Comparison of laparoscopy-assisted by conventional open distal gastrectomy and extraperigastric lymph node dissection in early gastric cancer

BACKGROUND AND OBJECTIVES: Laparoscopy-assisted gastrectomy with lymph node dissection for gastric cancer is considered technically more complicated than the open method. Moreover, the safety and efficacy of laparoscopy-assisted distal gastrectomy (LADG) with extraperigastric lymph node dissection in patients with gastric cancer have not been established yet. To evaluate short-term surgical validity, surgical outcome of the laparoscopy-assisted distal gastrectomy (LADG) with extraperigastric lymph node dissection was compared with that of the conventional open distal gastrectomy (CODG) in patients with early gastric cancer. METHODS: One hundred and forty-seven patients with early gastric cancer received radical distal gastrectomy during 2002 and 2003, where LADG was undergone in 71 patients. The clinicopathologic characteristics, postoperative outcomes and courses, and postoperative morbidities and mortalities were compared between the two groups. Data were retrieved from the stomach cancer database at Dong-A University Medical center. RESULTS: Baseline characteristics, including sex, age, body mass index (BMI), American Society of Anesthesiology (ASA) class, tumor size, T stage, and lymph node metastasis were similar between the two groups. No significant differences were found between these groups in terms of the number of retrieved lymph nodes with respect to D1 + alpha (D1 + no. 7) and D1 + beta (D1 + no. 7, 8a, and 9) lymphadenectomy. In the LADG group, wound size was smaller (P < 0.0001), but operation time was longer (P = 0.0001) than in the CODG group. Perioperative recovery was faster in the LADG group than in the CODG group, as reflected by a shorter hospital stay (P = 0.0176) and less times of additional analgesics (P = 0.0370). Serum albumin level in LADG was higher (P = 0.0002) on day 7 than that in CODG, and the leukocyte count in LADG lower (P = 0.0445) on day 1 than that in CODG. Postoperative morbidities and mortalities were not significantly different between the two groups. CONCLUSIONS: Our data confirmed that LADG with extraperigastric (no. 7, 8, and 9) lymph node dissection proved to be feasible and acceptable surgical technique for early gastric cancer. At least taking a surgical point of view, LADG with extraperigastric lymph node dissection is suggested to be a preferred surgical option for patients with early gastric cancer. Its oncologic validity awaits larger and prospective multicenter trials.     

Laparoscopic gastrectomy with lymph node dissection for gastric cancer

Since 1991, laparoscopic surgery has been adopted for the treatment of gastric cancer, and it has been performed worldwide, especially in Japan and Korea. We reviewed the English-language literature to clarify the current status of and problems associated with laparoscopic gastrectomy with lymph node dissection as treatment for gastric cancer. In Japan, early-stage gastric cancer (T1/T2, N0) is considered the only indication for laparoscopic gastrectomy. As yet, there is little high-level evidence based on long-term outcome supporting laparoscopic gastrectomy for cancer, but reports have provided level 3 evidence that the procedure is technically safe, and that it yields better short-term outcomes than open surgery; that is, recovery is faster, hospital stay is shorter, there is less pain, and cosmesis is better. However, investigation into the oncological outcome of laparoscopic gastrectomy as treatment for cancer is lacking. To establish laparoscopic surgery as a standard treatment for gastric cancer, multicenter randomized controlled trials to compare the short- and long-term outcomes of laparoscopic surgery versus open surgery are necessary.     

Quality control of lymph node dissection in the Dutch randomized trial of D1 and D2 lymph node dissection for gastric cancer

