Mesenteric-guided approach to pyloric lymphadenectomy in laparoscopic radical gastrectomy

Lymphadenectomy of the infrapyloric region remains technically demanding in laparoscopic radical gastrectomy. Traditional vessel-guided approaches often result in incomplete dissection and higher complication rates, especially at station No. 6.

To propose a mesentery-based strategy for infrapyloric lymphadenectomy and evaluate its safety, feasibility, and efficacy.

By identifying key anatomical landmarks and defining the inferior mesenteric boundary of the pyloric region (right gastro-omental mesentery), this approach enables full exposure and en bloc resection of anterior and posterior mesenteric planes, with proximal ligation at the root of feeding vessels. A retrospective cohort study was conducted on 330 gastric cancer patients who underwent D2 lymphadenectomy (D2) from January 2020 to December 2021. Outcomes were compared between 165 patients treated with D2 plus complete mesogastric excision (D2 + CME) and 165 matched controls receiving conventional D2.

The D2 + CME group demonstrated significantly improved surgical outcomes, including shorter total operative time (279.19 ± 45.50 minutes vs 301.25 ± 52.30 minutes, P < 0.001), reduced infrapyloric dissection time (22.24 ± 3.80 minutes vs 27.58 ± 4.20 minutes, P < 0.001), and lower blood loss (4.71 ± 1.12 mL vs 24.83 ± 6.35 mL, P < 0.001). More lymph nodes were retrieved overall (43.80 ± 10.05 vs 37.25 ± 8.80, P < 0.001), particularly at station No. 6 (5.26 ± 0.87 vs 4.14 ± 0.41, P < 0.001). Postoperative recovery indicators and hospital stay were comparable between groups, while the complication rate was significantly lower in the D2 + CME group (20% vs 30.3%, P = 0.042).

The mesentery-based approach enables safe pyloric lymphadenectomy. Systematic mesogastric excision improves operative efficiency and lymph node yield, especially at station No. 6, offering potential oncological benefits in gastric cancer surgery.