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Page 2 of 13 Ohmura et al. Mini-invasive Surg 2019;3:4 I http://dx.doi.org/10.20517/2574-1225.2018.69

Keywords: Laparoscopy, gastrectomy, anastomosis, Billroth I procedure, surgical margin

INTRODUCTION
[1]
Since the first laparoscopic gastrectomy was described in 1992 , the safety and feasibility of laparoscopic
[2,3]
gastrectomy have already been demonstrated in the treatment of early gastric cancer and several
advantages of laparoscopic gastrectomy were reported in comparison with open gastrectomy, such as
[4,5]
postoperative recovery and shorter hospital stay . Due to being less invasive, laparoscopic gastrectomy
was successfully performed in elderly patients and obese patients with an acceptable complication rate and
[6-9]
prognosis .

The reconstruction methods after distal gastrectomy are represented by Billroth-I (B-I), Billroth-II, and
Roux-en-Y method. Among them, B-I gastroduodenostomy is the most widely practiced procedure in
the world. Due to the fact that the procedure is relatively simple and does not require an anatomical
[10]
replacement of the digestive tract below the transverse colon . Moreover, it provides a physiologic flow of
food contents through the duodenum and decreases the possibility of metabolic problems and nutritional
[11]
deficiency while postoperative observation of the ampulla of Vater can be carried out reliably and easily.
When laparoscopic gastrectomies were first introduced, because of the technical challenges of achieving
an intracorporeal B-I reconstruction, most surgeons preferred laparoscopy-assisted approach with mini-
laparotomy [12,13] . In laparoscopy-assisted distal gastrectomy (LADG), gastroduodenostomy as well as gastric
transection was also performed through a small laparotomy. Therefore, especially in obese patients with
thick abdominal walls, it was difficult to pull out the stomach enough to secure an appropriate resection
range and to perform safe anastomosis through the small laparotomy.

Recently, several techniques of intracorporeal reconstruction have been developed. Currently, many gastric
surgeons are attempting to perform total laparoscopic gastrectomy with intracorporal reconstruction
[14]
because it offers a good operative field regardless of the patient’s figure . Furthermore, the transection
level of the stomach can be reliably determined by the intraoperative endoscope in a natural anatomical
position without deformation.

In our hospital, we have performed LADG with extracorporeal total hand-sewn (EC-THS) gastroduodenostomy
[15]
through mini-laparotomy until October 2013 . Since intracorporeal delta-shaped (IC-DS) gastroduodenostomy
was introduced, this method became the most widely implemented intracorporeal anastomotic
technique, especially in eastern countries [16-18] . However, several concerns have been reported, such as
anatomical twisting, excessive tension caused by side-to-side anastomosis, duodenal ischemia due to
duodenal dissection and preservation, and shortened distal surgical margin. In 2013, as the method of
total laparoscopic distal gastrectomy, we devised a new reconstruction method to create end-to-end
gastroduodenostomy, in which the posterior wall of the anastomosis was constructed with a linear stapler
and subsequently, the anterior wall was sutured with an intracorporeal hand-sewn technique, and reported
[19]
as intracorporeal “hemi-hand-sewn (HHS) technique” .
The purpose of this study was to evaluate the feasibility and efficacy of IC-HHS technique for end-to-end
B-I gastroduodenostomy after laparoscopic distal gastrectomy in comparison with conventional EC-THS
anastomosis in LADG. In addition, we assumed that there was a possibility that the range of resection
might be smaller in laparoscopy-assisted approach in obese patients, but the difference of resection range
between the extracorporeal transection and intracorporeal procedure were not reported. Therefore, we
evaluated the size of resected specimen and analyzed the differences of the resection range between each
procedure.