Background. Variability among surgeons and reduced protocol adherence threaten the conduct and outcome of surgical multicenter trials. We introduced, in the Dutch Gastric Cancer Trial of D1 and D2 (extended) lymph node dissection for gastric cancer, a novel way of managing instruction, quality control, and evaluation of protocol adherence. Methods. Of 1078 patients entered in the Dutch trial, 711 patients with potentially curative resections were evaluated. Numbers and locations of lymph nodes detected at pathological investigation were compared according to the guidelines of the Japanese Research Society for the Study of Gastric Carcer. Non-compliance indicated inadequate removal of lymph node stations, whereas contamination indicated that lymph nodes were detected outside the intended level of dissection. Protocol adherence during the course of the trial, and the impact on complications, hospital mortality, and survival were evaluated. Results. Major non-compliance was noted in 15.3% of D1 and 25.9% of D2 patients. Contamination was present in 22.9% of D1 and 23.5% of D2 patients, and was limited to one or two lymph node stations only. Intensification of quality control resulted in only a marginal improvement in protocol adherence and in the number of lymph nodes detected. There was no association between protocol adherence and the occurrence of complications or long term survival. Conclusions. Contamination proved an important parameter to substantiate protocol adherence by the surgeon, whereas non-compliance had a multifactorial cause. Non-adherence to the protocol did not lead to increased hospital morbidity and mortality, but also had no impact on long term survival. Received for publication on Aug. 17, 1998; accepted on Nov. 12, 1998     

Comments to young surgeons concerning laparoscopic spleen- preserving D2 lymph node dissection for advanced gastric cancer on the upper body

Qualified radical gastrectomy with lymph node dissection is very important to the prognosis of patients with gastric cancer. Now D2 lymph node dissection is standard procedure for gastric cancer surgery, and spleen hilar lymph node dissection is mandatory for gastric cancer in upper body. Because the anatomy of vessels in this area is very complicated, D2 lymph node dissection is technical challenging not only for open gastrectomy but also for laparoscopic one. Adapting a new technique is important to all surgeons, but we surgeons should always consider a patient＇s safety as the most important factor during surgery and that efforts should be based on scientific rationale with oncologic principles. I hope that the recent report by Huang et al. about laparoscopic spleen preserving hilar lymph node dissection would be helpful to young surgeons who will perform laparoscpic total gastrectomy for gastric cancer.     

Extended lymph node dissection in gastrointestinal cancer

We reviewed the literature concerning the effect of extended lymph node dissection on survival in patients with gastrointestinal cancer. Most retrospective and/or prospective nonrandomized comparative studies have claimed that extended lymph node dissection significantly improves survival rate in patients with esophageal cancer, gastric cancer, and colorectal cancer. However, it is difficult to interpret these results since specialized care provided in trials may itself improve survival. In gastric cancer, several prospective randomized trials have failed to demonstrate a survival advantage of extended dissection, while there are few well-done prospective randomized trials in esophageal or colorectal cancer. Therefore, the therapeutic value of extended lymph node dissection remains to be determined in gastrointestinal cancer. Randomized prospective studies within the bounds of the ethical treatment of patients can and should be done. J. Surg. Oncol. 1997;65:57-65. © 1997 Wiley-Liss, Inc.     

Station 10 lymph node dissections in laparoscopic-assisted spleen-preserving radical gastrectomy for advanced proximal gastric cancer

D2 gastric resection has been increasingly recognized as the optimal surgical treatment for advanced gastric cancer. Dissection of the station 10 splenic lymph nodes is required in the treatment of advanced proximal gastric cancer. Based on vascular anatomy and anatomical plane of fascial space, integrated with our experience in station 10 splenic lymph node dissection in open surgery and proven skills of laparoscopic operation, we have successfully mastered the surgical essentials and technical keypoints in laparoscopic-assisted station 10 lymph node dissection.Key Words: Stomach neoplasm, laparoscopy, lymph node excision, splenic hilarThe incidence of station 10 lymph node metastases is 9.8-20.9% in advanced proximal gastric cancer (1). The thoroughness of resection is an important prognostic factor. With further research, the critical role of the spleen as an immune organ in protecting the body against infection and tumors has been increasingly recognized (2). Meanwhile, the spleen-preserving station 10 lymph node dissection has also been accepted (3) since its first report by Hyung and colleagues in 2008 (4). In view of the complicated anatomical structures of the adjacent vessels, anatomical variations, limited space and deep location of the splenic region, as well as the bleeding-prone splenic parenchyma and the difficulty to manage splenic or vascular bleeding, the station 10 lymph node dissection is a technically demanding challenge for surgeons. Thus, a skilled and cooperative team of surgeons with experience in open surgery, solid grounding in anatomy and proven laparoscopic techniques will be needed to complete the task.     

