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Comparative Study
. 2013 Jan;27(1):325-32.
doi: 10.1007/s00464-012-2433-y. Epub 2012 Jun 26.

Progression From Laparoscopic-Assisted to Totally Laparoscopic Distal Gastrectomy: Comparison of Circular Stapler (i-DST) and Linear Stapler (BBT) for Intracorporeal Anastomosis

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Free PMC article
Comparative Study

Progression From Laparoscopic-Assisted to Totally Laparoscopic Distal Gastrectomy: Comparison of Circular Stapler (i-DST) and Linear Stapler (BBT) for Intracorporeal Anastomosis

Tetsuo Ikeda et al. Surg Endosc. .
Free PMC article

Abstract

Background: Billroth I (B-I) gastroduodenostomy is an anastomotic procedure that is widely performed after gastric resection for distal gastric cancer. A circular stapler often is used for B-I gastroduodenostomy in open and laparoscopic-assisted distal gastrectomy. Recently, totally laparoscopic distal gastrectomy (TLDG) has been considered less invasive than laparoscopic-assisted gastrectomy, and many institutions performing laparoscopic-assisted distal gastrectomy are trying to progress to TLDG without markedly changing the anastomosis method. The purpose of this report is to introduce the technical details of new methods of intracorporeal gastroduodenostomy using either a circular or linear stapler and to evaluate their technical feasibility and safety.

Methods: Seventeen patients who underwent TLDG with the intracorporeal double-stapling technique using a circular stapler (n = 7) or the book-binding technique (BBT) using a linear stapler (n = 10) between February 2010 and April 2011 were enrolled in the study. Clinicopathological data, surgical data, and postoperative outcomes were analyzed.

Results: There were no intraoperative complications or conversions to open surgery in any of the 17 patients. The usual postoperative complications following gastroduodenostomy, such as anastomotic leakage and stenosis, were not observed. Anastomosis took significantly longer to complete with DST (64 ± 24 min) than with BBT (34 ± 7 min), but more stapler cartridges were needed with BBT than with DST.

Conclusions: TLDG using a circular or linear stapler is feasible and safe to perform. DST will enable institutions performing laparoscopic-assisted distal gastrectomy with circular staplers to progress to TLDG without problems, and this progression may be more economical because fewer stapler cartridges are used during surgery. However, if an institution has already been performing δ anastomosis in TLDG but has been experiencing certain issues with δ anastomosis, converting from δ anastomosis to BBT should be beneficial.

Figures

Fig. 1
Fig. 1
Illustration of trocar placement for totally laparoscopic Billroth-I gastrectomy with A i-DST and B BBT. A 12-mm trocar was inserted through an umbilical incision, and four other trocars (two 12-mm trocars and two 5-mm trocars) were placed under laparoscopic guidance
Fig. 2
Fig. 2
Illustration of the i-DST. A 60-mm linear stapler was introduced through the epigastric midline port, and resection of the stomach was performed only once. B The distal side of the stomach was completely transected using bipolar scissors. C The circular stapler was introduced into the remnant stomach, attached to the previously inserted duodenal anvil head, and fired. D The unclosed part of the remnant stomach was closed with the linear stapler
Fig. 3
Fig. 3
Illustration of the BBT. A The duodenal bulb was transected just below the pyloric ring from the greater curvature side toward the lesser curvature side. B The stomach was transected from the lesser curvature side toward the greater curvature side. C 45-mm endoscopic linear stapler was inserted through the left lower port, and a jaw was inserted into each of the created holes. D After the first stapling, there were three staple lines including those from the transection of the stomach and duodenum, which ran parallel to the anterior wall. E All of the transection lines on the duodenum, anterior side of the anastomosis line between the duodenum and stomach, and approximately one-third of the transection line on the stomach were dissected, and holes were made in the anterior wall. F The anterior hole was closed from the center to the lesser curvature. G The remaining hole from the greater curvature to the center was then closed
Fig. 4
Fig. 4
A Laparoscopic view of the completed anastomosis with i-DST. B Laparoscopic view of the completed anastomosis with BBT
Fig. 5
Fig. 5
A Postoperative wounds of the patient who underwent TLDG with i-DST. B Postoperative wounds of the patient who underwent TLDG with BBT

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