Laparoscopic Spleen-preserving Splenic Hilar Lymphadenectomy Research Articles

Laparoscopic Spleen-Preserving Hilar Lymphadenectomy for Advanced Proximal Gastric Cancer Without Greater Curvature Invasion

Splenic hilar lymphadenectomy has been recommended for locally advanced proximal gastric cancer (APGC) involving the greater curvature. However, it is unclear whether laparoscopic spleen-preserving splenic hilar lymphadenectomy (LSPSHL) is associated with a long-term survival benefit for APGC without greater curvature invasion. To present the 5-year follow-up data from a randomized clinical trial that compared laparoscopic total gastrectomy (D2 group) with D2 plus LSPSHL (D2 + No. 10 group) among patients with resectable APGC. This is a post hoc secondary analysis of a randomized clinical trial that enrolled 536 patients with potentially resectable APGC (cT2-4a, N0 or N+, and M0) without greater curvature invasion from January 5, 2015, to October 10, 2018. All patients were tracked for at least 5 years. The final follow-up was on October 30, 2023. Patients were randomly assigned in a 1:1 ratio to the D2 + No. 10 or D2 groups. The 5-year disease-free survival (DFS) and overall survival (OS) rates were measured. Recurrence patterns and causes of death were compared. A total of 526 patients (392 men [74.5%]; mean [SD] age, 60.6 [9.6] years) were included in the modified intent-to-treat analysis, with 263 patients in each group. The 5-year DFS rate was 63.9% (95% CI, 58.1%-69.7%) for the D2 + No. 10 group and 55.1% (95% CI, 49.1%-61.1%) for the D2 group (log-rank P = .04). A statistically significant difference was observed in the 5-year OS between the D2 + No. 10 group and the D2 group (66.2% [95% CI, 60.4%-71.9%] vs 57.4% [95% CI, 51.4%-63.4%]; log-rank P = .03). The No. 10 lymph node exhibited a therapeutic value index (TVI) of 6.5, surpassing that of Nos. 8a (TVI, 3.0), 11 (TVI, 5.8), and 12a (TVI, 0.8). A total of 86 patients in the D2 + No. 10 group (cumulative incidence, 32.7%) and 111 patients in the D2 group (cumulative incidence, 42.2%) experienced recurrence (hazard ratio, 0.72; 95% CI, 0.54-0.95; P = .02). The multivariable competing risk regression model demonstrated that D2 + No. 10 remained an independent protective factor for a lower 5-year cumulative recurrence rate after surgery (hazard ratio, 0.75; 95% CI, 0.56-1.00; P = .05). There was a significant difference in the 5-year cumulative recurrence rate at the No. 10 lymph node area between the 2 groups (D2 + No. 10 group vs D2 group: 0% vs 2.3% [n = 6]; P = .01). This post hoc secondary analysis of a randomized clinical trial found that laparoscopic total gastrectomy with LSPSHL can improve the prognosis and reduce recurrence for APGC without greater curvature invasion. Future multicenter studies are warranted to validate these findings. ClinicalTrials.gov Identifier: NCT02333721.

Robotic spleen-preserving total gastrectomy shows better short-term advantages: a comparative study with laparoscopic surgery.

Robotic surgery may be advantageous for complex surgery. We aimed to compare the intraoperative and postoperative short-term outcomes of spleen-preserving splenic hilar lymphadenectomy (SPSHL) during robotic and laparoscopic total gastrectomy. From July 2016 to December 2020, the clinicopathological data of 115 patients who underwent robotic total gastrectomy combined with robotic SPSHL (RSPSHL) and 697 patients who underwent laparoscopic total gastrectomy combined with laparoscopic SPSHL (LSPSHL) were retrospectively analyzed. A 1:2 ratio propensity score matching (PSM) was used to balance the differences between the two groups to compare their outcomes. The Generic Error Rating Tool was used to evaluate the technical performance. After PSM, the baseline preoperative characteristics of the 115 patients in the RSPSHL and 230 patients in the LSPSHL groups were balanced. The dissection time of the region of the splenic artery trunk (5.4 ± 1.9min vs. 7.8 ± 3.6min, P < 0.001), the estimated blood loss during SPSHL (9.6 ± 4.8ml vs. 14.9 ± 7.8ml, P < 0.001), and the average number of intraoperative technical errors during SPSHL (15.1 ± 3.4 times/case vs. 20.7 ± 4.3 times/case, P < 0.001) were significantly lower in the RSPSHL group than in the LSPSHL group. The RSPSHL group showed higher dissection rates of No. 10 (78.3% vs. 70.0%, P = 0.104) and No. 11d (54.8% vs. 40.4%, P = 0.012) lymph nodes and significantly improved postoperative recovery results in terms of times to ambulation, first flatus, and first intake (P < 0.05). The splenectomy rates of the two groups were similar (1.7% vs. 0.4%, P = 0.539), and there was no significant difference in morbidity and mortality within postoperative 30days (13.0% vs. 15.2%, P = 0.589). Compared to LSPSHL, RSPSHL has more advantages in terms of surgical qualities and postoperative recovery process with similar morbidity and mortality. For complex SPSHL, robotic surgery may be a better choice.