On the road to standardization of D2 lymph node dissection in a European population of patients with gastric cancer

The amount of lymph node dissection (LD) required during surgical treatment of gastric cancer surgery has been quite controversial. In the 1970s and 1980s, Japanese surgeons developed a doctrine of aggressive preventive gastric cancer surgery that was based on extended (D2) LD volumes. The West has relatively lower incidence rates of gastric cancer, and in Europe and the United States the most common LD volume was D0-1. This eventually caused a scientific conflict between the Eastern and Western schools of surgical thought: Japanese surgeons determinedly used D2 LD in surgical practice, whereas European surgeons insisted on repetitive clinical trials in the European patient population. Today, however, one can observe the results of this complex evolution of views. The D2 LD is regarded as an unambiguous standard of gastric cancer surgical treatment in specialized European centers. Such a consensus of the Eastern and Western surgical schools became possible due to the longstanding scientific and practical search for methods that would help improve the results of gastric cancer surgeries using evidence-based medicine. Today, we can claim that D2 LD could improve the prognosis in European populations of patients with gastric cancer, but only when the surgical quality of LD execution is adequate.     

Laparoscopic gastrectomy with regional lymph node dissection for upper gastric cancer

Recently, a minimally invasive operation for gastric malignancies has been developed, and this laparoscopic operation is seen as a technique that will raise quality of life for patients. Previously, we reported this technique, as well as the results of a distal gastrectomy with regional lymph node dissection using hand-assisted laparoscopic surgery (HALS) for gastric cancer located in the middle or lower third of the stomach. This paper describes total or proximal gastrectomy with regional lymph node dissection by HALS on 28 cases of gastric cancer located in the upper portion of the stomach. After the mobilization of stomach and lymph node dissection via HALS, an anastomosis of the esophagus was performed intracorporeally with a conventional circular stapling device (PCEEA), whereas jejunojejunostomy and jejunogastrostomy were carried out extracorporeally with a conventional hand-sewn procedure through a HALS wound. The operation time and the amount of blood loss in all the patients were considered to be satisfactory, and the average number of dissected lymph nodes per patient was similar to that in open surgery. The patients had minimal morbidity and quick recovery after their operation. This technique was thought to be not only less invasive, but also similarly curative compared with open gastrectomy. Received: May 2, 2002 / Accepted: September 12, 2002 Offprint requests to: S. Tanimura     

Sentinel node biopsy to avoid axillary lymph node dissection in breast cancer

The role of sentinel node biopsy in breast cancer has increased over the last few years. Sentinel nodes can predict the status of all axillary lymph nodes precisely and select patients with negative nodes for whom axillary dissection is unnecessary. Many problems remain, such as the ideal injection technique, ideal agents, and ideal histological detection of sentinel node metastases, and must be addressed before sentinel node biopsy becomes the standard of care for patients with breast cancer.     

临床腋淋巴结阳性乳腺癌患者行全腋窝淋巴结清扫的应用探讨

背景与目的:临床腋淋巴结阳性乳腺癌患者常规行全腋窝淋巴结清扫,本研究探讨改良根治术时采用改进L3组淋巴结清扫方式的临床应用及意义.方法:322例临床腋淋巴结阳性的乳腺癌患者中,154例采用改进的L3组淋巴结清扫方式,168例行常规Auchinclos改良根治术,对两种手术方式所用时间和术后不良反应进行比较,同时随访观察患者的无病生存率.结果:两种手术方式所用手术时间、术后不良反应差异无统计学意义(P＞0.05),行改进术式患者腋下淋巴结总数及L3组淋巴结数较常规术式多,两组差异有统计学意义(P＜0.05),L3组淋巴结未转移患者5年无病生存率为68.6％,L3组淋巴结转移患者5年无病生存率为35.7％,差异有统计学意义(P＜0.05).结论:对临床腋淋巴结阳性乳腺癌患者行L3组淋巴结清扫具有一定的临床应用价值,采用改进的淋巴结清扫方式,便于L3组淋巴结的清扫.     

