This work was supported by grants from the Scientific Research Project of the Health Commission of Hubei Province and the Xiangyang Key Project of Science and Technology in the medical and health field (2021YL15).

The operation followed standard procedures and received ethics approval. This study was permitted by the Ethics Committee of Xiangyang Central Hospital, affiliated with Hubei University of Arts and Science. Informed written consent was obtained from the patient. The research content and methods adhered to medical ethics norms and requirements. The reagents and equipment used in the study are listed in the Table of Materials.
1. Pre-surgical steps
<ol>
	<li>The patient was instructed to take oral sodium phosphate salt for bowel preparation one day before surgery. The patient fasted for 8 h and was allowed water intake up to 2 h before surgery. An upper gastric tube was inserted before entering the operating room.</li>
	<li>The patient was positioned in a supine split-leg position with the head elevated and slightly tilted to the right.</li>
	<li>Endotracheal intubation was performed, and general anesthesia was administered according to institutionally approved protocols.</li>
</ol>
2. Surgical procedure
<ol>
	<li>A transverse incision measuring 3.0-3.5 cm was created around the navel to insert the SILS port equipped with four in-built trocars (Figure 4A). An additional 12-mm trocar was inserted in the left upper quadrant to serve as an operative port for surgical instruments, including the ultrasonic shear, endoscopic linear stapler, and postoperative drainage tube.</li>
	<li>An ultrasonic knife was used to dissect the adipose lymphoid tissue of groups 1, 2, 3, 4, 7, 8a, 9, and 11p (Figure 5A,B). A lower esophageal segment length of approximately 5-7 cm was ensured (Figure 5C), and the freedom of the greater curvature and lesser curvature of the stomach was maintained. 
	NOTE: The SILT-DT procedure is shown in Figure 5. The stomach and lymph node dissection was performed in accordance with the Guidelines for Laparoscopic Surgery for Gastric Cancer (2023 edition)10. A D2 lymphadenectomy and proximal gastrectomy were completed.</li>
	<li>The esophagus-jejunum (EJ) anastomosis was established. The EJ anastomosis site was identified on the jejunum, 20 cm distal to the ligament of Treitz and near the lower esophagus. The EJ anastomosis was accomplished through the 12-mm port in the left upper quadrant using a 60-mm endoscopic linear stapler (Figure 5D). 
	NOTE: The schematic diagram illustrating the digestive tract reconstruction is shown in Figure 4B.</li>
	<li>A 60-mm endoscopic linear stapler was used to resect specimens of the esophagus and close the anastomotic opening between the jejunum and esophagus (Figure 5E).</li>
	<li>The gastrojejunal (GJ) anastomosis was created, with the site marked on the jejunum 8-15 cm distal to the EJ anastomosis and on the posterior wall of the greater curvature of the remaining stomach (Figure 5F).</li>
	<li>The jejunojejunal anastomosis was established. The jejunojejunal anastomosis was made through the 3.5-cm incision at the navel using a 60-mm endoscopic linear stapler, marking 5 cm distal to the GJ anastomosis site (Figure 5G).</li>
	<li>The individual anastomoses were closed and strengthened. Both the common openings of the GJ anastomosis and the jejunojejunal anastomosis were closed using a 3-0 micro Joe thread. The mesangial hiatus was closed with a continuous suture.</li>
	<li>A drainage tube was placed behind the EJ anastomosis and exited from the left upper abdomen (Figure 5H).</li>
</ol>
3. Postoperative management
<ol>
	<li>Postoperative water fasting was implemented, and the gastric tube was drained with an indwelling bag.</li>
	<li>The gastric tube was removed after 48 h of observation, ensuring no evident presence of bloody drainage fluid.</li>
	<li>Fluid infusion was administered to maintain water, electrolyte, and acid-base balance, along with acid suppression. The duration of prophylactic antibiotics was limited to a maximum of 48 h.</li>
	<li>Early mobilization was actively promoted within 6-24 h post-surgery. A liquid diet was initiated for 2-3 days during recovery.</li>
	<li>Anastomotic leakage was assessed, and the development of the residual stomach was evaluated through upper gastrointestinal radiography on day 7.</li>
	<li>The abdominal cavity drainage tube was removed within 5 to 7 days after hospital discharge.</li>
</ol>

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The authors have no conflicts of interest or financial ties to disclose.

