Reconsideration of hot topics on laparoscopic radical gastrectomy

Abstract

Laparoscopic radical gastrectomy(LRG) has been popularized with the development of laparoscopic surgical techniques. As a result of the requirement of surgical skill of LRG, the evidence is always highly demanded. The surgical safety and radical resection of tumor is one of the most important principles. Based on published studies and authors' own experience, this article discusses the following topics on laparoscopic gastrectomy: (1)Indications of surgery: Laparoscopic gastrectomy for early gastric cancer is accepted all over the world. For locally advanced gastric cancer, laparoscopic gastrectomy with D2 dissection is considered to be safe and feasible based on domestic studies, especially the CLASS research. (2)Positions and approaches: Classic approaches of laparoscopic gastrectomy include left-side approach, right-side approach, anterior approach and posterior approach. Left-side position is the first choice in China, which is suitable for most laparoscopic gastrectomy. Meanwhile, right-side position is most recommended in Japan and Korea. The selection of approach could be varied by the feature of the tumor, the anatomy of the tumor and the habit of surgeons. (3) Lymphadenectomy of the superior area of pancreas: Based on Japanese Classification of Gastric Carcinoma (14th edition), Chinese Expert Consensus on Quality Control of Laparoscopic Radical Gastrectomy for Gastric Cancer (2017 edition) and authors' own experience, we define the lymph node dissection margin of the superior area of pancreas in laparoscopic distal gastrectomy with D2 dissection as follows: right side is the left wall of portal vein; left side is the posterior gastric artery; upper side is the commissure of diaphragmatic crura; lower side is the anterosuperior side of common hepatic artery and splenic artery; posterior side (on the right side of coeliac trunk) is the plane composed of portal vein, common hepatic artery and the root of coeliac trunk; posterior side (on the left side of coeliac trunk) is the Gerota's fascia. (4) Bursectomy or not: Bursectomy is not recommended as standard procedure in cT3 or cT4a gastric cancer based on the results of JCOG1001. However, to achieve a better surgical plane, dissection of anterior lobe of transverse mesocolon and pancreatic capsule in some area is accepted. (5) Totally laparoscopic reconstruction of digestive tract: along with the development of equipment and modification of anastomosis, the totally laparoscopic reconstruction of digestive tract becomes more and more welcome in laparoscopic gastrectomy as it provides a better and larger surgical scene compared to small incision assisted surgery. The whole procedure of anastomosis is overlooked by laparoscopy, without any over traction of tissue.