Total gastrectomy for locally advanced cancer: the pure laparoscopic approach

Total gastrectomy is the treatment of choice for adenocarcinoma of the upper and middle third of the stomach resected with curative intent. The laparoscopic approach allows satisfactory exploration of the peritoneal cavity and optimizes staging in borderline T3 or T4 tumours in patients affected by locally advanced tumours or intraperitoneal carcinomatosis. Laparoscopy can eliminate unnecessary laparotomies in 10% of patients affected by these conditions with formal contraindications for resection [1]. Complete resection of the stomach associated with D2 lymph node dissection is also performed using a currently well-established technique [2, 3]. The specificity of laparoscopic gastric resection for cancer is that the stomach and the great omentum are withdrawn separately. Reconstruction of the digestive tract is more complex and requires a variety of techniques (supra-umbilical mini-laparotomy, Orvil technique, enlarging a port-site for passage of a circular stapler, mechanical side-to-side anastomosis, etc), but none of these has become the ‘gold standard’ [4–7]. This explains the difficulties encountered in promoting the widespread use of minimally invasive resection in western countries. Scientific societies insist on the need for prospective studies to establish the place of laparoscopy for gastric cancer (prophylactic gastrectomy for CDH-1 related gastric cancer, <T3 tumours, palliative gastrectomy) [4]. Here we present our technique for total resection of the stomach and D2 lymph node dissection, which allows the manual creation of a feasible, safe, tension-free and effective oesophago-jejunal anastomosis. It can be performed by any surgeon familiar with laparoscopic surgery and the principles of oncological resection. The cost is also relatively low because neither a circular stapler nor other special equipment is required. Finally, the incision for extraction of the specimen can be placed in any area of the abdomen (usually through a suprapubic incision in our practice).