**4. Billroth II anastomosis**

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

Roux-en-Y reconstruction is one of the standard options after distal gastrectomy. In 1995, Kitano et al. used an extracorporeal gastrojejunostomy with manual suturing as a reconstruction procedure for distal gastrectomy. The improvements in stapling devices contributed to easy access to the site of operation. The advantage and disadvantage of RY reconstruction compared with Billroth I are as follows: prevention of bile reflex and reduction in incidence of

A 12-mm trocar is inserted through the umbilical region by the open procedure, and then CO<sup>2</sup> pneumoperitoneum is established. A 12-mm trocar is introduced into the left pre-axillary line 1 cm below the costal margin. A 5-mm trocar is inserted into the left midclavicular line 2 cm above the umbilicus. The second 5-mm trocar is inserted into the right pre-axillary line 1 cm below the costal margin. Another 12-mm trocar is placed by the camera assistant between the patient's legs. Laparoscopic mobilization of the stomach and lymph node dissection are carried out in a conventional procedure. The duodenum is divided distal to the pylorus with a 60-mm ELS; then, the stomach is divided with two ELSs. The specimen is removed through an extended 4-cm incision in the umbilical port. Following re-establishment of the pneumoperitoneum, the jejunum 20 cm distal to the ligament of Treitz is prepared for Roux limb, and the mesentery of this jejunum is divided for a distance of 8 cm. The prepared jejunum is then divided with an ELS to ensure a gastrojejunostomy without tension. A side-side jejunojejunostomy is fashioned 25 cm distal to the planed gastrojejunostomy using an ELS under direct vision through the umbilical incision. The jejunojejunostomy defect is closed with absorbable suture in an intermittent fashion. Following re-pneumoperitoneum, the jejunal limb is brought to the gastric remnant through an antecolic route. A right-oriented Roux limb is created such that the cut end of the Roux limb faces the greater curvature of remnant stomach. The jejunal limb is anastomosed to the greater curvature of remnant stomach side to side with an ELS; then, the site of entry hole is closed using an absorbable barbed suture. The duodenal stump is embedded with seromuscular suture and then fixed with the alimentary limb on the duodenal stump in a proper radian.

The duodenum and stomach are divided distal to the pylorus with three 60-mm ELSs. The specimen is removed through an extended 4-cm incision in the umbilical port. After

anastomotic stoma is complete (**Figure 20**).

**3. Roux-en-Y reconstruction (RY)**

**3.1. Antecolic isoperistaltic RY reconstruction**

**3.2. Antecolic antiperistaltic RY reconstruction**

anastomotic leakage.

54 Gastric Cancer - An Update

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