130P Reappraisal of the role of no. 10 lymphadenectomy for proximal gastric cancer in the era of minimal invasive surgery during total gastrectomy: A pooled analysis of 4 prospective trials

For patients with locally advanced proximal gastric cancer (LAPGC), the individualized selection of patients with highly suspected splenic hilar (No. 10) lymph node (LN) metastasis to undergo splenic hilar lymphadenectomy, is a clinical dilemma. This study aimed to re-evaluate the feasibility and safety of laparoscopic spleen-preserving splenic hilar lymphadenectomy (LSPSHL) and to identify the population who would benefit from it. A total of 1068 patients (D2 group=409; D2+No. 10 group=659) who underwent laparoscopic total gastrectomy from four prospective trials between January 2015 and July 2019 were analyzed. No significant difference in the incidence (16.9% vs. 16.4%; P = 0.837) of postoperative complications were found between the two groups. The metastasis rate of No. 10 LN among patients in the D2+No. 10 group was 10.3% (68/659). Based on the decision tree, patients with LAPGC with tumor invading the greater curvature (Gre), patients with non-Gre-invading LAPGC with a tumor size >5 cm and clinical positive locoregional LNs were defined as the high-priority No. 10 dissection group. The metastasis rate of No. 10 LNs in the high-priority group was 19.4% (41/211). In high-priority group, the 3-year overall survival of the D2+No. 10 group was better than that of the D2 group (74.4% vs. 42.1%; P = 0.005), and the therapeutic index of No. 10 was higher than the indices of most suprapancreatic stations. LSPSHL for LAPGC is safe and feasible when performed by experienced surgeons. LSPSHL could be recommended for the high-priority group patients even without invasion of the Gre.

156P Safety and feasibility of laparoscopic spleen-preserving splenic hilar lymphadenectomy during total gastrectomy for advanced proximal gastric cancer: A randomized clinical trial

156P Safety and feasibility of laparoscopic spleen-preserving splenic hilar lymphadenectomy during total gastrectomy for advanced proximal gastric cancer: A randomized clinical trial

Reappraise role of No. 10 lymphadenectomy for proximal gastric cancer in the era of minimal invasive surgery during total gastrectomy: a pooled analysis of 4 prospective trial.

For patients with locally advanced proximal gastric cancer (LAPGC), the individualized selection of patients with highly suspected splenic hilar (No. 10) lymph node (LN) metastasis to undergo splenic hilar lymphadenectomy, is a clinical dilemma. This study aimed to re-evaluate the feasibility and safety of laparoscopic spleen-preserving splenic hilar lymphadenectomy (LSPSHL) and to identify the population who would benefit from it. A total of 1068 patients (D2 group = 409; D2 + No. 10 group = 659) who underwent laparoscopic total gastrectomy from four prospective trials between January 2015 and July 2019 were analyzed. No significant difference in the incidence (16.9% vs. 16.4%; P = 0.837) of postoperative complications were found between the two groups. The metastasis rate of No. 10 LN among patients in the D2 + No. 10 group was 10.3% (68/659). Based on the decision tree, patients with LAPGC with tumor invading the greater curvature (Gre), patients with non-Gre-invading LAPGC with a tumor size > 5cm and clinical positive locoregional LNs were defined as the high-priority No. 10 dissection group. The metastasis rate of No. 10 LNs in the high-priority group was 19.4% (41/211). In high-priority group, the 3-year overall survival of the D2 + No. 10 group was better than that of the D2 group (74.4% vs. 42.1%; P = 0.005), and the therapeutic index of No. 10 was higher than the indices of most suprapancreatic stations. LSPSHL for LAPGC is safe and feasible when performed by experienced surgeons. LSPSHL could be recommended for the high-priority group patients even without invasion of the Gre.

