Single-incision laparoscopic total gastrectomy with D1+beta lymph node dissection for proximal early gastric cancer
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Single-incision laparoscopic distal gastrectomy for early gastric cancer has recently been reported by a few centers in Korea and Japan. In this technical report, we describe the world’s first pure single-incision laparoscopic total gastrectomy with D1+beta lymph node dissection for proximal early gastric cancer.
KeywordsSingle-incision laparoscopic surgery (SILS) Total gastrectomy Single-incision laparoscopic total gastrectomy (SITG) Gastric cancer Lymph node dissection
As the result of early detection of gastric cancer and technological advances, minimally invasive surgery (MIS) has become the main axis of treatment. In particular, laparoscopic gastrectomy for EGC has been widely accepted as an alternative to open gastrectomy in Korea and Japan [1, 2]. Further, new emerging techniques have been developed to reduce the invasiveness of laparoscopic surgery, such as the natural orifice transluminal endoscopic surgery (NOTES) and single-incision laparoscopic surgery (SILS). Although NOTES is still being studied because of the limitations of current instruments, SILS has been frequently applied in various clinical settings, such as cholecystectomy, appendectomy, colectomy, and sleeve gastrectomy for obesity [3, 4]. However, there have been only three reports about single-incision laparoscopic distal gastrectomy (SIDG) for gastric cancers [5, 6, 7]. Herein, we report a technical note of the first successful single-incision laparoscopic total gastrectomy (SITG) with D1+beta lymph node dissection (LND) for a patient with early proximal gastric cancer.
A 50-year-old man with a body mass index of 19.5 kg/m2 was diagnosed with a moderately differentiated early gastric adenocarcinoma by endoscopy as per national screening guidelines. Endoscopic ultrasonography indicated that the tumor invaded the submucosal layer of the high body of the posterior wall of the stomach. Computed tomography (CT) scan revealed that there was no regional lymph node (LN) enlargement or distant metastasis (cT1bN0M0). Informed consent for a single-incision laparoscopic total gastrectomy was obtained.
Single-incision laparoscopic total gastrectomy with D1+beta LN dissection
The total operative time was 175 min. Estimated blood loss was 50 ml. The patient was started on clear fluids on postoperative day 3 and tolerated a soft bland diet on postoperative day 4. Routine patient-controlled analgesia was administered for postoperative pain control, with good effect. The patient was discharged in stable condition without any complications or complaints on postoperative day 6. Results of final pathological analysis revealed no LN metastasis among 56 examined nodes (pT1bN0). The proximal and distal resection margin was 2.1 and 9.8 cm, respectively.
Single-incision laparoscopic surgery was introduced to reduce the minimal invasiveness of laparoscopy to the least invasiveness possible and to achieve excellent cosmetic results. SILS has been applied in various operations, with predominantly benign indications.
SILS is rarely applied for gastric cancer surgery. To the best of our knowledge, there have been only three reports describing this procedure for patients with EGC [5, 6, 7]. Furthermore, all these reports involve SIDG with one or two additional assistant ports.
This is the first case report describing successful single-incision laparoscopic total gastrectomy for early gastric cancer and also the first “pure” SITG without any additional assistant port. In our institution, we conducted an animal study in porcine models before the clinical application of SILS for EGC. We found that D1+beta LND could be performed during SIDG in this animal model .
After this animal study, we performed SIDG in 11 EGC patients with the approval of our institutional review board. We reported the first two cases as case reports . Based on these experiences, we prepared to perform pure SITG. The indication of SITG and conventional laparoscopic total gastrectomy (LTG) in our institution was clinical stage I (cT1-T2N0). The initial decision to perform SITG or LTG was mainly determined by the patient’s body mass index, which was between 18 and 21 kg/m2.
For pure SITG, the single-port device is very important for simple and less stressful surgery. The Glove port (Nelis, Buchen, Gyeonggi, Korea) is very effective, with the angle easily adjustable and no air leakage. Each valve can use 2- to 12-mm instruments. In addition, because the port is transparent, instruments can be inserted under direct visualization.
However, it can be difficult to maintain an optimal view in SITG, because of repeated clashes of the camera with the instruments. This technical challenge can be overcome with a flexible HD camera and an experienced camera operator. Further, a curved grasper can improve surgical performance, with less interference, thereby facilitating SILS with reduced time required and improved dexterity. In the future, a 5-mm flexible HD scope may help resolve the clashing of instruments, as more space would be available to move the instruments.
Conflict of interest
Drs. S.-H. Ahn, D.J. Park, S.Y. Son, C.-M. Lee, and H.-H. Kim have no conflicts of interest or financial ties to disclose.
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