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Han-Kwang YANG

Seoul National University Cancer Research Institute
Seoul, South Korea
MD, PhD, FACS
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Pylorus-preserving laparoscopic gastrectomy with pyloric balloon dilatation
Gastric cancer screening programs implemented by Japan and South Korea have shown impressive results in terms of the increasing proportion of early gastric cancer diagnosis. Because of this, more interest has been focused on preserving the organ function in order to improve postoperative quality of life aiming to reduce complications or sequelae and avoiding large resections. Pylorus-preserving gastrectomy (PPG) was first introduced by Maki et al. and it is probably the most representative technique of function-preserving gastrectomy. It has been reported that, due to an impaired pyloric function, patients may occasionally experience a sensation of gastric fullness after food intake as well as long-term food retention in the remnant stomach. This delayed gastric emptying caused by pyloric spasms has been shown to decrease the patient’s quality of life. There is no standardized management strategy at present, and consequently gastric surgeons have often found themselves hesitant to perform this minimally invasive, function-preserving surgery. Here, we present a PPG case followed by a pyloric spasm, which was successfully treated with balloon dilatation.
Surgical intervention
27 days ago
464 views
2 likes
1 comment
10:02
Pylorus-preserving laparoscopic gastrectomy with pyloric balloon dilatation
Gastric cancer screening programs implemented by Japan and South Korea have shown impressive results in terms of the increasing proportion of early gastric cancer diagnosis. Because of this, more interest has been focused on preserving the organ function in order to improve postoperative quality of life aiming to reduce complications or sequelae and avoiding large resections. Pylorus-preserving gastrectomy (PPG) was first introduced by Maki et al. and it is probably the most representative technique of function-preserving gastrectomy. It has been reported that, due to an impaired pyloric function, patients may occasionally experience a sensation of gastric fullness after food intake as well as long-term food retention in the remnant stomach. This delayed gastric emptying caused by pyloric spasms has been shown to decrease the patient’s quality of life. There is no standardized management strategy at present, and consequently gastric surgeons have often found themselves hesitant to perform this minimally invasive, function-preserving surgery. Here, we present a PPG case followed by a pyloric spasm, which was successfully treated with balloon dilatation.
Laparoscopic total gastrectomy guided by fluorescent lymphangiography using ICG injection around a tumor, followed by an intracorporeal double stapling esophagojejunostomy
Injecting indocyanine green (ICG) around the tumor enables the operators to identify the lymphatic channels and the lymph nodes in which the cancer cells can spread. It also allows them to decide on the extent of the dissection and validate the completeness of lymph node dissection. In this video, a laparoscopic near-infrared fluorescent camera was used, showing the fluorescent signal in diverse modes. A total gastrectomy with D1+ dissection is performed. The fluorescent signal shows the possible lymphatic pathways during the operation. An intracorporeal esophagojejunostomy was performed in a double stapling fashion; a round needle and a surgical thread are attached to the plastic part of the anvil of the circular stapler.
Surgical intervention
2 years ago
1768 views
78 likes
0 comments
15:56
Laparoscopic total gastrectomy guided by fluorescent lymphangiography using ICG injection around a tumor, followed by an intracorporeal double stapling esophagojejunostomy
Injecting indocyanine green (ICG) around the tumor enables the operators to identify the lymphatic channels and the lymph nodes in which the cancer cells can spread. It also allows them to decide on the extent of the dissection and validate the completeness of lymph node dissection. In this video, a laparoscopic near-infrared fluorescent camera was used, showing the fluorescent signal in diverse modes. A total gastrectomy with D1+ dissection is performed. The fluorescent signal shows the possible lymphatic pathways during the operation. An intracorporeal esophagojejunostomy was performed in a double stapling fashion; a round needle and a surgical thread are attached to the plastic part of the anvil of the circular stapler.
Three-trocar laparoscopic total gastrectomy and D2 lymphadenectomy with intracorporeal manual esophagojejunostomy
Background: Minimally invasive surgery (MIS) has proven to be oncologically feasible and safe. Over the last decade, a new philosophy of MIS reducing abdominal trauma and improving cosmetic results has been made popular. The authors report a three-trocar laparoscopic total gastrectomy combined with a D2 lymphadenectomy for smaller curvature gastric adenocarcinoma.