Safety and Feasibility of Laparoscopic Spleen-Preserving Splenic Hilar Lymphadenectomy During Total Gastrectomy for Advanced Proximal Gastric Cancer: A Randomized Clinical Trial

Background: The splenic hilar lymph node (No. 10 LN) dissection is still controversial for patients with advanced proximal gastric cancer (APGC) not invading the greater curvature. The present study aimed to evaluate the short-term outcomes of laparoscopic spleen-preserving No. 10 lymphadenectomy (LSPL) for APGC not invading the greater curvature and the characteristic of No. 10 LN metastasis. Methods: This single-center, open-label, randomized, phase III clinical trial was done in the Department of Gastric Surgery, Fujian Medical University Union Hospital (FMUUH). Individuals aged 18 to 75 years who had histologically proven gastric adenocarcinoma in proximal stomach with clinical stage cT2-4a/N0-3/M0 not invading the greater curvature were enrolled and randomized (1:1) to receive laparoscopy-assisted total gastrectomy with either D2 lymphadenectomy (D2 group) or D2 lymphadenectomy without No. 10 LN dissection (D2- group). The main outcomes were morbidity and mortality within 30 days after surgery, number of retrieved LNs, and the metastasis rate of No. 10 LN. Analysis was based on modified intention-to-treat. Findings: From Jan 5, 2015, to Dec 10, 2018, 268 participants were randomly assigned to the D2 and D2- groups respectively. The full analysis set consisted of 263 participants in the D2 and D2- groups respectively. There were no significant differences in the intraoperative and postoperative morbidity between the D2 and D2- groups (all P>0.05). And there was no mortality in either group. There were more retrieved LNs in the D2 group than in the D2- group (45.1 vs 40.6, P=0.001). The metastasis rate of the No. 10 LN was 13.3% (35/263): 4.9% (2/41) in the early stage, and 14.9% (18/223) in the advanced stage. Pathological T (pT) stage and pN stage were related to No. 10 LN metastasis. The metastasis rates of No. 10 LN in T3-4a tumors located in the lesser curvature, posterior wall or multiple parts were all higher than 10%. Interpretation: Experienced surgeons can safely perform LSPL for APGC with more retrieved LNs. For APGC located in the lesser curvature, posterior wall or multiple parts with a clinical stage cT3-4a, dissection of the No.10 LN is necessary. Trial Registration: The study is registered with ClinicalTrials.gov, number NCT02333721; the trial has ended and this report represents the final analysis. Funding Statement: This study was supported by Scientific and Technological Innovation Joint Capital Projects of Fujian Province (2016Y9031; 2017Y9011). Construction Project of Fujian Province Minimally Invasive Medical Center (No. [2017]171). Fujian Science and Technology Innovation Joint Fund Project (2017Y9004). Joint Funds for the Innovation of Science and Technology of Fujian Province (2018Y9041). Special Fund for Clinical Research of Wu Jieping Medical Foundation (No: 320.6750.17511). Declaration of Interests: There are no conflicts of interest or financial ties to disclose from any authors. Ethics Approval Statement: The trial protocol was approved by the FMUUH Ethics Committee, and all participants provided written informed consent.

Enlightenment and reflection of splenic hilar lymph node dissection for advanced proximal gastric cancer

Splenic hilar lymph node (LN) is the difficulty and focus of perigastric LN dissection during radical gastrectomy for advanced proximal gastric cancer (APGC). Although the new edition of Japanese Gastric Cancer Treatment Guidelines excluded the splenic hilar LN from the D2 lymphadenectomy in patients with APGC, there are still few high-level evidences. Meanwhile, the guideline recommends that splenectomy is still necessary for patients with APGC involving the greater curvature. With the support of increasing evidences, the spleen-preserving splenic hilar LN dissection has been recognized by more and more scholars. Additionally, the technique of laparoscopy provides a new method for splenic hilar LN dissection. Our center proposed a new technique named Huang′s three-step maneuver for laparoscopic spleen-preserving splenic hilar lymphadenectomy, which not only reduces the difficulty of operation, but also makes the technique easier to popularize and with a significance of minimally invasive effect. During the clinical practice, the dissection of LNs behind the splenic portal vessels is also one of the controversies. Therefore, the difficult technique of splenic hilar LN dissection not only requires us to make a technical exploration, but also requires us to explore precise indications, in order to avoid unnecessary operation in patients who do not require dissection of the No.10 LNs and to avoid missing the opportunity for radical surgery in high-risk patients because of the difficult techniques. Key words: Gastric neoplasms; Surgical procedure, operative; Splenic hilar lymph node; Lymphadenectomy; Laparoscopy

