Laparoscopic spleen-preserving No. 10 lymph node dissection for advanced proximal gastric cancer in left approach: a new operation procedure
© Jia-Bin et al.; licensee BioMed Central Ltd. 2012
Received: 12 July 2012
Accepted: 15 October 2012
Published: 12 November 2012
To explore the feasibility of laparoscopic spleen-preserving No. 10 lymph node dissection in a left-sided approach for advanced proximal gastric cancer.
The clinical data of 32 patients with advanced proximal gastric cancer who underwent laparoscopic spleen-preserving No. 10 lymph node dissection from June 2010 to December 2011 were analyzed.
Laparoscopic spleen-preserving No. 10 lymph node dissection using a left-sided approach was successfully performed for all patients without open conversion. The mean operation time was 206.4±54.3 minutes, mean intraoperative blood loss was 68.2±34.1 ml, mean number of No. 10 lymph nodes dissected was 2.8±2.1, mean number of positive No. 10 lymph nodes was 0.6±1.2, and the incidence of No. 10 lymph node metastasis was 11.6%. The mean postoperative hospital stay was 11.3±1.5 days. The postoperative morbidity rate was 9.4%, and there was no postoperative death. Splenic lobar vessels of all 32 patients were anatomically classified and divided into three types: 4 patients had a single lobar vessel, 22 had two lobar vessels and 6 had three lobar vessels.
Laparoscopic spleen-preserving No. 10 lymph node dissection for advanced proximal gastric cancer using a left-sided approach is technically feasible. It simplifies the complicated surgical procedure of No. 10 lymph node dissection and leads to the popularization and promotion of this technique.
KeywordsStomach neoplasms Spleen-preservation Laparoscopy Lymph node dissection
Many studies have reported that splenic hilar lymph nodes (No. 10 lymph nodes)metastasis in proximal gastric cancer is detected in 9.8% to 20.9% of cases[1, 2]. When a surgeon undertakes total gastrectomy with D2 lymph node dissection for advanced proximal gastric cancer, he must dissect No. 10 lymph nodes. In earlier years, the surgeon must undertake total gastrectomy with pancreaticosplenectomy in order to dissect the No. 10 and No. 11 lymph nodes. However, because of the high rate of morbidity and mortality, this procedure had been usedfor gastric cancer which directly invaded the body and tail of the pancreas or spleen. At the same time, pancreas-preserving splenectomyusing No. 10 lymph node dissection had the same rate of postoperative survival and recurrence as pancreatosplenectomy, and had a lower rate of morbidity and mortality. It has gradually replaced pancreatosplenectomy in total gastrectomy with D2 lymph node dissection[5–8]. However, because of advances in surgical concepts, improvementsin the anatomical techniques and the progress of organ retention, spleen-preserving No. 10 lymph node dissection has been more and more widely supported. Many surgeons have suggested that it is safe and feasible and that it also has the same radical effect as pancreas-preserving splenectomy[9–11].
With the development of laparoscopic surgery, a number of authors have presented their experiences with laparoscopic surgery for gastric cancer, but most authors only reported on laparoscopy-assisted distal gastrectomy (LADG) with D2 lymph node dissection in distal gastric cancer[12–15]. No. 10 lymph node dissection is required in laparoscopy-assisted total gastrectomy (LATG) with D2 lymph node dissection;the vessels in the splenic hilum are especially intricate and complex, making the technique of lymph node dissection difficult. Surgeons who undertake this procedure must be equipped with exquisite surgical skills. There are only a few reports about the application of LATG with D2 lymph node dissection. Some authors reported laparoscopic No. 10 lymph node dissection using a medial approach[16, 17], but that requires more complex surgical skills and more insertion of the trocars. The procedure has not been widely promoted.
In this study, we describe our experience of laparoscopic spleen-preserving No. 10 lymph node dissection for advanced proximal gastric cancer and investigate whether laparoscopic spleen-preserving No. 10 lymph node dissection using a left-sided approach is an innovative and feasible procedure which can simplify this complicated operation.