Single-port and reduced-port laparoscopic radical gastrectomy have become innovative approaches for treating gastric cancer and are steadily gaining acceptance. These techniques are receiving increased attention for their advantages, including improved cosmetic outcomes, reduced postoperative pain, a lower risk of surgical site infections, and faster recovery times.
The results of 12 studies involving 343 cases showed that single-port and reduced-port laparoscopic surgery was effective in treating distal gastric cancer, accounting for the majority of cases3,4,12,13,14,15,16,17,18,19,20,21. However, only four studies focused on total gastric resection22,23,24,25. These findings suggest that the clinical research and application of single-port gastric cancer surgery, particularly total gastrectomy, are limited due to the high surgical difficulty, the extensive dissection and lymph node removal required, and the complex technique of endoscopic digestive tract reconstruction.
We successfully performed the first laparoscopic proximal gastrectomy with double-tract anastomosis using a single incision plus one port for the treatment of proximal gastric cancer. Compared with traditional surgical methods, the single-incision plus one-port surgery is more minimally invasive. Relative to the single-port technique, the addition of the left upper abdominal port enhances convenience during the operation and allows for the rational placement of a drainage tube through an incision in the upper left abdomen.
Lee et al.26 reported the first case of single-port laparoscopic proximal gastrectomy with double-tract reconstruction for early gastric cancer in 2016. Compared to SILS, the single-incision plus one-port surgery includes an additional left upper abdominal port, creating a triangular structure composed of the umbilical region, left upper abdomen, and the surgical area. This innovative approach effectively addresses the limitations of pure single-incision surgery, such as inadequate anti-traction and linear visualization. Additionally, it enhances the flexibility of the surgeon&#39;s right-hand instrument, leading to significant improvements in operative efficiency and reduced complexity during each anastomosis under total laparoscopy.
Moreover, several strategies can enhance operational efficiency and reduce procedure duration. The surgeon may consider altering their positioning during lymph node dissection and digestive tract reconstruction, such as positioning themselves on the left side of the patient or between the patient&#39;s legs, to optimize exposure of the surgical area. For procedures like esophagojejunostomy and gastrojejunostomy, it is recommended that one assistant or the chief surgeon maintains a stable position while another performs docking, thereby improving anastomosis efficiency and minimizing the risk of tissue avulsion. Additionally, employing integrated laparoscopic instruments is advised to minimize interference between optical fibers and other instruments.
In summary, single-incision plus one-port laparoscopic proximal gastrectomy with double-channel anastomosis is feasible for treating proximal gastric cancer. In this case, the patient experienced a successful recovery. The operation is minimally invasive, and recovery is faster. However, the limitations of this protocol include the need for early-stage gastric cancer or benign gastric tumors, with the patient&#39;s BMI not being excessively high. The application of this protocol is not recommended for patients with locally advanced disease or high BMI due to the potential risk of positive tumor margins and increased surgical complexity. This protocol is still in the stage of technical exploration, with no established guidelines and insufficient clinical data to fully validate its long-term efficacy. The development of this protocol requires ethical approval from medical institutions and strict adherence to surgical indications. Further clinical research and exploration are necessary to determine the clinical applicability of the SILT-DT technique.

Laparoscopic techniques have recently become one of the main directions for the surgical treatment of gastric cancer1,2. The routine laparoscopic surgery for gastric cancer is mostly performed using the 5-hole method. With advancements in surgical techniques and continuous improvements in medical devices, reduced-port laparoscopic gastric cancer surgery has gradually developed to further reduce surgical trauma, minimize disturbance to the abdominal cavity, and accelerate postoperative recovery3,4,5,6.
Omori7 first reported single-port laparoscopic distal gastric cancer surgery in 2011. Pure single-port laparoscopic radical gastrectomy for gastric cancer is more difficult than traditional five-port laparoscopic gastrectomy. To address this, an auxiliary operating hole is added to the single-port laparoscopic procedure, which reduces the difficulty of the operation and facilitates the placement of an abdominal drainage tube8,9. Single-incision laparoscopic surgery plus one port (SILS+1), a minimally invasive technique for patients with gastric cancer, has gained popularity in recent years due to its reduced number of ports and shorter incision lengths.
Currently, single-port laparoscopic or SILS+1 gastric cancer surgery is relatively common in distal gastrectomy, while its application in total gastrectomy is rare. Additionally, the use of total laparoscopic double-tract gastric cancer anastomosis has not been reported.
Based on this, we first attempted single-port plus one-port total laparoscopic proximal gastrectomy with double-tract anastomosis (SILT-DT). The transumbilical port was used as the main operation port, and the left upper abdominal drainage port served as the auxiliary operation port. This technique was employed to perform proximal gastrectomy, D2 lymph node dissection, and double-tract anastomosis for digestive tract reconstruction.
CASE PRESENTATION: 
The patient, a 63-year-old male, was admitted to the hospital after a tumor was discovered at the esophagogastric junction during a gastroscopy (Figure 1). Biopsy results from the gastroscope suggested moderately differentiated adenocarcinoma (Figure 2). Preoperative chest and abdominal enhanced CT scans revealed no evidence of distant metastasis (Figure 3). The patient was previously healthy and had no history of abdominal surgery.
Patient selection 
Patients were eligible to participate if they had histologically confirmed Siewert type II or III gastroesophageal junction adenocarcinoma, with preoperative abdominal CT showing no enlarged lymph nodes around the stomach or distant metastasis. The maximum diameter of the tumor was required to be less than 3 cm, and the distance between the lower pole of the tumor and the gastric angle had to exceed 5 cm. Exclusion criteria included patients who had previously undergone abdominal surgery, those with a preoperative tumor diameter exceeding 3 cm and/or requiring multi-visceral resection, patients who had undergone multidisciplinary team (MDT) discussions regarding neoadjuvant chemoradiation, or those who had received neoadjuvant chemoradiation, and patients with intolerance to laparoscopic surgery.

