Total laparoscopic gastrectomy with D2 lymphadenectomy

Start the procedure by marking the trocar positions on the abdominal wall. After inserting the Veress needle and pressure-controlled CO2 insufflation, place the following trocars in a semicircle:

• • T1 = camera trocar (10 mm)
  • T2 = working trocar(10 mm)
  • T3 = working trocar 5 mm (later 12 mm for CEEA stapler and extension of incision for specimen retrieval)
  • T4 = working trocar (12 mm)
  • T5 = working trocar (5 mm)

Start the resection phase by opening the lesser peritoneal sac and incising the gastrocolic ligament. To do this, fold over the greater omentum craniad and divide the ligament step by step along the superior aspect of the transverse colon with the Thunderbeat® device.

Continue the dissection at the gastroduodenal junction. Mobilize the duodenum likewise with the Thunderbeat® device to around 2 cm distal to the pylorus. After lifting the stomach, locate the right gastric artery and divide it close to its origin at the proper hepatic artery.

Note: Pay particular attention when dissecting the posterior aspect of the duodenum. Make every attempt not to injure the pancreatic capsule as this could result in pancreatic fistula, local inflammatory reaction, and leakage from the duodenal remnant.

After exposing the common hepatic artery, divide the lesser omentum close to the liver. Transect the postpyloric duodenum with a 60 mm Endo-GIA stapler.

Next, dissect the suprapancreatic lymph nodes along the common hepatic artery to the celiac trunk, such that the lymph nodes remain attached to the specimen. Expose the left gastric artery and divide it between metal clips.

While preserving the spleen, divide the gastrosplenic ligament close to the spleen.

This step involves the cardioesophageal dissection and lymphadenectomy in the lower mediastinum. To that effect, mobilize both diaphragmatic crura and the terminal esophagus, while resecting also the paracardial lymph nodes. Divide both vagal trunks.