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Unaided Stapling Technique for Pure Single-Incision Distal Gastrectomy in Early Gastric Cancer: Unaided Delta-Shaped Anastomosis and Uncut Roux-en-Y Anastomosis.

Suh YS, Park JH, Kim TH, Huh YJ, Son YG, Yang JY, Kong SH, Lee HJ, Yang HK - J Gastric Cancer (2015)

Bottom Line: Mean operation times were 214.5±36.2 minutes for uDelta and 240.8±65.9 minutes for RY, which was not significantly different.Average length of hospital stay was 8.2±1.9 days in the uDelta group and 7.2±0.8 days in the RY group (P=0.320).After carefully considering indications, uDelta can be a feasible and can be a reproducible reconstruction method after SIDG in early gastric cancer.

View Article: PubMed Central - PubMed

Affiliation: Department of Surgery, Seoul National University College of Medicine, Seoul, Korea.

ABSTRACT

Purpose: Intracorporeal anastomosis is the most difficult procedure during pure single-incision distal gastrectomy (SIDG) that affects its generalization. We introduced unaided delta-shaped anastomosis (uDelta), a novel anastomosis technique, for gastroduodenostomy after pure SIDG, and compared the results with those of previously reported Roux-en-Y anastomosis (RY).

Materials and methods: Between March 2014 and March 2015, SIDG with D1+ lymph node dissection was performed for early gastric cancer through a 2.5-cm transumbilical incision without any additional port. uDelta was performed by the operator alone, without any intracorporeal assistance.

Results: uDelta was performed on 11 patents, and uncut RY was performed on 5-patients without open or multiport conversion. R0 resection was performed in all cases. No significant differences were observed in mean age and body mass index between patients who underwent uDelta or RY. Mean operation times were 214.5±36.2 minutes for uDelta and 240.8±65.9 minutes for RY, which was not significantly different. Reconstruction time for uDelta was shorter than that for RY, with marginal statistical significance (26.1±8.3 minutes vs. 38.0±9.1 minutes, P=0.05). There were no intraoperative transfusions, 30-day mortality, or anastomosis-related complications in either group. Average length of hospital stay was 8.2±1.9 days in the uDelta group and 7.2±0.8 days in the RY group (P=0.320).

Conclusions: After carefully considering indications, uDelta can be a feasible and can be a reproducible reconstruction method after SIDG in early gastric cancer.

No MeSH data available.


Related in: MedlinePlus

Unaided delta-shaped anastomosis. (A) A traction suture with 3/0 monofilament thread is added at the posterior wall of the small incision hole of the remnant stomach and pulled out through a single umbilical port. (B) An opened 45-mm linear stapler inserted at the remnant stomach is manipulated by the operator with one hand. (C) The other jaw of the stapler is inserted at the incision site of the duodenal stump, which is easily controlled by the operator alone. (D) After the first stapling of the gastroduodenostomy, one traction suture at the lesser curvature side of the common entry hole is pulled up by the operator's left hand. This suture can be replaced by the previous suture at the posterior wall of the remnant stomach. An additional traction suture at the greater curvature side of the common entry hole is pulled out through the single port and simultaneously manipulated outside the abdominal cavity with a linear stapler. (E) The common entry hole can be easily closed with a single application of a 60-mm linear stapler under gentle traction with 2 traction sutures inside and outside the abdominal cavity. (F) The unaided delta-shaped gastroduodenostomy is completed.
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Figure 1: Unaided delta-shaped anastomosis. (A) A traction suture with 3/0 monofilament thread is added at the posterior wall of the small incision hole of the remnant stomach and pulled out through a single umbilical port. (B) An opened 45-mm linear stapler inserted at the remnant stomach is manipulated by the operator with one hand. (C) The other jaw of the stapler is inserted at the incision site of the duodenal stump, which is easily controlled by the operator alone. (D) After the first stapling of the gastroduodenostomy, one traction suture at the lesser curvature side of the common entry hole is pulled up by the operator's left hand. This suture can be replaced by the previous suture at the posterior wall of the remnant stomach. An additional traction suture at the greater curvature side of the common entry hole is pulled out through the single port and simultaneously manipulated outside the abdominal cavity with a linear stapler. (E) The common entry hole can be easily closed with a single application of a 60-mm linear stapler under gentle traction with 2 traction sutures inside and outside the abdominal cavity. (F) The unaided delta-shaped gastroduodenostomy is completed.