<table><tbody><tr><td>3D laparoscope</td><td>KARL STORZ SE &amp;amp; Co. KG</td><td>26605BA</td><td></td></tr><tr><td>Absorbability surgical sutures</td><td>Johnson &amp;amp; Johnson</td><td>TLBJXZ</td><td></td></tr><tr><td>Absorbable ligature clip</td><td>Hangzhou KANGJI Medical Instrument co., LTD</td><td>KJ-JZJ02ML</td><td></td></tr><tr><td>Disposable puncture device</td><td>Hangzhou KANGJI Medical Instrument co., LTD</td><td>Type IV sets F</td><td></td></tr><tr><td>Disposable step type endoscopic cutting stapler and nail bin</td><td>Nanjing Maidixin Medical Device Co.,Ltd</td><td>MLCR-Mb,MLCNC-60b-purple, MLCNC-45b-white</td><td></td></tr><tr><td>laparoscopic instruments</td><td>Hangzhou KANGJI Medical Instrument co., LTD</td><td></td><td></td></tr><tr><td>Ultrasound knife</td><td>INNOLCON, Medical Science and Technology (suzhou) co., LTD</td><td></td><td></td></tr></tbody></table>

single incision plus one port laparoscopic proximal gastrectomy with double channel anastomosis for gastric cancer treatment

Single-incision plus one-port laparoscopic proximal gastrectomy with double-channel anastomosis (SILT-DT) is a minimally invasive surgical approach for treating proximal gastric cancer. This technique includes comprehensive laparoscopic resection of the proximal stomach, lymph node dissection, and double-tract anastomosis. By integrating single-port laparoscopic surgery with an auxiliary operating hole, SILT-DT reduces procedural difficulty while facilitating the placement of an abdominal drainage tube. Compared to the traditional five-port laparoscopic gastrectomy, SILT-DT requires fewer ports and results in shorter incision lengths, contributing to reduced postoperative pain and faster recovery. A thorough preoperative evaluation was conducted to ensure procedural success, with factors such as tumor size, stage, location, and patient BMI carefully considered. This comprehensive assessment allowed for optimal patient selection and surgical planning. Postoperative follow-up demonstrated no significant complications, underscoring the safety and efficacy of SILT-DT. This innovative technique offers a promising minimally invasive alternative for managing proximal gastric cancer while maintaining excellent clinical outcomes.