Effects of duodenal transection timing on clinical short-term outcomes of patients with laparoscopic spleen-preserving splenic hilar lymphadenectomy for advanced proximal gastric cancer

BackgroundTo determine the optimal timing of duodenal transection in patients undergoing laparoscopic-assisted total gastrectomy (LATG) in combination with laparoscopic spleen-preserving splenic hilar lymphadenectomy (LSPL) for advanced proximal gastric cancer (APGC).MethodsOne hundred twenty-seven patients with APGC who received LATG with duodenal transection as well as LSPL between January 2017 and July 2018 were retrospectively recruited in this study. According to the different transection timing, the patients were allocated into two groups: a conventional group (CG) who received the duodenal transection prior to the LSPL and an experimental group (EG) who were given LSPL before the duodenum was transected. Clinical short-term outcomes were compared in the two groups.ResultsAnalysis of the demographical and clinical characteristics showed that the two groups were comparable with no significant differences between CG and EG in the study patients regardless of their body mass indices (BMI). The intraoperative and postoperative indicators for clinical short-term outcomes were compared between the CG and EC, and results indicated that the EG had significant shorter mean time of LSPL and total operation time than those in the CG (P < 0.05). Of note, the numbers of patients with intraoperative injury and the volume of blood loss during the LSPL procedure were significantly reduced in the EG versus CG (P < 0.05). For the obese APGC patients, administration of LSPL prior to duodenal transection significantly increased the number of dissected No.10 lymph nodes (LNs) (P < 0.05). The other intraoperative and postoperative indicators did not show any differences between the two comparison groups.ConclusionsOur findings demonstrated that duodenal transection timing was significantly associated with clinical short-term outcomes of APGC patients. The duodenal transection prior to the LSPL is superior overall to the conventional transection timing in the treatment of APGC patients with LATG and LSPL in combination.

Randomized controlled trial comparing short-term outcomes of laparoscopic and open spleen-preserving splenic hilar lymphadenectomy for advanced proximal gastric cancer: An interim report.

We compared the clinical outcomes of laparoscopic and open spleen-preserving splenic hilar lymphadenectomy (LSPL and OSPL) for gastric cancer. We performed a single-center, randomized, controlled trial to compare the short-term surgical outcomes between LSPL and OSPL. The study was registered in ClinicalTrials.gov (NCT02980861). A total of 222 patients were enrolled (114 in the LSPL group and 108 in the OSPL group). There were no significant differences between the two groups in operative time (P = 0.152), a number of harvested lymph nodes (P = 0.669) including no. 10 lymph nodes (2.1 ± 1.4 vs 2.3 ± 1.2, P = 0.713). The time taken for no. 10 lymph node dissection was similar in both groups (13.9 ± 10.4 vs 15.2 ± 9.4 minutes, P = 0.217); however, the LSPL group experienced less total blood loss (P < 0.001) and less blood loss during no. 10 lymph node dissection compared with the OSPL group (15.3 ± 37.8 vs 29.5 ± 36.4 mL, P < 0.001). The postoperative complication rates of LSPL and OSPL were 18.3% and 16.1%, respectively (P = 0.331). LSPL is a safe and feasible surgical procedure in no. 10 LN dissection for patients with advanced proximal gastric cancer. Thus, this prospective trial is continuing.

Totally laparoscopic total gastrectomy for locally advanced middle-upper-third gastric cancer.

