Laparoscopic surgery with D2 lymph node (LN) dissection for advanced gastric cancer remains controversial for its technical difficulty and concern for the increase of complication. We will demonstrate our procedure of totally laparoscopic distal gastrectomy with D2 LN dissection.

After perigastric and infrapyloric LN dissection along the greater curvature is done, the duodenum is transected. Avascular plane between #8a LN and the common hepatic artery is dissected to expose the common hepatic artery and divide the right gastric artery. Before dissection of LN #11p, the avascular space left to the left gastric artery is entered to widely expose the left crus and the renal fascia. LN #11p along the splenic artery is then completely removed until the splenic vein is exposed. After the left gastric artery is divided, dissection along the common and proper hepatic arteries is continued, while LNs #8a and 12a are retracted to dissect from the portal vein. The crura are then skeletonized upward to remove LN #9. The lesser curvature is skeletonized, and the proximal side of the stomach is divided with a linear stapler. Excised specimen is removed through the umbilical port wound. Reconstruction is done laparoscopically by either Billroth-I or Roux-En-Y method using functional end-to-end anastomosis.

We successfully performed totally laparoscopic distal gastrectomy with D2 LN dissection for 66 patients. Mean operation time was 300 minutes, with estimated blood loss of 136 g. We experienced eight postoperative complications (12.1%), but no mortality.

Laparoscopic gastrectomy with D2 LN dissection is technically feasible and can be safely performed.