Ann Surg Treat Res.  2014 Nov;87(5):279-283. 10.4174/astr.2014.87.5.279.

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

• Ahn SH
• Jung DH
• Son SY
• Park DJ
• Kim HH

• KMID: 2266889
• DOI: http://doi.org/10.4174/astr.2014.87.5.279

Abstract

We developed a novel approach to perform a perfect 11p lymph node dissection (LND), the so-called 'midpancreas mobilization' (MPM) method. Briefly, in pure single-incision laparoscopic distal gastrectomy (SIDG), after the completion of 7, 8a/12a, and 9 LND in the suprapancreatic portion, we started 11p LND after midpancreas mobilization. After mobilization of the entire midpancreas from the white line of Toldt, two gauzes were inserted behind the pancreas. This maneuver facilitated exposure of the splenic vein and complete detachment of soft tissue, including 11p lymph nodes, from the white line of Toldt, which was possible because of the tilting of the pancreas. The dissection plane along the splenic artery and vein for 11p LND could be visualized just through control of the operator's grasper without the need of an assistant. Fourteen patients underwent the procedure without intraoperative events, conversion to conventional laparoscopy, or surgery-related complications, including postoperative pancreatic fistula. All patients underwent D2 LND by exposure of the splenic vein. The mean numbers of retrieved lymph node and 11p lymph node were 61.3 +/- 9.0 (range, 49-70), and 4.00 +/- 3.38 (range, 1-10). Thus, we concluded that MPM for 11p LND in pure SIDG appears feasible and embryologically ideal; this method can be used in conventional laparoscopic gastrectomy.

Keyword

Stomach neoplasms; D2 lymphadenectomy; Single-incision laparoscopic gastrectomy; Single-port; Midpancreas mobilization

MeSH Terms

Gastrectomy
Humans
Laparoscopy
Lymph Node Excision*
Lymph Nodes
Pancreas
Pancreatic Fistula
Splenic Artery
Splenic Vein
Stomach Neoplasms*
Veins

Figure

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  Fig. 1 An illustration of the concept for midpancreas mobilization; (A) normal arrangement of the pancreas, the splenic vessels and the soft tissue containing 11p lymph nodes; (B) ventrally migrated and tilted arrangement of the pancreas, the splenic vessels, and the soft tissue containing 11p lymph nodes.

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  Fig. 2 Midpancreas mobilization in pure single-incision laparoscopic distal gastrectomy.

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  Fig. 3 An 11p lymph node dissection with proper exposure of the splenic artery and vein.

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  Fig. 4 A complete view of 11p lymph node dissection.

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