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Zhang et al. Mini-invasive Surg 2019;3:2 I http://dx.doi.org/10.20517/2574-1225.2018.64 Page 3 of 7

in manipulating the stapler and the stomach in a narrow abdominal cavity. In order to enable the anvil
[8]
placement into the dudenum, many strategies were applied, such as a triple stapling procedure and the
[9]
use of the natural pyloric ring with endo-looping of the duodenum . Some techniques usually used in
esophagoenteral anastomosis were also reported, such as using specially modified laparoscopic purse-
[11]
[12]
string instrument and opening the lumen and applying manual purse-string suture . However, there
are still many difficulties to be overcome.
[13]
Kim et al. reported a method which seemed to be quick and economical. The atraumatic clamps were
used to prevent slippage of the duodenum which was cut with ultrasonic shear instead of linear stapler.
[14]
After that, a seromuscular suture was done around the duodenal outer layer along the clamp. Omori el al.
reported a method like reverse puncture technique used in total gastrectomy. The anvil secured with
vicryl suture was inserted into the duodenum through semicircumferential duodenotomy. The needle was
advanced to the anterior duodenal wall and then the duodenum was staple-transected. Finally, the center
rod penetrated the duodenal wall. In this method the need for purse-string suture placement was totally
eliminated.

Although the skill inserting anvil head in the duodenal stump can be improved, laparoscopically inserting
the circular stapler into the remnant stomach was not always easy. After removing two-thirds to three-
quarters of the stomach, the small remnant stomach was usually so small that it was difficult to insert the
stapler, even from the epigastric region. Sometime it was very difficult to form a straight line among the
[15]
duodenum, remnant stomach and the circular stapler from the umbilical wound. Omori el al. described
a novel method to insert the circular stapler to connect the anvil head. Firstly, the anvil head was passed
through the posterior gastric wall with laparoscopic endloop, which can make the duodenum and remnant
stomach form a straight line. Secondly anterior gastric suture was used to exteriorize the anvil shaft partly
from the gastrotomy. And then the anvil shaft was advanced into the remnant stomach to make the anvil
and the stapler join tighter.

LINEAR STAPLER INTRACORPOREAL B-I RECONSTRUCTION
Delta-shaped anastomosis and modified delta-shaped anastomosis
With the development of laparoscopic instruments and the continuous accumulation of surgical experience
in recent years, linear stapler intracorporeal gastrointestinal anastomosis techniques have been developed.

[16]
Kanaya et al. firstly reported a anastomosis method which used only laparoscopic linear staplers in the
hope of overcoming the drawbacks of extracorporeal reconstruction. The method named delta-shaped
anastomosis (DA) was a modified intracorporeal B-I reconstruction which was soon promoted. The
emergence of the DA method made intracorporeal gastroduodenostomy possible, which greatly promoted
the development of totally laparoscopic distal gastrectomy (TLDG). Utilization DA method allows
[17]
gastroduodenal anastomosis with a diameter of at least 30 mm while avoiding stricture. Kanaya et al.
analyzed the result of initial 100 procedures and showed that the mean time of the anastomosis was 13 min
and the rate of anastomosis related complications was rare in 2011.

But some surgeons worry about the blood supply affected during cutting, which would result in
leakages ranging from 0.42% to 8.5% [17-20] and anatomical distortion which exist in twisting around the
[21]
anastomosis . In order to overcome the twisting around the anastomosis, some modified delta-shaped
techniques were studied.

[22]
Huang et al. reported modified DA in 2014. This was different from the conventional DA in closing
the common stab incision of stomach and duodenum. In order to avoid the poor blood supply of the
duodenum, the duodenal cutting was totally resected. The appearance of the anastomoses was changed