Laparoscopic Gastrectomy for Gastric Cancer: Surgical Technique and Lymphadenectomy

357 Pages·2015·44.92 MB·English

by  Chang-Ming Huang, Chao-Hui Zheng (eds.)

Chang-Ming Huang
Chao-Hui Zheng
Editors
Laparoscopic Gastrectomy
f or Gastric Cancer
Surgical Technique and
Lymphadenectomy
123
Laparoscopic Gastrectomy for Gastric
Cancer

Chang-Ming Huang (cid:129) Chao-Hui Zheng
Editors
Laparoscopic
Gastrectomy for Gastric
Cancer
Surgical Technique
and Lymphadenectomy
Editors
Chang-Ming Huang Chao-Hui Zheng
Department of Gastric Surgery Department of Gastric Surgery
Fujian Medical University Union Hospital Fujian Medical University Union Hospital
Fuzhou Fuzhou
China China
ISBN 978-94-017-9872-3 ISBN 978-94-017-9873-0 (eBook)
DOI 10.1007/978-94-017-9873-0
Library of Congress Control Number: 2015938762
Springer Dordrecht Heidelberg New York London
© Springer Science+Business Media Dordrecht and People's Medical Publishing House 2015
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Pref ace
W e are delighted to witness the publication of the English edition of
Laparoscopic Gastrectomy for Gastric Cancer: Surgical Technique and
Lymphadenectomy .
G astric cancer is the fourth most common malignancy and second most
common cause of cancer-related death worldwide. Surgical treatment has
proven to be an important approach to improve the long-term prognosis, and
radical gastrectomy with D2 lymphadenectomy has become the standard sur-
gery for advanced gastric cancer. Since laparoscopic gastrectomy (LG) for
early gastric cancer was initially reported by Kitano et al. in 1994, laparo-
scopic techniques for early gastric cancer have gradually developed and pro-
gressed worldwide in the past 20 years. Moreover, the therapeutic range of
these laparoscopic techniques has been extended to include locally advanced
gastric cancer. Surgical treatment for gastric cancer has gradually stepped
into the era of minimal invasiveness.
The incidence of gastric cancer is relatively high in China, and most
affected patients develop advanced disease. Successful performance of LG
for advanced gastric cancer requires not only profi cient surgical techniques,
but also standardized and programmed surgical procedures. We fi rst began to
perform LG 7 years ago and have continuously summarized the experiences
of the practice in our untiring pursuit to establish a standardized and pro-
grammed strategy for this surgery. To date, we have performed more than
2500 LG procedures for gastric cancer and have thus gained extensive experi-
ence. In 2010, we completed the fi rst laparoscopic spleen-preserving splenic
hilar lymphadenectomy, and we are now able to routinely perform this proce-
dure for advanced middle- or upper-third gastric cancer. We also summarized
the operative procedure as Huang’s three-step maneuver, allowing increas-
ingly more surgeons to easily master this technique. In 2012, delta-shaped
gastroduodenostomy following totally laparoscopic distal gastrectomy was
fi rst performed in China in our center, and we have performed the largest
number of these surgeries in China.
We herein summarize and share our 7-year experience of LG without res-
ervation. This academic monograph can be used for clinical practice, scien-
tifi c research, and education. This book contains a large amount of
comprehensive material, and areas of particular importance are highlighted.
Wonderful pictures are included to enhance understanding and interest. All
material is original and based on clinical practice. The text describes our
v
vi Preface
understanding about what we have gained and lost from massive surgeries
and summarizes our accumulated experience throughout years of clinical
practice. We particularly focus on both the common and rare anatomy around
the stomach in minimally invasive surgery, describe in detail the procedures
and issues that require attention during the performance of radical LG for
gastric cancer, and present the techniques of lymphadenectomy with both text
and graphics. This information is both clinically useful and innovative. We
hope that this book will eventually provide new inspirations and become a
standard source of knowledge for all of our colleagues who have devoted
themselves to the surgical treatment for gastric cancer, and that it will facili-
tate the promotion and development of LG.
This book is written by the team members of the Department of Gastric
Surgery in Fujian Medical University Union Hospital, China. I would like to
thank everyone in my team, who has heavy clinical work and academic activ-
ities but still sacrifi ced plenty of his or her spare time to put an incredible
effort into publishing this book.
