Pure single-incision laparoscopic D2 lymphadenectomy for gastric cancer: a novel approach to 11p lymph node dissection (midpancreas mobilization)

Case Report: Single-port laparoscopic total gastrectomy for gastric cancer in patient with situs inversus totalis

Situs inversus totalis (SIT) is a rare anatomical condition, where all the viscera appear in its reverse position. Although minimally invasive surgery has evolved to achieve totally laparoscopic gastrectomy for gastric cancer patients with SIT, it is difficult to perform lymphadenectomy in such a transposed anatomical condition. Recently, we performed a single-port laparoscopic total gastrectomy (SPTG) for gastric cancer in a patient with SIT. No postoperative complications or dietary problems were observed. Based on this experience, we are to design a safe strategy to perform D2 lymphadenectomy during SPTG in patients with SIT.

Migration of Hem-o-lok clip into the common hepatic duct after laparoscopic bile duct exploration: A case report

Hem-o-lok clip migration into the bile duct can lead to stone formation and granulation tissue hyperplasia. This report discusses a case wherein four clips migrated into the bile duct after laparoscopic bile duct exploration.

Single-port laparoscopically harvested omental flap for immediate breast reconstruction

PURPOSE

Immediate breast reconstruction using laparoscopically harvested omental flap is a safe and feasible technique, providing natural contour and softness to reconstructed breasts with reduced donor-site morbidity and deformity. We report our experience using single-port laparoscopically harvested omental flap (SLOF) for immediate breast reconstruction.

METHODS

Between February 2015 and December 2018, 129 patients with malignant neoplasm of the breast underwent nipple-sparing mastectomy (NSM) or breast-conserving surgery (BCS) followed by immediate SLOF reconstruction at Seoul National University Bundang Hospital. We assessed their clinicopathological data, complications, and cosmetic and oncologic outcomes. Cosmetic outcomes were evaluated by three-panel assessment and the BCCT.core software program.

RESULTS

One hundred and six (82.2%) underwent NSM and 23 (17.8%) underwent BCS. Mean operation time was 205 (range, 134-316) minutes. Most patients had early-stage disease; 15 (11.6%) received neoadjuvant chemotherapy. Two had malignant phyllodes tumors. Cosmetic outcomes were excellent or good in 96.9% by three-panel assessment and 99.2% by the BCCT.core program with a nearly invisible donor-site scar in the umbilicus. Harvest-associated complications occurred in five (3.9%) patients, including two umbilical wound infections, one intra-abdominal infection, one umbilical hernia, and one pedicle injury. Fat necrosis (13.2%) and epigastric bulging (21.7%) were common mastectomy- or reconstruction-associated complications, but most were mild and some resolved spontaneously. Over a median 38-month follow-up, there were three local, two regional, and three systemic recurrences.

CONCLUSIONS

SLOF reconstruction is a feasible and safe option for immediate breast reconstruction after NSM or extensive BCS with minimal donor-site morbidity and great cosmetic outcomes.

Initial Experience of Dual-Port Laparoscopic Distal Gastrectomy for Gastric Cancer: A Single-Arm Study

INTRODUCTION

Dual-port laparoscopic gastrectomy (DPLG) has been widely performed in recent years for treating gastric cancers. The present study reports our initial experience of dual-port laparoscopic distal gastrectomy (DPLDG).

METHODS

From November 2016 to August 2018, 38 consecutive patients underwent DPLDG in our center. The observational outcomes included 30-day morbidity and mortality rates, time to first flatus, time to first oral liquid diet, time to first oral semiliquid diet, time to drainage tube removal, visual analogue scale (VAS) score, postoperative 4-day recovery rate, additional analgesic use, hospital stay and cosmetic benefits.

