Name: Laparoscopic Radical Gastrectomy for Remnant Gastric Cancer (Video) | JoVE Journal
Uploaded: 2025-10-31T14:40:00.000+00:00
Duration: 5 min 30 s
Description: Learn laparoscopic radical gastrectomy for remnant gastric cancer using minimally invasive techniques. This detailed procedure guides surgeons through adhesiolysis, tailored lymphadenectomy, and safe anastomosis to improve surgical outcomes.

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5 minutes

This work was supported by grants from the Science and Technology Planning Project of Guangzhou (No. 2025A03J4261), and the Medical Joint Fund of Jinan University (No. YXZY2024018).

The protocol was approved by the Institutional Review Board of The First Affiliated Hospital of Jinan University. This study included five patients who underwent LRG for RGC from January 2013 to December 2021.. Written informed consents were obtained from all the patients. The materials and the equipment used are listed in the Table of Materials.
1. Inclusion criteria
<ol>
	<li>Include patients with a history of distal gastrectomy for benign or malignant conditions and a diagnosis of RGC more than 5 years after the initial surgery.</li>
	<li>Confirm that pathological or imaging studies show the tumor is confined to the remnant stomach with no evidence of distant metastasis, and ensure preoperative evaluation confirms operability.</li>
	<li>Verify through upper gastroenterography, enhanced CT scan, or endoscopy that there is no significant anastomotic stricture or esophageal invasion, indicating the tumor is resectable.</li>
</ol>
2. Exclusion criteria
<ol>
	<li>Exclude patients with unresectable conditions, including peritoneal or liver metastases, or multiple fixed lymph node conglomerates.</li>
	<li>Exclude patients with severe adhesions from previous upper abdominal surgeries that preclude safe laparoscopic access.</li>
	<li>Exclude patients with clinically significant cardiac, pulmonary, or renal dysfunction.</li>
	<li>Exclude patients who cannot tolerate general anesthesia or pneumoperitoneum.</li>
</ol>
3. Preoperative preparation
<ol>
	<li>Perform routine laboratory tests, including complete blood count, urinalysis, stool examination, liver and renal function tests, coagulation function test, and tumor marker analysis.</li>
	<li>Perform electrocardiography, chest CT, contrast-enhanced abdominal CT (Figure 1A,B), and upper gastrointestinal contrast (Figure 1C) before surgery.</li>
	<li>Perform endoscopic biopsy to confirm the pathological diagnosis and assess anastomotic patency and tumor extent (Figure 1D).</li>
</ol>
4. Surgical technique
<ol>
	<li>Anesthesia and positioning
	<ol>
		<li>Administer general anesthesia via endotracheal intubation (following institutionally approved protocols). Place the patient in a supine position with legs spread at 45&#176;-60&#176;. Disinfect the surgical site using povidone-iodine.</li>
		<li>Stand between the patient&#39;s legs, with the assistant on the left and the laparoscope holder on the right. Adjust the surgical position intraoperatively as needed. When dissecting areas adjacent to the lateral abdomen, especially if instrument interference occurs with the laparoscope, stand on either side of the patient while the laparoscope holder moves between the patient&#39;s legs.</li>
	</ol>
	</li>
	<li>Pneumoperitoneum establishment and port placement
	<ol>
		<li>Make a 10 mm vertical infraumbilical incision for Veress needle insertion and establish pneumoperitoneum by CO2 insufflation to a pressure of 12 mmHg.</li>
		<li>Insert a 10 mm trocar at the umbilical site for laparoscope introduction. Under direct visualization, place two 12 mm trocars in the bilateral mid-abdomen and two 5 mm trocars in the bilateral upper abdomen.</li>
	</ol>
	</li>
	<li>Intraoperative exploration and adhesiolysis
	<ol>
		<li>Conduct a thorough assessment of adhesions within the abdominal cavity and evaluate the presence of tumor implantation and infiltration of adjacent organs (Figure 2A-D). To avoid injury to the jejunal limb, pancreatic tail, mesocolon, and portal vein trunk, perform adhesiolysis using a combination of blunt and sharp dissection (Figure 2E,F). 
