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

Endoscopic observation to the duodenum prior to resection made it possible to prevent spillage of
gastrointestinal contents during anastomosis. After completion of lymph node dissection, the duodenum
was divided with an endoscopic linear stapler: Echelon® 60-3.5 (Ethicon Endo-Surgery, Cincinnati, OH,
USA) without duodenal twisting. Transection of the stomach was also performed using endoscopic linear
staplers twice under intraoperative gastroscopic navigation (in middle third gastric cancer cases). Then the
resected specimen was retrieved via Lap Protector® (Hakko, Nagano, Japan) attached to a 3-cm incision
at the umbilical port. After the macroscopic evaluation, a frozen-section examination was performed if
needed.

Full-thickness posterior wall anastomosis
After retrieval of the resected stomach, a plate platform: E-Z access® (Hakko) was attached to the wound
protector and pneumoperitoneum was restarted, then an intracorporeal anastomosis was performed. First,
removal of a small part of the staple using Sonicbeat® (OLYMPUS, Tokyo, Japan) at 5 cm from the greater
curvature of the remnant stomach was completed to confirm anastomotic diameter. Then the staple line of
the remnant stomach was reinforced by continuous seromuscular suturing with 3-0 Vicryl from the lesser
curvature to the defect of the staple. Sero-muscular stay sutures with 3-0 Bear Braid were placed at both
the lesser and greater curvatures between the remnant stomach and the duodenum. An entry hole was
made by piercing the active blade of Sonicbeat at the greater curvature of the stomach wall, then a tissue
pad of Sonicbeat was put into the stomach cavity and the anterior wall was incised toward the staple defect.
A similar entry hole was made at the greater curvature of the duodenal wall and the anterior wall of the
duodenum was incised toward the lesser curvature side. The assistant grasped two stay sutures ligated at
the excessive tissues and lifted them up vertically. Then the posterior wall of the remnant stomach and the
duodenum were approximated by Echelon 60-3.5 inserted from the umbilical port. During closure of the
stapler forks, it was carefully confirmed that there was no excessive pinching of the anterior wall from left
and right lateral abdominal trocars. The endoscopic linear stapler was fired to excise the excessive gastric
and duodenal tissues and simultaneously the posterior wall anastomosis was constructed. Then the staple
line was observed to confirm that there was no bleeding or pinching of the anterior wall [Figure 2A-G].

Full-thickness anterior wall anastomosis
Subsequently, a full-thickness, continuous suture of the anterior wall was performed with 3-0 Vicryl. The
first suture was started at the lower edge of the posterior wall and the first knot was developed inside the
lumen involving the staple edge. Next suturing was made from the duodenal mucosa to the serosal side and
after 5 over and over suturings, the Vicryl was locked. Using another 20 cm Vicryl, continuous suturing
was started from the upper edge of the staple line of the posterior wall anastomosis. Continuous suturing
was carried out with an over and over technique and when the two sutures met each other, each end was
ligated intracorporeally to finish the full-thickness anterior wall anastomosis [Figure 2H].

Sero-muscular inverting anterior wall anastomosis
Afterwards, interrupted sero-muscular layer suturing of the anterior wall was performed with 3-0 Bear
Braid for complete inverting anastomosis [Figure 2I]. The first suture at the lesser curvature involved three
points, the anterior and posterior wall of the remnant stomach and the duodenal wall. Approximately
10 sero-muscular sutures were required for inverting gastroduodenostomy. Then, an intracorporeal B-I
gastroduodenostomy by HHS technique was completed, which was almost the same shape as a hand-
sewn inverting anastomosis by open surgery or EC-THS reconstruction. In the case with intraoperative
endoscopy, the anastomotic site was observed after the completion of reconstruction [Figure 3].

Patient evaluation
Total laparoscopic gastrectomy with IC-HHS technique was introduced since November 2013. A total of
452 patients who underwent surgery for gastric cancer in our hospital and related institutions between
September 2008 and December 2017 were identified. All patients underwent multi-detector-row computed