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 Table of Contents     
Year : 2013  |  Volume : 9  |  Issue : 2  |  Page : 53-54

Laparoscopic gastrectomy: Quo vadis?

Department of Minimally Invasive Upper GI Surgery, St James's University Hospital, Leeds, UK and P. D. Hinduja Hospital, Mumbai, India

Date of Web Publication22-Apr-2013

Correspondence Address:
Abeezar I Sarela
St James's University Hospital, Leeds, UK

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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0972-9941.110960

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How to cite this article:
Sarela AI. Laparoscopic gastrectomy: Quo vadis?. J Min Access Surg 2013;9:53-4

How to cite this URL:
Sarela AI. Laparoscopic gastrectomy: Quo vadis?. J Min Access Surg [serial online] 2013 [cited 2022 Jul 1];9:53-4. Available from:

Minimally invasive resection of the distal stomach for early gastric cancer was initially described as a laparoscopy-assisted approach, using abdominal wall elevation and an extracorporeal gastroduodenal anastomosis, by Kitano et al. in 1994. [1] Laparoscopy-assisted distal gastrectomy with D1 lymphadenectomy rapidly gained popularity for treatment of early gastric cancer in Japan and South Korea; up to date, 5 randomized clinical trials [2],[3],[4],[5],[6] have evaluated open distal gastrectomy versus a fairly standardized laparoscopic operation, in which the entire dissection is conducted laparoscopically, followed by a small epigastric incision for specimen removal and Billroth I reconstruction. The randomised trial data are not yet sufficiently mature to inform on oncological outcomes; however, a large, Japanese multi-centre, retrospective analysis indicates that 5-year disease-free survival from early gastric cancer is comparable for laparoscopy-assisted distal gastrectomy and open surgery. [7]

In contrast to early gastric cancer, the laparoscopic approach has been sparingly applied for advanced gastric cancer; published data on advanced cancer (T2 or more) are mainly from European and U.S. centres and comprise a single randomised trial (Huscher et al., Italy) [8] and various case series. [9] Western authors have reported mainly entirely laparoscopic sub-total and total gastrectomies, with intracorporeal anastomoses.

A meta-analysis of randomised trials and high-quality non-randomized studies of laparoscopic versus open distal gastrectomy has been very recently reported by the Memorial Sloan Kettering group. [10] The meta-analyses included 3055 patients with gastric adenocarcinoma; 89% had stage 1 disease. As compared to open surgery, laparoscopy was associated with fewer minor surgical complications and medical complications, shorter hospital stay (mean difference, 3.6 days), less blood loss (119 ml) and longer operating time (48 minutes) but major surgical complications and mortality were similar. More lymph nodes were retrieved by open surgery versus laparoscopy (mean difference, 3.9 nodes), although a similar proportion in both surgical arms had retrieval of greater than 15 lymph nodes (the minimum number of nodes required for adequate staging). Based on the latter, it may be inferred that the oncological quality of laparoscopic surgery is similar to open surgery.

Having achieved a status of at least comparability in oncological outcomes between open and laparoscopic distal gastrectomy, the next technical challenge is to further minimize the trauma of surgical access. In this issue of JMAS, Huddy et al., from Surrey, UK, report a single-incision laparoscopic distal gastrectomy, with intra-corporeal Billroth I reconstruction i.e., gastro-duodenal anastomosis. Huddy et al. used the Olympus Quadport™: an access device that accommodates an incision up to 6 cm long and has four gel valves for passage of instruments. A flexible tip video-scope and conventional straight instruments were used. The Covidien V-Loc™ Absorbable Wound Closure Device - a barbed suture that does not require knotting for tissue approximation - was used to construct the gastroduodenal anastomosis. Huddy et al. must be congratulated for their technical achievement, although, contrary to the authors' assertion, the present paper is not novel. The seminal reports of SILS distal gastrectomy with Billroth I reconstruction are by Omori et al. from Osaka, Japan; these authors initially reported 6 patients [11] and, in a subsequent paper, 20 patients. [12] Omori et al. placed multiple cannulae through one incision and used all conventional instruments, but with the addition of a Covidien Mini Loop Retractor™: a 2 mm instrument that is introduced via a separate puncture. Omori et al. used a circular stapler for the gastro-duodenal anastomosis and have described the technique in some detail. [12]

Reduced port surgery is clearly a laudable goal. In the case of gastrectomy for malignant disease, the prescient issue is to determine the balanced role of single incision surgery with respect to oncological quality and widespread applicability. For early gastric cancer - carcinoma that is limited to the mucosa (T1a) or submucosa (T1b) - there appears sufficient evidence to support a laparoscopic approach and reduction of access trauma should remain an important goal. However, a note of caution is salutary: a definite proportion of high-risk early cancers will have lymph node metastasis and for these cases, as for advanced cancers (T2 or more), surgical oncologists will argue that a D2 lymphadenectomy is de rigueur. In our surgical enthusiasm, we must not compromise oncological quality for technical bravado.

