Laparoscopic Total Gastrectomy

Distal pancreas was mobilized by incising the peritoneum along the inferior margin of the distal pancreas, during left-side omentectomy. If indicated, full mobilization of the spleen was performed for splenectomy. After dissecting LNs 7, 8, 9, and 12a, the lower esophagus was transected. Intracorporeal end-to-side esophagojejunostomy has been performed using an endoscopic purse-string instrument (Lap-Jack; Korea). We developed Lap-Jack, which can be inserted through the 12mm trocar site and reported a stable technique of esophagojejunostomy using it yielding good results (no anastomosis related complication). After transecting the lower esophagus, LNs 11p, 11d, and 10 were completely dissected. In cases in which the intracorporeal end-to-side esophagojejunostomy was performed using the endoscopic purse-string instrument, the left lower port was extended to a length of about 3 cm for removing the specimen and for inserting a circular stapler. In cases of intracorporeal side-to-side esophagojejunostomy, the specimen was extracted through an extended transumbilical incision and the negative resection margin was confirmed by frozen biopsy. The esophagojejunostomy was performed using a 45-mm length linear stapler and the common entry hole was subsequently closed with an intracorporeal continuous suture. Before any type of esophagojejunostomy was performed, an extracorporeal jejunojejunal anastomosis was performed at the site of specimen extraction. In cases of splenectomy, the caudal splenic artery was clipped and divided, and the splenic vein was clipped and divided at the point of entry into the distal pancreas.