Inventor’s Corner Surgical Innovation 2021, Vol. 28(1) 151–154 © The Author(s) 2020 Article reuse guidelines: sagepub.com/journals-permissions DOI: 10.1177/1553350620958237 journals.sagepub.com/home/sri Single-Incision Proximal Gastrectomy With Double-Flap Esophagogastrostomy Using Novel Laparoscopic Instruments So Hyun Kang, MD 1 , Yongjoon Won, MD 1 , Kanghaeng Lee, MD 1 , Sang Il Youn, MD 2 , Sa-Hong Min, MD 3 , Young Suk Park, MD 1,4 , Sang-Hoon Ahn, MD 1,4 , and Hyung-Ho Kim, MD, PhD 1,4 Abstract Background. The optimal type of anastomosis after proximal gastrectomy (PG) is still controversial. A novel technique termed “double-flap” esophagogastrostomy (EG) has been introduced. The application of this technique after PG is reported to have little gastroesophageal reflux without the need of creating an esophagojejunostomy. However, this procedure is technically challenging and hence difficult to apply in laparoscopic PG. This technical report describes in detail how to perform single-incision proximal gastrectomy (SIPG) with double-flap EG with the use of novel lapa- roscopic instruments. Methods. Two patients diagnosed with early gastric cancer underwent SIPG. A 2.5 cm incision was made, and a scope holder was used in place of a scopist. After performing PG with D1+ lymphadenectomy, double seromuscular flaps were created on the anterior wall of the stomach. After tagging the esophagus to the inferior edge of the flap window, the stomach and esophagus were opened through electrocautery. EG was performed intracorporeally using continuous barbed sutures, and the flap is then secured to the anastomosis. To facilitate this procedure, an intra- abdominal organ retractor and an articulating needle holder were used. The supplementary video illustrates in detail how these devices are used to perform the technique. Results. Total operation times were 190 and 110 minutes each, and anastomosis took 75 and 46 minutes each. Patients had no complications and were both discharged on postoperative day 6. Conclusion. Double-flap PG is technically feasible through a single incision with the use of articulating laparoscopic devices and intra-abdominal organ retractors to assist in intracorporeal anastomosis. Keywords stomach neoplasm, laparoscopy, minimally invasive surgical procedures Need Proximal gastrectomy (PG) is known to be superior to total gastrectomy in preventing nutritional deficiencies, anemia, and weight loss by maintaining a gastric res- ervoir. 1-3 Double-flap esophagogastrostomy (EG) was first introduced by Kamikawa in 1998 4 to prevent reflux esophagitis after PG. However, the mean operation time for laparoscopic PG with double-flap EG varies from 275 to 420 minutes due to intracorporeal hand sewing during EG anastomosis. 5,6 Due to the difficulty and complexity of the procedure, surgeons are reluctant to attempt single- port intracorporeal double-flap anastomosis. In this study, we discuss in detail the surgical techniques in performing single-incision proximal gastrectomy (SIPG) with double-flap EG, providing emphasis on the use of ar- ticulated devices and clip retractors to facilitate the procedure. Technical Solution Two patients diagnosed with early gastric cancer at the upper third portion of the stomach underwent SIPG on September and November 2018. Informed consent was 1 Department of Surgery, Seoul National University Bundang Hospital, Seongnam, Korea 2 Department of Surgery, Dangook University Hospital, Cheonan, Korea 3 Department of Surgery, Chungnam National University Hospital, Daejeon, Korea 4 Department of Surgery, Seoul National University College of Medicine, Seoul, Korea Corresponding Author: Sang-Hoon Ahn, Department of Surgery, Seoul National University Bundang Hospital, Seoul National University, College of Medicine, 300 Gumi-dong, Bundang-gu, Seongnam-si, Gyenggi-do 13620, Korea. Email: [email protected]
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Single-Incision Proximal Gastrectomy With Double-Flap Esophagogastrostomy Using Novel Laparoscopic InstrumentsSingle-Incision Proximal Gastrectomy With Double-Flap Esophagogastrostomy Using Novel Laparoscopic Instruments
