Single Incision Plus One Port Laparoscopic Proximal Gastrectomy with Double Channel Anastomosis for Gastric Cancer Treatment

Summary

The single-incision plus one-port laparoscopic proximal gastrectomy with double-channel anastomosis was initially employed for the radical resection of proximal gastric cancer. This study demonstrated the feasibility of the procedure and laid a foundation for further research.

Abstract

Single-incision plus one-port laparoscopic proximal gastrectomy with double-channel anastomosis (SILT-DT) is a minimally invasive surgical approach for treating proximal gastric cancer. This technique includes comprehensive laparoscopic resection of the proximal stomach, lymph node dissection, and double-tract anastomosis. By integrating single-port laparoscopic surgery with an auxiliary operating hole, SILT-DT reduces procedural difficulty while facilitating the placement of an abdominal drainage tube. Compared to the traditional five-port laparoscopic gastrectomy, SILT-DT requires fewer ports and results in shorter incision lengths, contributing to reduced postoperative pain and faster recovery. A thorough preoperative evaluation was conducted to ensure procedural success, with factors such as tumor size, stage, location, and patient BMI carefully considered. This comprehensive assessment allowed for optimal patient selection and surgical planning. Postoperative follow-up demonstrated no significant complications, underscoring the safety and efficacy of SILT-DT. This innovative technique offers a promising minimally invasive alternative for managing proximal gastric cancer while maintaining excellent clinical outcomes.

Introduction

Laparoscopic techniques have recently become one of the main directions for the surgical treatment of gastric cancer^1,2. The routine laparoscopic surgery for gastric cancer is mostly performed using the 5-hole method. With advancements in surgical techniques and continuous improvements in medical devices, reduced-port laparoscopic gastric cancer surgery has gradually developed to further reduce surgical trauma, minimize disturbance to the abdominal cavity, and accelerate postoperative recovery^3,4,5,6.

Omori⁷ first reported single-port laparoscopic distal gastric cancer surgery in 2011. Pure single-port laparoscopic radical gastrectomy for gastric cancer is more difficult than traditional five-port laparoscopic gastrectomy. To address this, an auxiliary operating hole is added to the single-port laparoscopic procedure, which reduces the difficulty of the operation and facilitates the placement of an abdominal drainage tube^8,9. Single-incision laparoscopic surgery plus one port (SILS+1), a minimally invasive technique for patients with gastric cancer, has gained popularity in recent years due to its reduced number of ports and shorter incision lengths.

Currently, single-port laparoscopic or SILS+1 gastric cancer surgery is relatively common in distal gastrectomy, while its application in total gastrectomy is rare. Additionally, the use of total laparoscopic double-tract gastric cancer anastomosis has not been reported.

Based on this, we first attempted single-port plus one-port total laparoscopic proximal gastrectomy with double-tract anastomosis (SILT-DT). The transumbilical port was used as the main operation port, and the left upper abdominal drainage port served as the auxiliary operation port. This technique was employed to perform proximal gastrectomy, D2 lymph node dissection, and double-tract anastomosis for digestive tract reconstruction.

CASE PRESENTATION:
The patient, a 63-year-old male, was admitted to the hospital after a tumor was discovered at the esophagogastric junction during a gastroscopy (Figure 1). Biopsy results from the gastroscope suggested moderately differentiated adenocarcinoma (Figure 2). Preoperative chest and abdominal enhanced CT scans revealed no evidence of distant metastasis (Figure 3). The patient was previously healthy and had no history of abdominal surgery.

Patient selection
Patients were eligible to participate if they had histologically confirmed Siewert type II or III gastroesophageal junction adenocarcinoma, with preoperative abdominal CT showing no enlarged lymph nodes around the stomach or distant metastasis. The maximum diameter of the tumor was required to be less than 3 cm, and the distance between the lower pole of the tumor and the gastric angle had to exceed 5 cm. Exclusion criteria included patients who had previously undergone abdominal surgery, those with a preoperative tumor diameter exceeding 3 cm and/or requiring multi-visceral resection, patients who had undergone multidisciplinary team (MDT) discussions regarding neoadjuvant chemoradiation, or those who had received neoadjuvant chemoradiation, and patients with intolerance to laparoscopic surgery.

Protocol

The operation followed standard procedures and received ethics approval. This study was permitted by the Ethics Committee of Xiangyang Central Hospital, affiliated with Hubei University of Arts and Science. Informed written consent was obtained from the patient. The research content and methods adhered to medical ethics norms and requirements. The reagents and equipment used in the study are listed in the Table of Materials.

1. Pre-surgical steps

1. The patient was instructed to take oral sodium phosphate salt for bowel preparation one day before surgery. The patient fasted for 8 h and was allowed water intake up to 2 h before surgery. An upper gastric tube was inserted before entering the operating room.
2. The patient was positioned in a supine split-leg position with the head elevated and slightly tilted to the right.
3. Endotracheal intubation was performed, and general anesthesia was administered according to institutionally approved protocols.

