**2. Billroth I**

Billroth I is the most common and physiological reconstruction method after distal gastrectomy. For laparoscopy-assisted distal gastrectomy (LADG), Billroth I reconstruction can be performed by an extracorporeal or intracorporeal method. Initially, hand-associated or small incisional open laparotomy reconstruction, so-called associated operation, was performed. Due to an increasing number of laparoscopic gastrectomies, the laparoscopic technique has become possible for total laparoscopic distal gastrectomy (TLDG). This portion describes old extra-methods and new intra-methods.

## **2.1. Extracorporeal Billroth I anastomosis**

Extracorporeal Billroth I anastomosis has several merits when compared to intracorporeal anastomosis. Tumor location is identified by palpitation. It is easily and rapidly performed like conventional open surgery, and it uses fewer staples than the intracorporeal anastomosis. For the problem of the cost, extracorporeal Billroth I is still the most common reconstruction method for LADG. Additionally, extracorporeal anastomosis is a procedure that should be considered as the first choice in view of safety in the inexperienced facility learning laparoscopic gastrectomy.

#### *2.1.1. Extracorporeal hemi-double stapling technique*

2013, 52.7% of patients who underwent distal gastrectomy underwent laparoscopic surgery [1]. After distal gastrectomy, several reconstruction methods are available, and the choice of reconstruction is usually dependent on surgeons or institutions. There are three famous reconstruction methods, Billroth I and II and Roux-en-Y. Studies comparing gastroduodenostomy with gastrojejunostomy are still lacking and inconsistent; therefore, controversy

Billroth I gastroduodenostomy is one of most common reconstruction methods, and it offers advantages such as the following: (1) it is the only way to preserve the physiological root of the food passing through the duodenum, (2) it has technical simplicity during open surgery, and (3) it confers a lower incidence of internal hernia or adhesions. However, the risk of anastomotic failure is higher, and the laparoscopic gastrointestinal anastomosis involves a high degree of difficulty. Of course, if the size of gastric remnant is too small, Billroth I reconstruction cannot be done. These methods for total laparoscopic operation are the most difficult and

Billroth II gastrojejunostomy shares some pros and cons with the Billroth I and Roux-en-Y methods. It enables a wide stomach resection without anastomotic tension and is relatively easy during laparoscopic surgery. However, postoperative bile reflux into the remnant stom-

Roux-en-Y gastrojejunostomy prevents bile reflux [1]. Other advantages over Billroth I are as follows. It is acceptable if the gastric remnant is too small to perform Billroth I, and there is less anastomotic tension. However, the high incidence of Roux stasis syndrome is one of its major drawbacks and, although rare, leakage of duodenal stump is a severe complication.

Billroth I is the most common and physiological reconstruction method after distal gastrectomy. For laparoscopy-assisted distal gastrectomy (LADG), Billroth I reconstruction can be performed by an extracorporeal or intracorporeal method. Initially, hand-associated or small incisional open laparotomy reconstruction, so-called associated operation, was performed. Due to an increasing number of laparoscopic gastrectomies, the laparoscopic technique has become possible for total laparoscopic distal gastrectomy (TLDG). This portion describes old

Extracorporeal Billroth I anastomosis has several merits when compared to intracorporeal anastomosis. Tumor location is identified by palpitation. It is easily and rapidly performed like conventional open surgery, and it uses fewer staples than the intracorporeal anastomosis. For the problem of the cost, extracorporeal Billroth I is still the most common reconstruction method for LADG. Additionally, extracorporeal anastomosis is a procedure that should be considered as the first choice in view of safety in the inexperienced facility learning laparoscopic gastrectomy.

ach is more frequent, and, although rare, afferent loop syndrome can develop.

remains regarding which method is the best after distal gastrectomy.

have developed by experts during more than 10 years.

**2. Billroth I**

44 Gastric Cancer - An Update

extra-methods and new intra-methods.

**2.1. Extracorporeal Billroth I anastomosis**

After lymph node dissection, a 4–6 cm minilaparotomy is made at the upper midline (**Figure 1**) [6]. The stomach is pulled out of the peritoneal cavity through the small incision, which is applied by a wound retractor (**Figure 2**). A purse-string instrument is applied to the duodenum distal to the resection line. A Lister forceps is applied just proximal to the purse-string clamp, and the duodenum is transected between the two clamps (**Figure 3**). The duodenal stump is unclamped and held by Alice forceps equally at three points. An anvil is inserted into the duodenal stump, and a purse-string suture is tied over the anvil (**Figure 4**). Then, the duodenal stump is returned to the abdominal cavity; at this time, the purse-string suture thread is clamped without cutting it, leaving the clamp outside of the abdominal cavity. The greater curvature side of the proximal resection margin is transited with an 80-mm linear stapler (**Figure 5**). Thereafter, an entry hole is made along the lesser curvature side of the previous staple line at the disbanded of 3 cm to the lesser curvature; the shaft of the circular stapler is introduced into the gastric remnant through the gastrostomy (**Figure 6**). The shaft is rotated toward the duodenum with the distal stomach, and then the trocar is advanced to penetrate the corner of the stapling line at the greater curvature (**Figure 7**). The trocar is connected to the anvil placed in the duodenum. The instrument is closed and fired, completing the end-to-end gastroduodenostomy. After checking for bleeding at the anastomotic line, the lesser curvature side of proximal resection margin is transected with another linear stapler (**Figure 8**).

