Laparoscopic distal gastrectomy with intracorporeal handsewn Billroth-I anastomosis (ICHSA)

Abstract

The number of cases of laparoscopic surgery has been increasing. Lymph node dissection has been standardized, and the enlarged view provided by laparoscopes allows for the procedure to be performed successfully entirely within the abdominal cavity, but many cases of reconstruction using the Billroth-I method are performed under direct vision through a small incision. In this study, by placing an anchor thread on a suture line on the lesser curvature of the stomach, we simplified the procedure for handsewn anastomosis and safely performed gastroduodenal anastomosis at low cost to obtain good results. From January 2009 to December 2010, we performed handsewn gastroduodenal anastomosis in 18 cases. After performing lymph node dissection, the duodenum and the stomach were separated using an automatic stapling device. Anchor sutures were placed on the suture line of the lesser curvature of the stomach. First, the seromuscular layer of the stomach and the seromuscular layer of the duodenum were sutured by performing interrupted suturing using an extracorporeal knot-tying method. With the stomach and the duodenum in a fixed state, the anastomosis area was opened. The thread of the anchor suture was pulled toward the abdominal wall, and then all layers of the stomach and the duodenum at the posterior wall were continuously sutured. Similarly, for the anterior wall, all layers were continuously sutured from the lesser curvature toward the greater curvature. We performed this anastomotic procedure in 18 patients with early gastric carcinoma. The mean time required for the anastomosis was 64.6 ± 17.1 min, and the estimated blood loss was 53.1 ± 91 g. All operations were curative, and the mean number of retrieved lymph node was 27.1 ± 10.8. A nasogastric tube was removed on the first or second day. An upper gastrointestinal series performed on postoperative days 5-6 showed no anastomotic leakage and normal transit. Oral intake was started on days 6-7. Postoperative complications included one case of a ruptured suture, but this was resolved through a conservative approach. There was no mortality. Postoperative endoscopy revealed that the anastomosis area was extremely soft, and no abnormalities were observed. Moreover, the only costs related to the anastomosis were for the thread and needles, and although more time was required compared with mechanical anastomosis, the cost was extremely low. We performed gastroduodenal anastomosis under a total laparoscopic approach by handsewn. This method is economical, because it does not require the use of machinery for anastomosis, and the duodenal stump is short. We believe that this method, which can be performed in a similar manner even for obese patients, can be used as a standard method of anastomosis.