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Page 10 of 13 Ohmura et al. Mini-invasive Surg 2019;3:4 I http://dx.doi.org/10.20517/2574-1225.2018.69

it is difficult to keep a sufficient operative field for safe intracorporeal anastomosis. Currently, IC-DS
anastomosis has been widely performed in East Asian countries [14,16] . Shorter operation time and superior
short-term surgical outcomes were reported in comparison with the other methods [27,28] , however, some
concerns were reported. First, due to anatomical twisting from the IC-DS method, it is relatively difficult
for inexperienced surgeons to understand deviated anatomy. Second, a IC-DS gastroduodenostomy is
a functional end-to-end anastomosis, but is an anatomical side-to-side anastomosis, more tension is
[23]
generated compared to anatomical end-to-end anastomosis . Moreover, additional duodenal dissection
and formation of the triangular area of the duodenal wall might be responsible for the ischemic status,
which is one of the most significant risk factors of anastomotic failure. Technically, a skillful assistant is
[29]
desirable for cooperative work when inserting a stapler during IC-DS gastroduodenostomy. Okabe et al.
reported two cases of duodenal injury during IC-DS gastroduodenostomies and they had to change the
reconstruction method.

On the other hand, other anastomotic procedures using intracorporeal hand-sewn techniques were
[30]
reported [30-32] . Takiguchi et al. performed a total laparoscopic method by performing Billroth-I hand-
sewn anastomosis and reported excellent postoperative recovery. In attempting to intracorporeal
anastomosis, we initially applied total hand-sewn Albert-Leinbert anastomosis which was a promising
and stable anastomotic method in open surgery after thorough training and since 2012. Total hand-sewn
Albert-Leinbert anastomosis was performed in 19 patients. Although there was no major problem in
their postoperative course, it took an average of nearly 100 min longer compared to the EC-THS method.
Then, 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 by an intracorporeal hand-sewn technique. We previously reported this procedure as a
[19]
“HHS technique” in 2013 . Koeda and colleagues reported similar technique as a hybrid technique using
linear staplers and manual suturing in 19 pylorus-preserving gastrectomy cases with good postoperative
[33]
results .
There are some reports using a barbed suture in order to facilitate intracorporeal suturing, however,
complications following the use of this unique suture have been reported in several other surgeries [34-36] .
The most commonly encountered complication with the use of barbed sutures was postoperative bowel
obstruction. In terms of its intended shape, a barbed suture develops irreversible tension created during the
suturing. Therefore, excessive traction narrows the anastomotic lumen, which can also cause postoperative
stricture. Therefore, we used absorbable blade for continuous Albert suturing and nylon blade for
interrupted Leinbert suturing, as were adopted to conventional open surgery.

Although single layer continuous anastomosis could simplify the procedure and shorten operation
time, we performed two-layer anastomosis. In bariatric surgery, staple-line reinforcement was strongly
[37]
recommended for laparoscopic sleeve gastrectomy to decrease complications . Also, it was reported that
laparoscopic reinforcement with Lembert’s sutures of a duodenal stump could help to avoid duodenal
stump leakage in Rou-en Y reconstruction [38,39] . We applied a two-layer technique with interrupted
inverting sutures for the intracorporeal gastroduodenostomy. Due to the fact laparoscopic surgery has
been developed as a minimally invasive surgery, once postoperative complications arise, the disadvantages
incurred by patients are greater than that of conventional laparotomy surgery. Reconstruction can
be done without hand suturing by other anastomotic techniques in most cases, however, there are no
reports showing the result of delta-shaped anastomosis in open gastrectomy even at medical facility that
introduced IC-DS anastomosis as the standard procedure. This does not mean that delta anastomosis is the
best anastomotic method but may indicate that it is a complementary procedure during the development
of laparoscopic surgery. We believe that acquisition of intracorporeal suturing skills are still important and
the ideal reconstruction methods established in the long history of open surgery deserved to be reproduced
as much as possible in laparoscopic surgery. IC-HHS anastomosis requires an advanced suturing technique