Mentions: Using a single incision site without any additional port or assistance, laparoscopic distal gastrectomy with D1+ lymph node dissection is performed according to the Japanese gastric cancer treatment guidelines.16 For Billroth I anastomosis, after full mobilization around the first part of the duodenum, the duodenum is rotated 90 degrees and transected with a 60 mm linear stapler (Endo GIA™ purple or tan; Covidien, Mansfield, MA, USA), which creates a duodenal transection in the ventrodorsal direction (supplementary video). This duodenal transection was occasionally performed before ligation of the right gastric artery in totally laparoscopic distal gastrectomy (TLDG). However, in SIDG with uDelta, we performed duodenal transection after ligation of the right gastric artery to ensure sufficient mobilization and rotation of the duodenal first portion without any other assistance. After distal gastrectomy with lymph node dissection is completed, an en bloc resected specimen with lymph nodes wrapped in a plastic bag is harvested through a single umbilical incision site. To perform an intracorporeal gastroduodenostomy, a small incision is created in the previous stapled line at the corner of the greater curvature side of the remnant stomach and the dorsal side of the duodenum in order to insert a linear stapler. To achieve adequate traction without assistance inside the peritoneal cavity, a traction suture with a 3/0 monofilament thread is added at the posterior wall of the small incision hole of the remnant stomach and pulled out through a single umbilical port (Fig. 1A). After inserting a 45 mm linear stapler (Endo GIA™ purple) into the remnant stomach, an opened linear stapler with a traction suture at the remnant stomach is easily maintained by the operator's right hand, allowing for simultaneous unaided manipulation of the stapler and remnant stomach. A linear stapler gently holding the posterior wall of the remnant stomach is rotated clockwise to the duodenal side, which is then ready for gastroduodenostomy (Fig. 1B). The other jaw of the stapler is inserted at the incision site of the duodenal stump, which is simply controlled by the operator himself. The posterior wall of the stomach and cranial side of the duodenum are approximated and anastomosed (Fig. 1C). To close the common entry hole, one traction suture at the lesser curvature side of the common entry hole (which occasionally can be replaced by a previous traction suture at the remnant stomach) is simply pulled up with the operator's left hand inside the abdominal cavity. The newly added suture at the greater curvature side of the common entry hole is pulled out through the single port and simultaneously manipulated outside the abdominal cavity with a linear stapler by the operator's right hand (Fig. 1D). Under the gentle traction of 2 traction sutures inside and outside the abdominal cavity, the common entry hole can be closed up with a single application of a 60 mm linear stapler (Endo GIA™ purple) (Fig. 1E).


Unaided Stapling Technique for Pure Single-Incision Distal Gastrectomy in Early Gastric Cancer: Unaided Delta-Shaped Anastomosis and Uncut Roux-en-Y Anastomosis.

Suh YS, Park JH, Kim TH, Huh YJ, Son YG, Yang JY, Kong SH, Lee HJ, Yang HK - J Gastric Cancer (2015)

Unaided delta-shaped anastomosis. (A) A traction suture with 3/0 monofilament thread is added at the posterior wall of the small incision hole of the remnant stomach and pulled out through a single umbilical port. (B) An opened 45-mm linear stapler inserted at the remnant stomach is manipulated by the operator with one hand. (C) The other jaw of the stapler is inserted at the incision site of the duodenal stump, which is easily controlled by the operator alone. (D) After the first stapling of the gastroduodenostomy, one traction suture at the lesser curvature side of the common entry hole is pulled up by the operator's left hand. This suture can be replaced by the previous suture at the posterior wall of the remnant stomach. An additional traction suture at the greater curvature side of the common entry hole is pulled out through the single port and simultaneously manipulated outside the abdominal cavity with a linear stapler. (E) The common entry hole can be easily closed with a single application of a 60-mm linear stapler under gentle traction with 2 traction sutures inside and outside the abdominal cavity. (F) The unaided delta-shaped gastroduodenostomy is completed.
© Copyright Policy - open-access
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC4496436&req=5