The surgery was completed within 150 min, with minimal intraoperative bleeding of 5 mL. There were no short-term complications, and the patient&#39;s postoperative recovery was successful. A total of 24 lymph nodes were retrieved, and no lymph node metastasis was found. The operating time was 150 min, and the estimated blood loss was 5 mL. The patient remained in bed for 2 days. The time to first flatus was 70 h, and the patient began consuming liquid food and drinks after 3 days. The gastric tube was removed on the 4th day, and the drainage tube was removed within 7 days. The contrast agent persisted in the remnant stomach for 30-50 min without reflux into the esophagus (Figure 6). The cosmetic outcome of the postoperative abdominal incisions was satisfactory (Figure 4C). Pain was evaluated by an 11-point numeric rating scale (NRS) where 0 is no pain and 10 is the worst pain imaginable11. Detailed data for the patient are presented in Table 1.
<img alt="Figure 1" class="xfigimg" src="/files/ftp_upload/67447/67447fig01.jpg" /> 
Figure 1: Gastroscopic images. <a href="https://www-jove-com.remotexs.ntu.edu.sg/files/ftp_upload/67447/67447fig01large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<img alt="Figure 2" class="xfigimg" src="/files/ftp_upload/67447/67447fig02.jpg" /> 
Figure 2: The findings from the gastroscopic biopsy. The gastroscopic biopsy revealed a moderately differentiated adenocarcinoma. Scale bar: 50 &#181;m; magnification: 200x. <a href="https://www-jove-com.remotexs.ntu.edu.sg/files/ftp_upload/67447/67447fig02large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<img alt="Figure 3" class="xfigimg" src="/files/ftp_upload/67447/67447fig03.jpg" /> 
Figure 3: Abdominal enhanced CT scans. Heterogeneous enhancement was seen in the cardia, which was considered as a neoplastic lesion, and the tumor did not invade the muscular layer. <a href="https://www-jove-com.remotexs.ntu.edu.sg/files/ftp_upload/67447/67447fig03large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<img alt="Figure 4" class="xfigimg" src="/files/ftp_upload/67447/67447fig04.jpg" /> 
Figure 4: Surgical setup and postoperative wound condition. (A) Four in-built trocars used in the procedure. (B) Double-tract anastomosis performed during surgery. (C) Postoperative wound condition shown after the procedure. <a href="https://www-jove-com.remotexs.ntu.edu.sg/files/ftp_upload/67447/67447fig04large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<img alt="Figure 5" class="xfigimg" src="/files/ftp_upload/67447/67447fig05.jpg" /> 
Figure 5: Surgical procedure details. (A,B) The process of cleansing the lymph nodes during the surgery. (C) Transection of the esophagus and opening of the lower esophageal end. (D) Side-to-side esophagojejunostomy performed as part of the anastomosis. (E) Closure of the common opening at the esophagojejunal anastomosis site. (F) Remnant gastrojejunostomy completed. (G) Side-to-side entero-intestinal anastomosis performed through the umbilical incision. (H) Position of the drainage tube. <a href="https://www-jove-com.remotexs.ntu.edu.sg/files/ftp_upload/67447/67447fig05large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<img alt="Figure 6" class="xfigimg" src="/files/ftp_upload/67447/67447fig06.jpg" /> 
Figure 6: Upper gastrointestinal radiography. The upper gastrointestinal radiography showed that the anastomosis was open and the remaining stomach was clearly visible. <a href="https://www-jove-com.remotexs.ntu.edu.sg/files/ftp_upload/67447/67447fig06large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<table border="1" fo:keep-together.within-page="1" fo:keep-with-next.within-page="always">
	<tbody>
		<tr>
			<td>Items</td>
			<td>Result</td>
		</tr>
		<tr>
			<td>Gender</td>
			<td>Male</td>
		</tr>
		<tr>
			<td>Year</td>
			<td>63</td>
		</tr>
		<tr>
			<td>BMI (kg/m2)</td>
			<td>23.5</td>
		</tr>
		<tr>
			<td>Anesthesia grade</td>
			<td>III</td>
		</tr>
		<tr>
			<td>Preoperative TNM-staging</td>
			<td>cT1N0M0</td>
		</tr>
		<tr>
			<td>Operation time (min)</td>
			<td>150</td>
		</tr>
		<tr>
			<td>Incision length (cm)</td>
			<td>2.8</td>
		</tr>
		<tr>
			<td>Intraoperative bleeding volume (mL)</td>
			<td>5</td>
		</tr>
		<tr>
			<td>Pathology</td>
			<td>moderately differentiated adenocarcinoma</td>
		</tr>
		<tr>
			<td>The distance of the proximal margin (cm)</td>
			<td>3.4</td>
		</tr>
		<tr>
			<td>The distance of the distal margin (cm)</td>
			<td>5.5</td>
		</tr>
		<tr>
			<td>Tumor size (cm)</td>
			<td>1.5*2*1.2</td>
		</tr>
		<tr>
			<td>The number of retrieved lymph nodes&#160;</td>
			<td>24</td>
		</tr>
		<tr>
			<td>&#160;TNM-staging</td>
			<td>pT2N0M0</td>
		</tr>
		<tr>
			<td>The duration of gastric tube removal after surgery (d)</td>
			<td>4</td>
		</tr>
		<tr>
			<td>The duration until the initial meal</td>
			<td>3</td>
		</tr>
		<tr>
			<td>The duration of bed activity</td>
			<td>2</td>
		</tr>
		<tr>
			<td>The duration to flatus (h)</td>
			<td>70</td>
		</tr>
		<tr>
			<td>The time for bowel movement (d)</td>
			<td>6</td>
		</tr>
		<tr>
			<td>The duration of the drainage tube (d)</td>
			<td>7</td>
		</tr>
		<tr>
			<td>Pain score on the first day after surgery</td>
			<td>2</td>
		</tr>
		<tr>
			<td>Postoperative hospital stay (day)</td>
			<td>8</td>
		</tr>
		<tr>
			<td>Complications</td>
			<td>None</td>
		</tr>
	</tbody>
</table>
Table 1: Perioperative data of the patient. Details regarding the perioperative data for the patient, including key measurements and outcomes.