RESULTS

Mean operative time was 191.6 ± 44.4 min, mean intra-operative blood loss was 39.8 ± 48.7 ml, and the mean number of dissected lymph nodes was 38.3 ± 13.7 nodes. One case was converted to five-port laparoscopic surgery, and no intraoperative complications occurred in any of the cases. The mean time to postoperative first flatus was 45.3 ± 18.0 h. The mean time to intake of an oral liquid diet was 56.7 ± 30.4 h. The mean time to drainage tube removal was 97.9 ± 52.3 h. The mean VAS scores for the 3 days after surgery were 2.3 ± 0.7, 2.0 ± 0.6 and 1.6 ± 0.5, respectively. A total of 81.6% of the enrolled patients met the postoperative 4-day recovery standard, and 15.8% of patients received additional analgesics. The mean postoperative hospital stay was 6.0 ± 2.0 days. No deaths were observed, and the 30-day morbidity rate was 13.2%.

CONCLUSION

DPLDG is a feasible and safe procedure for experienced surgeons with acceptable short-term outcomes, reduced invasiveness and good cosmetic effects.

The Safety and Feasibility of Single-Port Laparoscopic Gastrectomy for Advanced Gastric Cancer

BACKGROUND

Single-port laparoscopic surgery maximizes the advantages of laparoscopic surgery by reducing damage of the abdominal wall. However, no comparative studies have addressed its application to gastrectomy for advanced gastric cancer (AGC). We therefore aimed to demonstrate the safety and feasibility of single-port laparoscopic gastrectomy (SLG) for the treatment of AGC by comparing it with conventional multi-port laparoscopic gastrectomy (MLG).

METHODS

We searched the prospective gastric cancer database of our institute for patients with AGC who underwent SLG or MLG between October 2007 and December 2013. Cases of R2 resection with distant metastasis or concurrent surgery for comorbid malignant lesions were excluded. One-to-one propensity score matching was performed to reduce bias from confounding patient-related variables, and the short- and long-term outcomes were compared between the two groups.

RESULTS

We identified 216 patients who underwent SLG (n = 100) or MLG (n = 116). After propensity score matching, we selected 73 pairs of patients who underwent SLG (distal gastrectomy, 49; total gastrectomy, 24) or MLG (distal gastrectomy, 45; total gastrectomy, 28). While the mean operative times were comparable between the groups, the SLG group had less blood loss, a lower postoperative morbidity, and shorter postoperative hospital stays. The 5-year survival rates were 74.2% in the SLG group and 60.2% in the MLG group (P = 0.081 by log-rank test).

CONCLUSIONS

SLG is shown to be safe and feasible for the treatment of AGC, with better short-term results and acceptable oncologic outcomes and may be applicable for AGC treatment.

The anatomical configuration of the splenic artery influences suprapancreatic lymph node dissection in laparoscopic gastrectomy: analysis using a 3D volume rendering program

BACKGROUND

The aim of this study is to categorize splenic artery and vein configurations, and examine their influence on suprapancreatic lymph node (LN) dissection in laparoscopic gastrectomy.

METHODS

Digital Imaging and Communications in Medicine images from 169 advanced cancer patients who underwent laparoscopic gastrectomy with D2 dissection were used to reconstruct perigastric vessels in 3D using a volume rendering program (VP Planning®). Splenic artery and vein configuration were classified depending on the relative position of their lowest part in regard to the pancreas. Number of resected LNs and surgical outcomes were analyzed.

RESULTS

The splenic artery was categorized as superficial (36.7%), middle (49.1%), and concealed (14.2%), and the splenic vein was categorized as superior (6.5%), middle (42.0%), and inferior to the pancreas (51.5%). The number of resected LNs around the proximal half of the splenic artery (#11p) and the proportion of the splenic vein located inferiorly to the pancreas were significantly higher in splenic arteries of concealed types. LN metastasis of station #7 was an independent risk factor of LN metastasis in station #11p (p = 0.010). Concealed types showed a tendency towards longer operating times, more blood loss, longer hospital stays, and a higher postoperative morbidity.

