Satoh Seiji, Okabe Hiroshi, Kondo Kan, Tanaka Eiji, Itami Atsushi, Kawamura Junichiro, Nomura Akinari, Nagayama Satoshi, Watanabe Go, Sakai Yoshiharu
Division of Gastrointestinal Surgery, Department of Surgery, Kyoto University Hospital, 54 Kawara-cho, Shogoin, Sakyo-ku, Kyoto City 606-8507, Japan.
Surg Endosc. 2009 Feb;23(2):436-7. doi: 10.1007/s00464-008-9978-9. Epub 2008 Jun 5.
Lymph node dissection is a crucial procedure for curative resection of gastric cancer [1]. To avoid portal vein injury during laparoscopic extended lymph node dissection for gastric cancer, taping of the common hepatic artery and subsequent confirmation of the portal vein have been recommended [2, 3]. This taping method, however, makes laparoscopic nodal dissection technically complicated. This study introduces a novel procedure for safe and simple laparoscopic suprapancreatic nodal dissection without taping of the common hepatic artery.
The authors' novel, simplified method consists of four steps: (1) dissection along the cranial edge of the pancreas from right to left, (2) dissection along the splenic artery with exposure of the left renal fascia, (3) dissection along the left gastric and the common hepatic arteries, and (4) retraction of the lymph nodes surrounding the common and proper hepatic arteries and their complete dissection from the portal vein. This procedure is reversely directed compared with conventional open gastrectomy (i.e., the nodal dissection is from left to right). For this study, the lymph node stations and groups were defined according to the 13th edition of the Japanese Classification for Gastric Carcinoma. The described procedures were performed for 58 consecutive patients with gastric cancer. The indication for this operation is primary T1/T2 gastric cancer without clinical nodal metastasis.
In all cases, safely extended suprapancreatic lymph node dissection was successfully accomplished using the described technique. A total of 43.5 +/- 18 lymph nodes were retrieved, including 14.4 +/- 6.3 second-tier lymph nodes. The overall number of retrieved lymph nodes in this study was similar to that reported previously [4]. Postoperative morbidity occurred at a rate of 22.3%, and the mortality rate was 0%. There was no conversion to open surgery. The mean blood loss was 127 ml (range, 0-490 ml), and the mean operative time was 289 min (range, 104-416 min) in the last 20 consecutive cases. To date, no tumor recurrence has been observed. The median postoperative observation period was 1.4 years (range, 0.4-2.4 years).
The described novel procedure would be sufficient and convenient for dissection of the suprapancreatic lymph nodes.
淋巴结清扫是胃癌根治性切除的关键步骤[1]。为避免在腹腔镜下扩大胃癌淋巴结清扫术中损伤门静脉，建议对肝总动脉进行结扎并随后确认门静脉[2,3]。然而，这种结扎方法使腹腔镜淋巴结清扫术在技术上变得复杂。本研究介绍了一种无需结扎肝总动脉即可安全、简单地进行腹腔镜胰上淋巴结清扫的新方法。
作者的新颖简化方法包括四个步骤：（1）从右向左沿胰腺上缘进行清扫；（2）沿脾动脉清扫并暴露左肾筋膜；（3）沿胃左动脉和肝总动脉清扫；（4）牵拉肝固有动脉和肝总动脉周围的淋巴结并将其与门静脉完全分离。与传统的开放胃切除术相比，该手术步骤是反向的（即淋巴结清扫从左向右）。在本研究中，淋巴结站和组根据日本胃癌分类第13版进行定义。对58例连续的胃癌患者进行了所述手术。该手术的适应证为无临床淋巴结转移的原发性T1/T2胃癌。
在所有病例中，使用所述技术均成功完成了安全的扩大胰上淋巴结清扫。共获取43.5±18枚淋巴结，其中包括14.4±6.3枚第二站淋巴结。本研究中获取淋巴结的总数与先前报道的相似[4]。术后发病率为22.3%，死亡率为0%。无中转开腹手术。在最后连续20例病例中，平均失血量为127 ml（范围0-490 ml），平均手术时间为289 min（范围104-416 min）。迄今为止，未观察到肿瘤复发。术后中位观察期为1.4年（范围0.4-2.4年）。
所述新方法对于胰上淋巴结清扫是充分且方便的。