Totally laparoscopic total gastrectomy (TLTG) for locally advanced middle-upper-third gastric cancer is becoming increasingly popular. The difficulty of TLTG for locally advanced middle-upper-third gastric cancer is laparoscopic spleen-preserving splenic hilar lymphadenectomy and the intracorporeal digestive tract reconstruction. We summed up a set of unique experience through clinical practice to simplify operation procedures. We performed TLTG with Huang's three-step maneuver in laparoscopic spleen-preserving splenic hilar lymphadenectomy and a later-cut overlap Roux-en-Y anastomosis in the intracorporeal digestive tract reconstruction for patients with locally advanced middle-upper-third gastric cancer. The Huang's three-step maneuver divided the complicated procedure of laparoscopic spleen-preserving splenic hilar lymphadenectomy into three steps, including the dissection of the lymph nodes (LNs) in the inferior pole region of the spleen (1st step), the region of the splenic artery trunk (2nd step), and the superior pole region of the spleen (3rd step). The later-cut overlap Roux-en-Y anastomosis used only endoscopic linear staplers intracorporeally and the small intestine was cut off after the esophagojejunostomy was completed, so that we could grasp the small intestine more easily and determine the direction of anastomosis more conveniently. One patient experienced later anastomotic leakage and was successfully treated by conservative in 16 consecutive patients. No patient experienced any operation-related complications. At a median follow-up of 15 months, no patients had died or experienced recurrent or metastatic disease. TLTG with Huang's three-step maneuver in laparoscopic spleen-preserving splenic hilar lymphadenectomy and a later-cut overlap Roux-en-Y anastomosis in the intracorporeal digestive tract reconstruction for locally advanced middle-upper-third gastric cancer was technically safe and feasible, with acceptable short-term outcomes.

Totally laparoscopic total gastrectomy (TLTG) with Huang’s three-step maneuver in laparoscopic spleen-preserving splenic hilar lymphadenectomy and a later-cut overlap Roux-en-Y anastomosis

Totally laparoscopic total gastrectomy (TLTG) with Huang’s three-step maneuver in laparoscopic spleen-preserving splenic hilar lymphadenectomy and a later-cut overlap Roux-en-Y anastomosis

Laparoscopic spleen-preserving complete splenic hilum lymphadenectomy for advanced proximal gastric cancer

For advanced proximal gastric cancer, total gastrectomy with D2 lymphadenectomy is the standard surgical therapy containing splenic hilum lymph nodes (LNs) dissection. However, laparoscopic spleen-preserving complete splenic hilum LNs dissection for advanced proximal gastric cancer is technically challenging. Herein, we introduced an omnibearing method for laparoscopic spleen-preserving complete splenic hilar lymphadenectomy in racial total gastrectomy. The order of lymphadenectomy was No. 4d and 6 LNs-No. 12a, 8a, 9 and 7 LNs-No. 1, 3 and 5 LNs-No. 4sb, 4sa and 2 LNs-No. 10 and 11 (anterosuperior) LNs-No. 10 and 11 (posterior) LNs. During dissecting No. 10 and 11 LNs, we divided them into two parts, namely LNs anterosuperior and posterior to the splenic vessel. Laparoscopic total gastrectomy with spleen-preserving splenic hilum LNs dissection using an omnibearing method for advanced proximal gastric cancer was safe and technically feasible in experienced hands. Further studies in terms of its clinical significance are needed.

The effects of laparoscopic spleen-preserving splenic hilar lymphadenectomy on the surgical outcome of proximal gastric cancer: a propensity score-matched, case-control study.

The evidence regarding the long-term results of laparoscopic spleen-preserving splenic hilar lymphadenectomy (LSPL) has only been rarely reported. The aim of this study was to investigate the feasibility and oncologic efficacy of LSPL for locally advanced proximal gastric cancer. From May 2007 to December 2012, we prospectively collected and retrospectively analyzed the data of 548 patients who underwent laparoscopic radical total gastrectomy due to proximal gastric cancer. The patients were grouped according to spleen-preserving splenic hilar lymphadenectomy (200 in the D2 group and 348 in the D2-group). The short- and long-term outcomes were compared between the two groups after propensity score matching. Before matching, TNM stages were significantly different between the D2 and D2-groups. After propensity score matching, the two groups were well balanced in clinicopathologic characteristics. After matching, the time for lymph node dissection was longer in the D2 group, but a greater number of lymph nodes were dissected; the estimated blood loss, time to first flatus and duration of hospital stay were similar in the two groups. Furthermore, no significant differences in morbidity and mortality were found. Before matching, the 3-year overall survival (OS) and disease-free survival (DFS) rates of the D2 group were comparable with those of the D2-group (62.4 vs. 57.7%, p=0.076). After matching, the 3-year OS remained comparable, but the D2 group showed significantly longer 3-year DFS (61.6 vs. 53.7%, p=0.034). Stratified analysis showed that, in stage III patients, the D2 group had better 3-year DFS. Multivariate Cox regression showed that age (p=0.003), operation (p=0.001) and pN stage (p<0.001) were independent prognostic factors. LSPL is a safe and feasible procedure, and patients with stage III proximal gastric cancer might obtain higher 3-year DFS rates.

