PMOD in the right hand. The greater omentum was dissected from the transverse colon together with the anterior sheet of the mesocolon. At the midpoint of the colon, where the interstitial space between the anterior lobe and the posterior lobe of the mesocolon is narrow, we used the CADT together with electrical coagulation and cutting to widen this space by pushing aside and separating the tissue. As we dissected this sheet, the right accessory colic vein was located and followed cranially to the point where it joins Henle’s surgical trunk. The origin of the right gastroepiploic vein was then identified, ligated, and divided at its origin. This dissection was performed from the inferior to the superior border of the pancreas and from the middle of the pancreas toward the duodenum until the gastroduodenal artery was found. This artery was then followed caudally to the right gastroepiploic artery, which was ligated and divided at its origin. Nodal station numbers 13, 15, 14v, 6, 4d, and 4sb were dissected in the first step.

Step two consisted of the dissection of the lesser omentum. Tissue in the hepatoduodenal ligament was dissected along the proper hepatic artery from the liver toward the duodenum. We divided the right gastric artery at its origin after the proper hepatic artery was located to eliminate the possibility of damage and to obtain clear visualization (Figure 7). The lesser omentum was then divided just below the liver by using electrical coagulation with PMOD from the right side of the proper hepatic artery to the left side of the esophageal artery. This division was followed caudally along the lesser curvature, if required. During this step, since the space was narrow, we used PMOD to push the tissue aside and open the space. The operator finished this step alone in order to obtain clear surgical visualization and minimize operation time (Figure 8). Nodal station numbers 12, 5, 1, and 3 were dissected in the second step.

Step three consisted of a lymphadenectomy along the main vessels. A dissection was performed from the proper hepatic artery to the common hepatic artery and from the common hepatic artery to the left gastric artery until the celiac artery was located (Figure 7). The dissection was initiated at the proper hepatic artery, and lymphadenectomy was performed along the main arteries. Next, the origin of the splenic artery was located, and the dissection was performed along the splenic artery until the secondary branches of the splenic pedicle were located (Figures 8 and9)[8]. If the tumor involved the upper or middle third of the stomach, the dissection was performed up to the left side of the cardia in this step. Nodal station numbers 8, 7, 9, 11p, 11d, 10, 4sa, and 2 were dissected in the final step.