Based on our experience of suprapancreatic nodal dissection in laparoscopic gastrectomy, we developed an outermost layer-oriented medial approach for infrapyloric nodal dissection. The objective of this single-institution retrospective study was to determine the feasibility, safety, and reproducibility of this novel and unique dissection procedure.
This approach can be performed in the same manner as suprapancreatic nodal dissection but by replacing the left gastric artery with the right gastroepiploic artery (RGEA), the common hepatic artery with the anterior superior pancreaticoduodenal artery (ASPDA), and the splenic artery with the gastroduodenal artery. It comprises five steps: (1) mobilization of the transverse mesocolon along the prepancreatic membrane, (2) medial dissection along the dissectable layer between the pancreatic head and the dorsal side of the right gastroepiploic vein (RGEV), (3) division of the RGEV and determination of the lateral and cranial borders, (4) dissection along the outermost layer of the RGEA and ASPDA and transection of the infrapyloric artery and RGEA, and (5) transection of the duodenal bulb.
This novel method was applied in 112 patients who underwent laparoscopic distal gastrectomy from 2014 to 2015. The anatomical landmarks that we determined to appropriately identify the outermost layer were highly reproducible, and our novel procedure based on these landmarks was successfully completed in all cases, without any intraoperative complications. Furthermore, in all cases, no. 6 lymph nodes were fully and adequately dissected within the infrapyloric area anatomically defined in the Japanese Classification of Gastric Carcinoma ver. 14. Pancreatic fistula occurred only in 1.8% cases.
This novel outermost layer-oriented medial approach is a robust procedure that may help laparoscopic surgeons in performing safe and reproducible infrapyloric nodal dissection.
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Laparoscopic distal gastrectomy
Right gastroepiploic artery
Anterior superior pancreaticoduodenal artery
Right gastroepiploic vein
Accessory right colic vein
Anterior superior pancreaticoduodenal vein
Right gastric artery
Superior mesenteric vein.
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Supplemental video clip #1—The inferior edge of the pancreatic body was incised in the direction of the pancreatic head. Then, the GCT and the origins of the RGEV and accessory RCV were identified. Mobilization of the transverse mesocolon was started from the right side of the junction of these three veins, toward the descending part of the duodenum in the mediolateral direction in front of the fusion plane on the transverse mesocolon. Through this process, the dissectable layer was identified between the transverse mesocolon and the prepancreatic fascia, and we could trace it easily. Once dissection was extended up to the duodenal wall, the mobilization process of the transverse mesocolon was completed. The greater omentum was then divided and preconditioning for the infrapyloric dissection process was completed. (WMV 23513 KB)
Supplemental video clip #2—Along the right side of the autonomic nerve sheaths of the RGEA, the delta zone was dissected and widened in the mediolateral direction. The autonomic nerves of the RGEA usually run down the surface of the pancreatic neck. Along these nerves of the pancreatic neck, we could identify the thin loose connective tissue layer between these nerves and the adipose tissue as the dissectable layer. Once dissection was continued up to the ASPDV and the autonomic nerve of the ASPDA was identified, adequate space could be found behind the RGEV. Then, the RGEV was divided after clipping, and incised along the ASPDV, which acted as the lateral border of the no. 6v LNs. In turn, the cranial border of the no. 6a/6i LNs was incised from the ventral side, along the greater curvature of the duodenal bulb. Then, the adipose tissue containing the no. 6 LNs was lifted up ventrally by the assistant and maintained adequate tension at the dissection line along the outermost layer. Dissection was continued along the outermost layer of the ASPDA, and the infrapyloric artery was identified and divided. After completing dissection around the outermost layer of the RGEA, the autonomic nerves around the RGEA were divided to elongate the neck of the RGEA. Then, the RGEA was divided after clipping. (WMV 39740 KB)
Supplemental video clip #3—The remnant tissues attached to the duodenal bulb were dissected along the greater curvature via the dorsal aspect of the duodenum. Subsequently, the RGA was identified at the dorsal side of the stomach. The right side of the RGA was incised along the lesser curvature of the duodenal wall. Then, the assistant retracted the adipose tissue at the lesser curvature from the ventral side, and the opening was widened. After the duodenal bulb was dissected circumferentially, the duodenum was transected using a linear stapler. (WMV 17122 KB)
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Shibasaki, S., Suda, K., Nakauchi, M. et al. Outermost layer-oriented medial approach for infrapyloric nodal dissection in laparoscopic distal gastrectomy. Surg Endosc 32, 2137–2148 (2018). https://doi.org/10.1007/s00464-018-6111-6
- Stomach neoplasms
- Minimally invasive surgical procedures
- Lymph node excision
- Pancreatic fistula