So Hyun Kang, MD1 , Yongjoon Won, MD1,
Kanghaeng Lee, MD1, Sang Il Youn, MD2, Sa-Hong Min, MD3, Young Suk Park, MD1,4, Sang-Hoon Ahn, MD1,4, and Hyung-Ho Kim, MD, PhD1,4
Abstract Background. The optimal type of anastomosis after proximal gastrectomy (PG) is still controversial. A novel technique termed “double-flap” esophagogastrostomy (EG) has been introduced. The application of this technique after PG is reported to have little gastroesophageal reflux without the need of creating an esophagojejunostomy. However, this procedure is technically challenging and hence difficult to apply in laparoscopic PG. This technical report describes in detail how to perform single-incision proximal gastrectomy (SIPG) with double-flap EG with the use of novel lapa- roscopic instruments.Methods. Two patients diagnosed with early gastric cancer underwent SIPG. A 2.5 cm incision was made, and a scope holder was used in place of a scopist. After performing PG with D1+ lymphadenectomy, double seromuscular flaps were created on the anterior wall of the stomach. After tagging the esophagus to the inferior edge of the flap window, the stomach and esophagus were opened through electrocautery. EG was performed intracorporeally using continuous barbed sutures, and the flap is then secured to the anastomosis. To facilitate this procedure, an intra- abdominal organ retractor and an articulating needle holder were used. The supplementary video illustrates in detail how these devices are used to perform the technique. Results. Total operation times were 190 and 110 minutes each, and anastomosis took 75 and 46 minutes each. Patients had no complications and were both discharged on postoperative day 6. Conclusion. Double-flap PG is technically feasible through a single incision with the use of articulating laparoscopic devices and intra-abdominal organ retractors to assist in intracorporeal anastomosis.
Keywords stomach neoplasm, laparoscopy, minimally invasive surgical procedures
Need
Proximal gastrectomy (PG) is known to be superior to total gastrectomy in preventing nutritional deficiencies, anemia, and weight loss by maintaining a gastric res- ervoir.1-3 Double-flap esophagogastrostomy (EG) was first introduced by Kamikawa in 19984 to prevent reflux esophagitis after PG. However, the mean operation time for laparoscopic PG with double-flap EG varies from 275 to 420 minutes due to intracorporeal hand sewing during EG anastomosis.5,6 Due to the difficulty and complexity of the procedure, surgeons are reluctant to attempt single- port intracorporeal double-flap anastomosis. In this study, we discuss in detail the surgical techniques in performing single-incision proximal gastrectomy (SIPG) with double-flap EG, providing emphasis on the use of ar- ticulated devices and clip retractors to facilitate the procedure.
Technical Solution
Two patients diagnosed with early gastric cancer at the upper third portion of the stomach underwent SIPG on September and November 2018. Informed consent was
1Department of Surgery, Seoul National University Bundang Hospital, Seongnam, Korea 2Department of Surgery, Dangook University Hospital, Cheonan, Korea 3Department of Surgery, Chungnam National University Hospital, Daejeon, Korea 4Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
Corresponding Author: Sang-Hoon Ahn, Department of Surgery, Seoul National University Bundang Hospital, Seoul National University, College of Medicine, 300 Gumi-dong, Bundang-gu, Seongnam-si, Gyenggi-do 13620, Korea. Email: [email protected]
SIPG
Patients were placed in lithotomy position and a scope holder (Laparostat; CIVCO Medical Solutions, Iowa, USA) was installed on the left side of the patient. A 2.5 cm vertical transumbilical incision was made, and port (EZ access; Hakko, Japan) was inserted. An artic- ulating grasper (Artisential, Livsmed, Korea) was used to facilitate the D1+ lymphadenectomy. An intra-abdominal organ retractor such as the FJ Clip (Charmant, Sabae, Japan) was tied with 2 Prolene sutures (Figure 1A) that were pulled out of the abdominal cavity at 2 points— upper epigastric and right lateral flank (Figure 1B).
