A number of technical obstacles remain for the application of minimally invasive surgical techniques to patients who require total gastrectomy. Difficulties remain in the performance of an adequate lymphadenectomy and in the reconstruction of intestinal continuity following total gastrectomy.

We have developed a technique employing laparoscopy for gastric resection and omentectomy and the use of the DaVinci surgical robot for D2 lymphadenectomy. Intestinal continuity is achieved through an esophagojejunostomy performed with the EEA stapler using the OrVil device.

Laparoscopic complete omentectomy is performed followed by laparoscopic transection of the base of the right gastroepiploic vessels. The proximal duodenum is transected and the robot is docked for D2 lymphadenectomy. Lymphadenectomy involves clearing nodes from the hepatic artery, the celiac axis and the splenic artery. The left gastric artery and vein are ligated at their origins and the distal esophagus is transected using a stapler. The Orvil delivery tube is then inserted through the mouth and withdrawn through an enterotomy in the distal esophagus adjacent to the staple line. A Roux-En-Y limb is formed and an EEA stapler is inserted through the end of Roux-En-Y limb and connected to the anvil and the esophagojejunostomy is completed.

Laparoscopic total gastrectomy with robotic lymphadenectomy provides an oncologically sound approach to the management of gastric cancer requiring total gastrectomy. EEA esophagojejunostomy using the OrVil delivery system provides a convenient and straightforward method of achieving intestinal continuity following total gastrectomy.