title: Laparoscopic and mini-invasive surgery.
abstract: BACKGROUND
  JGCA Gastric Cancer Treatment Guidelines (2004) include Laparoscopic Assisted Distal Gastrectomy (LADG) within the chapter of modified surgery. A metanalysis published in 2010 shows that LADG is significantly superior to Open Distal Gastrectomy (ODG) if comparing short term outcomes. Oncologic results prove to be comparable to ODG by one RCT and 2 retrospective studies. Little evidence is available on Laparoscopic Total Gastrectomy and concerns are raised about long-term oncologic outcomes.
  
  
  METHODS
  Laparoscopic Subtotal Gastrectomy is carried out with 4 to 5 ports in the periumbilical region (Hasson trocar for laparoscope) and upper quadrants. After exploration of the abdominal cavity surgical steps include coloepiploic detachment, omentectomy, dissection of the gastrocolic ligament, division of the left gastroepiploic vessels, division of right gastroepiploic vessels, division of pyloric vessels. The duodenum is transected with a linear stapler. Incision of the lesser omentum and dissection of the hepatoduodenal ligament allows completion of D2 lymphadenectomy. The 4/5ths of the stomach are transected starting from the greater curve at the junction of left and right gastroepiploic arcades by linear stapler. Roux-en-Y loop reconstruction is performed through a stapled side-to-side gastro-jejunal anastomosis and a side-to-side jejuno-jejunal anastomosis. Reconstruction after Laparoscopic Total Gastrectomy is performed preferably by a side-to-side esophago-jejunal anastomosis according to Orringer.
  
  
  CONCLUSIONS
  A robotic assisted approach adds precision on lymphadenectomy and reconstructive techniques.
authors.affiliation: Chirurgia Generale Oncologica e Mininvasiva, Ospedale Niguarda, Cà Granda, Milano, Italy.
authors.forename: Raffaele
authors.initials: R
authors.lastname: Pugliese
authors.forename: Dario
authors.initials: D
authors.lastname: Maggioni
authors.forename: Andrea
authors.initials: A
authors.lastname: Costanzi
authors.forename: Giovanni
authors.initials: G
authors.lastname: Ferrari
authors.forename: Monica
authors.initials: M
authors.lastname: Gualtierotti
mesh_terms: D005743:Gastrectomy / Q000379:methods*; D006801:Humans; D010535:Laparoscopy; D013274:Stomach Neoplasms / Q000601:surgery*