Since Kitano reported the first laparoscopic-assisted distal gastrectomy in 1994, Goh PM reported the first laparoscopic D2 radical surgery in 1997, and Azagra JS reported the first laparoscopic total gastrectomy in 1999, the trajectory of laparoscopic gastric cancer development has almost covered the history of gastric cancer surgery for more than 100 years in just a decade. With the continuous maturation of surgical techniques and the continuous updating of surgical equipment and instruments, laparoscopic gastric surgery has gradually become acceptable to everyone, and laparoscopic-assisted distal gastrectomy is the first procedure that beginners need to master. Since laparoscopic surgery is different from traditional open surgery in terms of anatomical pathways, separation levels, and surgical steps, long operative times and surgery-related complications may be encountered in the early stage of the procedure. Clinical data prove that complications of LADG surgery are mainly concentrated in the early stage of carrying out, and analyzing the causes of these complications and giving sufficient attention to them is believed to help operators cross the learning curve smoothly.
We categorize the surgical complications of LADG into two major parts: complications specific to laparoscopic surgery and complications related to laparoscopic gastrectomy.
I. Complications specific to laparoscopic surgery
Complications specific to laparoscopic surgery mainly include puncture complications and pneumoperitoneum-related complications.
Puncture complications are commonly puncture hole infection and bleeding, and of course there are some distant complications such as puncture hole hernia and puncture hole tumor implantation.
Based on our clinical experience combined with other literature, we believe that the main points of operation to avoid complications are.
1.Apply skin towel to the abdomen before puncture.
2. Pay attention to avoiding the blood vessels under the abdominal wall under the observation of the lens when entering the trocar. We chose knife-free trocar, which significantly reduced the bleeding from the puncture hole.
3.The CO2 gas in the abdominal cavity was released from the trocar before removing the trocar to prevent the tumor tissue from being ejected with the gas and causing incisional implantation.
4. Observe again for bleeding and oozing of blood here before suturing the puncture hole, and start suturing from the peritoneal layer when suturing to avoid the incidence of puncture hole hernia.
The main complications associated with pneumoperitoneum are subcutaneous emphysema and hypercapnia. Subcutaneous emphysema is generally associated with incorrect puncture level, high abdominal pressure, and air leakage around the puncture hole incision more roughly trocar.
We believe that the key points of operation are.
1, the skin incision is made small enough to hoop the trocar so that it does not slip in and out.
2, the lens observation clearly trocar into the abdominal cavity before establishing a pneumoperitoneum, to ensure that the peritoneum is tightly wrapped around the trocar and not into the subcutaneous. If there is a special need to enter the abdomen under direct vision, do not open the innermost layer of the peritoneum, and let the trocar break through directly into the peritoneum, which can make the peritoneum and trocar wrapped around closely.
3, pneumoperitoneum pressure is maintained at 10 mmHg, which can reduce the pressure gradient between CO2 abdominal cavity – blood.
4, small-scale emphysema can be suspended and closely observed, but if it leads to hypercapnia and affects the stability of vital signs, it should be promptly transferred to open abdomen.
II. Complications related to laparoscopic gastrectomy
Complications related to laparoscopic gastrectomy mainly include intra-abdominal bleeding, organ damage, duodenal stump leakage and anastomotic complications.
Intraoperative bleeding is one of the common complications of laparoscopic surgery, especially bleeding caused by large vessel injury is an important factor leading to intermediate open abdomen and other injuries, and its incidence is reported in the literature to be 2%-3%. Intraoperative bleeding can lead to life-threatening hemorrhagic shock if not treated in time, and its common causes are: wrong anatomical level, improper technique of ultrasonic knife use, and incomplete vascular clamping. Postoperative bleeding is one of the important causes of secondary surgery after surgery, and its incidence is reported in the literature as 1-4%.
We believe that the key points of intraoperative operation are.
1. familiarity with anatomy, careful search for the correct anatomical gap, and use of specific organs and tissues as references, allowing the operation to be performed at the correct level.
2. a fixed surgical sequence regional operation. Always use the pancreas as a positioning marker and operate regionally in the order from right to left and from bottom to top, which can ensure correct and efficient surgery.
3, need to master the use of ultrasound knife techniques, the process of disconnection requires patience not to pull, do not clamp large pieces of tissue, when using ultrasound knife bare vessels, especially veins, try to use non-functional knife head close to the vessels to avoid causing thermal damage.
4, on the vascular clamps under the direct vision of the lens to confirm the complete clamping of vessels before disconnecting them, and prefer to clamp again when there is incomplete clamping.
5, repeatedly rinse to stop bleeding before closing the abdomen.
6.If intraoperative vascular injury occurs and bleeding should first remain calm. If the amount of bleeding is small, the blood in the operative field can be aspirated first, and the bleeding site can be found and then compressed with small gauze before using ultrasonic knife, electrocoagulation or titanium clips to stop bleeding. If the bleeding is large and cannot be controlled under lumpectomy, the abdomen should be opened in time, avoiding blind clamping or cautery under lumpectomy, which may easily cause more damage to the surrounding organ tissues.
