*2.2.3. Augmented rectangle technique*

**2.2. Intracorporeal Billroth I anastomosis**

The delta-shaped anastomosis originally created by Professor Kanaya is a functional end-to-

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

For the duodenal bulbus resection, the direction of the stapling is more vertical than the mesenteric-antimesenteric direction. End-to-end anastomosis is done vertically to maintain an enough blood supply to the anastomosis and to preserve a space for the jaw of 45-mm linear stapler to be inserted into the entry hole. Before stapler firing, the staple line on the remnant stomach is rotated to the left side, and the staple line on the duodenal stump is rotated to the right side to form a side-to-side gastroduodenostomy between the posterior wall of the remnant stomach and the posterior wall of the duodenum. After firing the stapler, a relatively large entry hole is made, and the operator checks for anastomotic bleeding through this hole. After transient approximation of the entry hole with clips, the hole is closed by two consecutive firings of a 45-mm liner stapler.

The other intracorporeal anastomosis method, novel intracorporeal triangular anastomotic

After all dissection of lymph nodes is finished, the stomach and duodenal bulb are stapletransected parallelly, and the resected stomach with dissected LNs is retrieved through the umbilical incision. Small entry holes are made on the greater curvature side, for each of the remnant stomach and the duodenal bulb, leaving a space almost 1 cm away from each stapling line. The cartridge side of the linear stapler (45-mm articulating medium/thick cartridge) is inserted to the transection line of the stomach. Then, the linear stapler fork side is carefully inserted into the bulb via the hole parallelly. This process makes The cartridge side is inserted parallel to the transection line of the stomach. The posterior walls, so-call V-shaped anastomosis, of both the gastric remnant and the bulbs, the dorsal side of the posterior suture line of the Billroth I. After arresting hemorrhage of the suture line, the entry hole is sutured by 2–3 points temporarily, avoiding slipping the liner staple. Finally, the entry hole is closed by a 45-mm linear stapler suture and created completing the anterior half of the anastomosis. The almost

end gastroduodenostomy technique using endoscopic linear staplers [7].

*2.2.2. Intracorporeal triangular anastomotic technique (INTACT)*

technique, was reported by Omori et al. [8].

*2.2.1. Delta-shaped anastomosis*

48 Gastric Cancer - An Update

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

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

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

Gastric resection is also done using two 60-mm ELS through the 12-mm trocar of the left lower quadrant from greater curvature to lesser curvature (**Figure 11**).

The superior duodenal vessels along the lesser curvature are transected to mobilize the duodenum (**Figure 12**).

An entry hole is made on the tip of the greater curvature side of the duodenal stump. The surgeon holds the tip of greater curvature side of the duodenal stump by his left hand located upside, and the assistant holds the tip of lesser curvature side of the duodenal stump by her right hand. Also, an assistant holds a suction by her left hand to prevent contamination by digestive tract contents in the abdominal cavity. A 5-mm incision is created in the previous stapled line at the greater curvature side of duodenal stump (**Figure 13**). Also, an entry hole is

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The thicker cartridge fork of the 60-mm ELS is inserted into the stomach through the 12-mm trocar of the left lower quadrant. At this time, the tip of the ELS is pressed against the posterior gastric wall 2 cm away from the gastric resection margin, and the ELS is used to grasp the

An ELS gently holding the posterior wall of the remnant stomach is rotated clockwise to the duodenal side, which is then ready for the gastroduodenostomy. The surgeon, who is standing on the patient's right, opens the ELS and moves its thinner jaw to cover the duodenum. The margin of resection at the lesser curvature end of the duodenum is rotated externally by 90° (**Figure 16**). The entire length of the ELS is inserted, and the device is then closed and

made on the tip of greater curvature side of remnant stomach (**Figure 14**).

**Figure 14.** Augmented rectangle technique – depiction of procedure as described in the text, step 6.

**Figure 13.** Augmented rectangle technique – depiction of procedure as described in the text, step 5.

tissue close to the suture line near the ELS entry hole (**Figure 15**).

