A modified efficient purse-string stapling technique (mEST) that uses a new metal rod for intracorporeal esophagojejunostomy in laparoscopic total gastrectomy

Abstract

Intracorporeal esophagojejunostomy after laparoscopic total gastrectomy is technically difficult because this procedure should be performed in a narrow surgical field in the upper abdomen even when completely laparoscopic approaches are used. The placement of the anvil of a circular stapling device into the esophagus and connection the instrument to the anvil are extremely difficult steps in this surgery. Therefore, we developed a simple technique for intracorporeal esophagojejunostomy using hemi-double stapling technique; we named this technique the efficient purse-string stapling technique (EST). More recently, we have developed a modified EST (mEST) that utilizes a new stainless steel anvil rod instead of a plastic rod. Relative to the plastic rod, the steel rod is reusable and shorter; thus, it was easier to perform anvil placement into the esophagus with the steel rod. Anvil preparation for mEST: a stainless steel rod is attached to the shaft of the anvil, and the needle and thread are sutured to the tip of the rod. After complete insertion of the anvil into the esophageal cavity, the needle and thread are used to penetrate the anterior esophageal wall, and the esophagus is then clamped using a linear stapler just distal to the site penetrated by the thread. The linear stapler is fired, and anvil placement in the esophagus is simultaneously accomplished. After the rod is removed from the anvil, the instrument is intracorporeally connected to the anvil and then fired to complete the gastrojejunostomy. This technique is simple and facilitates intracorporeal reconstruction procedures in laparoscopic total gastrectomy.

Keywords: Laparoscopic total gastrectomy; circular stapling device; efficient purse-string stapling technique (EST); gastric cancer; hemi-double stapling technique.

Figure 1

Cranial approach. (A) The peritoneum was cut along the right crus of the diaphragm; (B) completion of the cranial approach. The splenic artery and vein were completely mobilized from Gerota’s fascia.

Figure 2

Suprapancreatic lymph node dissection (at station 11). (A) Dissection of station 11p. The splenic vein, a landmark of the dorsal plane, was clearly exposed; (B) the posterior gastric artery and vein were identified and transected by clipping; (C) dissection of station 11d was performed until the bifurcations of the splenic artery and the distal splenic vein were exposed; (D) completion of dissection of station 11p/11d. The ventral side of the splenic hilum lymph nodes was partially dissected.

Figure 3

Anvil preparation for the EST (5). (A) The tip of a green plastic rod is tapered to blunt the tip. The rod is attached to the shaft of the anvil, and the needle and thread are sutured to the tip of the rod. Another thread is tied at the neck of the shaft; (B) after complete insertion of the anvil, the needle and thread are used to penetrate the anterior esophageal wall, and the esophagus is then clamped using a linear stapler just distal to the site penetrated by the thread; (C) the linear stapler is fired, and anvil placement in the esophagus is simultaneously accomplished; (D) rod removal. The rod is rotated and pulled to remove it from the anvil. EST, efficient purse-string stapling technique.

Figure 4

Anvil preparation for the modified EST. (A) The Endo Mini Rod is composed of stainless steel, and it is clearly shorter than the green plastic rod used in the EST; (B) the Endo Mini Rod with a needle and thread was attached to the anvil shaft.

Figure 5

Placement of the anvil head on the esophagus. (A) The distal esophagus was clamped using a detachable gastrointestinal forceps; (B) creation of the semi circumferential esophagotomy; (C) the anvil head was placed over the window; (D) fixation of the anvil head on the esophagus.

Figure 6

Insertion of the anvil into the esophagus. (A) The anvil with the rod was fully inserted into the esophagus; (B) needle penetration of the anterior esophageal wall; (C) the knot was entirely exteriorized from the esophageal cavity.

Figure 7

Fixation of the anvil in the esophagus. (A) The thread was held and retracted ventrally by the main surgeon’s left hand, and the bilateral side of the esophageal window was held by the first assistant; (B) the esophagus was clamped using a linear stapling device just distal to the site penetrated by the thread; (C) the esophagus was transected by firing the stapling device, and the thread was simultaneously pulled to exteriorize the anvil rod; (D) the anvil was fixed in the esophagus.

Figure 8

Removal of the rod from the anvil. (A) The rod was rotated and then pulled to remove it from the anvil shaft; (B) completion of anvil placement into the esophagus.

Figure 9

Connection between the anvil and the circular stapling device. (A) The trocar of a circular stapling device was connected to the anvil. The retraction of the thread was useful for upholding the anvil; (B) the instrument was fired to create the esophagojejunostomy; (C) completion of anastomosis.