The single-incision plus one-port laparoscopic proximal gastrectomy with double-channel anastomosis was initially employed for the radical resection of proximal gastric cancer. This study demonstrated the feasibility of the procedure and laid a foundation for further research.

Single Incision Plus One Port Laparoscopic Proximal Gastrectomy with Double Channel Anastomosis for Gastric Cancer Treatment

Single-incision plus one-port laparoscopic proximal gastrectomy with double-channel anastomosis (SILT-DT) is a minimally invasive surgical approach for ...

single-incision-plus-one-port-laparoscopic-proximal-gastrectomy-with

Nanyang Technological University

Research

JoVE Journal

Medicine

606 Views.  Affiliated Hospital of Hubei University of Arts and Science. Na endotracheale intubatie en het toedienen van algemene anesthesie werd een transversale incisie van 3 tot 3,5 centimeter rond de navel gemaakt om de SILS-poort in te brengen die was uitgerust met vier ingebouwde trocars. Een extra trocar van 12 millimeter werd in het linker bovenste kwadrant ingebracht om te dienen als operatiepoort voor chirurgische instrumenten. Het ultrasone mes werd gebruikt om het vetlymfoïde weefsel van de groepen 1, 2, 3, 4, 7, 8a, ...

Video: Enkele incisie plus laparoscopische proximale gastrectomie met dubbele poort anastomose voor de behandeling van maagkanker

Single Port Donor Nephrectomy

In 2007, Rane presented the first single port nephrectomy for a small non-functioning kidney at the World Congress of Endourology. Since that time, the use of single port surgery for nephrectomy has expanded to include donor nephrectomy. Over the next two years the technique was adopted for many others types of nephrectomies to include donor nephrectomy. We present our technique for single port donor nephrectomy using the Gelpoint device. We have successfully performed this surgery in over 100 patients and add this experience to our experience of over 1000 laparoscopic nephrectomies. With the proper equipment and technique, single port donor nephrectomy can be performed safely and effectively in the majority of live donors. We have found that our operative times and most importantly our transplant outcomes have not changed significantly with the adoption of the single port donor nephrectomy. We believe that single port donor nephrectomy represents a step forward in the care of living donors.

Single port laparoscopic surgery is changing the standard of care in surgical care like nothing since the laparoscopic technique was introduced 20 years ago. We present out technique of single port donor nephrectomy using the Gelpoint device. We have successfully performed this surgery in 100 patients.

In 2007, Rane presented the first single port nephrectomy for a small non-functioning kidney at the World Congress of Endourology.  Since that time, the ...

Robotic Pancreatoduodenectomy for Pancreatic Head Cancer: a Case Report of a Standardized Technique

Robotic pancreatoduodenectomy (RPD) for pancreatic cancer is a challenging procedure. Aberrant vasculature may increase the technical difficulty. Several studies have described the safety of RPD in case of a replaced or aberrant right hepatic artery, but detailed video descriptions of the approach are lacking. This case report describes a step-&#173;by-&#173;step technical video in case of a replaced right hepatic artery. A 58-year-old woman presented with an incidental finding of a 1.7 cm pancreatic head mass. RPD was performed using the da Vinci Xi system and involves a robotic-assisted pancreatico- and hepatico-jejunostomy and open gastro-jejunostomy at the specimen extraction site. The operation time was 410 min with 220 mL of blood loss. The patient had an uncomplicated postoperative course and was discharged after 5 days. Pathology revealed a pancreatic head cancer. RPD is a feasible and safe procedure in case of a replaced hepatic artery when performed in selected patients in high-volume centers by experienced surgeons.

Robotic pancreatoduodenctomy (RPD) has been highly standardized in recent years and may be used in selected patients with pancreatic head cancer, including those with a replaced right hepatic artery. This case report describes a standardized and reproducible technique for RPD, which includes the approach of the Dutch LAELAPS-3 training program to an aberrant vasculature.

Robotic pancreatoduodenectomy (RPD) for pancreatic cancer is a challenging procedure. Aberrant vasculature may increase the technical difficulty. Several ...

