Setting the stomach transection line based on anatomical landmarks in laparoscopic distal gastrectomy

Abstract

Laparoscopic distal gastrectomy has become widespread as a treatment for early gastric cancer in eastern Asia, but a standard method for setting the stomach transection line has not been established. Here we report a novel method of setting this line based on anatomical landmarks. At the start of the operation, two anatomical landmarks along the greater curvature of the stomach were marked with ink: the proximal landmark at the avascular area between the last branch of the short gastric artery and the first branch of the left gastroepiploic artery, and the distal landmark at the point of communication between the right and left gastroepiploic arteries. Just before specimen retrieval, the stomach was transected from the center of these two landmarks toward the lesser curvature. Then, about two-third of the stomach was reproducibly resected, and gastroduodenostomy was successfully performed in 26 consecutive cases. This novel method could be used as a standard technique for setting the transection line in laparoscopic distal gastrectomy.

Keywords: Gastroduodenostomy; Laparoscopic distal gastrectomy; Transection line.

Fig. 1. Overview of the stomach transection plan. The blue dots show the position of the proximal and distal anatomical landmarks to which Gentian violet ink is applied during laparoscopic distal gastrectomy. The proximal landmark is located in the avascular area between the last branch of the short gastric artery and the first branch of short gastric artery (LGEA), and the distal one, at the point of communication between the right gastroepiploic artery and the LGEA. The opened arrow shows the transection line. AGB = arteria gastricae breves; AGES = arteria gastroepiploica sinistra; APIS = arteria phrenica inferior sinistra; VGED =vena gastroepiploica dextra; VCDA =vena colica dextra accessoria; VCD = vena colica dextra; VCM = vena colica media. Data from the article of Japanese Gastric Cancer Association (Gastric Cancer 2011;14:101-112) with original copyright holder's permission.

Fig. 2. Marking of the two stomach anatomical landmarks. (A) The avascular area between the last branch of the short gastric artery (SGA) and the first branch of the short gastric artery (LGEA) is marked with Gentian violet ink. The branches of the LGEA and SGA are indicated with white and dotted white arrows, respectively. The spleen dorsal to the omental fat is outlined by the black dotted line. (B) The white star shows the middle point between the right gastroepiploic artery (white arrow) and the LGEA (dotted white arrow). In this patient, there is no direct communication between the two arteries. (C) View of the stomach after dissection of the lymph nodes along the LGEA (No. 4sb). The dotted white line shows the SGA while the two landmarks appear clearly marked with Gentian violet ink. (D) Prior to stomach transection, the transection line is outlined with Gentian violet ink from the middle point between the two landmarks (dotted white circles) towards the lesser curvature.