Double-Flap EG
A 2.5 × 3.5 cm H-shaped seromuscular flap is created extracorporeally on the anterior wall of the gastric remnant. A continuous barbed suture (V-loc, Med- tronic, Minnesota, USA) was used to connect the posterior wall of the esophagus to the upper lip of the stomach opening. After creating an opening, the upper lip of the esophagus was retracted upward using the intra-abdominal organ retractor (Figure 2A). For in- tracorporeal suture, an articulated needle holder (Ar- tisential, Livsmed, Korea) was used. The wrist-like articulating motion enabled vertical running sutures to be performed (Figure 2B). After EG, the anastomosis was covered using the seromuscular flap, and the flap
was closed using 2 or 3 same barbed sutures (Figures 2C and 2D). After closure of the wound using intradermal sutures and surgical bond, intraoperative esophagogastro- scopy was performed to check for leakage or stricture.
Proof of Concept
Patient Outcome
For the first patient, total operation time was 195 minutes, and the anastomosis time was 75 minutes. Within the anastomosis time, it took 6 minutes to create the flap extracorporeally and 69 minutes for the intracorporeal suture. The second patient had a total operation time of 110 minutes and had 46 minutes for anastomosis with 5 minutes for flap dissection and 41 minutes for intra- corporeal hand sewing. Estimated blood loss was less than 30 mL for both patients. Patients were discharged without complications.
In our technical description, we made use of various laparoscopic tools to help overcome the limitations of single-port laparoscopic surgery. Reusable organ pen- dant clips (FJ Clip, Charmant, Sabae, Japan) were used to assist in retraction whenever it was necessary. By tying 2 Prolene sutures, the retractor clip is provided with 2 vectors of force that can be manipulated into various directions. Barbed sutures were used to reduce time and effort. Also, articulating needle holders such as the ArtiSential needle holder (Livsmed, Korea) were able to reduce the anastomosis time and helped in performing an accurate suture without disrupting the anastomosis. This device showed equal suture time compared to the da Vinci system in a previous dry lab study7 and was in- troduced to clinical cases since 2018.8
Figure 1. Technique in using the intra-abdominal organ retractor (FJ Clip, Charmant, Sabae, Japan). (A) 2 Prolene sutures are tied to both sides of the clip. (B) Straight needles are pulled out of the abdomen in 2 points—upper epigastric and right flank—allowing 2 vectors that may be used for traction.
152 Surgical Innovation 28(1)
Next Steps
Although this technical report shows the feasibility of using these novel instruments, there are still major con- cerns to be taken into account. First, the operator has a substantial experience in single-incision laparoscopic gastrectomy, and it does not guarantee the same results from a surgeon with less experience. Also, the use of the articulating laparoscopic device has a learning curve of its own, and some dry lab practice may be needed. However, this description of the surgical technique may give insight into other surgeons who experience difficulty in per- forming this procedure and help in providing a stepping stone to future research and surgical skills.
Conclusion
SIPG with double-flap EG may be a feasible technique with the active use of new laparoscopic tools such as clip retractors and articulated needle holders.
Author Contributions
Study conception and design: So Hyun Kang, Young Suk Park, Sang-Hoon Ahn, Hyung-Ho Kim Acquisition of data: So Hyun Kang, Yongjoon Won, Kanghaeng Lee, Sang Il Youn, Sang-Hoon Ahn Analysis and interpretation: So Hyun Kang, Yongjoon Won, Kanghaeng Lee, Sang Il Youn, Sa-Hong Min, Young Suk Park, Sang-Hoon Ahn Drafting of manuscript: So Hyun Kang, Sang-Hoon Ahn Critical revision of manuscript: Sa-Hong Min, Young Suk Park, Sang-Hoon Ahn, Hyung-Ho Kim
Declaration of Conflicting Interest
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.
