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Ohmura et al. Mini-invasive Surg 2019;3:4 I http://dx.doi.org/10.20517/2574-1225.2018.69 Page 11 of 13

and longer operation time, but we believe it is undesirable to give too much priority to shortening
operation time. Completing a straight suture line in gastroduodenostomy at the co-axial position is a great
opportunity to acquire basic intracorporeal suturing technique and the acquired technique will be useful
in unexpected difficult situations, such as unintended bowel injury.

In LADG, extracorporeal stomach transection with a linear stapler is performed from the greater
curvature and it is sometimes difficult to ensure an optimal proximal margin in obese patients with
middle third gastric cancer. When the patient has a thick abdominal wall, it is necessary to pull out the
stomach with considerable traction however there is an absolute limitation to our ability. At the beginning
of the totally laparoscopic distal gastrectomy (TLDG), there were some concerns about the difficulty of
locating the tumor and securing the resection margin as a technical limitation. However, with the routine
intraoperative endoscopy, it has become possible to decide the transection line more reliably. Although
there were some reports analyzing the data of proximal and distal resection margin [40-43] , the difference
of the resected specimen between extracorporeal and intracorporeal approach had not been discussed.
Therefore, we conducted an evaluation of the size of the resected specimen in this study. The result of our
study revealed that the length of the greater curvature of the resected stomach was shorter in the EC-THS
group compared to the IC-HHS group. In the EC-THS group, the length of the greater curvature tended to
shorten as BMI increases. Resectable range of the proximal stomach might be limited in the EC-THS group
as the degree of obesity increases. On the other hand, with regard to the transection at the lesser curvature
side, it is possible to insert the tip of the linear stapler near the esophago-gastric junction. We supposed
that this was the reason why there was no difference in the length of the resected lesser curvature. Despite
of the higher proportion of middle third gastric cancer in the IC-HHS group, there was no difference in the
proximal margin between the two groups. The intracorporeal procedure was superior not only in terms of
intracorporeal reconstruction but also of intracorporeal transection, because it was possible to determine
a more reliable transection level of the stomach to secure an optimal surgical margin. As described
above, the extracorporeal anastomosis through a small incision sometimes requires excessive traction
on the organs and increases intraoperative manipulation, especially in obese patients. The excessive
traction of the organs in a narrow operative field sometimes causes unexpected vessel injuries in a blind
spot. Additionally, although we carefully confirmed that there was no bleeding before making a small
laparotomy, unexpected bleeding due to congestion of the stomach was often experienced at the time when
the stomach was pulled out from the small laparotomy. This might cause the difference of intraoperative
blood loss. In total laparoscopic gastrectomy, wide and anatomically undeviated surgical field minimizes
unintended surgical trauma.

In conclusion, the IC-HHS technique for end-to-end Bi-I gastroduodenostomy revealed feasible with
acceptable operation time and postoperative outcome. The DSLT and IC-HHS techniques allowed the
operator to perform all procedures from initial skin incision to wound closure at the co-axial position
without changing position. Although IC-HHS anastomosis requires an advanced suturing technique, we
believe that it is necessary to keep basic training for intracorporeal suturing in addition to using automatic
suturing equipment. Resectable range of the stomach was limited as the BMI increases in extracorporeal
stomach transection. Intracorporeal stomach transection is desirable especially in obese patients. The
advantage of TLDG has been reported providing a safe operative field during the reconstruction regardless
of patient’s figure. Additionally, the results of this study demonstrated another advantage of TLDG. It
means that intracorporeal gastric resection makes it possible to perform safe gastric transection at a more
proximal site in obese middle third gastric cancer patients without unexpected tissue damage.

DECLARATIONS
Authors’ contributions
Conception and design of the study, data analysis, literature research, manuscript writing, manuscript
editing, and manuscript revision: Ohmura Y, Suzuki H, Kotani K, Teramoto A