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Page 4 of 11 Shimada et al. Mini-invasive Surg 2019;3:7 I http://dx.doi.org/10.20517/2574-1225.2018.78

endoscopic forceps with concerns of spillage of cancer cells. Thus, primary open surgery with D2 LND and
adjuvant chemotherapy remains the standard treatment for type 4 or large type 3 tumors.

Probably, majority of surgeons will be convinced of the indication of LG about positive nodes and large
tumor as below: (1) lymph nodes are not bulky; (2) no invasion to other organ or major vessels; (3) tumor
[5]
size is less than 8cm in diameter; and (4) non-type4 tumor. In that context, Okabe et al. disclosed a phase
II study (KUGC04), which demonstrated safety and efficacy of LG for gastric cancer of clinical stage II or
higher, including patients with prior chemotherapy, tumors requiring TG, tumors that invaded adjacent
organs, and patients with bulky nodes metastasis. Solid evidence of the surgical and oncological safety of
LG for AGC requires performance of a multicenter, prospective study with experienced surgeons.

Splenic hilar dissection for proximal gastric cancer
In Japan, splenic hilar nodes (No.10) have been included within the extent of D2 LND in the treatment
of proximal AGC for a long time. However, the final result of JCOG 0110 (UMINC000000004) has been
disclosed, which compared splenectomy vs. non-splenectomy for proximal AGC not invading greater
curvature line. There was no difference in long-term survival rate. Furthermore, splenectomy was
[19]
associated with increased incidence of morbidity . Therefore, splenectomy is not recommended as a
standard treatment, except for tumors invading the greater curvature line. Conversely, there is a possibility
that such tumors invading the greater curvature line or tumors with metastases of splenic hilar lymph
node may be indicated for splenic hilar dissection. Laparoscopic approach has a great advantage for
procedures in deep surgical fields around spleen. However, for complicated cases, such as invading the
splenogastric ligament or the pancreatic tail, there are strong doubts about whether laparoscopic maneuver
is applicable or not.

THE TECHNICAL TIPS OF LND FOR AGC
Preoperative evaluation
Preoperative esophagogastroduodenoscopy, contrast enhanced computed tomography, and positron
emission tomography are important for accurate diagnosis on tumor depth, invasion adjacent organs,
lymph node metastases, or distant metastases. Three-dimensional computed tomography is also helpful to
[20]
recognize the branching of celiac artery or anatomical diversity of the splenic hilar vessels .

Positions of trocars
Reverse Trendelenberg position with head elevated about 15-20°. The surgeon stands on the patient’s right
side, the assistant is on the left side, and the assistant for camera stand between the patient’s legs. A scope
port is inserted via umbilical mini-laparotomy. For manipulation, 5 mm trocars are inserted on bilateral
subcostal midclavicular line, and 12 mm trocars are inserted on bilateral lateroabdominal region, which
arranged in an inverted trapezoidally. Especially, because the raised pancreatic head or vertebral body
get in the way of dissection in case of dissection around esophagus or deep suprapancreatic lymph node
dissection, right lateroabdominal trocar should be arranged slightly medially and cranially.

Laparoscopic inspection
At first, it is identified that there is no metastasis on the surface of the liver and peritoneal dissemination in
the omentum, mesocolon, and mesenterium. Subsequently, intraoperative cytology of ascites in the pelvic
cavity or peritoneal lavage specimen is examined. If the intraoperative cytology detects free cancer cells,
it is considered to be “non-curative factor (CY1)”. However, if there is no “non-curative factor” other than
CY1, it is often recommend now that we should convert LG into OG with D2 LND for standard radical
surgery and extensive intraoperative peritoneal lavage using a large amount of saline solution.

Dividing the greater omentum and dissection of the gastrosplenic ligament
Omentectomy is performed for almost patients having tumors deeper than T3. Discussion of the greater
omentum is started near transverse colon. Surgeon’s left forceps and the assistant’s right forceps elevate