Laparoscopic modified lymphadenectomy in gastric cancer surgery using systematic mesogastric excision: a novel technique based on a concept.

PURPOSE: Radical surgery for gastrointestinal cancer involves en bloc removal of the primary tumor and organ-specific mesenteries. However, the surgical concept and technique for lymphadenectomy during gastric cancer surgery remain unclear. We examined a novel technique for laparoscopic modified lymphadenectomy during gastric cancer surgery involving systematic mesogastric excision (SME) and focused on the topographic anatomy, surgical technique, and specimens. METHODS: Our surgical technique involved the following: mesenterization by dissociating embryological planes, separating fat tissue containing lymph nodes from the pancreas and its associated vessels by tracing the intramesenteric dissectable layers, and dissecting the lymph node that is dependent on the D1+ criteria. RESULTS: Between October 2011 and September 2016, 227 patients underwent laparoscopic D1+ gastrectomy using SME. Of these, total gastrectomy was performed in 47 cases and distal gastrectomy was performed in 180 cases. The median operative time was 303 min (range, 201-722 min), and estimated blood loss was 50 mL (range, 0-550 mL). The median number of harvested lymph nodes was 54 (range, 18-163). There was no conversion to open surgery. CONCLUSIONS: SME was adapted for modified gastrectomy and is considered safe. Modified lymphadenectomy during gastrectomy is determined by the resection margin of the mesogastrium.

Universalization of the operative strategy by systematic mesogastric excision for stomach cancer with that for total mesorectal excision and complete mesocolic excision colorectal counterparts.

Gastrointestinal cancer surgery aims at en bloc removal of the primary tumor with its lymphatic drainage by excising organ-specific mesentery as an "intact package". This concept was advocated in colorectal cancer surgery as total mesorectal excision (TME) or complete mesocolic excision (CME) procedures, but is not directly applicable to stomach cancer as a result of the morphological complexities of the gastric mesentery. In this review, we discuss the unique anatomical features of the mesogastrium by introducing its embryology, disclose its similarity to the mesosigmoid, and then propose a theoretical concept to mesentery-based D2 gastrectomy, namely systematic mesogastric excision, which can universalize the operative strategy of stomach cancer with that of TME and CME colorectal counterparts.