		NOTE: Pay attention to areas prone to adhesions, such as the left hepatic lobe and remnant stomach, the transverse colon and greater omentum, and the splenic hilum and pancreatic tail.</li>
	</ol>
	</li>
	<li>Lymphadenectomy and organ mobilization
	<ol>
		<li>Tailor lymphadenectomy for RGC according to the prior surgical approach, tumor location, and initial reconstruction method (Billroth I/II/Roux-en-Y). Follow the standard D2+ radical surgery guidelines, with special attention to ectopic nodes around the celiac axis, splenic hilum, and jejunal mesentery (Figure 3A-F, Figure 4A-F). 
		NOTE: During lymph node dissection, maintain awareness of altered lymphatic drainage pathways resulting from previous gastric surgery. Pay particular attention to ectopic lymph nodes located along the mesenteric border and adjacent to the colic arteries to avoid missed metastases.</li>
		<li>Mobilize the cardia and at least 6 cm of the distal esophagus using an ultrasonic scalpel (Figure 5A) to ensure a safe and tension-free anastomosis, especially for tumors involving the cardia or distal esophagus. 
		NOTE: If the lesion involves the pancreatic tail or splenic hilum, perform a combined distal pancreatectomy or splenectomy as indicated.</li>
	</ol>
	</li>
	<li>Remnant stomach resection and digestive tract reconstruction (Roux-en-Y anastomosis)
	<ol>
		<li>For cases with previous distal gastrectomy and Billroth II reconstruction, transect the jejunal input and output loops at the prior gastrojejunostomy using a linear stapler (Figure 5B,C). 
		NOTE: If the tumor involves the previous gastrojejunostomy, remove the jejunal input and output loops approximately 10 cm away from the anastomosis.</li>
		<li>When the tumor does not involve the cardia, perform a side-to-side esophagojejunostomy using a linear stapler before transecting the lower esophagus to prevent retraction into the thoracic cavity after transection (Figure 5D-F). 
		NOTE: When the tumor involves the cardia, first transect the lower esophagus using a linear stapler to preserve tumor integrity, then perform side-to-side esophagojejunostomy.</li>
		<li>Perform a side-to-side jejunojejunostomy at the distal jejunum located 45 cm from the esophagoduodenal anastomosis (Figure 6A,B). 
		NOTE: Ensure all anastomoses are tension-free and patent to prevent leakage and stenosis. Inject the methylene blue solution through the gastric tube after completion of all anastomoses. Absence of dye leakage confirms anastomotic integrity.</li>
	</ol>
	</li>
	<li>Specimen extraction and incision suturing
	<ol>
		<li>Place the resected specimen in a sterile retrieval bag. Irrigate the surgical field with sterile distilled water to ensure hemostasis and confirm the absence of gastric leakage (Figure 6C).</li>
		<li>Place one or two drainage tubes near the left subphrenic space and around the jejunal anastomosis to facilitate postoperative monitoring and prevent complications such as anastomotic leakage (Figure 6C).</li>
		<li>Extend the umbilical incision to approximately 6-8 cm to remove the specimen bag. Send the sample for intraoperative rapid frozen pathological examination and postoperative routine pathological analysis (Figure 6D). After confirming negative margins via frozen section, remove all trocars and close the abdominal incisions to complete the procedure.</li>
	</ol>
	</li>
</ol>
5. Postoperative procedure
<ol>
	<li>Continuously monitor vital signs, including heart rate, blood pressure, respiratory rate, and temperature, to enable early detection and management of postoperative complications.</li>
	<li>Administer intravenous antibiotics, somatostatin analogs, and hepatoprotective agents, and adjust regimens based on individual patient conditions. For patients without infectious complications, ensure that prophylactic antibiotic use after surgery does not exceed 48 h.</li>
	<li>Inspect surgical incisions regularly for signs of infection, such as erythema or exudate, and provide prompt intervention when infection is suspected.</li>
	<li>In the absence of anastomotic leakage, remove abdominal drains 5-7 days after surgery.</li>
	<li>Perform routine blood tests regularly, including complete blood count and other relevant parameters.</li>
</ol>