The study group consisted of 32 patients from the Department of Gastric Surgery, Affiliated Union Hospital of Fujian Medical University from June 2010 to December 2011. Laparoscopic spleen-preserving No. 10 lymph node dissection using a left-sided approach was successfully performed for all patients. In this study, the surgeon (HuangChangming) had performed more than 500 cases of laparoscopy-assisted gastrectomy(LAG) with D2 lymph node dissection in gastric cancer before starting to perform this procedure.
All subjects were preoperatively confirmed to have gastric cancer by analyses of endoscopic biopsy specimens. Preoperative imaging studies were routinely performed following endoscopic examination, computed tomography (CT) scanning, ultrasonography (US) of the abdomen and endoscopic US. Patients having T4 gastric cancer preoperatively according to the Japanese classification of gastric carcinoma (JCGC) were excluded from this study. Patients with enlargement and integration of No. 10 lymph nodes were not considered candidates for surgery. Intraoperative diagnostic laparoscopy,which included a complete examination of the peritoneal cavity and liver, was also performed in all patients,. We explained the surgical procedure to the prospective patients, including its advantages and risks, and obtained informed consent before the procedure. Written informed consent was obtained from the patient for publication of this report and any accompanying images.
Surgical outcome and postoperative course
Patient characteristics and surgical outcomes
Age, years (mean±SD)
Depth of invasion
Lymph node metastasis
Operation time, minutes (mean±SD)
Blood loss, ml (mean±SD)
Number of dissected lymph nodes, number (mean±SD)
Number of positive lymph nodes, number (mean±SD)
Number of dissected splenic lymph nodes, number (mean±SD)
Number of positive splenic lymph nodes, number (mean±SD)
Postoperative hospital stay, days (mean±SD)
The time to first flatus, days (mean±SD)
The time to ambulation, days (mean±SD)
Postoperative complications, number
Postoperative morbidity rate,%
Anatomical classification of splenic lobar vessels
Since Kitano et al. first performed LADG for early gastric cancer in 1994, many studies have reported the benefits of laparoscopic gastric surgery. More and more patients who have gastric cancer receive laparoscopic surgery. Gohet al. first performed LADG with D2 lymph node dissection for advanced gastric cancer in 1997, and produced good short-term results. Laparoscopic gastric surgery gradually expanded the indications for surgeryfrom early gastric cancer to moderately advanced gastric cancer. Therefore, more and more letters report about LADG with D2 lymph node dissection in patients with advanced lower gastric cancer. However, when the advanced proximal gastric cancer patients undergo laparoscopic D2 lymph node dissection, the No. 10 lymph node must be cleaned. In clinical practice, laparoscopic No. 10 lymph node dissection is considerably difficult and risky. A surgeon must skillfully master a difficult surgical technique in laparoscopic lymph node dissection to complete this operation. Therefore, only a few reports of LATG with D2 lymph node dissection were associated with advanced proximal gastric cancer.
Clinically, vessels in the splenic hilum are intricate and complicated;they are in a narrow space and this location is very deep. Both open and laparoscopic No. 10 lymph node dissection, dissection of these regional lymph nodes, is quite difficult. In open surgery, the spleen and distal pancreas must be mobilized from the retroperitoneum and No. 10 lymph nodes can be dissected thoroughly. However, this operation is traumatic and time-consuming. There is a risk of spleen walk or reverse after the operation. If the spleen and distal pancreas are not free, No. 10 lymph nodes are difficult to clean because of inadequate exposure. In laparoscopic surgery, we donot have the surgeon’s intuitive touch and exposure, and we only use laparoscopic grasping forceps for traction and separation in the local area. Therefore, we cannot intuitively judge the vessels’ shape, and it is easy to cause bleeding because of vascular injury. If surgeons donot have skilled laparoscopic operation experience, there would be increased bleeding and conversion from laparoscopy to laparotomy. Therefore, No. 10 lymph node dissection is a very important and difficult aspect of the treatment of patients with advanced proximal gastric cancer.
In conclusion, we believe laparoscopic spleen-preserving No. 10 lymph node dissection for proximal advanced gastric cancer using a medial approach is technically feasible. It simplifies the complicated surgical procedure of No. 10 lymph node dissection and leads to greater popularization and promotion.
We thank the Follow-up Office established by the Department of Gastric Surgery, Fujian Medical University Union Hospital, Fuzhou, Fujian Province, China.
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