**1. Introduction**

Gastric cancer operations have the most impact on food intake and body weight loss, resulting in more changes in patient's circumstances than any other surgery [1–3]. Its morbidity and mortality are, respectively, ranked fifth and third in the world—with the incidence in China, Japan, and Korea, the highest in the world. Even now, with chemotherapy and immunotherapy well progressed, surgery is still required for the curable treatment for that cancer [4, 5].

Laparoscopy-assisted distal gastrectomy (LADG) with gastroduodenostomy for early gastric cancer was first reported in 1994 by professor Kitano. Initially, hand-associated or small incisional open laparotomy reconstruction, the so-called associated operation, was performed. Full laparoscopic operation is much better for the patients, due to small wound, less pain, and quick recovery. According to the 12th Nationwide Survey of Endoscopic Surgery in Japan, in

© 2016 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. © 2019 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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 remains regarding which method is the best after distal gastrectomy.

*2.1.1. Extracorporeal hemi-double stapling technique*

linear stapler (**Figure 8**).

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

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

Reconstruction after Laparoscopic Distal Gastrectomy http://dx.doi.org/10.5772/intechopen.80630 45

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.

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 have developed by experts during more than 10 years.

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

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.
