An asymptomatic ulcerative lesion was found during screening gastroscopy of the upper body of the stomach in a 71-year-old woman. On the endoscopic ultrasonogram, the 2-cm ulcerative lesion was invading the submucosal layer. Computed tomography (CT) revealed that she had SIT without lymph node or distant metastases, and three-dimensional (3D) reconstruction of an abdominal CT angiogram showed no vessel anomalies (Fig. 1). We diagnosed her with EGC, U, post, cType 0–IIc, cT1bN0M0, cStageIA, and it was thought to be contraindicated for endoscopic resection. We decided to perform robotic-assisted PG (using da Vinci Xi Surgical Systems) and D1 + lymphadenectomy based on Japanese gastric cancer treatment guidelines 2018 (5th edition) [9].
A scope was inserted into the abdominal cavity through an 8-mm port on the umbilicus, and four more trocars were inserted. As shown in Fig. 2, the location of the trocar placement is the same as usual, whereas we adjusted their arrangement. In performing RAG, we normally set 4th arm at the left lateral side to develop macro-surgical field and handle 1st arm at the right lateral and 3rd arm at the left medial to proceed the surgical procedure. In this SIT case, we adjusted to set 1st arm at the right lateral as developing the field and handle 2nd at the left medial and 4th at the left medial, because it might be difficult to approach to the esophagus and cardia located in the right upper area if we had adopted normal setting. Accordingly, assistant trocar was moved from the right medial to the left lateral.
The liver was retracted with internal organ retractors. After a thorough examination, the greater omentum was divided 3 cm away from the gastroepiploic vessels. The right (left in the normal anatomy) gastroepiploic artery and vein were clipped and divided near the spleen. The gastrosplenic ligament was divided by a sealing device. Next, the lesser omentum was opened and the lymph nodes along the lesser curvature of the stomach were dissected. We moved to the suprapancreatic area, and lymph node numbers 8a, 9, and 7 were dissected safely. Finally, by tracing the splenic artery behind the splenic vein, the number 11 group of lymphatic tissue was harvested. The postperitoneal fascia between the upper border of the pancreatic tail and cardia was dissected along a plane superior to the Gerota fascia. The pericardiac and periesophageal tissue in the esophageal hiatus was dissected, and the esophagus was transected with the Endowrist Stapler. The stomach was extracted through a 3-cm umbilical incision and resected at the level of the upper one-third of the stomach.
The double seromuscular flaps were prepared extracorporeally at the anterior wall of the remnant stomach in order to cautiously remove the submucosal layer from the mucosal layer. After establishing the pneumoperitoneum again, we performed handsewn esophagogastrostomy intracorporeally. Firstly, four stitches were used to fix the posterior wall of the esophagus to the superior edge of the mucosal window. Secondly, the posterior wall of the esophagus and the superior opening of the mucosa on the remnant stomach were closed by continuous suturing using barbed sutures. The anterior wall of the esophagus and gastric wall at the lower end of the flap were also anastomosed layer-by-layer by continuous suturing using barbed sutures. Finally, the anastomosis was finished by covering the anastomosis site with seromuscular flaps using barbed sutures. An air leakage test was performed to confirm closure of the anastomosis (Fig. 3).
The operative time was 448 min, and blood loss was 45 ml. The final pathology demonstrated a poorly differentiated 0–IIc lesion with invasion to the submucosa. There was no metastasis in any of the retrieved lymph nodes. The final stage was pT1b1N0M0, pStage IA according to the Japanese Classification of Gastric Carcinoma staging system. No intraoperative complications occurred. The patient’s postoperative course was uneventful; she was discharged on postoperative day 10.