ORCID iD
References
1. Ahn S-H, Lee JH, Park DJ, Kim H-H. Comparative study of clinical outcomes between laparoscopy-assisted proximal gastrectomy (LAPG) and laparoscopy-assisted total gas- trectomy (LATG) for proximal gastric cancer. Gastric Cancer. 2012;16(3):282-289. doi:10.1007/s10120-012-0178-x
2. Ahn S-H, Jung DH, Son S-Y, Lee C-M, Park DJ, Kim H-H. Laparoscopic double-tract proximal gastrectomy for proxi- mal early gastric cancer. Gastric Cancer. 2013;17(3): 562-570. doi:10.1007/s10120-013-0303-5
3. Jung DH, Lee Y, Kim DW, et al. Laparoscopic proximal gastrectomy with double tract reconstruction is superior to laparoscopic total gastrectomy for proximal early gastric cancer. Surg Endosc. 2017;31(10):3961-3969. doi:10.1007/ s00464-017-5429-9
Figure 2. Intracorporeal double-flap reconstruction through a single incision. (A) Posterior wall of the esophagus is fixated with the anterior wall of the stomach, and the intra-abdominal clip retractor pulls the upper lip upward to better vision. (B) Articulating needle holders such as the ArtiSential (Livsmed, Korea) can facilitate vertical sutures for hand-sewn EG. (C) H-shaped seromuscular flap is sutured over the EG. (D) Final shape of the double-flap EG. EG = esophagogastrostomy.
Kang et al 153
5. Omori T, Moon J-H, Yanagimoto Y, Sugimura K, Miyata H, Yano M. Pure single-port laparoscopic proximal gastrectomy using a novel double-flap technique. Ann of Laparosc and Endosc Surg. 2017;2:123. doi:10.21037/ales.2017.06.01
6. Shoji Y, Nunobe S, Ida S, et al. Surgical outcomes and risk assessment for anastomotic complications after laparoscopic proximal gastrectomy with double-flap technique for upper-
third gastric cancer. Gastric Cancer. 2019;22(5):1036-1043. doi:10.1007/s10120-019-00940-0
7. Min S-H, Cho Y-S, Park K, et al. Multi-DOF (degree of freedom) articulating laparoscopic instrument is an effective device in performing challenging sutures. J Minim Invasive Surg. 2019;22(4):157-163. doi:10.7602/jmis.2019.22.4. 157
8. Kang SH, Cho Y-S, Min S-H, et al. Intracorporeal overlap gastro-gastrostomy for solo single-incision pylorus-preserving gastrectomy in early gastric cancer. Surg Today. 2019;49: 1074-1076. doi:10.1007/s00595-019-01820-x
154 Surgical Innovation 28(1)
Need
So Hyun Kang, MD1 , Yongjoon Won, MD1,
Kanghaeng Lee, MD1, Sang Il Youn, MD2, Sa-Hong Min, MD3, Young Suk Park, MD1,4, Sang-Hoon Ahn, MD1,4, and Hyung-Ho Kim, MD, PhD1,4
Abstract Background. The optimal type of anastomosis after proximal gastrectomy (PG) is still controversial. A novel technique termed “double-flap” esophagogastrostomy (EG) has been introduced. The application of this technique after PG is reported to have little gastroesophageal reflux without the need of creating an esophagojejunostomy. However, this procedure is technically challenging and hence difficult to apply in laparoscopic PG. This technical report describes in detail how to perform single-incision proximal gastrectomy (SIPG) with double-flap EG with the use of novel lapa- roscopic instruments.Methods. Two patients diagnosed with early gastric cancer underwent SIPG. A 2.5 cm incision was made, and a scope holder was used in place of a scopist. After performing PG with D1+ lymphadenectomy, double seromuscular flaps were created on the anterior wall of the stomach. After tagging the esophagus to the inferior edge of the flap window, the stomach and esophagus were opened through electrocautery. EG was performed intracorporeally using continuous barbed sutures, and the flap is then secured to the anastomosis. To facilitate this procedure, an intra- abdominal organ retractor and an articulating needle holder were used. The supplementary video illustrates in detail how these devices are used to perform the technique. Results. Total operation times were 190 and 110 minutes each, and anastomosis took 75 and 46 minutes each. Patients had no complications and were both discharged on postoperative day 6. Conclusion. Double-flap PG is technically feasible through a single incision with the use of articulating laparoscopic devices and intra-abdominal organ retractors to assist in intracorporeal anastomosis.