2. Surgical procedure

1. A transverse incision measuring 3.0-3.5 cm was created around the navel to insert the SILS port equipped with four in-built trocars (Figure 4A). An additional 12-mm trocar was inserted in the left upper quadrant to serve as an operative port for surgical instruments, including the ultrasonic shear, endoscopic linear stapler, and postoperative drainage tube.
2. An ultrasonic knife was used to dissect the adipose lymphoid tissue of groups 1, 2, 3, 4, 7, 8a, 9, and 11p (Figure 5A,B). A lower esophageal segment length of approximately 5-7 cm was ensured (Figure 5C), and the freedom of the greater curvature and lesser curvature of the stomach was maintained.
   NOTE: The SILT-DT procedure is shown in Figure 5. The stomach and lymph node dissection was performed in accordance with the Guidelines for Laparoscopic Surgery for Gastric Cancer (2023 edition)¹⁰. A D2 lymphadenectomy and proximal gastrectomy were completed.
3. The esophagus-jejunum (EJ) anastomosis was established. The EJ anastomosis site was identified on the jejunum, 20 cm distal to the ligament of Treitz and near the lower esophagus. The EJ anastomosis was accomplished through the 12-mm port in the left upper quadrant using a 60-mm endoscopic linear stapler (Figure 5D).
   NOTE: The schematic diagram illustrating the digestive tract reconstruction is shown in Figure 4B.
4. A 60-mm endoscopic linear stapler was used to resect specimens of the esophagus and close the anastomotic opening between the jejunum and esophagus (Figure 5E).
5. The gastrojejunal (GJ) anastomosis was created, with the site marked on the jejunum 8-15 cm distal to the EJ anastomosis and on the posterior wall of the greater curvature of the remaining stomach (Figure 5F).
6. The jejunojejunal anastomosis was established. The jejunojejunal anastomosis was made through the 3.5-cm incision at the navel using a 60-mm endoscopic linear stapler, marking 5 cm distal to the GJ anastomosis site (Figure 5G).
7. The individual anastomoses were closed and strengthened. Both the common openings of the GJ anastomosis and the jejunojejunal anastomosis were closed using a 3-0 micro Joe thread. The mesangial hiatus was closed with a continuous suture.
8. A drainage tube was placed behind the EJ anastomosis and exited from the left upper abdomen (Figure 5H).

3. Postoperative management

1. Postoperative water fasting was implemented, and the gastric tube was drained with an indwelling bag.
2. The gastric tube was removed after 48 h of observation, ensuring no evident presence of bloody drainage fluid.
3. Fluid infusion was administered to maintain water, electrolyte, and acid-base balance, along with acid suppression. The duration of prophylactic antibiotics was limited to a maximum of 48 h.
4. Early mobilization was actively promoted within 6-24 h post-surgery. A liquid diet was initiated for 2-3 days during recovery.
5. Anastomotic leakage was assessed, and the development of the residual stomach was evaluated through upper gastrointestinal radiography on day 7.
6. The abdominal cavity drainage tube was removed within 5 to 7 days after hospital discharge.

Results

The surgery was completed within 150 min, with minimal intraoperative bleeding of 5 mL. There were no short-term complications, and the patient's postoperative recovery was successful. A total of 24 lymph nodes were retrieved, and no lymph node metastasis was found. The operating time was 150 min, and the estimated blood loss was 5 mL. The patient remained in bed for 2 days. The time to first flatus was 70 h, and the patient began consuming liquid food and drinks after 3 days. The gastric tube was removed on the 4^th day, and the drainage tube was removed within 7 days. The contrast agent persisted in the remnant stomach for 30-50 min without reflux into the esophagus (Figure 6). The cosmetic outcome of the postoperative abdominal incisions was satisfactory (Figure 4C). Pain was evaluated by an 11-point numeric rating scale (NRS) where 0 is no pain and 10 is the worst pain imaginable¹¹. Detailed data for the patient are presented in Table 1.

Figure 1: Gastroscopic images. Please click here to view a larger version of this figure.

Figure 2: The findings from the gastroscopic biopsy. The gastroscopic biopsy revealed a moderately differentiated adenocarcinoma. Scale bar: 50 µm; magnification: 200x. Please click here to view a larger version of this figure.

Figure 3: Abdominal enhanced CT scans. Heterogeneous enhancement was seen in the cardia, which was considered as a neoplastic lesion, and the tumor did not invade the muscular layer. Please click here to view a larger version of this figure.

Figure 4: Surgical setup and postoperative wound condition. (A) Four in-built trocars used in the procedure. (B) Double-tract anastomosis performed during surgery. (C) Postoperative wound condition shown after the procedure. Please click here to view a larger version of this figure.

Figure 5: Surgical procedure details. (A,B) The process of cleansing the lymph nodes during the surgery. (C) Transection of the esophagus and opening of the lower esophageal end. (D) Side-to-side esophagojejunostomy performed as part of the anastomosis. (E) Closure of the common opening at the esophagojejunal anastomosis site. (F) Remnant gastrojejunostomy completed. (G) Side-to-side entero-intestinal anastomosis performed through the umbilical incision. (H) Position of the drainage tube. Please click here to view a larger version of this figure.

