Tian Lin1, Jiang Yu1, Yanfeng Hu1, Hao Liu1, Yiming Lu1, Mingli Zhao1, Hao Chen1, Xinhua Chen1, Guoxin Li2. 1. Department of General Surgery, Nanfang Hospital, Southern Medical University, Guangzhou 510155, China. 2. Department of General Surgery, Nanfang Hospital, Southern Medical University, Guangzhou 510155, China.Email: gzliguoxin@163.com.
Abstract
OBJECTIVE: To evaluate the short-term efficacy and cosmetic effect of dual-port laparoscopic distal gastrectomy (DPLDG) for gastric cancer. METHODS: Thirty consecutive patients underwent DPLDG at the Department of General Surgery, Nanfang Hospital from November 2016 to August 2018. INCLUSION CRITERIA: (1) age of 18 to 75 years; (2) primary gastric adenocarcinoma confirmed pathologically by endoscopic biopsy; (3) tumor located at middle-low stomach and planned for distal gastrectomy; (4) cT1b-2N0-1M0 at preoperative staging; (5) tumor diameter ≤3 cm; (6) US Eastern Cancer Cooperative Group(ECOG) score 0 to 1 points; (7) American Society of Anesthesiologists grade I to II; (8) perioperative management based on enhanced recovery after surgery (ERAS) principle. EXCLUSION CRITERIA: previous upper abdominal surgery (except laparoscopic cholecystectomy), history of other malignant disease, and body mass index ≥30 kg/m². A self-developed single-incision, multiport, laparoscopic surgery Trocar (Surgaid Medical, Xiamen, China, comprising 3 channels for observation, main surgeon and assistant surgeon) was placed through a 3-4 cm incision under or at the left side of the umbilicus. An additional 5 mm Trocar was inserted under the rib margin of the right clavicle to serve as the secondary operating hole and the position of the drainage tube. The liver was suspended to expose the surgical field clearly. Surgical procedure was as follows: conventional laparoscopic instruments were used. After entering the omental sac, dissection was performed along the transverse colon to the spleen flexure. Left gastroepiploic vessels were identified and then ligated at the root. No.4sb lymph nodes were dissected. The No.4d lymph nodes were dissected along the greater curvature of the stomach. Then the dissection was continued rightward to the hepatic flexure to separate mesogastrium and mesocolon. The right gastroepiploic artery was ligated at the root to allow the removal of No.6 lymph nodes. The duodenal bulb was transacted by liner stapler, the right gastric artery was ligated at the root and the No.5 lymph nodes were removed. Peritoneal trunk, common hepatic artery, splenic artery and left gastric artery and vein in posterior pancreatic space at upper pancreas were separated, then left gastric vessels were ligated, and No.9, No.8a, No.11p and No.7 lymph nodes were dissected. The left side wall of portal vein was exposed and No.12a lymph nodes were removed. No.1 and No.3 lymph nodes were dissected along the lesser curvature. The stomach corpus was transacted by liner stapler at 4-5 cm proximal end of the tumor. Roux-en-Y anastomosis or Billroth II anastomosis was performed in the cavity. A drainage tube was placed near the gastrojejunal anastomosis through the right upper abdomen secondary operating hole. Postoperative short-term efficacy (operation time, blood loss, 5-port conversion rate, open conversion rate, number of retrieved lymph nodes, time to postoperative first flatus, time to first soft diet intake, time to removal of drainage tube, postoperative hospital stay, postoperative analgesics use, and postoperative 30-day complication rate) and cosmetic scale (questionnaire: degree of satisfaction with scar, description of scar, grade of scar; total score ranged from the lowest 3 to the highest 24; the higher the better) were evaluated in all 30 patients. RESULTS: No serious complication and death were observed intraoperatively. The mean operative time was (197.8±46.9) minutes. The median blood loss was 30 ml (quartile 31.25 ml). The mean number of retrieved lymph node was 38.7±14.1. Five-port conversion rate was 3.3% (1/30), and no open conversion occurred. Mean time to postoperative first flatus, time to first soft diet intake, time to removal of drainage tube and postoperative hospital stay were (45.3±18.9) hours, (87.6±35.6) hours, (101.8±58.0) hours and (6.1±2.1) days, respectively. Twenty-four (80%) of patients had no additional analgesics use. The postoperative complication rate within 30 days was 16.7% (5/30). Postoperative overall cosmetic score was 22.1±1.3, and cosmetic score of 96.7%(29/30) of patients was 18 to 24. CONCLUSION: DPLDG is safe and feasible with advantages of faster postoperative recovery, reducing pain and better cosmetic outcomes.