Keywords stomach neoplasm, laparoscopy, minimally invasive surgical procedures
Need
Proximal gastrectomy (PG) is known to be superior to total gastrectomy in preventing nutritional deficiencies, anemia, and weight loss by maintaining a gastric res- ervoir.1-3 Double-flap esophagogastrostomy (EG) was first introduced by Kamikawa in 19984 to prevent reflux esophagitis after PG. However, the mean operation time for laparoscopic PG with double-flap EG varies from 275 to 420 minutes due to intracorporeal hand sewing during EG anastomosis.5,6 Due to the difficulty and complexity of the procedure, surgeons are reluctant to attempt single- port intracorporeal double-flap anastomosis. In this study, we discuss in detail the surgical techniques in performing single-incision proximal gastrectomy (SIPG) with double-flap EG, providing emphasis on the use of ar- ticulated devices and clip retractors to facilitate the procedure.
Technical Solution
Two patients diagnosed with early gastric cancer at the upper third portion of the stomach underwent SIPG on September and November 2018. Informed consent was
1Department of Surgery, Seoul National University Bundang Hospital, Seongnam, Korea 2Department of Surgery, Dangook University Hospital, Cheonan, Korea 3Department of Surgery, Chungnam National University Hospital, Daejeon, Korea 4Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
Corresponding Author: Sang-Hoon Ahn, Department of Surgery, Seoul National University Bundang Hospital, Seoul National University, College of Medicine, 300 Gumi-dong, Bundang-gu, Seongnam-si, Gyenggi-do 13620, Korea. Email: [email protected]
SIPG
Patients were placed in lithotomy position and a scope holder (Laparostat; CIVCO Medical Solutions, Iowa, USA) was installed on the left side of the patient. A 2.5 cm vertical transumbilical incision was made, and port (EZ access; Hakko, Japan) was inserted. An artic- ulating grasper (Artisential, Livsmed, Korea) was used to facilitate the D1+ lymphadenectomy. An intra-abdominal organ retractor such as the FJ Clip (Charmant, Sabae, Japan) was tied with 2 Prolene sutures (Figure 1A) that were pulled out of the abdominal cavity at 2 points— upper epigastric and right lateral flank (Figure 1B).
Double-Flap EG
A 2.5 × 3.5 cm H-shaped seromuscular flap is created extracorporeally on the anterior wall of the gastric remnant. A continuous barbed suture (V-loc, Med- tronic, Minnesota, USA) was used to connect the posterior wall of the esophagus to the upper lip of the stomach opening. After creating an opening, the upper lip of the esophagus was retracted upward using the intra-abdominal organ retractor (Figure 2A). For in- tracorporeal suture, an articulated needle holder (Ar- tisential, Livsmed, Korea) was used. The wrist-like articulating motion enabled vertical running sutures to be performed (Figure 2B). After EG, the anastomosis was covered using the seromuscular flap, and the flap
was closed using 2 or 3 same barbed sutures (Figures 2C and 2D). After closure of the wound using intradermal sutures and surgical bond, intraoperative esophagogastro- scopy was performed to check for leakage or stricture.
Proof of Concept
Patient Outcome
For the first patient, total operation time was 195 minutes, and the anastomosis time was 75 minutes. Within the anastomosis time, it took 6 minutes to create the flap extracorporeally and 69 minutes for the intracorporeal suture. The second patient had a total operation time of 110 minutes and had 46 minutes for anastomosis with 5 minutes for flap dissection and 41 minutes for intra- corporeal hand sewing. Estimated blood loss was less than 30 mL for both patients. Patients were discharged without complications.
In our technical description, we made use of various laparoscopic tools to help overcome the limitations of single-port laparoscopic surgery. Reusable organ pen- dant clips (FJ Clip, Charmant, Sabae, Japan) were used to assist in retraction whenever it was necessary. By tying 2 Prolene sutures, the retractor clip is provided with 2 vectors of force that can be manipulated into various directions. Barbed sutures were used to reduce time and effort. Also, articulating needle holders such as the ArtiSential needle holder (Livsmed, Korea) were able to reduce the anastomosis time and helped in performing an accurate suture without disrupting the anastomosis. This device showed equal suture time compared to the da Vinci system in a previous dry lab study7 and was in- troduced to clinical cases since 2018.8
Figure 1. Technique in using the intra-abdominal organ retractor (FJ Clip, Charmant, Sabae, Japan). (A) 2 Prolene sutures are tied to both sides of the clip. (B) Straight needles are pulled out of the abdomen in 2 points—upper epigastric and right flank—allowing 2 vectors that may be used for traction.
