Objective: To explore the feasibility, safety, and preliminary technical experience of single incision plus one port laparoscopic total gastrectomy combined with π-shaped esophagojejunal anastomosis (SILT-π) in the surgical treatment of gastric cancer.
Methods: Clinical data of 5 gastric cancer patients undergoing SILT-π operation at the Department of General Surgery, The Second Affiliated Hospital of the Army Medical University from August to October 2017 were retrospectively analyzed. A 2.5-3.0 cm incision around the umbilicus was made for placing the gloveport as the passage for the lens, and the instruments of the surgeon and the assistant. Another operative port was placed in the left upper quadrant with a 12-mm Trocar for the passage of the energy device, the endoscopic cutting closure, as well as the postoperative drainage tube. A D2 lymph node (LNs) dissection was regularly conducted. After the abdominal esophagus was routinely mobilized, a side-to-side esophagus-jejunum anastomosis was made through a gastric pre-pulling esophagojejunal π-shaped anastomosis. The transection was then performed with a ligation on the cardia (or esophagus above the upper margin of the tumor) using a sterilized hemp rope in order to better expose the abdominal esophagus. Throughout the course of reconstruction, the ligature rope was held by the assistant to hold down the esophagus to allow easier esophagojejunal anastomosis. A hole was then made on the posterior wall of the esophagus, between 2 cm and 3 cm above the ligature rope, and another hole was made at the anti-mesenteric border of the jejunum 40 cm distal to the Treitz ligament. A side-to-side esophagojejunal π-shaped anastomosis was performed through two holes. An entry hole was formed after the anastomosis. After checking the anastomosis, this entry hole was closed through an intestinal mesenteric hole pre-made on its opposite side. The resected esophagus and stomach, together with the afferent loop jejunum, were simultaneously transected above the level of the entry hole by a stapler from the Trocar of the left upper abdominal quadrant. After the gloveport was closed, a side-to-side jejunojejunostomy anastomosis applied with another two staples was performed between the afferent loop stump and the roux limb 30 cm below the esophagojejunal anastomosis.
Results: These five patients were all male, and aged (56.8±8.2) years with preoperative clinical stage cT2-4N0-2M0. All the 5 patients underwent SILT-π operation successfully. The average length of surgical incision was (2.9±0.2) cm. The average operation time was (396.0±36.1) minutes. The intraoperative blood loss was (140.0±66.7) ml. Postoperative pathology showed proximal and distal margins were (2.6±1.1) cm and (8.7±2.5) cm apart respectively, and the average number of retrieved lymph node was 25.8±7.2. Perioperative management was based on enhanced recovery following surgical (ERAS) principles. The average time to the first flatus was (2.6±0.5) days, and the average time to defecation was (3.6±0.5) days. The pain score on postoperative day 1 was 1-2, and the average postoperative hospital stay was (7.0±0.7) days. No perioperative complications occurred.
Conclusions: SILT-π procedure is safe and feasible for patients with gastric cancer, and has positive short-term outcomes, satisfactory cosmetic abdominal incision, light postoperative abdominal pain and rapid postoperative recovery. Preliminary observations show that SILT-π procedure has good potential for clinical application in future.