胃癌D2根治术后大出血的临床分析

目的总结分析胃癌D2根治术后发生大出血的原因及治疗方法并探讨其对生存预后的影响。方法回顾性分析广东省中医院2012年1月至2016年3月258例行胃癌D2根治术患者的临床资料,根据术后是否发生大出血分为出血组和非出血组。结果14例患者(5.4%)术后发生大出血;吻合口出血、十二指肠残端瘘或破裂是出血的主要原因;二次手术和胃镜止血是主要治疗措施。两组的短期总生存期有统计学意义(1年:P=0.017,3年:P=0.011)。结论吻合口出血、十二指肠残端瘘或破裂是胃癌D2根治术后出血的主要原因,及时诊断和治疗能有效降低病死率。胃癌D2根治术后大出血会降低患者的短期总生存期。     

200 Sentinel lymph node biopsies without axillary lymph node dissection -- no axillary recurrences after a 3-year follow-up

The aim of this study is to evaluate the rate of axillary recurrences in sentinel lymph node (SLN)-negative breast cancer patients after sentinel lymph node biopsy (SLNB) alone without further axillary lymph node dissection (ALND). Between May 1999 and February 2002, 333 consecutive patients with primary invasive breast cancer up to 4 cm and clinically negative axillae were entered into this prospective study. Sentinel lymph nodes were identified using the combined method with blue dye (Patent blue V) and technetium 99m-labelled albumin (Nanocoll). Sentinel lymph nodes were examined by frozen sections, standard haematoxylin and eosin staining and immunohistochemistry staining. In SLN-positive patients, ALND was performed. Sentinel lymph node-negative patients had no further ALND. The SLN identification rate was 98.5% (328 out of 333). In all, 128 out of 328 (39.0%) patients had positive SLNs and complete ALND. A total of 200 out of 328 (61.0%) patients were SLN negative and had no further ALND. The mean tumour size of SLN-negative patients was 16.5 mm. The mean number of SLNs removed was 2.1 per patient. There were no local or axillary recurrences at a median follow-up of 36 months. The absence of axillary recurrences after SLNB without ALND in SLN-negative breast cancer patients supports the hypothesis that SLNB is accurate and safe while providing less surgical morbidity than ALND. Short-term results are very promising that SLNB without ALND in SLN-negative patients is an excellent procedure for axillary staging in a cohort of breast cancer patients with small tumours.     

Lateral lymph node dissection in rectal cancer: State of the art review

Half of the local regional recurrences from rectal cancer are nowadays located in the lateral compartments, most likely due to lateral lymph node (LLN) metastases. There is evidence that a lateral lymph node dissection (LLND) can lower the lateral local recurrence rate. An LLND without neoadjuvant (chemo)radiotherapy in patients with or without suspected LLN metastases has been the standard of care in the East, while Western surgeons believed LLN metastases to be cured by neoadjuvant treatment and total mesorectal excision (TME) only. An LLND in patients without enlarged LLNs might result in overtreatment with low rates of pathological LLNs, but in patients with enlarged LLNs who are treated with (C)RT and TME only, the risk of a lateral local recurrence significantly increases to 20%. Certain Eastern and Western centers are increasingly performing a selective LLND after neoadjuvant treatment in the presence of suspicious LLNs due to new scientific insights, but (inter)national consensus on the indication and surgical approach of LLND is lacking. An LLND is an anatomically challenging procedure with intraoperative risks such as bleeding and postoperative morbidity. It is therefore essential to carefully select the patients who will benefit from this procedure and where possible to perform the LLND in a minimally invasive manner to limit these risks. This review gives an overview of the current evidence of the assessment of LLNs, the indications for LLND, the surgical technique, pitfalls in performing this procedure and the future studies are discussed, aiming to contribute to more (inter)national consensus.     

