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

Herein, a laparoscopy-assisted uncut Roux-en-Y operation after distal gastrectomy as reported by Uyama et al. is described [11].

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

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 gastrojejunostomy, using laparoscopic coagulating shears.

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 point, due to the remaining tension.
