Read Aloud the Text Content

This audio was created by Woord's Text to Speech service by content creators from all around the world.

Text Content or SSML code:

An oncologic sound laparoscopic total gastrectomy with D2 lymphadenectomy for locally advanced gastric cancer is challenging but may be carried out even in complex cases like the one showed in this video. A 55-year-old symptomatic woman with a huge mass infiltrating both the posterior gastric wall and the transverse colon and mesocolon and a gastroscopy negative for endoluminal lesions, was referred to surgery for diagnostic laparoscopy and following histologic assessment. Laparoscopy showed a malignant tumor presumably arising from the stomach and infiltrating the transverse colon with localized peritoneal and omental seeding. Histology confirmed the gastric origin of tumor and the patient underwent neo-adjuvant therapy. Re-staging after 6 months by CT scan revealed a significant decrease in gastric wall thickening, shrinkage of lymphadenopathy, and disappearance of the disseminated peritoneal lesions. After multidisciplinary discussion, the patient was addressed to surgery with the aim of performing an intent-to-treat procedure. The patient underwent laparoscopic spleen-preserving total gastrectomy with D2 lymph node dissection en-bloc with segmental transverse colectomy. No metastatic lesions were observed intraoperatively. Opposite to standard laparoscopic D2 lymphadenectomy, node dissection started with the dissection of node 12a - lesser omentum, followed by group 8, 9, 7, 11p node dissection. Gastric and node dissection was furthered with excision of group 1 and 2 nodes, opening the hiatus according to Pinotti, dissecting free the distal esophagus with bilateral vagotomy, and then dissecting group 10 and 4 nodes. The entire upper and mid stomach were fully mobilized at this point. The mid third of transverse colon with relevant mesocolon appeared indissociable from the posterior gastric wall. An en-bloc segmental resection of the transverse colon was carried out after proximal and distal third colo-epiploic detachment. This step allowed the identification of the right gastroepiploic vessels which were ligated and divided thus completing the D2 lymphadenectomy. The gastrointestinal tract was reconstructed with a Roux-en-Y esophagojejunostomy and a side-to side colo-colic mechanical anastomosis. Total operative time was 400 min. Histo-pathology exam showed an intestinal and diffuse gastric signet ring cell carcinoma, poorly differentiated, and staged as pT1b and pN0 (with 0 out of 67 nodes examined. All margins were negative - R0 resection, with no evidence of perineural or lympho-vascular invasion. The patient had an uneventful recovery. She is still alive without any evidence of local recurrence or metastatic disease at 9-month follow-up. Laparoscopic total gastrectomy with D2 lymphadenectomy for gastric cancer is technically feasible and safe in the hands of experienced surgeons even in difficult and challenging advanced cases. Minimally invasive surgery, combined with multimodal oncologic treatments, offers same results of open surgery with further benefits in term of postoperative QoL. All these are key factors for the implementation of laparoscopy in the management of malignant gastric diseases.