Laparoscopic Total Gastrectomy in a Gastric Cancer Patient with Intestinal Malrotation
A 44-year-old male was diagnosed with early gastric cancer on a routine health evaluation. Physical examination was unremarkable, and laboratory findings showed no abnormalities. He had no abdominal pain, nausea, or vomiting. He did not receive any previous abdominal surgery. Esophagogastroduodenoscopy revealed gastric cancer at the upper body of the stomach (). Contrast-enhanced computed tomography showed no demonstrable mass in the stomach. Additionally, incidental intestinal malrotation was revealed (). He was scheduled for laparoscopic surgery after obtaining informed consent for the procedure.\nAfter general endotracheal anesthesia was induced, an infraumbilical incision was made, and a 10-mm trocar was introduced into the peritoneal cavity using an open technique. Pneumoperitoneum was established, and other trocars were inserted under direct vision in the superior parts of the left upper quadrant (left upper port, 5 mm), right upper quadrant (right upper port, 5 mm), left flank (left lower port, 12 mm), and right flank (right lower port, 12 mm) of the abdomen. The locations of the trocars were the same as in other total gastrectomies performed at our institution. The operation was performed as previously described, with slight modification., The greater omentum was divided and dissected toward the lower pole of the spleen. The left gastroepiploic vessels and short gastric arteries were isolated and ligated. After dissection of the head of the pancreas, the right gastroepiploic vessels were ligated and divided. After ligation of right gastric artery, the duodenum was transected with a linear stapler. The left gastric vessels were exposed and divided for adequate lymph node dissection. Lymph nodes along the splenic vessels were cleared. After two laparoscopic bulldog clamps were applied on the distal esophagus, the esophagus was transected with an energy device. We used nonabsorbable 2-0 thickness monofilament with grasper and needle driver for purse string suture. After the purse-string suture at the esophagus was completed, the jejunum was identified under direct vision for the esophagojejunostomy. The small bowel was located on the right side of the abdomen, and the ligament of Treitz was absent (). The appendix and colon were found on the left side of the patient (). There were no Ladd's band and no vascular anomaly while preparing jejunal limb. Due to the altered small bowel configuration, we modified the minilaparotomy site. We extended the right lower port site up to 3.5 cm rather than in the usual left lower port site to account for the intestinal malrotation. The previously identified jejunum was brought out and transected with a linear stapler. A jejunojejunostomy was made 50 cm distal to the tentative esophagojejunostomy site. A circular stapler was inserted into the transected jejunum. After extracorporeal installation of anvil to the circular stapler, the prepared jejunum with circular stapler were introduced into the peritoneal cavity (). When the anvil was inserted in the esophagus appropriately, a previously made pursestring suture was tied, and a circular stapler was fired. The jejunal stump was closed with a linear stapler. The jejunojejunostomy remained in the right upper quadrant. The Roux limb was brought up in a 'reverse C fashion' due to the abnormal anatomy (). We did not perform appendectomy. The patient recovered without any complications. He was discharged on postoperative day 5. At the six-month outpatient follow-up, he was recovering well and tolerating a regular diet ().