How to step over the learning curve of laparoscopic spleen-preserving splenic hilar lymphadenectomy.

As the reported incidence of No. 10 lymph node metastases is about 9.8–20.9% (1), the lymph nodes in the splenic hilar area should be dissected for D2 LN dissection during total gastrectomy for advanced proximal gastric cancer (2).

Laparoscopic splenic hilar lymphadenectomy for advanced gastric cancer.

Laparoscopic distal gastrectomy has recently become accepted as a surgical option for early gastric cancer in the distal stomach, but laparoscopic total gastrectomy (LTG) has not become widespread because of technical difficulties of esophagojejunal anastomosis and splenic hilar lymphadenectomy. Splenic hilar lymphadenectomy should be employed in the treatment of advanced proximal gastric cancer to complete D2 dissection, but laparoscopically it is technically difficult even for skilled surgeons. Based on the evidence that prophylactic combined resection of spleen in total gastrectomy increased the risk of postoperative morbidity with no survival impact, surgeons have preferred laparoscopic spleen-preserving splenic hilar lymphadenectomy (LSPL) for advanced tumors without metastasis to splenic hilar nodes or invasion to the greater curvature of the stomach, and reports with LSPL have been increasing rather than LTG with splenectomy. In this paper, recent reports with laparoscopic splenic hilar lymphadenectomy were reviewed.

Learning Curve of the Application of Huang Three-Step Maneuver in a Laparoscopic Spleen-Preserving Splenic Hilar Lymphadenectomy for Advanced Gastric Cancer.

To investigate the learning curve of the application of Huang 3-step maneuver, which was summarized and proposed by our center for the treatment of advanced upper gastric cancer.From April 2012 to March 2013, 130 consecutive patients who underwent a laparoscopic spleen-preserving splenic hilar lymphadenectomy (LSPL) by a single surgeon who performed Huang 3-step maneuver were retrospectively analyzed. The learning curve was analyzed based on the moving average (MA) method and the cumulative sum method (CUSUM). Surgical outcomes, short-term outcomes, and follow-up results before and after learning curve were contrastively analyzed. A stepwise multivariate logistic regression was used for a multivariable analysis to determine the factors that affect the operative time using Huang 3-step maneuver.Based on the CUSUM, the learning curve for Huang 3-step maneuver was divided into phase 1 (cases 1–40) and phase 2 (cases 41–130). The dissection time (DT) (P < 0.001), blood loss (BL) (P < 0.001), and number of vessels injured in phase 2 were significantly less than those in phase 1. There were no significant differences in the clinicopathological characteristics, short-term outcomes, or major postoperative complications between the learning curve phases. Univariate and multivariate analyses revealed that body mass index (BMI), short gastric vessels (SGVs), splenic hilar artery (SpA) type, and learning curve phase were significantly associated with DT. In the entire group, 124 patients were followed for a median time of 23.0 months (range, 3–30 months). There was no significant difference in the survival curve between phases.AUGC patients with a BMI less than 25 kg/m2, a small number of SGVs, and a concentrated type of SpA are ideal candidates for surgeons who are in phase 1 of the learning curve.

Laparoscopic spleen-preserving complete splenic hilum lymphadenectomy for advanced proximal gastric cancer

For advanced proximal gastric cancer, total gastrectomy with D2 lymphadenectomy is the standard surgical therapy containing splenic hilum lymph nodes (LNs) dissection. However, laparoscopic spleen-preserving complete splenic hilum LNs dissection for advanced proximal gastric cancer is technically challenging. Herein, we introduced an omnibearing method for laparoscopic spleen-preserving complete splenic hilar lymphadenectomy in racial total gastrectomy. The order of lymphadenectomy was No. 4d and 6 LNs-No. 12a, 8a, 9 and 7 LNs-No. 1, 3 and 5 LNs-No. 4sb, 4sa and 2 LNs-No. 10 and 11 (anterosuperior) LNs-No. 10 and 11 (posterior) LNs. During dissecting No. 10 and 11 LNs, we divided them into two parts, namely LNs anterosuperior and posterior to the splenic vessel. Laparoscopic total gastrectomy with spleen-preserving splenic hilum LNs dissection using an omnibearing method for advanced proximal gastric cancer was safe and technically feasible in experienced hands. Further studies in terms of its clinical significance are needed.