Cancer Research

Intraoperative Gastroscopy for Tumor Localization in Laparoscopic Surgery for Gastric Adenocarcinoma

Determining resection margins for gastric cancer, which are not exposed to the serosal surface of the stomach, is the most important procedure during totally laparoscopic gastrectomy (TLG). The aim of this protocol is to introduce a procedure for intraoperative gastroscopy, in order to directly mark tumors during TLG for gastric cancer in the middle third of the stomach. Patients who were diagnosed with adenocarcinoma in the middle third of the stomach were enrolled in this case series. Before surgery, additional gastroscopy for tumor localization is not performed. Under general anesthesia, laparoscopic mobilization of the stomach is performed first. After the first portion of the duodenum is mobilized from the pancreas and clamped, the surgeon moves to the other side for the gastroscopic procedure. On the insertion of a gastroscope through the oral cavity into the stomach, 2 - 3 cc of indigo carmine is administered via an endoscopic injector into the gastric muscle layer at the proximal margin of the stomach. The location of stained serosa in the laparoscopic view is used to guide distal subtotal gastrectomy, however, total gastrectomy is performed if the tumor is too close to the esophagogastric junction. A specimen is sampled after distal gastrectomy to confirm sufficient length from resection margin to tumor before reconstruction. In our case series, all patients had tumor-free margins and required no additional resection. There was no morbidity related to the gastroscopic procedure, and the time required for the procedure has gradually decreased to about five minutes. Intraoperative gastroscopy for tumor localization is an accurate and tolerated method for gastric cancer patients undergoing totally laparoscopic distal gastrectomy.

In early gastric cancer, the aim of surgery is to precisely remove the distal stomach including the primary tumor. To do this, accurate localization of the tumor is crucial, especially in totally laparoscopic surgery. This protocol describes a procedure for intraoperative gastroscopy in totally laparoscopic subtotal gastrectomy.

Determining resection margins for gastric cancer, which are not exposed to the serosal surface of the stomach, is the most important procedure during ...

Low-Cost Single-Port (LoCoSP) Device for a Transcervical Approach in Minimally Invasive Transhiatal Esophagectomy

Esophagectomy remains the preferred option to achieve curative treatment in advanced esophageal cancer, but the choice of surgical approach remains controversial. A transthoracic approach may improve lymph node dissection, but it has considerable morbidity and respiratory complications. Transhiatal access has been demonstrated as an efficient means of minimizing post-operative complications. Minimally invasive transhiatal esophagectomy may reduce operative trauma and morbidity as well as enhance postoperative recovery with no compromise in cancer recurrence or survival. Nevertheless, it has a technical limitation in terms of cervical esophagus dissection. Thus, a low-cost single-port device was developed to complete upper mediastinal dissection by a transcervical approach during minimally invasive transhiatal esophagectomy. This device uses a nasogastric tube, a number-eight sterile glove, a sterile sponge, and 3 permanent 5-mm trocars. The step-by-step process of transhiatal esophagectomy and the development of this device are described. This technique allows for the dissection of the upper mediastinum, as well as the esophagus over the aortic arch and behind the superior portion of the trachea. The harvesting of lymph nodes along the left recurrent laryngeal nerve and paratracheals was improved.

Low-Cost Single-Port LoCoSP Device for a Transcervical Approach in Minimally Invasive Transhiatal Esophagectomy

Here, we describe a step-by-step description of transhiatal esophagectomy and the development of a low-cost single-port device for a transcervical approach in a minimally invasive transhiatal esophagectomy.

Esophagectomy remains the preferred option to achieve curative treatment in advanced esophageal cancer, but the choice of surgical approach remains ...

Laparoscopy-endoscopy Cooperative Surgery for the Treatment of Gastric Gastrointestinal Stromal Tumors

In view of the shortcomings of endoscopic or laparoscopic surgeries alone in the treatment of gastric gastrointestinal stromal tumors (G-GISTs), this approach makes an innovative improvement in the treatment of G-GISTs that are less than 5 cm in size. Laparoscopy-endoscopy cooperative surgery (LECS) is used to combine endoscopic and laparoscopic surgeries, fully realizing their respective advantages and avoiding their drawbacks. The main steps are as follows. First, gastroscopy and laparoscopy are combined to confirm the location and boundary of the tumor. Tumor resection is carried out laparoscopically, guided by a gastroscope. The specimen is removed orally and the gastric wound closed laparoscopically. Then, gastroscopy and laparoscopy are combined to determine whether there is wound bleeding, if the suture is satisfactory, and if the gastric cavity is deformed.
LECS has natural advantages in the treatment of G-GISTs that are less than 5 cm in size. The accurate estimation of tumor location and boundary greatly improves the complete resection rate of tumors. The risk of tumor rupture is substantially reduced, and the long-term prognosis of patients is significantly improved. The process allows for accurate resection of the tumor, maximum preservation of normal gastric tissue and organ function, and avoids postoperative gastric deformation. The patient's postoperative rehabilitation is greatly accelerated, and oral feeding can resume on the day of the operation. The specimen is taken out through the mouth to avoid the need for an extended abdominal incision. This greatly reduces the patient's postoperative pain and scarring. The method greatly shortens the postoperative hospital stay (i.e., discharge is possible on the day after the operation), increasing the turnover of hospital beds.