Fuzhou, China Chang-Ming Huang
December 2014
Contents
1 Summary of Anatomy and Physiology
of Perigastric Lymphatic System . . . . . . . . . . . . . . . . . . . . . . . . . 1
1.1 Lymphatic Drainage Routes of the Stomach. . . . . . . . . . . . . . 1
1.2 Lymph Node Groups in Gastric Cancer . . . . . . . . . . . . . . . . . 3
1.3 Pattern of Metastatic Spread and Characteristics
of Metastatic LNs in Gastric Cancer. . . . . . . . . . . . . . . . . . . . 4
1.4 Types and Characteristics of Metastatic LNs
in Gastric Cancer. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
2 The Current Status and Development
of Lymph Node Dissection for Gastric Cancer . . . . . . . . . . . . . . 7
2.1 The Extent of Lymphadenectomy
in Early Gastric Cancer (EGC). . . . . . . . . . . . . . . . . . . . . . . . 8
2.2 The Extent of Lymphadenectomy
for Advanced Gastric Cancer . . . . . . . . . . . . . . . . . . . . . . . . . 9
2.3 The Application of Laparoscopic Techniques
in Lymphadenectomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
3 Preoperative Notes of Laparoscopic Lymph
Node Dissection for Gastric Cancer. . . . . . . . . . . . . . . . . . . . . . . 13
3.1 Instruments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
3.1.1 Routine Devices . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
3.1.2 Special Devices. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
3.2 Patient’s Position. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
3.3 Surgeons’ Locations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
3.4 Location of Trocars. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
3.5 Establishment of Pneumoperitoneum. . . . . . . . . . . . . . . . . . . 16
3.6 Preoperative Exploration. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
3.7 Sequence of a Lymphadenectomy. . . . . . . . . . . . . . . . . . . . . . 18
3.8 Nursing Cooperation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
3.8.1 Preoperative Visit . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
3.8.2 Preparation of Instruments . . . . . . . . . . . . . . . . . . . . . 22
3.8.3 Preparation of Operating Room . . . . . . . . . . . . . . . . . 22
vii
viii Contents
4 Laparoscopic Infrapyloric Area Lymph Node
Dissection for Gastric Cancer. . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
4.1 Review of Laparoscopic Infrapyloric Area
Lymph Node Dissection for Gastric Cancer. . . . . . . . . . . . . . 25
4.2 Anatomy Associated with Lymph Node Dissection
in the Infrapyloric Area. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27
4.2.1 Fascia and Intrafascial Space
in the Infrapyloric Area. . . . . . . . . . . . . . . . . . . . . . . . 27
4.2.2 Vascular Anatomy Associated
with Lymph Node Dissection
in the Infrapyloric Area. . . . . . . . . . . . . . . . . . . . . . . . 29
4.2.3 Lymph Node Anatomy of the Infrapyloric Area. . . . . 35
4.3 Procedures for Lymph Node Dissection
in the Infrapyloric Area. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38
4.3.1 Removing the Greater Omentum
and Peeling the Anterior Lobe
of the Transverse Mesocolon (ATM) . . . . . . . . . . . . . 38
4.3.2 Dissection of the No. 14v LNs . . . . . . . . . . . . . . . . . . 41
4.3.3 Dissection of the No. 6 LNs . . . . . . . . . . . . . . . . . . . . 44
4.4 Common Situations Encountered and Surgical
Techniques Utilized During the Dissection
of the Infrapyloric Region. . . . . . . . . . . . . . . . . . . . . . . . . . . . 47
4.4.1 Surgical Techniques Utilized in Resection
of the Greater Omentum and Division of the ATM. . . 47
4.4.2 Surgical Techniques Involved in Dissection
of the No. 14v LNs . . . . . . . . . . . . . . . . . . . . . . . . . . . 54
4.4.3 Surgical Techniques Involved in Dissection
of the No. 6 LNs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 95
5 Laparoscopic Suprapancreatic Area Lymph Node
Dissection for Gastric Cancer. . . . . . . . . . . . . . . . . . . . . . . . . . . . 97