Figure 1: Unaided delta-shaped anastomosis. (A) A traction suture with 3/0 monofilament thread is added at the posterior wall of the small incision hole of the remnant stomach and pulled out through a single umbilical port. (B) An opened 45-mm linear stapler inserted at the remnant stomach is manipulated by the operator with one hand. (C) The other jaw of the stapler is inserted at the incision site of the duodenal stump, which is easily controlled by the operator alone. (D) After the first stapling of the gastroduodenostomy, one traction suture at the lesser curvature side of the common entry hole is pulled up by the operator's left hand. This suture can be replaced by the previous suture at the posterior wall of the remnant stomach. An additional traction suture at the greater curvature side of the common entry hole is pulled out through the single port and simultaneously manipulated outside the abdominal cavity with a linear stapler. (E) The common entry hole can be easily closed with a single application of a 60-mm linear stapler under gentle traction with 2 traction sutures inside and outside the abdominal cavity. (F) The unaided delta-shaped gastroduodenostomy is completed.
Mentions: Using a single incision site without any additional port or assistance, laparoscopic distal gastrectomy with D1+ lymph node dissection is performed according to the Japanese gastric cancer treatment guidelines.16 For Billroth I anastomosis, after full mobilization around the first part of the duodenum, the duodenum is rotated 90 degrees and transected with a 60 mm linear stapler (Endo GIA™ purple or tan; Covidien, Mansfield, MA, USA), which creates a duodenal transection in the ventrodorsal direction (supplementary video). This duodenal transection was occasionally performed before ligation of the right gastric artery in totally laparoscopic distal gastrectomy (TLDG). However, in SIDG with uDelta, we performed duodenal transection after ligation of the right gastric artery to ensure sufficient mobilization and rotation of the duodenal first portion without any other assistance. After distal gastrectomy with lymph node dissection is completed, an en bloc resected specimen with lymph nodes wrapped in a plastic bag is harvested through a single umbilical incision site. To perform an intracorporeal gastroduodenostomy, a small incision is created in the previous stapled line at the corner of the greater curvature side of the remnant stomach and the dorsal side of the duodenum in order to insert a linear stapler. To achieve adequate traction without assistance inside the peritoneal cavity, a traction suture with a 3/0 monofilament thread is added at the posterior wall of the small incision hole of the remnant stomach and pulled out through a single umbilical port (Fig. 1A). After inserting a 45 mm linear stapler (Endo GIA™ purple) into the remnant stomach, an opened linear stapler with a traction suture at the remnant stomach is easily maintained by the operator's right hand, allowing for simultaneous unaided manipulation of the stapler and remnant stomach. A linear stapler gently holding the posterior wall of the remnant stomach is rotated clockwise to the duodenal side, which is then ready for gastroduodenostomy (Fig. 1B). The other jaw of the stapler is inserted at the incision site of the duodenal stump, which is simply controlled by the operator himself. The posterior wall of the stomach and cranial side of the duodenum are approximated and anastomosed (Fig. 1C). To close the common entry hole, one traction suture at the lesser curvature side of the common entry hole (which occasionally can be replaced by a previous traction suture at the remnant stomach) is simply pulled up with the operator's left hand inside the abdominal cavity. The newly added suture at the greater curvature side of the common entry hole is pulled out through the single port and simultaneously manipulated outside the abdominal cavity with a linear stapler by the operator's right hand (Fig. 1D). Under the gentle traction of 2 traction sutures inside and outside the abdominal cavity, the common entry hole can be closed up with a single application of a 60 mm linear stapler (Endo GIA™ purple) (Fig. 1E).

Bottom Line: Mean operation times were 214.5±36.2 minutes for uDelta and 240.8±65.9 minutes for RY, which was not significantly different.Average length of hospital stay was 8.2±1.9 days in the uDelta group and 7.2±0.8 days in the RY group (P=0.320).After carefully considering indications, uDelta can be a feasible and can be a reproducible reconstruction method after SIDG in early gastric cancer.

View Article: PubMed Central - PubMed

Affiliation: Department of Surgery, Seoul National University College of Medicine, Seoul, Korea.

ABSTRACT

Purpose: Intracorporeal anastomosis is the most difficult procedure during pure single-incision distal gastrectomy (SIDG) that affects its generalization. We introduced unaided delta-shaped anastomosis (uDelta), a novel anastomosis technique, for gastroduodenostomy after pure SIDG, and compared the results with those of previously reported Roux-en-Y anastomosis (RY).

Materials and methods: Between March 2014 and March 2015, SIDG with D1+ lymph node dissection was performed for early gastric cancer through a 2.5-cm transumbilical incision without any additional port. uDelta was performed by the operator alone, without any intracorporeal assistance.

Results: uDelta was performed on 11 patents, and uncut RY was performed on 5-patients without open or multiport conversion. R0 resection was performed in all cases. No significant differences were observed in mean age and body mass index between patients who underwent uDelta or RY. Mean operation times were 214.5±36.2 minutes for uDelta and 240.8±65.9 minutes for RY, which was not significantly different. Reconstruction time for uDelta was shorter than that for RY, with marginal statistical significance (26.1±8.3 minutes vs. 38.0±9.1 minutes, P=0.05). There were no intraoperative transfusions, 30-day mortality, or anastomosis-related complications in either group. Average length of hospital stay was 8.2±1.9 days in the uDelta group and 7.2±0.8 days in the RY group (P=0.320).

Conclusions: After carefully considering indications, uDelta can be a feasible and can be a reproducible reconstruction method after SIDG in early gastric cancer.

No MeSH data available.


Related in: MedlinePlus