**Figure 10.** Augmented rectangle technique – depiction of procedure as described in the text, step 2.

**Figure 11.** Augmented rectangle technique – depiction of procedure as described in the text, step 3.

**Figure 12.** Augmented rectangle technique – depiction of procedure as described in the text, step 4.

**Figure 13.** Augmented rectangle technique – depiction of procedure as described in the text, step 5.

Gastric resection is also done using two 60-mm ELS through the 12-mm trocar of the left lower

The superior duodenal vessels along the lesser curvature are transected to mobilize the duo-

quadrant from greater curvature to lesser curvature (**Figure 11**).

**Figure 11.** Augmented rectangle technique – depiction of procedure as described in the text, step 3.

**Figure 10.** Augmented rectangle technique – depiction of procedure as described in the text, step 2.

**Figure 12.** Augmented rectangle technique – depiction of procedure as described in the text, step 4.

denum (**Figure 12**).

50 Gastric Cancer - An Update

An entry hole is made on the tip of the greater curvature side of the duodenal stump. The surgeon holds the tip of greater curvature side of the duodenal stump by his left hand located upside, and the assistant holds the tip of lesser curvature side of the duodenal stump by her right hand. Also, an assistant holds a suction by her left hand to prevent contamination by digestive tract contents in the abdominal cavity. A 5-mm incision is created in the previous stapled line at the greater curvature side of duodenal stump (**Figure 13**). Also, an entry hole is made on the tip of greater curvature side of remnant stomach (**Figure 14**).

The thicker cartridge fork of the 60-mm ELS is inserted into the stomach through the 12-mm trocar of the left lower quadrant. At this time, the tip of the ELS is pressed against the posterior gastric wall 2 cm away from the gastric resection margin, and the ELS is used to grasp the tissue close to the suture line near the ELS entry hole (**Figure 15**).

An ELS gently holding the posterior wall of the remnant stomach is rotated clockwise to the duodenal side, which is then ready for the gastroduodenostomy. The surgeon, who is standing on the patient's right, opens the ELS and moves its thinner jaw to cover the duodenum. The margin of resection at the lesser curvature end of the duodenum is rotated externally by 90° (**Figure 16**). The entire length of the ELS is inserted, and the device is then closed and

**Figure 14.** Augmented rectangle technique – depiction of procedure as described in the text, step 6.

fired. The ELS is withdrawn, the lumen is examined to confirm the absence of hemorrhage, and the residual duodenum and stomach are once again placed under adequate traction (**Figure 17**).

Next, the insertion hole is closed, and a margin is created with the use of a 30-mm ELS. This margin is closed on this side to avoid the need for stapling the transected duodenal margin (**Figure 18**). The surgeon grasps the cranial ends of a V-shaped suture line created with the first ELS, and care is taken to ensure that the gastric and duodenal resection margins remain

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**Figure 18.** Augmented rectangle technique – depiction of procedure as described in the text, step 10.

**Figure 19.** Augmented rectangle technique – depiction of procedure as described in the text, step 11.

**Figure 20.** Augmented rectangle technique – depiction of procedure as described in the text, step 12.

**Figure 15.** Augmented rectangle technique – depiction of procedure as described in the text, step 7.

**Figure 16.** Augmented rectangle technique – depiction of procedure as described in the text, step 8.

**Figure 17.** Augmented rectangle technique – depiction of procedure as described in the text, step 9.

Next, the insertion hole is closed, and a margin is created with the use of a 30-mm ELS. This margin is closed on this side to avoid the need for stapling the transected duodenal margin (**Figure 18**). The surgeon grasps the cranial ends of a V-shaped suture line created with the first ELS, and care is taken to ensure that the gastric and duodenal resection margins remain

fired. The ELS is withdrawn, the lumen is examined to confirm the absence of hemorrhage, and the residual duodenum and stomach are once again placed under adequate traction

**Figure 15.** Augmented rectangle technique – depiction of procedure as described in the text, step 7.

**Figure 16.** Augmented rectangle technique – depiction of procedure as described in the text, step 8.

**Figure 17.** Augmented rectangle technique – depiction of procedure as described in the text, step 9.

(**Figure 17**).

