Anatomic variations in the left gastric vein and their clinical significance during laparoscopic gastrectomy

Surgeons normally encounter the left gastric vein (LGV) during laparoscopic gastrectomy (LG) for gastric cancer, and the various anatomic variants of this vessel make the procedure difficult. The objective of this study was to classify anatomic variants of the LGV in the laparoscopic operation field and clarify their clinical significance during LG.

In total, 405 patients who underwent LG in 2013-2017 for gastric cancer were enrolled in the study. LGV drainage was classified into six types by the anatomic relation of the LGV to the arteries of the celiac axis: Type Ia [LGV runs anteriorly to the common hepatic artery (CHA)], Type Ip (LGV runs posteriorly to CHA), Type II (LGV runs anteriorly to the left gastric artery), Type IIIa [LGV runs anteriorly to the splenic artery (SA)], Type IIIp (LGV runs posteriorly to SA), and Type IV (LGV runs cranially into the proximal portal vein or liver parenchyma). If the LGV was injured during the operation, the patient was included as a member of the injury group (IG).

Most patients (n = 391, 96.5%) had a single LGV, whereas 14 (3.5%) patients had double LGVs. Type Ip was the most common of the six drainage types (n = 195, 48.1%). The number of patients in the IG was 49 (13.0%). Types I and III were relatively easily injured when compared with type II (p = 0.025). Patients in the IG had longer operation times, more blood loss, and more lymph node metastases than the non-IG patients.

In most patients, the LGV drains posteriorly to the CHA or anteriorly to the LGA. Gastric surgeons should take great care not to injure the LGV during LG when it is not present on the anterior side of the celiac axis.