Figure 6: Upper gastrointestinal radiography. The upper gastrointestinal radiography showed that the anastomosis was open and the remaining stomach was clearly visible. Please click here to view a larger version of this figure.

Items	Result
Gender	Male
Year	63
BMI (kg/m2)	23.5
Anesthesia grade	III
Preoperative TNM-staging	cT1N0M0
Operation time (min)	150
Incision length (cm)	2.8
Intraoperative bleeding volume (mL)	5
Pathology	moderately differentiated adenocarcinoma
The distance of the proximal margin (cm)	3.4
The distance of the distal margin (cm)	5.5
Tumor size (cm)	1.5*2*1.2
The number of retrieved lymph nodes	24
TNM-staging	pT2N0M0
The duration of gastric tube removal after surgery (d)	4
The duration until the initial meal	3
The duration of bed activity	2
The duration to flatus (h)	70
The time for bowel movement (d)	6
The duration of the drainage tube (d)	7
Pain score on the first day after surgery	2
Postoperative hospital stay (day)	8
Complications	None

Table 1: Perioperative data of the patient. Details regarding the perioperative data for the patient, including key measurements and outcomes.

Discussion

Single-port and reduced-port laparoscopic radical gastrectomy have become innovative approaches for treating gastric cancer and are steadily gaining acceptance. These techniques are receiving increased attention for their advantages, including improved cosmetic outcomes, reduced postoperative pain, a lower risk of surgical site infections, and faster recovery times.

The results of 12 studies involving 343 cases showed that single-port and reduced-port laparoscopic surgery was effective in treating distal gastric cancer, accounting for the majority of cases^{3,4,12,13,14,15,16,17,18,19,20,21}. However, only four studies focused on total gastric resection^22,23,24,25. These findings suggest that the clinical research and application of single-port gastric cancer surgery, particularly total gastrectomy, are limited due to the high surgical difficulty, the extensive dissection and lymph node removal required, and the complex technique of endoscopic digestive tract reconstruction.

We successfully performed the first laparoscopic proximal gastrectomy with double-tract anastomosis using a single incision plus one port for the treatment of proximal gastric cancer. Compared with traditional surgical methods, the single-incision plus one-port surgery is more minimally invasive. Relative to the single-port technique, the addition of the left upper abdominal port enhances convenience during the operation and allows for the rational placement of a drainage tube through an incision in the upper left abdomen.

Lee et al.²⁶ reported the first case of single-port laparoscopic proximal gastrectomy with double-tract reconstruction for early gastric cancer in 2016. Compared to SILS, the single-incision plus one-port surgery includes an additional left upper abdominal port, creating a triangular structure composed of the umbilical region, left upper abdomen, and the surgical area. This innovative approach effectively addresses the limitations of pure single-incision surgery, such as inadequate anti-traction and linear visualization. Additionally, it enhances the flexibility of the surgeon's right-hand instrument, leading to significant improvements in operative efficiency and reduced complexity during each anastomosis under total laparoscopy.

Moreover, several strategies can enhance operational efficiency and reduce procedure duration. The surgeon may consider altering their positioning during lymph node dissection and digestive tract reconstruction, such as positioning themselves on the left side of the patient or between the patient's legs, to optimize exposure of the surgical area. For procedures like esophagojejunostomy and gastrojejunostomy, it is recommended that one assistant or the chief surgeon maintains a stable position while another performs docking, thereby improving anastomosis efficiency and minimizing the risk of tissue avulsion. Additionally, employing integrated laparoscopic instruments is advised to minimize interference between optical fibers and other instruments.

In summary, single-incision plus one-port laparoscopic proximal gastrectomy with double-channel anastomosis is feasible for treating proximal gastric cancer. In this case, the patient experienced a successful recovery. The operation is minimally invasive, and recovery is faster. However, the limitations of this protocol include the need for early-stage gastric cancer or benign gastric tumors, with the patient's BMI not being excessively high. The application of this protocol is not recommended for patients with locally advanced disease or high BMI due to the potential risk of positive tumor margins and increased surgical complexity. This protocol is still in the stage of technical exploration, with no established guidelines and insufficient clinical data to fully validate its long-term efficacy. The development of this protocol requires ethical approval from medical institutions and strict adherence to surgical indications. Further clinical research and exploration are necessary to determine the clinical applicability of the SILT-DT technique.

Materials

List of materials used in this article

Name	Company	Catalog Number	Comments
3D laparoscope	KARL STORZ SE & Co. KG	26605BA
Absorbability surgical sutures	Johnson & Johnson	TLBJXZ
Absorbable ligature clip	Hangzhou KANGJI Medical Instrument co., LTD	KJ-JZJ02ML
Disposable puncture device	Hangzhou KANGJI Medical Instrument co., LTD	Type IV sets F
Disposable step type endoscopic cutting stapler and nail bin	Nanjing Maidixin Medical Device Co.,Ltd	MLCR-Mb,MLCNC-60b-purple, MLCNC-45b-white
laparoscopic instruments	Hangzhou KANGJI Medical Instrument co., LTD
Ultrasound knife	INNOLCON, Medical Science and Technology (suzhou) co., LTD