Intracorporeal circular-stapled esophagojejunostomy using hand-sewn purse-string suture after laparoscopic total gastrectomy

Laparoscopic total gastrectomy (LTG) has not gained widespread acceptance because of technical difficulties, especially esophagojejunal anastomosis. Various modified procedures for reconstruction have been reported, but an optimal method has not been established. The authors report a circular-stapled anastomosis using hand-sewn purse-string sutures, which is a simple and classic method. However, no previous study has assessed its reliability.

From September 2008 to May 2009, 10 consecutive patients (9 men and 1 woman) with gastric cancer underwent LTG at the authors’ institution. These patients had a median age of 63.7 years (range, 45–80 years) and a body mass index of 22.4 kg/m² (range, 18–26 kg/m²). After transection of the abdominal esophagus, a hand-sewn purse-string suture along the cut end of the esophagus was performed using 3-0 monofilament thread. An anvil head then was inserted into the esophagus, and the thread was tied. A monofilament pretied loop suture was added to reinforce the ligation. After the creation of an Roux-en-Y jejunal limb, laparoscopic esophagojejunal anastomosis was performed using a circular stapler inserted via a surgical glove attached to a wound retractor at the incision point at the umbilicus. The jejunal stump was closed with an endoscopic linear stapler.

Laparoscopic esophagojejunostomy was performed successfully for all the patients. No postoperative complications related to anastomosis occurred. In one patient, an intraabdominal abscess developed postoperatively and was treated conservatively. The mean operation time was 257 min, and the estimated blood loss was 69 ml.

With the described method, esophagojejunostomy can be performed as in conventional open surgery. Hand-sewn purse-string suturing is demanding technically, but it can be performed safely by experienced laparoscopic surgeons. This technique is feasible and can lower the cost of the laparoscopic procedure. It may be considered in countries with limited access to other special devices.