Laparoscopic Gastrectomy – Surgical Technique
Gastric disease is the second reason for malignant growth-related demise and the fourth most incessant threat around the world. Numerous examinations, predominantly Asian, have approved the security and the short and long-haul oncological results of laparoscopic gastrectomy. The signs for this strategy limits to ahead of schedule with locally advanced gastric malignant growth. Considering that D2 lymphatic analyzation presents extraordinary procedural difficulty. Laparoscopic Trainer.
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Numerous elements sway the consequence of this strategy: connected with the specialist, the actual technique, and the patient. Patients have more fulfillment and better personal satisfaction.
Regarding laparoscopic total gastrectomy, it is technically more demanding than laparoscopic distal gastrectomy. This is mainly due to the requirements of an esophageal-jejunal anastomosis.
Reconstruction of an esophageal-jejunal anastomosis performs with hand sutures, with an EEA circular stapler or with an Endo-GIA linear stapler (Gastrointestinal anastomosis). The intracorporeal technique with EEA uses an anvil that passes trans-orally (the OrVil device). The staple line at the distal jejunal stump removes to allow insertion of the stapler handle.
After the stapler tip traverses through the jejunal wall, it engages the incus and the stapler fires to create a circular anastomosis. The stapler handle removes and the jejunotomy closes with an additional shot of the Endo-GIA stapler. A Roux limb measures from 50 to 60 cm.
Analysis of Methods
The study analysis, evaluated the different methods of esophageal-jejunal anastomosis, circular extracorporeal, circular intracorporeal (IC), and linear intracorporeal (IL). Concluding that there was no significant difference in the rate of early complications between the three groups (26.7% vs 18.8% vs 17.6%, CE vs CI vs IL respectively).
The length of the mini-laparotomy is greater in the EC anastomosis group. The anastomosis time was shorter in the EC anastomosis group. There was no significant difference between the three groups in terms of the rate of long-term complications. However, a higher rate of stricture of the esophago-jejunal anastomosis demonstrates in the IC anastomosis group (10.9%) vs EC (0 %) and IL (2.0%). The extracorporeal technique with EEA. Laparoscopic Training simulation with Laparoscopic Trainer is a prudent choice.
Results Of Techniques
The technique of esophageal-jejunal anastomosis with Endo-GIA shows to be as effective as those performed with EEA. Also, with a lower rate of narrowing of the esophageal-jejunal anastomosis compared to intracorporeal EEA. Regarding laparoscopic distal gastrectomy: the gastrointestinal tract reconstructs with a Billroth II type gastrojejunostomy or a Roux-en-Y type gastrojejunostomy.
Intra Or Extra-Corporeal Anastomosis
Extracorporeal anastomoses report in cases of Gastro-duodenal anastomosis, Gastro-jejunal anastomosis, and esophageal-jejunal anastomosis after laparoscopic gastric-tomies. However, patients with a high body mass index require a significantly larger skin incision for an Extra-Corporeal anastomosis compared to patients with a low body mass index.
For Extra-Corporeal anastomosis, disadvantages include larger skin incision than mini-laparotomy, lack of adequate vision, and excessive traction on the serosa of the stomach and intestines. This can cause serosal tears and bleeding. Therefore, if surgeons can perform the anastomosis safely, an intracorporeal anastomosis would be the option of choice.
In total gastrectomy, a naso-jejunal tube places through the esophago-jejunal anastomosis as a transanastomotic stent. This usually removes after a negative swallow study performed on postoperative days 4 or 5. A swallow test not routinely performs in patients undergoing distal gastrectomy.
The diet is generally advanced as tolerated from postoperative day 1 or 2 after distal gastrectomy and after a negative swallow study for those undergoing total gastrectomy. In patients with total gastrectomy, enteral nutrition via nasojejunal tube uses, starting 24 hours after surgery, and slowly progressing until the combination of oral intake. Once the patient takes a sufficient oral intake, the jejunal feeding tube removes. Surgeons in East largely avoid the use of feeding tubes, even in total gastrectomy patients.
Laparoscopic Compares with Open Gastrectomy
In Eastern countries, laparoscopic gastrectomy compares with open gastrectomy in multiple randomized studies, as previously described. A 2016 systematic review and meta-analysis of 14 studies that included 2307 gastric cancer patients, comparing laparoscopic vs open gastrectomy. This concluded that laparoscopy demonstrated greater satisfaction and better quality of life in patients, less blood loss, shorter hospital stays and less postoperative morbidity.
In addition, he manifested longer operative time, less time for the first bowel movement, less time to walk and tolerate oral administration, less use of analgesics and fewer days of fever. There were no significant differences in the number of lymph nodes resected, mortality, recurrence, long-term survival, and disease-free survival.
In the impact on survival of minimally invasive gastrectomy evidences in a study in which the national database reviews to identify patients who underwent gastrectomy for adenocarcinoma between 2010 and 2015. The study included 17,449 patients, where laparoscopic surgery shows to improve survival. Predictors of worse survival included patients with comorbidities, tumor size, extent of gastrectomy, and greater T and N staging. Laparoscopic surgery had better survival at 5 years compared to the open approach, 51.9% vs 47.7%, respectively.
The progress of laparoscopic surgery directly reflects in gastric surgery. With the studies described in this article, it has been possible to demonstrate the safety of partial and total gastrectomy in early and locally advanced gastric cancer. Considering that more studies still need to reinforce and expand the results in locally advanced gastric cancer.
The oncological safety of these procedures confirms, and the learning curve and the adequate selection of patients must consider. Studies needs at the level to compare the progress in laparoscopic gastrectomy, however, there are no specialized centers, which makes it difficult to accelerate this curve.
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