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Mazzola et al. Mini-invasive Surg 2019;3:12 I http://dx.doi.org/10.20517/2574-1225.2019.05 Page 7 of 10

Table 2. Intraoperative outcomes
Duration of surgery (min)* 369 (275-440)
Type of anastomosis:
HDS technique with transorally inserted anvil 1
S-S overlap anastomosis 5
E-S anastomosis 4
Intraoperative complication 1
Associated procedures 6
Conversion to open surgery 1
Data is expressed as number of patients. *Data is expressed as an average with range in brackets. HDS: hemi-double-stapling; S-S: side-
to-side; E-S: end-to-side

Table 3. Postoperative outcomes
Length of hospital stay (day)* 10 (8-58)
Overall complications 7
Severe complications 3
Reoperations 2
Anastomotic leakage 1
Anastomotic stenosis 0
Abdominal abscess 1
POPF 0
Duodenal stump leak 0
Wound infection 0
Ileus caused by internal hernia 1
Number of LNs harvested § 29 (15-38)
Number of LNs positive § 5 (0-22)
Tumor dimension (mm) 49 (17-130)
Pathological T1b/T2/T3/T4a # 1/1/6/2
Pathological N0/N1/N2/N3a/N3b 3/1/1/4/1
Pathological stagingIb/IIa/IIIa/IIIb/IIIc # 2/2/1/4/1

Median OS* (months) 15.5 (6-32)
Median DFS* (months) 12.5 (6-28)
§
Data is expressed as number of patients. *Continuous variables are reported as mean values and range; data is expressed as an average
with range in brackets; #clinical staging according AJCC 8th Edition. POPF: postoperative pancreatic fistula; LNs: lymph-nodes; OS:
overall survival; DFS: disease free survival

Some critical aspects of this procedure however still make it open to debate, one of these being the
possibility to perform a correct lymphadenectomy, especially to dissect the station 10. A large meta-
analysis, comparing open and laparoscopic total gastrectomy, reported no statistical differences between
the two techniques in terms of lymph-nodes clearance, 5-year OS and DFS, and free proximal resection
[5]
margins, confirming their same oncological safety and adequacy . This data was confirmed by another
meta-analysis, including totally laparoscopic total gastrectomy only, reporting no difference in the number
[21]
[22]
of the harvested lymph-nodes . Furthermore a recent RCT reported an incidence of positive lymph-
nodes in the station 10 of 2.4%, in a cohort of well selected patients, all candidates to total gastrectomy,
concluding that, for these kind of patients, the station 10 lymphadenectomy is not mandatory; however
in case of macroscopic lymph-nodes at splenic hilum it seems possible to perform a laparoscopic spleen-
[23]
preserving dissection . Our small series confirmed this data with a mean number of lymph-nodes
harvested of 29; D2 lymphadenectomy and complete omentectomy were always performed in all the
patients and they didn’t cause intraoperative nor postoperative complications; 2 patients needed, in
addition, the spleen-preserving lymphadenectomy of the station 10 for slightly enlarged, suspicious, lymph-
nodes without further morbidity.

Therefore the major concern of laparoscopic total gastrectomy seems related to the E-J reconstruction. The
first attempt to overcome this obstacle was to perform a midline mini-laparotomy for a hybrid approach;