OBJECTIVE: To evaluate the short-term efficacy and cosmetic effect of dual-port laparoscopic distal gastrectomy (DPLDG) for gastric cancer. METHODS: Thirty consecutive patients underwent DPLDG at the Department of General Surgery, Nanfang Hospital from November 2016 to August 2018. INCLUSION CRITERIA: (1) age of 18 to 75 years; (2) primary gastric adenocarcinoma confirmed pathologically by endoscopic biopsy; (3) tumor located at middle-low stomach and planned for distal gastrectomy; (4) cT1b-2N0-1M0 at preoperative staging; (5) tumor diameter ≤3 cm; (6) US Eastern Cancer Cooperative Group(ECOG) score 0 to 1 points; (7) American Society of Anesthesiologists grade I to II; (8) perioperative management based on enhanced recovery after surgery (ERAS) principle. EXCLUSION CRITERIA: previous upper abdominal surgery (except laparoscopic cholecystectomy), history of other malignant disease, and body mass index ≥30 kg/m². A self-developed single-incision, multiport, laparoscopic surgery Trocar (Surgaid Medical, Xiamen, China, comprising 3 channels for observation, main surgeon and assistant surgeon) was placed through a 3-4 cm incision under or at the left side of the umbilicus. An additional 5 mm Trocar was inserted under the rib margin of the right clavicle to serve as the secondary operating hole and the position of the drainage tube. The liver was suspended to expose the surgical field clearly. Surgical procedure was as follows: conventional laparoscopic instruments were used. After entering the omental sac, dissection was performed along the transverse colon to the spleen flexure. Left gastroepiploic vessels were identified and then ligated at the root. No.4sb lymph nodes were dissected. The No.4d lymph nodes were dissected along the greater curvature of the stomach. Then the dissection was continued rightward to the hepatic flexure to separate mesogastrium and mesocolon. The right gastroepiploic artery was ligated at the root to allow the removal of No.6 lymph nodes. The duodenal bulb was transacted by liner stapler, the right gastric artery was ligated at the root and the No.5 lymph nodes were removed. Peritoneal trunk, common hepatic artery, splenic artery and left gastric artery and vein in posterior pancreatic space at upper pancreas were separated, then left gastric vessels were ligated, and No.9, No.8a, No.11p and No.7 lymph nodes were dissected. The left side wall of portal vein was exposed and No.12a lymph nodes were removed. No.1 and No.3 lymph nodes were dissected along the lesser curvature. The stomach corpus was transacted by liner stapler at 4-5 cm proximal end of the tumor. Roux-en-Y anastomosis or Billroth II anastomosis was performed in the cavity. A drainage tube was placed near the gastrojejunal anastomosis through the right upper abdomen secondary operating hole. Postoperative short-term efficacy (operation time, blood loss, 5-port conversion rate, open conversion rate, number of retrieved lymph nodes, time to postoperative first flatus, time to first soft diet intake, time to removal of drainage tube, postoperative hospital stay, postoperative analgesics use, and postoperative 30-day complication rate) and cosmetic scale (questionnaire: degree of satisfaction with scar, description of scar, grade of scar; total score ranged from the lowest 3 to the highest 24; the higher the better) were evaluated in all 30 patients. RESULTS: No serious complication and death were observed intraoperatively. The mean operative time was (197.8±46.9) minutes. The median blood loss was 30 ml (quartile 31.25 ml). The mean number of retrieved lymph node was 38.7±14.1. Five-port conversion rate was 3.3% (1/30), and no open conversion occurred. Mean time to postoperative first flatus, time to first soft diet intake, time to removal of drainage tube and postoperative hospital stay were (45.3±18.9) hours, (87.6±35.6) hours, (101.8±58.0) hours and (6.1±2.1) days, respectively. Twenty-four (80%) of patients had no additional analgesics use. The postoperative complication rate within 30 days was 16.7% (5/30). Postoperative overall cosmetic score was 22.1±1.3, and cosmetic score of 96.7%(29/30) of patients was 18 to 24. CONCLUSION:DPLDG is safe and feasible with advantages of faster postoperative recovery, reducing pain and better cosmetic outcomes.