Current status of lymph node dissection in gastric cancer

Gastrectomy with lymph node (LN) dissection has been regarded as the standard surgery for gastric cancer (GC), however, the rational extent of lymphadenectomy remains controversial. Though gastrectomy with extended lymphadenectomy beyond D2 is classified as a non-standard gastrectomy, its clinical significance has been evaluated in many studies. Although hard evidence is lacking, D2 plus superior mesenteric vein (No. 14v) LN dissection is recommended when harbor metastasis to No. 6 nodes is suspected in the lower stomach, and dissection of splenic hilar (No. 10) LN can be performed for advanced GC invading the greater curvature of the upper stomach, and D2 plus posterior surface of the pancreatic head (No. 13) LN dissection may be an option in a potentially curative gastrectomy for cancer invading the duodenum. Prophylactic D2+ para-aortic nodal dissection (PAND) was not routinely recommended for advanced GC patients, but therapeutic D2 plus PAND may offer a chance of cure in selected patients, preoperative chemotherapy was considered as the standard treatment for GC with para-aortic node metastasis. There has been no consensus on the extent of lymphadenectomy for the adenocarcinoma of the esophagogastric junction (AEG) so far. The length of esophageal invasion can be used as a reference point for mediastinal LN metastases, and the distance from the esophagogastric junction to the distal end of the tumor is essential for determining the optimal extent of resection. The quality of lymphadenectomy may influence prognosis in GC patients. Both hospital volume and surgeon volume were important factors for the quality of radical gastrectomy. Centralization of GC surgery may be needed to improve prognosis.     

Avoidance of axillary lymph node dissection in selected patients with node-positive breast cancer

Aims

Currently, it is standard practice to avoid ALND in patients with negative SLN, whereas this procedure is mandated for those with positive SLN. However, there has been some debate regarding the necessity of complete ALND in all patients with positive SLN. This review article discusses the issues related to eliminating the need for ALND in selected patients with positive nodes.

Methods

A review of the English language medical literature was performed using the MEDLINE database and cross-referencing major articles on the subject, focusing on the last 10 years.

Results

Currently, complete ALND is mandated in patients with SLN macrometastases as well as those with clinically positive nodes. It is not clear whether SLN biopsy is appropriate for axillary staging in patients with initially clinically positive nodes (N1) that become clinically node-negative (N0) after neoadjuvant chemotherapy. Although there is debate regarding whether ALND should be performed in patients with micrometastases in the SLN, it seems premature to abandon ALND in clinical practice. Moreover, it remains unclear whether it is appropriate to avoid complete ALND in patients with ITC-positive SLN alone.

Conclusions

In the absence of data from randomised trials, the long-term impact of SLN biopsy alone on axillary recurrence and survival rate in patients with SLN micrometastases as well as those with ITC-positive SLN remains uncertain. These important issues must be determined by careful analysis of the results of ongoing clinical trials.     

治疗性腹腔镜胃癌腹主动脉旁淋巴结清扫术的操作技巧及临床意义

目的探讨治疗性腹腔镜胃癌腹主动脉旁淋巴结清扫术的安全性和有效性。方法回顾性分析2017年1月至2018年12月就诊广东省中医院胃肠外科实施治疗性腹腔镜胃癌腹主动脉旁淋巴结术的6例病人基线资料、术中及术后短期结果。结果6例病人术前经影像学评估均存在第16组淋巴结转移,无其他远处转移,经转化治疗后,均达到部分缓解并顺利完成腹腔镜胃癌D2根治并腹主动脉旁淋巴结清扫术,术中1例因合并胰腺侵犯而联合行胰体尾+脾切除术,无中转开腹、腹腔出血、脏器损伤等并发症发生;中位手术时长482.5(445,510)min;中位淋巴结清扫总数、腹主动脉旁淋巴结(para-aortic lymph nodes,PALN)清扫总数及PALN阳性数目分别为50(16,80)枚、18(3,31)枚、3.5(0,15)枚,其中5例PALN病理阳性,1例阴性;术后1例出现胰瘘,1例胸腔积液,1例腹泻,Clavien-Dindo分级均为2级,经对症治疗后均好转出院;术后中位住院时间17(6,30)天,术后30天内无二次手术及死亡发生;中位随访时间13.25(10~18)月,3例病人因肿瘤复发死亡,术后存活时间10~18月,余3例均未见肿瘤复发转移。结论治疗性腹腔镜腹主动脉旁淋巴结清扫术在技术上是可行的,对于胃癌合并PALN转移的患者。     

