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70 year-old male patient
Preoperative work-up: Gastric adenocarcinoma of the lesser curvature, cT3 cN+ cM0
Multidisciplinar evaluation: preoperative FLOT chemiotherapy
The video shows a laparoscopic 4/5 distal gastrectomy with D2 node dissection with Roux-en-Y reconstruction performed for an advanced gastric cancer located on the lesser curvature.
With the patient in a standard French position, the procedure began with colo-epiploic detachement. Right gastro-epiloic vessels were then divided at their origin, performing the dissection of infrapyloric nodes. The lesser omentum was subsequently opened and the right gastric vessels isolated and divided fulfilling the dissection of suprapyloric nodes. The transection of the duodenum was completed using a linear stapler with a violet cartridge. The nodes dissection continued along the common hepatic artery, the left side of the hepatoduodenal ligament and the proximal part of the splenic artery. Left gastric vessels were therefore isolated and divided at their origin and the nodes along left gastric artery and coeliac axis dissected. The greater curvature was freed from the first branches of the short gastric vessels and the greater curvature nodes were dissected, thus allowing the completion of D2 lymphadenectomy for distal gastrectomy. An intraoperative EGDS was used to precisely locate the tumor margin and decide the best option between distal and total gastectomy. The stomach was then transected using a linear stapler and the specimen, along with the nodes, sent to pathology for frozen section examination of the proximal resection margin. Bowel continuity was restored using a Roux-en-Y reconstruction. The final pathology report showed an intestinal-type gastric adenocarcinoma Gx, ypT3 N2. Fifty nodes were examined, among which 6 were metastatic.