Laparoscopy-endoscopy cooperative surgery is appropriate for the treatment of gastric gastrointestinal stromal tumors less than 5 cm in size. It can achieve the respective advantages of endoscopic and laparoscopic surgeries while avoiding their drawbacks.

In view of the shortcomings of endoscopic or laparoscopic surgeries alone in the treatment of gastric gastrointestinal stromal tumors (G-GISTs), this ...

Laparoscopic Pancreatoduodenectomy for Pancreatic Cancer Using In-Situ No-Touch Isolation Technique

Laparoscopic pancreatoduodenectomy (LPD) is a standard radical operation for pancreatic head malignant tumors by now. Due to the complex laparoscopic resection and reconstruction techniques, it is difficult to perform LPD for patients with locally advanced pancreatic head cancer after neoadjuvant therapy. Our team initiates LPD using the in-situ No-Touch isolation technique. The innovation and optimization of this modified No-Touch isolation technique emphasize exploring the distal section of superior mesenteric vein&#160;(SMV) and the left side of the superior mesenteric artery (SMA) prior to evaluating the resectability by subcolonic mesenteric approach, which is an ideal exploring approach. After that, we use the median-anterior, and left-posterior of SMA approaches to cut off the blood flow of the pancreatic head to make the tumor isolated intact, then move and dissect the tumor. It is a process fitting the surgical principle of tumor-free. This article aims to demonstrate the feasibility and safety of performing LPD using the in-situ No-Touch isolation technique, which might elevate the R0 resection rate. It is an oncological ideal operation process.

Laparoscopic Pancreatoduodenectomy for Pancreatic Cancer Using In-Situ No-Touch Isolation Technique

No-Touch isolation procedures might prevent the dissemination of cancer cells from the primary tumor. However, these techniques are not widely accepted in laparoscopic pancreatoduodenectomy (LPD) by now. We herein present in-situ No-Touch isolation LPD with partial resection and reconstruction of the superior mesenteric vein (SMV) for pancreatic cancer after neoadjuvant therapy.

Laparoscopic pancreatoduodenectomy (LPD) is a standard radical operation for pancreatic head malignant tumors by now. Due to the complex laparoscopic ...

Clinical Application of Single-Surgeon, Three-Port, Laparoscopic Resection for Colorectal Cancer with Natural Orifice Specimen Extraction

Reduced-port laparoscopic surgery (RPLS) has been widely used for the radical resection of gastrointestinal tumors. Single-surgeon, three-port, laparoscopic radical resection for sigmoid colon or high rectal cancer with natural orifice specimen extraction surgery (NOSES) has the advantage of a small incision, quick postoperative recovery, and short hospital stay. Yet, there are still only a few reports on NOSES. This paper describes the indications, preoperative preparations, surgical steps, and precautions for single-surgeon, three-port, laparoscopic radical resection of the sigmoid colon and high rectal cancer, and intraoperative specimen collection through the natural orifice. 
The protocol focuses on the steps of radical dissection and the main technical points of resection and reconstruction. At the same time, a procedure for fixing an anvil seat by self-traction of extracorporeal silk thread, used for purse-string suture fixation after the proximal anvil was placed in the abdominal cavity, was creatively improved. This operation could effectively avoid problems such as an insufficient proximal intestinal tube, shaking off the anvil seat, and weak purse-string suture during a single operation. The surgical care had less variability and was easy to perform, effectively avoiding postoperative anastomotic leakage and bleeding due to excessive intraoperative anastomotic tissue. This surgery could be widely promoted in primary hospitals.

Here, we present a protocol to successfully perform single-surgeon, three-port, laparoscopic resection for colorectal cancer with natural orifice specimen extraction.

Reduced-port laparoscopic surgery (RPLS) has been widely used for the radical resection of gastrointestinal tumors. Single-surgeon, three-port, ...

Modified Laparoscopic Anatomic Hepatectomy: Two-Surgeon Technique Combined with the Simple Extracorporeal Pringle Maneuver