电视内腔镜在乳腺癌腋窝淋巴结清扫的应用

目的:总结应用电视内腔镜在乳腺癌腋窝淋巴结清扫中的体会。方法:回顾性分析2005年10月至2006年11月我院35例乳腺癌患者接受电视内腔镜腋窝淋巴结清扫手术的临床资料,并对手术适应证、手术要点及注意事项进行讨论。结果:35例乳腺癌患者中26例行乳房切除,9例行保乳手术。腔镜腋窝淋巴结清扫平均时间111.3min(75min～177min)。切除淋巴结平均每例17.5枚(8～37枚)。其中吸脂液中检出淋巴结0～19枚,每例平均2.2枚,最大直径0.6cm。术后随访1～13个月(平均4.6个月)。35例患者均无患侧上肢淋巴水肿,肩关节活动良好。随访期间未发现肿瘤复发及切口种植转移。结论:选择临床体检和/或超声检查腋窝淋巴结直径小于1cm的乳腺癌病例行电视内腔镜腋窝淋巴结清扫手术可达到开放手术效果,既缩小手术切口、又改善美观效果。     

Laparoscopic distal gastrectomy with D2 dissection for advanced gastric cancer

The successful application of the laparoscopic distal gastrectomy with D2 dissection for gastric cancer requires adequate understanding of the anatomic characteristics of peripancreatic and intrathecal spaces, the role of pancreas and vascular bifurcation as the surgical landmarks, as well as the variations of gastric vascular anatomy. The standardized surgical procedures based on distribution of regional lymph node should be clarified.Key Words: Gastric cancer, gastrectomy, laparoscopyThe D2 lymph node dissection has been widely applied in traditional open surgery for locally advanced gastric cancer with curative intent (1). However, the feasibility of this procedure in laparoscopic surgery has only been reported in a few conclusive studies around the world (2,3). That is because of the technical threshold for laparoscopic lymph node dissection derived from the perigastric anatomical complexity (4), which is an important factor of the surgical performance and the indicator of prognosis (5). Since the inception of this technique in our department in 2004, we have clinically accumulated proven experience in laparoscopic lymph node dissection for advanced gastric cancer. We believe that it is a combination of proper arrangement of surgical procedures and skilled application of laparoscopic techniques based on complete understanding of the perigastric space (6), surgical landmarks and variations in blood vessels.The key step in the radical treatment of distal gastric cancer lies in the regional lymph node dissection. The extent of D2 dissection for distal gastric cancer defined in the Japanese Gastric Cancer Surgery Guidelines and the Treatment Guideline for Gastric Cancer in Japan (7) involves stations number 1, 3, 4sb, 4d, 5, 6, 7, 8a, 9, 11p, 12a and 14v lymph nodes, while station 14v is excluded in the latest guidelines.According to the distribution of perigastric lymph nodes and the characteristics of laparoscopic techniques, especially the perigastric anatomical features of the gastric body and antrum flipped towards the head under laparoscopy, the scope of D2 lymph nodes can be divided into five regions: (I) lower left region (stations number 4sb and 4d around the left gastroepiploic vessel); (II) lower right region (mainly including station number 6 inferior to the pylorus, and at the root of the right gastroepiploic artery; station number 14v around the superior mesenteric vein in the former version); (III) upper right region (station number 5 superior to the pylorus and number 12a in the hepatoduodenal ligament); (IV) central region posterior to the gastric body (stations number 7, 8a, 9 and 11p surrounding the celiac artery and along its three branches); and (V) hepatogastric region (stations number 1 and 3 along the lesser curvature).Based on the above classification, we have established the standard procedure for laparoscopic D2 lymphadenectomy for distal gastric cancer in our department (Video 1):Open in a separate windowVideo 1Laparoscopic distal gastrectomy with D2 dissection for advanced gastric cancer