52 Gastric Cancer - An Update

**Figure 18.** Augmented rectangle technique – depiction of procedure as described in the text, step 10.

**Figure 19.** Augmented rectangle technique – depiction of procedure as described in the text, step 11.

**Figure 20.** Augmented rectangle technique – depiction of procedure as described in the text, step 12.

close together. This creates the third side of a rectangle. Next, a 60-mm ELS is used to create the fourth side of the rectangle, while the entire stapled duodenal stump is being removed. The surgeon places caudolateral traction on the duodenal stump. Meanwhile, the assistant adjusts the position of the ELS to ensure overlap between the two suture lines, the first being along the second staple line and the second being along the gastric stump (**Figure 19**). With this suturing, the end-to-end anastomosis with an augmented rectangular gastroduodenal anastomotic stoma is complete (**Figure 20**).

re-pneumoperitoneum, the proximal jejunum is identified and divided 25 cm distal to the Treitz ligament, and the mesentery of the jejunum is divided. The jejunum is divided with a 60-mm ELS. Small holes are made at the tips of linear stapler of the greater curvature side of the remnant stomach and distal side of jejunal stump. The gastrojejunostomy is performed between the posterior wall of remnant stomach and antimesenteric border of the distal jejunum with a 60-mm ELS. The common entry hole is closed with a 60-mm ELS. The jejunojejunostomy is performed through an umbilical minilaparotomy with a 60-mm ELS and hand-sewn suture.

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A Billroth II gastrojejunostomy enables wide stomach resection without anastomotic tension and is relatively easy during laparoscopic surgery. However, postoperative bile reflex into the remnant stomach is bothersome, and although rare, afferent loop syndrome can develop. So, Billroth II is rarely performed in Japan, but according to a nationwide survey conducted in 2014 in Korea,

Herein, a laparoscopy-assisted uncut Roux-en-Y operation after distal gastrectomy as reported

A laparoscopic mobilization of the stomach and en bloc lymph node dissection is performed, with a 4-cm long minilaparotomy made on the upper abdomen, through which the en bloc

Laparoscopy-assisted reconstruction is then started. First, the transverse colon is retracted cephalad to expose the ligament of Treitz, and the jejunum 25 cm distal to this ligament is delivered via the minilaparotomy. The position of the gastrojejunostomy, whose length is 4 cm, is determined. Next, a Braun anastomosis is created extracorporeally. A stapler without a blade is placed across the afferent jejunal limb just distal to the created Braun anastomosis. This stapler is closed and fired extracorporeally, which enables occlusion of the afferent jejunal lumen without division of the jejunum. Seromuscular sutures are placed on this staple line, and delivered jejunum is replaced into the abdominal cavity. The operation turns again to a laparoscopic procedure. The gastrojejunostomy is started while observing the created Braun anastomosis and stapling across the jejunum laparoscopically. The corner of the greater curvature of the stomach stump is cut, and a small hole is made on the site of the planned

One jaw of the endoscopic linear stapler is inserted into the jejunum and the other into the stomach. The device is closed and fired, creating a gastrojejunostomy. The firing of the stapler converts the two holes into one common entry hole, which is closed by a laparoscopic handsewn technique. Two seromuscular sutures are placed between the afferent loop and lesser curvature of the gastric remnant to lift up the afferent loop, with the aim of preventing food flowing into the afferent loop. Finally, the seromuscular suture between the stomach and efferent loop is placed on the top of created V-shaped anastomosis, because this is the weakest

Billroth II was the adopted reconstruction after distal gastrectomy in 35.8% of cases [2].

mobilized stomach and lymph nodes were delivered and the stomach is transected.

**4.1. Surgical procedure of Billroth II gastrojejunostomy**

gastrojejunostomy, using laparoscopic coagulating shears.

point, due to the remaining tension.

**4. Billroth II anastomosis**

by Uyama et al. is described [11].
