Hand-Assisted Laparoscopic D2 Radical Gastrectomy: A Promising Surgical Approach

[...]with the increased number of completed cases, we found that this pattern has many drawbacks; e.g., lymph node dissection using this pattern was often difficult to complete during surgical procedures under direct vision in patients with obesity, omentum hypertrophy, huge gastric tumors, a short transverse mesocolon, or a history of right upper abdominal surgery because the stomach and a portion of the colon blocked the operative field under direct vision. To overcome these difficulties, we have modified and improved the lymph node dissection and have devised the current pattern of a reverse-sweeping procedure (Fig. 2), which is also divided into two sections for completion: 1) hand-assisted laparoscopy was used to remove lymph node group No. 4sb, No. 10, No. 2, and No. 11d (left zone of the gastric bare area) and then lymph node group No. 11p, No. 9, No. 1, and No. 3 (right zone of the gastric bare area); 2) lymph node group No. 9, No. 8, No. 5, No. 12a, and No. 6 was dissected under direct vision after the excised stomach and omentum were removed from the abdominal cavity. The reverse-sheet-folding-like pattern of lymph node dissection is a hybrid pattern of lymph node dissection combining conventional open abdominal surgery with hand-assisted laparoscopic surgery, which does not give up the technical advantages under direct vision but optimizes the surgical procedure. The "black spot" during lymph node dissection by laparoscopy is completely eliminated, and the upper and lower regions of the pylorus can be easily exposed. [...]the reverse-sheet-folding-like pattern of lymph node dissection is easy to learn and constitutes an intact and smooth procedure that is more compliant with the principle of nontumor surgery.