Current status of laparoscopic total gastrectomy

In this article, the current state of laparoscopic total gastrectomy (LTG) was reviewed, focusing on lymph node dissection and reconstruction. Lymph node dissection in LTG is technically similar to that in laparoscopic distal gastrectomy for early gastric cancer; however, LTG for advanced gastric cancer requires extended lymph node dissections including splenic hilar lymph nodes. Although a recent randomized controlled trial clearly indicated no survival benefit in prophylactic splenectomy for lymph node dissection at the splenic hilum, some patients may receive prognostic benefit from adequate splenic hilar lymph node dissection. Considering reconstruction, there are two major esophagojejunostomy (EJS) techniques, using a circular stapler (CS) or using a linear stapler (LS). A few studies have shown that the LS method has fewer complications; however, almost all studies have reported that morbidity (such as anastomotic leakage and stricture) is not significantly different for the two methods. As for CS, we grouped various studies addressing complications in LTG into categories according to the insertion procedure of the anvil and the insertion site in the abdominal wall for the CS. We compared the rate of complications, particularly for leakage and stricture. The rate of anastomotic leakage and stricture was the lowest when inserting the CS from the upper left abdomen and was significantly the highest when inserting the CS from the midline umbilical. Scrupulous attention to EJS techniques is required by surgeons with a clear understanding of the advantages and disadvantages of each anastomotic device and approach.