[Lymphadenectomy in supra-pancreatic area during laparoscopy-assisted D2 radical distal gastrectomy]

Laparoscopy-assisted D2 radical distal gastrectomy has been acknowledged as standard procedure for local advanced gastric cancer. But due to the abundant blood vessels and complicated anatomy of the stomach, lymphadenectomy has been considered as one of the difficulties of the operation, especially in the supra-pancreatic area. This article is to share the experiences of this topic from Department of Gastrointestinal Oncology Surgery, The First Affiliated Hospital of Xiamen University with the following five aspects. (1) How to dissect No.11p lymph nodes thoroughly and whether the exposure of splenic vein is needed? (2) Is it necessary to reveal portal vein during the lymphadenectomy of supra-pylorus and supra-pancreatic areas?(3) During laparoscopic operation, where is the posterior boundary of No.9 lymph nodes at the right side of celiac artery?(4) How to make it easier, safer, and more complete for supra-pancreatic lymphadenectomy? (5) How to deal with the tandem enlarged lymph nodes at the right side of celiac artery? According to the authors' experiences of laparoscopic radical gastrectomy, the following points may be helpful to make the supra-pancreatic lymphadenectomy safe, complete, and standard: (1) Transection of vessels of duodenum, right stomach and left stomach in advance will make the lymphadenectomy at the right side of the celiac artery easier. (2) The exposure of splenic vein as far as possible is necessary during the dissection of No.11p lymph nodes, and it is necessary to dissect the lymph-adipose tissue at the posterior-superior border of splenic artery and pancreas in front of Gerota fascia. (3) The left side of portal vein must be revealed initiatively for dissection of No.12a lymph nodes. (4) The lymph-adipose tissue must be dissected at the included angle of common hepatic artery and celiac artery and the right wall of the celiac artery should be revealed during the dissection of No.8a and the right side of No.9 lymph nodes. (5) The exposure of portal vein and the transection of left gastric vein at the root will make the dissection of this area safer and complete. (6) En bloc D2 plus operation will be a better option, when comfronted with tandem enlarged lymph nodes at the right side of celiac artery.