gms | German Medical Science

Background: D2 gastrectomy has been widely accepted as a standard procedure for surgical treatment of local advanced gastric cancer¹. However, neither the boundary nor the extent of the excision for perigastric soft tissues has been described. Our previous research demonstrated the existence of cancer cells in the mesogastrium which consists of perigastric adipose tissue, designated as Metastasis V². By employing video laparoscopy, we further demonstrated that mesogastrium, covered by Proper Fascia with anterior surface (A) and posterior surface (P), extends towards and fuses with the “mesogastrium bed”. Therefore, D2 lymphadenectomy plus complete mesogastrium excision (CME) is proposed as a novel approach to en bloc for advanced gastric cancer². The mobilization of mesogastrium from the mesogastrium bed in laparoscopic D2 plus CME may facilitate the standardization of D2 radical surgery and improve the prognosis of advanced gastric cancer patients.

Materials and methods: All participants provided informed written consent to participate in the study. This study was approved by the Tongji Hospital Ethics Committee. For laparoscopic D2 plus CME, in brief, divide the middle part of the gastro-colic ligament with ultrasonically activated device (USAD) until the lesser sac is accessible. Dissect to the gastro-colic ligament at left colic flexture, with special made gauze. Bluntly separate the adipose tissue. Expose the fascia plane³ and mesogastrium of Left Gastroepiploic Vessels (mLGEV). Proceed with the mobilization to the bottom of left mLGEV, clip and cut. Next, the greater omentum is removed from left to the right. Continue with the dissection of mesogastrium of Right Gastroepiploic Vessels (mRGEV) using gauze. Excise the adjacent part between mesogastrium and mesocolon of transverse colon. Expose the surface of superior mesentery vein. Incise the serosa along the superior border of pancreas. After this, turn to the common hepatic artery, and remove the adipose tissue and expose the meosgastrium of Right Gastric Vessels (mRGV). Expose the root of left gastric vein, clip and cut. Dissect the thick sheath of left gastric artery, expose it at the root, trip-clip and cut. Mobilize the fibro tissues laterally and expose the mesogastrium of Left Gastric Vessels (mLGV). Incise the left side of mLGV, dissect the splenic artery until reaching the posterior gastric wall (this is also the part of mesogastrium of short gastric vessels and posterior gastric vessels). Dissect along the hepatic portal vein. Divide the lesser omentum. Clean up the adipose tissue and nerves along the lesser curvature up to the upper part of the stomach. Expose the right gastric vessels, clip and cut.

Results: A total of 54 patients underwent laparoscopic D2+CME with membrane anatomy. The mean number of retrieved regional lymph nodes was 35.04±10.70 (ranges 14-55 lymph nodes). The mean volume of blood loss was 12.44±22.89 ml. The mean laparoscopic surgery time was 127.82±17.63 mins (ranges 110-165 mins). The mean hospitalization time was 11.09±4.28 days (ranges 8-28 days). No operative complication was observed during hospitalization. All the patients are disease-free during the follow-up periods, the mean follow-up time 3.37±1.68 months (ranges 0.5-6 months).

Conclusion: We believe that the laparoscopic D2 plus CME can minimize the differences in the number of lymph nodes harvested, and substantially reduce the intraoperative blood losses and surgery-related injuries in advanced gastric cancer patients.