Unaided Stapling Technique for Pure Single-Incision Distal Gastrectomy in Early Gastric Cancer: Unaided Delta-Shaped Anastomosis and Uncut Roux-en-Y Anastomosis

Abstract

Purpose: Intracorporeal anastomosis is the most difficult procedure during pure single-incision distal gastrectomy (SIDG) that affects its generalization. We introduced unaided delta-shaped anastomosis (uDelta), a novel anastomosis technique, for gastroduodenostomy after pure SIDG, and compared the results with those of previously reported Roux-en-Y anastomosis (RY).

Materials and methods: Between March 2014 and March 2015, SIDG with D1+ lymph node dissection was performed for early gastric cancer through a 2.5-cm transumbilical incision without any additional port. uDelta was performed by the operator alone, without any intracorporeal assistance.

Results: uDelta was performed on 11 patents, and uncut RY was performed on 5-patients without open or multiport conversion. R0 resection was performed in all cases. No significant differences were observed in mean age and body mass index between patients who underwent uDelta or RY. Mean operation times were 214.5±36.2 minutes for uDelta and 240.8±65.9 minutes for RY, which was not significantly different. Reconstruction time for uDelta was shorter than that for RY, with marginal statistical significance (26.1±8.3 minutes vs. 38.0±9.1 minutes, P=0.05). There were no intraoperative transfusions, 30-day mortality, or anastomosis-related complications in either group. Average length of hospital stay was 8.2±1.9 days in the uDelta group and 7.2±0.8 days in the RY group (P=0.320).

Conclusions: After carefully considering indications, uDelta can be a feasible and can be a reproducible reconstruction method after SIDG in early gastric cancer.

Keywords: Billroth I; Gastrectomy; Laparoscopy; Roux-en-Y anastomosis; Stomach neoplasm.

Fig. 1. Unaided delta-shaped anastomosis. (A) A traction suture with 3/0 monofilament thread is added at the posterior wall of the small incision hole of the remnant stomach and pulled out through a single umbilical port. (B) An opened 45-mm linear stapler inserted at the remnant stomach is manipulated by the operator with one hand. (C) The other jaw of the stapler is inserted at the incision site of the duodenal stump, which is easily controlled by the operator alone. (D) After the first stapling of the gastroduodenostomy, one traction suture at the lesser curvature side of the common entry hole is pulled up by the operator's left hand. This suture can be replaced by the previous suture at the posterior wall of the remnant stomach. An additional traction suture at the greater curvature side of the common entry hole is pulled out through the single port and simultaneously manipulated outside the abdominal cavity with a linear stapler. (E) The common entry hole can be easily closed with a single application of a 60-mm linear stapler under gentle traction with 2 traction sutures inside and outside the abdominal cavity. (F) The unaided delta-shaped gastroduodenostomy is completed.

Fig. 2. Median number of estimated lymph nodes (LNs) at each lymph node station after total cases of single-incision distal gastrectomy with D1+ lymph node dissection.

Fig. 3. Operation time of single-incision distal gastrectomy. BI indicates unaided delta-shaped anastomosis, and RY indicates Roux-en-Y anastomosis.