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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 7 of 13

Surgically resected gastric cancer patients
(Sep.2008-Dec.2017)
N = 452
Open surgery
n = 229
Laparoscopic surgery
n = 223
Total gastrectomy (n = 21)
Proximal gastrectomy (n = 3)
Distal gastrectomy
n = 199
Colectomy (n = 3)
Nephrectomy (n = 1)
Enrolled patients
n = 195
Anastomotic procedure

Hand-sewn via small laparotomy Intracorporeal HHS technique
n = 85 n = 110

Figure 4. Flow chart for the current study detailing inclusion and exclusion criteria; HHS: hemi-hand-sewn

time was longer in the IC-HHS group (276.4 min) than in the EC-THS group (234.6 min) (P = 0.04) and
intraoperative blood loss was smaller in IC-HHS group (26.3 mL) compared to EC-THS group (48.9 mL)
(P < 0.01). R0 resection was achieved in all patients with free surgical margin defined by pathological
examination.

Postoperative outcome
Surgical site infection was observed at the epigastric wound in the EC-THS group (5 cases) and at the
umbilical wound in the IC-HHS group (1 case). Laparoscopic cholecystectomy was required in one case
of the IC-HHS group due to necrotic cholecystitis resistant to conservative treatment on day 9 after
gastrectomy. One case of delayed gastric emptying was observed in the EC-THS group. The frequency of
intra-abdominal abscess or pancreatic fistula development in the EC-THS and IC-HHS group were 3.5%
and 1.8%, respectively and they were all cured by administration of antibiotics. One case of postoperative
pneumonia in the EC-THS group was also successfully treated by antibiotics.

Evaluation of resected specimen
Table 2 shows the measured length of each part of the resected specimens. The greater curvature of the IC-
HHS group was significantly longer than that of EC-THS group (214.6 vs. 228.7 mm, P < 0.01). The length of
the lesser curvature and the duodenum were not significantly different. There was no correlation between
BMI and the length of the greater curvature in the IC-HHS group (r = 0.03, P = 0.47), while in the EC-HS
group, the length of the greater curvature weakly correlated with BMI (r = -0.44, P < 0.01). The length of
the great curvature of the resected stomach tends to be shorter as BMI increases [Figure 5A and B].

DISCUSSION
This study found that the IC-HHS technique for laparoscopic B-I gastroduodenostomy was successfully
accomplished in all 110 cases without any procedure-specific complications, indicating its technical
feasibility. The average operation time was about 40 min longer than EC-THS reconstruction. The similar
difference in the subgroup analysis in D1+ cases suggested that the extended operation time was due to
the difference in the anastomotic procedures. Anastomotic leakage and stricture were not observed in our
experiences.