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The authors have nothing to disclose.

RGC is a primary malignancy that arises in the residual stomach after partial gastrectomy. It was first described by Balfour in 192215. Although the overall incidence of RGC remains relatively low, it has been steadily rising due to improvements in gastric cancer detection and increased postoperative survival16. A previous gastrectomy often results in extensive intra-abdominal adhesions and altered anatomy around the remnant stomach, particularly in lymphatic drainage pathw...

Remnant gastric cancer (RGC) refers to a primary malignancy developing in the residual stomach after partial gastrectomy, which typically manifests more than five years after surgery. Although RGC has a relatively low incidence (about 2.6%)1, it is frequently diagnosed at an advanced stage due to its long latency and nonspecific clinical presentation, leading to a poor prognosis2. The pathogenesis of RGC is linked to multiple factors, including impaired mucosal defense, bile reflux, chronic inflammation, reconstruction technique, and Helicobacter pylori infection3,4,5.
Similar to common gastric cancer, the treatment plan for residual gastric cancer mainly depends on the TNM staging. R0 resection is the preferred treatment option, and for patients who can undergo R0 resection, their prognosis is also similar to that of common gastric cancer.
Similar to common gastric cancer, the treatment for RGC mainly depends on the TNM stage. R0 resection is the preferred option, and for patients who can undergo R0 resection, the prognosis is similar to that of common gastric cancer6,7,8. Although systemic chemotherapy, targeted therapy, and immunotherapy have shown progress in recent years, radical surgery remains the cornerstone of RGC treatment9. Conventional open surgery is often not preferred in elderly or high-risk patients due to extensive surgical trauma, high bleeding risk, and a high incidence of postoperative complications. Laparoscopy-assisted surgery for RGC was first reported by Yamada et al. in 200510. Since then, with the growing adoption of minimally invasive techniques in gastric surgery, reports on laparoscopic radical gastrectomy (LRG) for RGC have gradually emerged. LRG offers advantages such as minimal trauma, faster recovery, and lower complication rates, making it a promising and increasingly utilized approach for RGC. Multiple studies have confirmed that, in experienced centers, LRG achieves R0 resection rates and lymph node yields comparable to those of open surgery, while significantly reducing intraoperative blood loss, shortening hospital stays, and facilitating faster gastrointestinal recovery11,12,13.
However, LRG requires excellent anatomical orientation and advanced laparoscopic skills, particularly when dealing with adhesions near the anastomosis, jejunal mesentery, and splenic hilum, where procedural risks are high14. This article aims to systematically summarize the essential operative techniques and strategies in this procedure.

<table><tbody><tr><td>10-mm trocar</td><td>Xiamen Surgaid Medical Device Co., LTD</td><td>NGCS 100-1-10</td><td>Sterile, ethylene oxide sterilized, disposable</td></tr><tr><td>12-mm trocar</td><td>Xiamen Surgaid Medical Device Co., LTD</td><td>NGCS 100-1-12</td><td>Sterile, ethylene oxide sterilized, disposable</td></tr><tr><td>5-mm trocar</td><td>Xiamen Surgaid Medical Device Co., LTD</td><td>NGCS 100-1-5</td><td>Sterile, ethylene oxide sterilized, disposable</td></tr><tr><td>Hem-o-lok</td><td>America Teleflex Medical Technology Co., LTD</td><td>544240</td><td>Sterile, ethylene oxide sterilized, disposable</td></tr><tr><td>Linear stapling device</td><td>America Ethicon Medical Technology Co., LTD</td><td>PSEE60A</td><td>Sterile, ethylene oxide sterilized, disposable</td></tr><tr><td>Pneumoperitoneum needle</td><td>Xiamen Surgaid Medical Device Co., LTD</td><td>NGCS 100-1</td><td>Sterile, ethylene oxide sterilized, disposable</td></tr><tr><td>Suction and irrigation tube</td><td>Tonglu Hengfeng Medical Device Co., LTD</td><td>HF6518.035</td><td>Sterile,dry heat sterilized, reusable</td></tr><tr><td>Ultrasounic-harmonic scalpel</td><td>Chongqing Maikewei Medical Technology Co., LTD</td><td>QUHS36S&amp;nbsp;</td><td>Sterile, ethylene oxide sterilized, disposable</td></tr></tbody></table>

laparoscopic radical gastrectomy for remnant gastric cancer

Laparoscopic Radical Gastrectomy for Remnant Gastric Cancer

Remnant gastric cancer (RGC) is a serious long-term complication following gastrectomy, for which radical resection remains the standard treatment. With continued advancements in laparoscopic techniques, laparoscopic radical gastrectomy (LRG) has emerged as an important therapeutic option for early-stage and select advanced cases of RGC. This procedure offers reduced surgical trauma, faster postoperative recovery, and a lower incidence of complications. However, several challenges remain in its clinical application. On the one hand, postoperative anatomical changes and intra-abdominal adhesions can limit the surgical field, complicating lymphadenectomy and digestive tract reconstruction. On the other hand, no consensus has been reached regarding the optimal surgical approach, the extent of lymphadenectomy, or the anastomotic technique, resulting in variation in procedural standardization. Nonetheless, with ongoing refinement of laparoscopic techniques, this approach has been increasingly adopted across multiple centers. Its successful implementation largely depends on the surgeons' technical proficiency and clinical experience. This study aims to systematically introduce the experiences of LRG for RGC and provide supplementary information for the existing research data on these techniques.