5.1 Review of Laparoscopic Suprapancreatic Area
Lymph Node Dissection for Gastric Cancer. . . . . . . . . . . . . . 97
5.2 Anatomy Associated with Lymph Node Dissection
in the Suprapancreatic Area . . . . . . . . . . . . . . . . . . . . . . . . . . 99
5.2.1 Fascia and Intrafascial Space
in the Suprapancreatic Area . . . . . . . . . . . . . . . . . . . . 99
5.2.2 Vascular Anatomy Associated with Lymph
Node Dissection in the Suprapancreatic Area. . . . . . . 102
5.2.3 Lymph Node Anatomy
of the Suprapancreatic Area . . . . . . . . . . . . . . . . . . . . 114
5.3 Procedures for Lymph Node Dissection
in the Suprapancreatic Area . . . . . . . . . . . . . . . . . . . . . . . . . . 116
5.3.1 Dissection of the No. 7, 8a, 9, and 11p LNs . . . . . . . . 117
5.3.2 Dissection of the No. 5 and No. 12a LNs . . . . . . . . . . 121
5.4 Common Situations Encountered and Surgical Techniques
Utilized During the Dissection of the Suprapancreatic
Region . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 123
Contents ix
5.4.1 Surgical Techniques Involved in Dissection
of No. 7, 8a, 9, and 11p LNs. . . . . . . . . . . . . . . . . . . . 123
5.4.2 Surgical Techniques Involved in Dissection
of the No. 12a and 5 LNs . . . . . . . . . . . . . . . . . . . . . . 136
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 202
6 Laparoscopic Splenic Hilar Area Lymph Node Dissection
for Gastric Cancer. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 205
6.1 Review of Laparoscopic Splenic Hilar Area Lymph Node
Dissection for Gastric Cancer. . . . . . . . . . . . . . . . . . . . . . . . . 205
6.2 Anatomy Associated with Lymph Node Dissection
in the Splenic Hilar Area. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 207
6.2.1 Fascia and Intrafascial Space
in the Splenic Hilar Area. . . . . . . . . . . . . . . . . . . . . . . 207
6.2.2 Vascular Anatomy Associated with Lymph
Node Dissection in the Splenic Hilar Area. . . . . . . . . 209
6.2.3 Lymph Node Anatomy Associated with
Lymph Node Dissection in the Splenic Hilar Area. . . 216
6.3 Procedures for Lymph Node Dissection
in the Splenic Hilar Area. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 218
6.3.1 Operative Approach. . . . . . . . . . . . . . . . . . . . . . . . . . . 219
6.3.2 Exposure Methods. . . . . . . . . . . . . . . . . . . . . . . . . . . . 220
6.3.3 Operative Procedures. . . . . . . . . . . . . . . . . . . . . . . . . . 222
6.4 Common Situations Encountered and Surgical
Techniques Utilized During the Dissection
of the Splenic Hilar Region. . . . . . . . . . . . . . . . . . . . . . . . . . . 231
6.4.1 Surgical Techniques Involved in Division. . . . . . . . . . 231
6.4.2 Prevention of Damage to Adjacent Tissues
and Organs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 243
6.4.3 Prevention of Vascular Injury . . . . . . . . . . . . . . . . . . . 246
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 275
7 Laparoscopic Cardial Area Lymph Node Dissection
for Gastric Cancer. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 277
7.1 Review of Laparoscopic Cardial Area Lymph Node
Dissection for Gastric Cancer. . . . . . . . . . . . . . . . . . . . . . . . . 277
7.2 Anatomy Associated with Lymph Node Dissection
in the Cardial Area . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 278
7.2.1 Fascia and Intrafascial Space in the Cardial Area. . . . 278
7.2.2 Vascular Anatomy Associated with Lymph
Node Dissection in the Cardial Area. . . . . . . . . . . . . . 278
7.2.3 Lymph Node Anatomy of the Cardial Area . . . . . . . . 281
7.3 Procedures for Lymph Node Dissection
in the Cardial Area . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 284
7.3.1 Baring of the Gastric Lesser Curvature
and Dissection of the No. 1 and No. 3 LNs. . . . . . . . . 284
7.3.2 Baring of the Left Side of the Esophagus
and Dissection of the No. 2 LNs. . . . . . . . . . . . . . . . . 287