#### *2.1.2. Extracorporeal end-to-side posterior wall method*

The distal gastrectomy procedure is the same as for the abovementioned method [6]. For resection of the proximal margin, the stomach is transected 5 cm from the greater curvature to the middle of the planned resection line using two clamps, and the remaining proximal resection is done using an 80-mm linear stapler. After distal gastrectomy, the head of the circular stapler is inserted into the remnant stomach through the opening of the greater curvature side of the proximal resection, which was temporarily clamped. The trocar is advanced

**Figure 1.** Extracorporeal hemi-double stapling technique – depiction of procedure as described in the text, step 1.

to pass through the posterior wall of the remnant stomach and then coupled on the anvil placed in the duodenum. The device is closed and fired, completing the end-to-side gastroduodenostomy. Finally, the opening in the remnant stomach is shuttered using an additional linear stapler.

**Figure 2.** Extracorporeal hemi-double stapling technique – depiction of procedure as described in the text, step 2.

**Figure 3.** Extracorporeal hemi-double stapling technique – depiction of procedure as described in the text, step 3.

In this method, there is no overlap between the liner stapler and circular stapler, which is said to be likely to cause anastomotic leakage in general, but the possibility of an ischemic area remaining between the liner stapler and the circular stapler is considered a problem. In order to avoid this complication, it is said to set the place to puncture the back wall ten from liner

**Figure 7.** Extracorporeal hemi-double stapling technique – depiction of procedure as described in the text, step 7.

**Figure 5.** Extracorporeal hemi-double stapling technique – depiction of procedure as described in the text, step 5.

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**Figure 6.** Extracorporeal hemi-double stapling technique – depiction of procedure as described in the text, step 6.

stapler, but then the "dog's ear" deformation remains widely.

**Figure 4.** Extracorporeal hemi-double stapling technique – depiction of procedure as described in the text, step 4.

Reconstruction after Laparoscopic Distal Gastrectomy http://dx.doi.org/10.5772/intechopen.80630 47

to pass through the posterior wall of the remnant stomach and then coupled on the anvil placed in the duodenum. The device is closed and fired, completing the end-to-side gastroduodenostomy. Finally, the opening in the remnant stomach is shuttered using an additional

**Figure 2.** Extracorporeal hemi-double stapling technique – depiction of procedure as described in the text, step 2.

**Figure 3.** Extracorporeal hemi-double stapling technique – depiction of procedure as described in the text, step 3.

**Figure 4.** Extracorporeal hemi-double stapling technique – depiction of procedure as described in the text, step 4.

linear stapler.

46 Gastric Cancer - An Update

**Figure 5.** Extracorporeal hemi-double stapling technique – depiction of procedure as described in the text, step 5.

**Figure 6.** Extracorporeal hemi-double stapling technique – depiction of procedure as described in the text, step 6.

**Figure 7.** Extracorporeal hemi-double stapling technique – depiction of procedure as described in the text, step 7.

In this method, there is no overlap between the liner stapler and circular stapler, which is said to be likely to cause anastomotic leakage in general, but the possibility of an ischemic area remaining between the liner stapler and the circular stapler is considered a problem. In order to avoid this complication, it is said to set the place to puncture the back wall ten from liner stapler, but then the "dog's ear" deformation remains widely.

60° anastomotic angle between the second anastomotic line and the first suture line is best designed for passing the food. This second anastomotic line length should be approximately 30 mm without the ventral staple lines. Thirdly, the linear staple with a 60-mm articulating medium/thick cartridge is placed in the direction toward the posterior wall and also placed almost perpendicular to the transection line of the stomach for resecting the blood less area. Those three staplers created the triangular anastomosis and simultaneously removed three staple lines of the duodenal transection line, the ventral line of the first anastomosis, the end of gastric transection line, and the ischemic tissues in between these staple lines. This tech-

Reconstruction after Laparoscopic Distal Gastrectomy http://dx.doi.org/10.5772/intechopen.80630 49

We have reported that laparoscopy-assisted distal gastrectomy (LADG) with extended lymph node dissection for gastric cancer was technically feasible and had favorable oncologic outcomes compared to the open gastrectomy [1, 10]. Unlike the extracorporeal anastomosis performed during the LADG, a standardized reconstruction method has not been established for the Billroth I (BI) gastroduodenostomy in the totally laparoscopic distal gastrectomy (LDG). A triangle anastomosis or a delta-shaped anastomosis is reported for the LDG without associated laparotomy. However, these two methods seem complicated for the LDG because of the need for stay sutures and further have the risks of ischemia or stenosis postoperatively. Therefore, we have developed an "augmented rectangle technique (ART)" as a new BI anastomosis performed during the LDG. The ART does not need stay sutures and therefore facilitates the LDG. A 12-mm trocar for the laparoscope is inserted into the umbilicus. A 12-mm trocar is introduced into the left premaxillary line 1 cm below the costal margin. A second 12-mm trocar is inserted into the left midclavicular line 2 cm above the umbilicus. A 5-mm trocar is inserted into the right premaxillary line 1 cm below the costal margin. A third 12-mm trocar is placed

Duodenal resection is performed with the surgeon's right hand using a 60-mm endoscopic linear stapler (ELS) from the greater curvature side of duodenum to lesser curvature side. The duodenum is transected just below the pyloric ring because it is necessary to preserve a long

nique yielded an end-to-end anastomosis of a triangular orifice [9].

by the camera assistant between the patient's legs (**Figure 9**).

**Figure 9.** Augmented rectangle technique – depiction of procedure as described in the text, step 1.

duodenum for anastomosis (**Figure 10**).

*2.2.3. Augmented rectangle technique*

**Figure 8.** Extracorporeal hemi-double stapling technique – depiction of procedure as described in the text, step 8.