A total of 5 patients (median age: 73 years, range: 57-77 years), all of whom were male, underwent laparoscopic radical gastrectomy for remnant gastric cancer. The original disease in all cases was benign, and all patients had previously undergone open distal gastrectomy with Billroth-II reconstruction. The median interval between the initial surgery and the diagnosis of remnant gastric cancer was 480 months (range: 300-696 months). The median body mass index (BMI) of the patients was 22.1 kg/m2 (range: 20.1-2...

Laparoscopic radical gastrectomy for remnant gastric cancer has been increasingly adopted as a minimally invasive surgical approach in recent years. This article proposes a detailed operating procedure, aiming to provide practical technical guidance for surgeons and promote the broader adoption of laparoscopic surgery in managing remnant gastric cancer.

Remnant gastric cancer (RGC) is a serious long-term complication following gastrectomy, for which radical resection remains the standard treatment. With ...

The research outlines a practical operating procedure to guide surgeons and encourage wider adoption of laparoscopic surgery for remnant gastric cancer management. The current experimental challenges include demanding anatomical orientation and advanced laparoscopic skill to manage adhesions near the anastomosis, jejunal mesentery, and splenic hilum. To begin, conduct a thorough assessment of adhesions within the abdominal cavity and evaluate the presence of tumor implantation and infiltration of adjacent organs.To avoid injury to the jejunal limb, pancreatic tail, mesocolon and portal vein trunk, perform adhesiolysis using a combination of blunt and sharp dissection. Tailor lymph adenectomy for remnant gastric cancer according to the prior surgical approach, tumor location, and initial reconstruction method. Follow the standard D2 plus radical surgery guidelines with special attention to ectopic nodes around the celiac axis, splenic hilum, and jejunal mesentery.Mobilize the cardia and at least six centimeters of the distal esophagus using an ultrasonic scalpel to ensure a safe and tension-free anastomosis, especially for tumors involving the cardia or distal esophagus. For cases with previous distal gastrectomy and Billroth II reconstruction, transect the jejunal input and output loops at the prior gastrojejunostomy with a linear stapler. When the tumor does not involve the cardia, perform a side-to-side esophagojejunostomy using a linear stapler before transecting the lower esophagus to prevent retraction into the thoracic cavity after transection.Perform a side-to-side jejunojejunostomy at the distal jejunum located 45 centimeters from the esophagal duodenal anastomosis. Place the resected specimen in a sterile retrieval bag. Then irrigate the surgical field with sterile distilled water to ensure hemostasis and confirm the absence of gastric leakage.Place one or two drainage tubes near the left sub phrenic space and around the jejunal anastomosis to facilitate postoperative monitoring. All five male patients had previously undergone open distal gastrectomy with Billroth II reconstruction for benign disease with a median time interval of 480 months between initial surgery and remnant gastric cancer diagnosis. The median body mass index was 22.1 kilograms per square meter.Preoperative laboratory values showed a median white blood cell count of 7.16 times 10 to the power of 9 per liter, a median hemoglobin level of 10 to the power of 5 grams per liter, and a median platelet count of 230 times 10 to the power of 9 per liter. The median carcino embryonic antigen level was 1.64 nanograms per milliliter. All patients underwent laparoscopic radical gastrectomy without conversion to open surgery with a median operation time of 380 minutes and a median intraoperative blood loss of 100 milliliters.One patient developed a postoperative pulmonary infection, while no other postoperative complications were observed. Pathologic T classification was T3 in three patients and T4 in two patients. Lymph node classification showed N0 in two patients, N1 in one patient, and N3 in two patients.All five patients were classified as M0, indicating no distant metastasis. Tumor differentiation was moderate in three cases and poor in two cases. This study aims to systematically introduce the experiences of laparoscopic radical gastrectomy for remnant gastric cancer and provide supplementary information for the existing research data.The findings aim to support broader use of laparoscopic radical gastrectomy as remnant gastric cancer cases rise, emphasizing expert surgeons, sound judgment, and high volume specialized centers. Future research will focus on larger clinical studies to validate outcomes and strengthen evidence beyond this technical demonstration.

laparoscopic-radical-gastrectomy-for-remnant-gastric-cancer

Research

JoVE Journal

Medicine

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Learn laparoscopic radical gastrectomy for remnant gastric cancer using minimally invasive techniques. This detailed procedure guides surgeons through adhesiolysis, tailored lymphadenectomy, and safe anastomosis to improve surgical outcomes.

Laparoscopic Radical Gastrectomy for Remnant Gastric Cancer

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