CONCLUSION

Concealed types of splenic artery are associated with an increased difficulty in the dissection of LN station #11p around the splenic artery. A 3D volume rendering program is a useful tool to rapidly and intuitively identify individual anatomical variations, to plan a tailored surgical strategy, and to predict potential challenges.

Single-incision Laparoscopic Gastrectomy for Gastric Cancer

The implementation of national cancer screening has increased the detection rates of early gastric cancer (EGC) in Korea. Since the successful introduction of laparoscopic gastrectomy for gastric cancer in the early 1990s, this technique has demonstrated improved short-term outcomes without compromising long-term oncologic results. It is associated with reduced pain, shorter hospitalization, reduced morbidity rates, better cosmetic outcomes, and equivalent mortality rates as those for open surgery. Laparoscopic gastrectomy improves patients' quality of life (QOL) and provides favorable prognosis. Single-incision laparoscopic gastrectomy (SILG) is one extremely minimally invasive method, theoretically offering improved cosmetic results, less postoperative pain, and earlier recovery after surgery than conventional multiport laparoscopic gastrectomy. In this context, SILG is thought to be an optimal method to promote and maximize patients' QOL in the acute postoperative phase. However, the technical difficulties of this procedure have limited its use. Since the first report describing single-incision distal gastrectomy in 2011, only 16 studies to date have evaluated SILG. Most of these studies have focused on the technical feasibility and safety of SILG because its long-term outcomes have not been reported. This article reviews the advantages and limitations of SILG.

Single-Port Laparoscopic Proximal Gastrectomy with Double Tract Reconstruction for Early Gastric Cancer: Report of a Case

In Korea, proximal gastrectomy has recently attracted attention as a better choice of function-preserving surgery for proximal early gastric cancer than total gastrectomy. Of the various strategies to overcome reflux symptoms from remnant stomach, double tract reconstruction not only reduces the incidence of anastomosis-related complications, but is also sufficiently reproducible as a laparoscopic procedure. Catching up with the recent rise of single-port laparoscopic surgeries, we performed a pure single-port laparoscopic proximal gastrectomy with DTR. This procedure was designed by merging the function-preserving concept of proximal gastrectomy with single-port laparoscopic total gastrectomy.

Single incision gastrectomy for gastric cancer

Based on rapid development of laparoscopic techniques and instruments, single-incision laparoscopic surgery (SILS) is expected to be the next step of "more" minimally invasive surgery. A few institutions gradually started to report their experience of single incision gastrectomy (SIG) for gastric cancer, but it is still difficult to accept that SIG can be performed as a popular procedure because of its technical difficulty. For wide adoption of SIG, the simplicity, safety and reproducibility of not only lymph node dissection but also reconstruction should be evaluated compared to a conventional procedure. With a thorough understanding of unique characteristics of SILS, single incision distal gastrectomy (SIDG) for early gastric cancer performed by laparoscopic surgeons with advanced technique is expected to have promising potential about excellent cosmesis, comparable morbidity and mortality in carefully selected patients. For appropriate adoption and steady progress of this state-of-the art surgery, scientific evaluation with healthy critics is necessary with new generation of SILS instrument platform.

Reduced port laparoscopic gastrectomy for gastric cancer

The use of reduced port laparoscopic surgery (RPS) has become increasingly popular. The concept of RPS includes all procedures derived from various efforts minimizing the invasiveness of surgery, with single-incision laparoscopic surgery (SILS) being the ultimate reduced port technique. Reduced-port laparoscopic gastrectomy (RPLG) for gastric cancer has not yet been fully established and still has issues such as feasibility, oncological validity, training, and education. The short-term results of reported studies are acceptable. However, long-term results that verify positive results or radical cure even in cases of cancer have not yet been published. Patients for whom RPLG is indicated should be selected carefully. Prospective multicenter studies should be conducted to establish RPS as a truly evidence-based practice that addresses not only cosmesis but also the appropriate balance between minimal invasiveness and radical cure.