In contrast to gastric adenocarcinoma, there is limited literature on laparoscopic surgery for gastrointestinal stromal tumours (GIST). Single incision laparoscopic surgery for GIST is truly appealing because, as with most soft-tissue sarcomas, lymphadenectomy is not necessary. For exophytic tumours, a limited, stapled resection of the gastric wall (a "wedge gastrectomy") may be sufficient. For endoluminal tumours, a gastrotomy may be required to evert the tumour or, in case of tumour location close to the pylorus or the gastro-oesophageal junction, a formal gastric resection and reconstruction will be necessary. Oncological quality of laparoscopic and open surgery appears comparable for GISTs with a diameter up to 8 cm. [13]

Notwithstanding the evidence base and the zeal of laparoscopic enthusiasts, it is likely that only a very small proportion of all patients with gastric tumours will receive minimally invasive resection. The most meaningful application of laparoscopy to the management of gastric carcinoma will remain for disease staging [14] and it is sobering to note that laparoscopic staging is significantly under-utilised. [15]

  References Top

1.Kitano S, Iso Y, Moriyama M, Sugimachi K. Laparoscopy-assisted Billroth I gastrectomy. Surg Laparosc Endosc 1994;4:146-8.  Back to cited text no. 1
2.Kitano S, Shiraishi N, Fujii K, Yasuda K, Inomata M, Adachi Y. A randomized controlled trial comparing open vs laparoscopy-assisted distal gastrectomy for the treatment of early gastric cancer: An interim report. Surgery 2002;131 Suppl 1:S306-11.  Back to cited text no. 2
3.Hayashi H, Ochiai T, Shimada H, Gunji Y. Prospective randomized study of open versus laparoscopy-assisted distal gastrectomy with extraperigastric lymph node dissection for early gastric cancer. Surg Endosc 2005;19:1172-6.  Back to cited text no. 3
4.Kim HH, Hyung WJ, Cho GS, Kim MC, Han SU, Kim W, et al. Morbidity and mortality of laparoscopic gastrectomy versus open gastrectomy for gastric cancer: An interim report--a phase III multicenter, prospective, randomized Trial (KLASS Trial). Ann Surg 2010;251:417-20.  Back to cited text no. 4
5.Kim YW, Baik YH, Yun YH, Nam BH, Kim DH, Choi IJ, et al. Improved quality of life outcomes after laparoscopy-assisted distal gastrectomy for early gastric cancer: Results of a prospective randomized clinical trial. Ann Surg 2008;248:721-7.  Back to cited text no. 5
6.Lee JH, Han HS. A prospective randomized study comparing open vs laparoscopy-assisted distal gastrectomy in early gastric cancer: Early results. Surg Endosc 2005;19:168-73.  Back to cited text no. 6
7.Kitano S, Shiraishi N, Uyama I, Sugihara K, Tanigawa N. A multicenter study on oncologic outcome of laparoscopic gastrectomy for early cancer in Japan. Ann Surg 2007;245:68-72.  Back to cited text no. 7
8.Huscher CG, Mingoli A, Sgarzini G, Sansonetti A, Di Paola M, Recher A, et al. Laparoscopic versus open subtotal gastrectomy for distal gastric cancer: Five-year results of a randomized prospective trial. Ann Surg 2005;241:232-7.  Back to cited text no. 8
9.Sarela AI. Entirely laparoscopic radical gastrectomy for adenocarcinoma: Lymph node yield and resection margins. Surg Endosc 2009;23:153-60.  Back to cited text no. 9
10.Vinuela EF, Gonen M, Brennan MF, Coit DG, Strong VE. Laparoscopic versus open distal gastrectomy for gastric cancer: A meta-analysis of randomized controlled trials and high-quality nonrandomized studies. Ann Surg 2012;255:446-56.  Back to cited text no. 10
11.Omori T, Oyama T, Akamatsu H, Tori M, Ueshima S, Nishida T. Transumbilical single-incision laparoscopic distal gastrectomy for early gastric cancer. Surg Endosc 2011;25:2400-4.  Back to cited text no. 11
12.Omori T, Tanaka K, Tori M, Ueshima S, Akamatsu H, Nishida T. Intracorporeal circular-stapled Billroth I anastomosis in single-incision laparoscopic distal gastrectomy. Surg Endosc 2012;26:1490-4.  Back to cited text no. 12
13.Karakousis GC, Singer S, Zheng J, Gonen M, Coit D, DeMatteo RP, et al. Laparoscopic versus open gastric resections for primary gastrointestinal stromal tumors (GISTs): A size-matched comparison. Ann Surg Oncol 2011;18:1599-605.  Back to cited text no. 13
14.Sarela AI, Miner TJ, Karpeh MS, Coit DG, Jaques DP, Brennan MF. Clinical outcomes with laparoscopic stage M1, unresected gastric adenocarcinoma. Ann Surg 2006;243:189-95.  Back to cited text no. 14
15.Karanicolas PJ, Elkin EB, Jacks LM, Atoria CL, Strong VE, Brennan MF, et al. Staging laparoscopy in the management of gastric cancer: A population-based analysis. J Am Coll Surg 2011;213:644-51, 651.e1.  Back to cited text no. 15


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