Laparoscopic anatomic hepatectomy (LAH) has become increasingly prevalent worldwide in recent years. However, LAH remains a challenging procedure due to the anatomical characteristics of the liver, with intraoperative hemorrhage being a primary concern. Intraoperative blood loss is the leading cause of conversion to open surgery; therefore, effective management of bleeding and hemostasis is crucial for a successful LAH.
The two-surgeon technique is proposed as an alternative to the traditional single-surgeon approach, with potential benefits in reducing intraoperative bleeding during laparoscopic hepatectomy. However, there remains a lack of evidence to determine which mode of the two-surgeon technique yields superior patient outcomes. Besides, to our knowledge, the LAH technique, which involves the use of a cavitron ultrasonic surgical aspirator (CUSA) by the primary surgeon while an ultrasonic dissector by the second surgeon, has been rarely reported before.
Herein, we present a modified, two-surgeon LAH technique, wherein one surgeon employs a CUSA while the other uses an ultrasonic dissector. This technique is combined with a simple extracorporeal Pringle maneuver and low central venous pressure (CVP) approach. In this modified technique, the primary and secondary surgeons utilize a laparoscopic CUSA and an ultrasonic dissectorconcurrently to achieve precise and expeditious hepatectomy. A simple extracorporeal Pringle maneuver, combined with the maintenance of low CVP, is employed to regulate the hepatic inflow and outflow in order to minimize intraoperative bleeding. This approach facilitates the attainment of a dry and clean operative field, which allows for the precise ligation and dissection of blood vessels and bile ducts. The modified LAH procedure is simpler and safer due to its effective control over bleeding as well as the seamless transition between the roles of primary and secondary surgeons. It holds great promise for future clinical applications.

Here, we present a protocol to perform a modified laparoscopic anatomic hepatectomy using improved techniques and instruments.

Laparoscopic anatomic hepatectomy (LAH) has become increasingly prevalent worldwide in recent years. However, LAH remains a challenging procedure due to ...

Advancing LRPS: Optimal Techniques for Challenging Liver Resections

Techniques of Laparoscopic Right Posterior Sectionectomy: Glissonian Approach and a Parenchymal Transection Technique

Laparoscopic liver resections (LLR) have been widely accepted as a treatment option for liver tumors. They offer several advantages over open liver resections, including less blood loss, reduced wound pain, and shorter hospital stays with a comparable oncological outcome. However, laparoscopic resection of lesions in the right posterior section of the liver is challenging due to difficulties in bleeding control and visualizing the surgical field. In the past, laparoscopic right posterior sectionectomy (LRPS) was still in the exploration phase, with undefined risks in the Second International Consensus Conference on LLR in 2014. However, recent technological advancements and increased surgical experience have shown that LRPS can be safe and feasible. It has been found to reduce hospital stay and blood loss compared to open surgery. This manuscript aims to provide a detailed description of the steps involved in LRPS. The key factors contributing to our success in this challenging procedure include proper liver retraction and exposure, the use of an intrahepatic Glissonian approach for inflow control, a technique called the 'ultrasonic scalpel mimic Cavitron ultrasonic surgical aspirator (CUSA)' for parenchymal transection, early identification of the right hepatic vein, and meticulous bleeding control using bipolar diathermy.

Here, we present a protocol to perform laparoscopic right posterior sectionectomy, focusing on two key aspects: the intrahepatic Glissonian approach for inflow control and a parenchymal transection technique using an ultrasonic surgical aspirator.

Laparoscopic liver resections (LLR) have been widely accepted as a treatment option for liver tumors. They offer several advantages over open liver ...

Robotic Vagus-Sparing Total Gastrectomy for CDH1 Gene Mutation Treatment

Hereditary diffuse gastric cancer (HDGC) caused by the CDH1 gene mutation is an inherited cancer syndrome that increases the risk of diffuse gastric cancer and is nearly impossible to detect by screening gastroscopy. The recommended preventative treatment is a total gastrectomy. Robotic surgery facilitates the use of minimally invasive surgical (MIS) techniques for anastomoses and posterior vagus preservation to potentially reduce adverse functional outcomes. An asymptomatic 24 year old male with the CDH1 gene mutation proven by genetic testing and a family history of a brother having a total gastrectomy for HDGC was treated with this technique. This video case report demonstrates the techniques and pitfalls of robotic surgery in terms of the patient positioning and port placement, posterior vagus-preserving dissection, sutured esophagojejunostomy, jejunal pouch formation, and Roux-en-Y reconstruction with a staple-stapled jejunojejunostomy. While these techniques are demonstrated in the case of prophylactic gastrectomy, many of them can be applied to other benign and bariatric foregut and general surgery types.Robotic surgery can facilitate the foregut MIS technique, as described in this case of a vagus-sparing total gastrectomy.

This article focuses on robotic vagus-sparing total gastrectomy. The techniques and pitfalls of vagus preservation, sutured esophagojejunostomy, jejunal pouch formation, and Roux-en-Y reconstruction with a staple-stapled jejunojejunostomy are discussed.

Hereditary diffuse gastric cancer (HDGC) caused by the CDH1 gene mutation is an inherited cancer syndrome that increases the risk of diffuse gastric ...

Single Incision Plus One Port Laparoscopic Proximal Gastrectomy with Double Channel Anastomosis for Gastric Cancer Treatment

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