Transverse colonic mesenteric injury is often seen due to lack of familiarity with the layers between the lumpectomized gastric omentum and the transverse colonic mesentery. It is more likely to occur especially in the early stages of the procedure when inexperience is lacking. We believe that during the separation of the omentum from the transverse colonic mesenteric gap, it is crucial to reveal the pancreas in time to identify the level. At the same time, in the process of separating the omentum and the anterior lobe of the transverse mesentery, it is important to open the omentum from the left side of the transverse colon from the bottom to the top in a linear area, and when the pancreas is seen, it can be extended to the right side to the face, so that even if the transverse mesentery is broken, the blood supply will not be destroyed, resulting in the need to perform partial bowel resection.
Leakage of the duodenal stump is one of the serious complications after Bi-II reconstruction, and its incidence in the lumpectomy has been reported in the literature to be 4.2%. The use of ultrasonic knife to free the duodenum during laparoscopic gastric surgery can easily lead to duodenal stump leakage due to functional surface burns if care is not taken. In addition, incomplete closure of the stump, obstruction of the inflow loop, and poor blood supply to the duodenal stump are also common causes.
To reduce the occurrence of this complication, our operational experience is to
1, avoid ultrasonic knife or electric hook burns to the duodenal wall during surgery, and promptly repair and then close if there is damage.
2, do not reluctantly close the duodenal stump, can be completely free of the duodenal bulb after a one-time closure with a cutting suture, and if necessary, again absorbable thread suture.
3. In most cases, a 45 mm cutting anastomosis is sufficient to close the duodenal stump. Sometimes the cutting anastomosis inserted through the main operating hole will be at an angle to the duodenum, so a 60 mm cutting anastomosis or a cutting anastomosis inserted through the assistant operating hole can be used instead.
Anastomotic complications of laparoscopic gastric surgery include anastomotic leak, anastomotic bleeding, and anastomotic stricture, with an incidence of 1.7-4% reported in the literature. Most anastomotic complications are caused by improper use of the anastomosis clutch. Other causes such as acute obstruction causing anastomotic distention and fracture, mucosal tearing, ligature wire dislodgement, perianastomotic inflammatory exudation, anemia, and hypoproteinemia are also causes of anastomotic complications.
The key points of intraoperative operation are.
1. Excess tissue around the two broken ends to be anastomosed should be removed before using the anastomosis to avoid incomplete anastomosis due to clamping into the anastomosis. However, care should be taken to protect the nutrient vessels on both ends of the anastomosis to avoid affecting the blood supply to the anastomosis.
2. After completion of the anastomosis, check the integrity of the excised tissue at both ends of the anastomosis, and if the anastomosis is unsatisfactory, reinforce it with absorbable sutures. However, it is necessary to avoid too close a stitch distance and too many sutures during the reinforcement process, which may lead to postoperative anastomotic stenosis.
3. Ensure that no tension exists in the anastomosis after the anastomosis. If performing Bi-I reconstruction will lead to the presence of tension, Roux-en-Y reconstruction can be chosen, which can ensure that enough stomach is removed and the anastomosis is free of tension.
4. Routinely flush the gastric tube before the end of surgery in order to detect anastomotic bleeding in time.
Laparoscopic gastric surgery is a difficult operation with complex anatomical levels. Compared with other laparoscopic surgeries, laparoscopic gastrectomy has a longer and more arduous growth curve.
Practice has confirmed that the following conditions help to cross the learning curve smoothly.
1. proficiency in perigastric anatomy and levels, and the chief surgeon and assistant need to have some experience in open gastric surgery, especially with the concept of three-dimensional anatomy and the need to adapt to a different anatomical perspective than that of open surgery.
2, have some experience in laparoscopic surgery, get used to laparoscopic operation, preferably have some experience in laparoscopic colorectal surgery. Be familiar with the use of ultrasonic knife.
3, the surgical team should be relatively fixed, including the supporting mirror hand and hand washing, roving nurses, so as to achieve tacit cooperation and thus improve the efficiency of surgery.
4, pay attention to the training of the members of the surgical team, and improve the operating skills of each person. The completion of laparoscopic gastric surgery needs to rely on the strength of the team, which has high requirements not only for the operator, but also for the assistant and the supporting hand. The assistant can help to reveal and counteract the traction; the hand holding the mirror should have tacit cooperation with the operator, have foresight, and be able to make changes of distant and near view and longitudinal rotation of the lens according to the surgical needs to maintain a good operative field. In order to ensure the smooth implementation of the operation.
5. Repeatedly study the surgical videos of the pioneers at home and abroad and learn from the strengths of a hundred schools of thought. Try to avoid complications so as not to affect confidence with an unfavorable start. In addition, in addition to the number of surgeries, the frequency of surgeries is also an important factor affecting the proficiency of laparoscopic gastric surgery. Only when a certain number of surgeries and a moderate frequency of surgeries are achieved, a qualitative leap in technique will naturally occur.