152 Surgical Innovation 28(1)
Next Steps
Although this technical report shows the feasibility of using these novel instruments, there are still major con- cerns to be taken into account. First, the operator has a substantial experience in single-incision laparoscopic gastrectomy, and it does not guarantee the same results from a surgeon with less experience. Also, the use of the articulating laparoscopic device has a learning curve of its own, and some dry lab practice may be needed. However, this description of the surgical technique may give insight into other surgeons who experience difficulty in per- forming this procedure and help in providing a stepping stone to future research and surgical skills.
Conclusion
SIPG with double-flap EG may be a feasible technique with the active use of new laparoscopic tools such as clip retractors and articulated needle holders.
Author Contributions
Study conception and design: So Hyun Kang, Young Suk Park, Sang-Hoon Ahn, Hyung-Ho Kim Acquisition of data: So Hyun Kang, Yongjoon Won, Kanghaeng Lee, Sang Il Youn, Sang-Hoon Ahn Analysis and interpretation: So Hyun Kang, Yongjoon Won, Kanghaeng Lee, Sang Il Youn, Sa-Hong Min, Young Suk Park, Sang-Hoon Ahn Drafting of manuscript: So Hyun Kang, Sang-Hoon Ahn Critical revision of manuscript: Sa-Hong Min, Young Suk Park, Sang-Hoon Ahn, Hyung-Ho Kim
Declaration of Conflicting Interest
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.
ORCID iD
References
1. Ahn S-H, Lee JH, Park DJ, Kim H-H. Comparative study of clinical outcomes between laparoscopy-assisted proximal gastrectomy (LAPG) and laparoscopy-assisted total gas- trectomy (LATG) for proximal gastric cancer. Gastric Cancer. 2012;16(3):282-289. doi:10.1007/s10120-012-0178-x
2. Ahn S-H, Jung DH, Son S-Y, Lee C-M, Park DJ, Kim H-H. Laparoscopic double-tract proximal gastrectomy for proxi- mal early gastric cancer. Gastric Cancer. 2013;17(3): 562-570. doi:10.1007/s10120-013-0303-5
3. Jung DH, Lee Y, Kim DW, et al. Laparoscopic proximal gastrectomy with double tract reconstruction is superior to laparoscopic total gastrectomy for proximal early gastric cancer. Surg Endosc. 2017;31(10):3961-3969. doi:10.1007/ s00464-017-5429-9
Figure 2. Intracorporeal double-flap reconstruction through a single incision. (A) Posterior wall of the esophagus is fixated with the anterior wall of the stomach, and the intra-abdominal clip retractor pulls the upper lip upward to better vision. (B) Articulating needle holders such as the ArtiSential (Livsmed, Korea) can facilitate vertical sutures for hand-sewn EG. (C) H-shaped seromuscular flap is sutured over the EG. (D) Final shape of the double-flap EG. EG = esophagogastrostomy.
Kang et al 153
5. Omori T, Moon J-H, Yanagimoto Y, Sugimura K, Miyata H, Yano M. Pure single-port laparoscopic proximal gastrectomy using a novel double-flap technique. Ann of Laparosc and Endosc Surg. 2017;2:123. doi:10.21037/ales.2017.06.01
6. Shoji Y, Nunobe S, Ida S, et al. Surgical outcomes and risk assessment for anastomotic complications after laparoscopic proximal gastrectomy with double-flap technique for upper-
third gastric cancer. Gastric Cancer. 2019;22(5):1036-1043. doi:10.1007/s10120-019-00940-0
7. Min S-H, Cho Y-S, Park K, et al. Multi-DOF (degree of freedom) articulating laparoscopic instrument is an effective device in performing challenging sutures. J Minim Invasive Surg. 2019;22(4):157-163. doi:10.7602/jmis.2019.22.4. 157
8. Kang SH, Cho Y-S, Min S-H, et al. Intracorporeal overlap gastro-gastrostomy for solo single-incision pylorus-preserving gastrectomy in early gastric cancer. Surg Today. 2019;49: 1074-1076. doi:10.1007/s00595-019-01820-x
154 Surgical Innovation 28(1)
Need
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