The decision to perform a laparoscopic versus an open gastrectomy depends on several factors. The most important consideration is the skill and experience of the operating surgeon. Laparoscopic gastrectomy is an operation requiring advanced laparoscopic skills to perform an adequate lymphadenectomy and an intestinal anastomosis. The procedure also requires an operating room team equipped with appropriate laparoscopic atraumatic graspers, an energy device, liver retractor, wound protector, and laparoscopic reticulating staplers. The procedure is particularly demanding in obese patients. Challenges in laparoscopic resection in obese patients include decreased surgical visibility, dissection hindered by adipose tissue, and difficulty with anastomoses. Higher BMI is an independent risk factor for pancreatic fistula following laparoscopic distal gastrectomy [31].

Prior upper abdominal surgery can make laparoscopic gastrectomy technically difficult. Laparoscopic or open cholecystectomy often results in adhesion of the first portion of the duodenum to the gallbladder bed. Careful dissection can usually allow full mobilization of the duodenum off the liver bed. An adequate lymphadenectomy can be performed following an open or laparoscopic cholecystectomy as long as the patient did not undergo an open common bile duct exploration. Prior right hemicolectomy or splenectomy can complicate laparoscopic distal gastrectomy. Prior gastric resection or transverse colectomy is a relative contraindication to laparoscopic gastrectomy because the plane of dissection for lymphadenectomy will have been altered or obliterated. In general, adequate resection with lymphadenectomy can be accomplished following neoadjuvant chemotherapy but may be technically demanding in some patients who have had prior radiation therapy. As with any laparoscopic procedure, it is incumbent on the operating surgeon to be cognizant of their own surgical limitations and have a low threshold to convert any case to open if it cannot be performed thoroughly and safely laparoscopically. Poor cardiopulmonary reserve is a relative contraindication to laparoscopic gastrectomy because of the decrease in venous return and increase in pulmonary resistance associated with prolonged pneumoperitoneum.

Hand-assisted laparoscopic gastrectomy has been advocated by some surgeons in an attempt to overcome the technical challenges associated with a totally laparoscopic approach [32]. Although a hand assist approach may enable a surgeon early in their learning curve to complete a laparoscopic-assisted distal gastrectomy, it will inevitably require an incision significantly larger than that required for specimen extraction with a totally laparoscopic approach. Routine reliance on the use of a hand port might also limit the surgeon’s own technical development and proficiency.

The patient is placed in the supine position with both arms tucked. General endotracheal anesthesia is administered. A nasogastric tube is placed to decompress the stomach, and a Foley catheter is inserted into the bladder. Intravenous antibiotics are administered within 1 h of the incision and redosed as necessary. Deep venous thrombosis prophylaxis is accomplished with sequential pneumatic compression stockings on the lower extremities. In addition, all patients are administered 5,000 units of subcutaneous unfractionated heparin in the immediate preoperative period.

Eggcrate foam is secured to the operating room with wide tape, and the patient is placed on the eggcrate without an intervening bedsheet. This secures the patient to the surgical bed and prevents shifting during maximum reverse Trendelenburg position [33]. The video monitors are positioned near the shoulders on each side of the operating table. The procedure is performed with a surgeon and an assistant. The surgeon begins on the right side of the table with the assistant on the left side of the table. The scrub nurse is positioned on the right side of the table.

The procedure is performed with four 5 mm ports and a single 12 mm port for laparoscopic stapling (Fig. 22.1). The peritoneal cavity is entered and insufflated with a Veress needle after a stab wound is made in the left subcostal space at Palmer’s point. A 5 mm camera trocar is placed in the supra-umbilical region. A left upper quadrant 5 mm dissection port is placed. This port should be placed laterally enough to allow for placement of a 12 mm stapling port midway between the left upper quadrant and supra-umbilical ports. The abdomen is thoroughly explored for evidence of liver or peritoneal metastatic disease. If metastatic disease is identified, the operation can be aborted or converted to a gastrojejunal bypass, if clinically indicated. If distant metastatic disease is not identified, an extreme right lateral subcostal port is then placed. A snake retractor placed through the right lateral port is triangulated closed and used to elevate the left lobe of the liver. The snake retractor is fixed in place with an adjustable robot arm-type retractor system. A right upper quadrant 5 mm dissecting port is placed. A 5 mm 30° angled camera is used for the entire operation. With some equipment, the 5 mm camera does not allow enough light to accomplish advanced laparoscopy. If the operation cannot be performed safely with a 5 mm camera, the supra-umbilical 5 mm port can be exchanged for a 10–12 mm port for a 30° angled 10 mm camera.

The omentum is reflected into the upper abdomen and dissected off of the transverse colon using a 5 mm energy device (Table 22.3). Dissection is conducted from the right side of the table, beginning at the midline and extending up to the lowest short gastric vessels. For this dissection, the camera can be moved to the left 12 mm port to allow the surgeon to work with both hands through the right upper quadrant and supra-umbilical port. The omental dissection is then carried up to the greater curvature. The camera is moved from the left to the supra-umbilical port, and the right side of the omentum is dissected from the transverse colon. This is best performed from the left side of the patient. After the complete separation of the omentum from the transverse colon, the base of the right gastroepiploic vessels are dissected at the level of the inferior border of the pancreas. The right gastroepiploic vessels are transected using an energy device. Attention is then turned to the supra-duodenal region, and the lesser omentum is opened. The first portion of the duodenum is surrounded and transected using a 60 mm endoscopic stapler using 3.5 mm (blue) staples or Tri-Staple^TM 2.0, 2.5, and 3.0 mm (tan) staples. Staple line buttressing material is not used for any of the stapling in the procedure. None of the staple lines are imbricated with sutures, and sutures are not generally used to take tension off the staple lines.