Laparoscopic Proximal Gastrectomy with Double Tract Reconstruction
Authors
Dr Joel Wong, Dr Charleen Yeo, Dr Aung Myint Oo
Affiliations
Department of General Surgery, Tan Tock Seng Hospital, Singapore
Introduction
Gastric cancer is the 5th most common cancer in the world. For upper gastric cancers, total gastrectomy is accepted as the standard treatment. However, this is associated with significant nutritional and malabsorptive issues post-operatively. In recent years, proximal gastrectomy with double-tract reconstruction has been shown to be a safe and oncologically sound alternative.
In this video we present a step-by-step instructional video on performing a laparoscopic proximal gastrectomy with double tract reconstruction.
Case Presentation
Our patient is a 67 year-old lady who presented with weight loss. She underwent an oesophagogastroduodenoscopy which showed a proximal greater curve polyp. Histology revealed high-grade dysplasia. She then underwent endoscopic submucosal dissection of the lesion and the histology returned as pT1b adenocarcinoma with submucosal invasion more than 0.5mm. The patient was hence counselled for surgery.
The patient was positioned supine, with 4 laparoscopic trocars. Diagnostic laparoscopy showed no palpable tumour, enlarged lymph nodes or peritoneal metastasis. The stomach was mobilized with division of the gastrocolic ligament. Short gastrics were taken and fundus mobilized. The lesser curve was dissected with preservation of the left gastric artery to supply the remnant stomach. Proximal gastrectomy was then performed. The reconstruction was done in a double-tract fashion with oesophagojejunostomy, gastrojejunostomy and jejuno-jejunostomy all intra-corporeal. Anastomoses were performed with linear staplers in a side-to-side fashion with closure of the enterotomies in 2 layers with absorbable V-loc 3-0 and PDS 3-0.
Operative time was 347 minutes with no intraoperative complications. The post-operative course was uneventful. The patient underwent a gastrograffin meal and swallow on POD5 which showed smooth flow of contrast into the stomach and jejunum and no anastomotic leak. The patient was given liquid diet in POD5, soft diet in POD6 and she was discharged on POD8. The histological exam revealed no residual tumour. Final histology was pT1bN0.