Application progress of different approaches splenic hilar lymph node dissection in laparoscopic radical gastrectomy for gastric cancer

Laparoscopic spleen-preserving splenic hilar lymphadenectomy (LSPL) is a operation conducted experimentally in the current. Current reports showed that it can be safely completed through different approach, such as the right, left, medial and retropancreatic approach. This paper summarized the steps and characteristics of different approaches LSPL and compared the differences between each other. The application status of LSPL in laparoscopy-assisted radical gastrectomy were reviewed. The security, feasibility and the problem to be solved of LSPL, improvement measure also be explored in this paper.

Application of Huang's three-step maneuver for laparoscopic spleen-preserving splenic hilus lymphadenectomy for advanced proximal gastric cancer

Objective To investigate the clinical efficacy of Huang's three-step maneuver in laparoscopic spleen-preserving splenic hilar (No. 10 lymph node) lymphadenectomy for advanced proximal gastric cancer. Methods The clinical data of 122 patients who underwent laparoscopic spleen-preserving No. 10 lymphadenectomy for advanced proximal gastric cancer by Huang's three-step maneuver at the Affiliated Union Hospital of Fujian Medical University from March 2013 to December 2013 were retrospectively analyzed. All the patients received laparoscopy-assisted radical total gastrectomy combined with spleen-preserving D2 lymph node dissection. The intraoperative and postoperative recoveries and complications of patients were analyzed. All patients were followed up by outpatient examination, visit, correspondence and telephone interview up to March 1, 2014. Results One patient received splenectomy due to intraoperative splenic artery injury and the other 121 patients received successfully laparoscopic spleen-preserving No. 10 lymphadenectomy. The operation time, volume of intraoperative blood loss, time and volume of blood loss in No. 10 lymphadenectomy were (175 ±27) minutes, (60 ±43) mL, (21 ± 8) minutes and (15 ±13 ) mL, respectively. The total and mean numbers of lymph node dissection in 122 patients were 4 797 and 44 ±18, respectively. The total and mean numbers of No. 10 lymph node dissection were 354 and 2.9 ± 2.4, respectively. Thirty-seven No. 10 lymph node metastases were detected in 15 patients, with a metastasis rate of 12.30% (15/ 122). The time to anal exsufflation, time for fluid diet intake, duration of hospital stay and incidence of complications were (4.0 ± 0.8) days, (4.9 ± 1.8) days, (12 ± 7) days and 11.48% (14/ 122) , respectively. All the 122 patients were followed up for a median time of 8 months (range, 2-12 months). No tumor recurrence, tumor metastasis and death were observed during follow-up. Conclusions Huang's three-step maneuver simplifies the complicated surgical procedures of laparoscopic spleen-preserving No. 10 lymphadenectomy for advanced proximal gastric cancer, its clinical efficacy is satisfactory with an advantage of clinical application. Key words: Gastric neoplasms; Laparoscopy; Splenic hilar; Lymph node dissection

Huang's three-step maneuver for laparoscopic spleen-preserving No. 10 lymph node dissection for advanced proximal gastric cancer.

Due to the complexity of the splenic hilar vessels, their anatomical variation and the narrow and deep space, as well as the bleeding-prone splenic parenchyma and the difficulty to manage splenic or vascular bleeding at the splenic hilum,the procedure remains challenging and technically demanding procedure for the performance of laparoscopic pancreas- and spleen-preserving splenic hilar lymph nodes dissection. Based on our experiences, we gradually explored a set of procedural operation steps called "Huang's three-step maneuver". In this paper, we not only provide the concrete operation steps for the surgeon, but we also provide our recommended technique of pulling and exposure for assistants. This new maneuver simplifies the complicated procedure and improves the efficiency of laparoscopic spleen-preserving splenic hilar lymphadenectomy, making it easier to master and allowing for its widespread adoption.