1. The left side of the gastrocolic ligament is dissected near the transverse colon through to the lower splenic pole and the pancreatic tail. The key steps include extending and stretching the attachment of the greater omentum to the transverse colon tightly, and then separating from the greater sac into the anterior and posterior space of the transverse mesocolon near splenic flexure, until the lower edge of the tail of the pancreas is exposed;
2. The origin of the left gastroepiploic vessels are ligated. The key steps include extending and stretching the gastrosplenic ligament and fending off the posterior wall of the gastric fundus to expose the splenic hilum and the tail of the pancreas, and thereby the pancreatic capsule can be flipped from the lower edge to the upper edge of its tail. During this process, the left gastroepiploic artery and vein are ligated at the roots near the upper edge of the pancreatic tail, and division is continued from the greater curvature towards distal gastric body. The goal is the dissection of stations number 4sb and 4d lymph nodes;
3. The right side of the gastrocolic ligament is cut near the transverse ligament through to the hepatic flexure, the hepatic flexure of the colon is separated from the duodenal bulb and the surface of the pancreatic head. The key steps include cutting the mesogastrium and the mesocolon along the attachment line between the posterior wall of gastric antrum and mesocolon, and retracting the posterior wall of the sinus to the left anterior direction and the colon and its mesentery to the lower right direction to expose the underlying loose fusion fascial space. Take time to divide the vessels. In the process, the anatomical layer should be fully exposed to separate the right side of the transverse colon and its mesentery from the duodenal descending part, the surface of pancreatic head and the lower edge of pancreatic neck it is attached to. In this way, the gastrocolic trunk (variations may be present in certain patients) formed by the right gastroepiploic vein, right colic vein and their confluence has been completely revealed;
4. The right gastroepiploic vessels are transected. The key steps include fully exposing the lower edge of the pancreatic neck, the pancreatic head and the duodenum, so that the right gastroepiploic vein can be transected above the point where the anterior superior pancreaticoduodenal vein joins. Using the pancreas as a starting point, the pancreatic capsule is lifted and the tissue is separated from the lower edge of the pancreas along the anterior pancreatic space on the surface of the pancreas towards the external superior region, until the origin of the right gastroepiploic artery from the gastroduodenal artery is reached. The right gastroepiploic artery is then cut. The posterior inferior wall of duodenal bulb is denuded near the surface of the pancreatic head along the anterior pancreatic space. The goal is the dissection of stations number 6 lymph nodes;
5. The gastroduodenal artery is exposed and the right gastric artery is transected. The key steps include transecting the duodenum only after dissecting the tissue around the pancreatic head and the upper part of the pancreatic neck from inferior to superior along the gastroduodenal artery in the posterior region of the duodenal bulb on the surface of the pancreas and on the plane of the anterior pancreatic space, in which the bifurcation of the common hepatic artery is exposed at the upper edge of the pancreatic edge for the access to the inner layer of arterial sheath, and the proper hepatic artery is denuded along the adventitia through to hepatoduodenal ligament, where the right gastric artery is cut at its root. The goal is the dissection of stations number 12a and 5 lymph nodes;
6. The three branches of the celiac trunk are divided and the left gastric artery is transected. The key steps include stretching the left gastric vascular pedicle in the gastropancreatic fold and fending the gastric body towards the anterior superior region while pulling the pancreas downwards to fully expose the upper edge of the pancreas for access to the posterior pancreatic space. The three branches of the celiac trunk are denuded here and the left gastric artery is transected at the root. The division is continued upwards in the space until the crura of the diaphragm. The goal is dissection of stations number 7, 8a, 9 and 11p lymph nodes;
7. The hepatogastric ligament and the anterior lobe of the hepatoduodenal ligament are transected close to the lower edge of the liver, and the right side of the cardia and the lesser curvature are fully separated. The key steps include retracting the liver upwards and the gastric downwards to stretch the hepatogastric ligament so that the hepatogastric ligament and the anterior lobe of the hepatoduodenal ligament can be transected and the division can continue towards the right to reach the anterior surface of the proper hepatic artery, which has been separated previously, and towards the left to reach the right side of the cardia, where the lesser curvature is fully divided and denuded. Stations number 1 and 3 lymph nodes are dissected;
8. The distal subtotal gastrectomy, and reconstruction of the digestive tract were completed through minilaparotomy.

The above surgical procedure is designed to accommodate the characteristics of laparoscopic techniques by organizing the sequence of operations from proximal to distal, inferior to superior, and posterior to anterior. More importantly, it has incorporated with our understanding of the anatomical structures under laparoscopy, so that we can make full use of the advantages of visual amplification to identify the relevant anatomical landmarks based on the shape, color and other features, and always proceed at the correct surgical plane while minimizing bleeding.