Video: A 52-year-old woman presenting with a non-differentiated gastric adenocarcinoma at the incisura angularis was admitted to our department. Preoperative work-up showed a T3N+M0 tumor. After neoadjuvant chemotherapy, laparoscopy was scheduled. Three ports (5mm, 12mm, 5mm) were placed in the abdomen. Exposure of the operative field was improved with percutaneous sutures. En-bloc total gastrectomy and omentectomy were performed with a D2 lymphadenectomy, including the nodes of stations 1, 2, 3, 4, 5, 6, 7, 8a, 8p, 9, 10, 11p, 11d, and 12a. A completely manual end-to-side esophagojejunostomy, and a linear mechanical side-to-side jejunojejunostomy were performed, with closure of both mesenteric and mesocolic defects. The specimen was retrieved through a suprapubic access.
Results: Operative time was 4 hours and 45 minutes (anastomosis: 30) and perioperative bleeding amounted to 100cc. The pathological report confirmed the presence of a non-differentiated adenocarcinoma, mucinous, G3, interesting the gastric wall completely, with 63 (4 positive) nodes removed; 7 edition UICC stage: pT4aN2aM0; keratine AE1/AE3 negative, HER2/neu and HER2/CEP17 non-amplified. During the postoperative follow-up, no recurrence was demonstrated at 12 months.
Conclusions: Reduced port laparoscopic surgery provides the same quality of oncologic surgery as conventional multiport laparoscopy. However, a superior cosmesis and a reduced abdominal trauma are offered.
Surgical intervention
3 years ago
3070 views
96 likes
0 comments
11:03
Three-trocar laparoscopic total gastrectomy and D2 lymphadenectomy with intracorporeal manual esophagojejunostomy
Background: Minimally invasive surgery (MIS) has proven to be oncologically feasible and safe. Over the last decade, a new philosophy of MIS reducing abdominal trauma and improving cosmetic results has been made popular. The authors report a three-trocar laparoscopic total gastrectomy combined with a D2 lymphadenectomy for smaller curvature gastric adenocarcinoma.
Video: A 52-year-old woman presenting with a non-differentiated gastric adenocarcinoma at the incisura angularis was admitted to our department. Preoperative work-up showed a T3N+M0 tumor. After neoadjuvant chemotherapy, laparoscopy was scheduled. Three ports (5mm, 12mm, 5mm) were placed in the abdomen. Exposure of the operative field was improved with percutaneous sutures. En-bloc total gastrectomy and omentectomy were performed with a D2 lymphadenectomy, including the nodes of stations 1, 2, 3, 4, 5, 6, 7, 8a, 8p, 9, 10, 11p, 11d, and 12a. A completely manual end-to-side esophagojejunostomy, and a linear mechanical side-to-side jejunojejunostomy were performed, with closure of both mesenteric and mesocolic defects. The specimen was retrieved through a suprapubic access.
Results: Operative time was 4 hours and 45 minutes (anastomosis: 30) and perioperative bleeding amounted to 100cc. The pathological report confirmed the presence of a non-differentiated adenocarcinoma, mucinous, G3, interesting the gastric wall completely, with 63 (4 positive) nodes removed; 7 edition UICC stage: pT4aN2aM0; keratine AE1/AE3 negative, HER2/neu and HER2/CEP17 non-amplified. During the postoperative follow-up, no recurrence was demonstrated at 12 months.
Conclusions: Reduced port laparoscopic surgery provides the same quality of oncologic surgery as conventional multiport laparoscopy. However, a superior cosmesis and a reduced abdominal trauma are offered.
Robotic distal gastrectomy with the EndoWrist® One Vessel Sealer
The EndoWrist® One vessel sealer is a wristed, single-use instrument of the da Vinci surgical robotic system intended for bipolar coagulation and mechanical transection of vessels up to 7mm in diameter and tissue bundles. It could be a potential instrument to overcome the limitation of straight energy-based devices. Although it has the advantage of having an endowrist function which allows easy access to the surgical planes in ideal directions, it requires special caution and know-how to use the device safely and effectively, because of a relatively blunt tip and the absence of an active blade at the tip.
This video of the robotic distal gastrectomy for early gastric cancer shows how to harmonize the use of a sharp instrument with conventional bipolar electricity and of the vessel sealer device to maximize the advantages of such devices and to ensure safety. A conventional bipolar forceps is used to make entrance holes on the tissue for a safe application of the vessel sealer, and to perform fine dissections of small tissues, which are difficult to manage using a vessel sealer. Once the access hole has been made, the vessel sealer is applied in an ideal axis to the avascular tissue plane, thanks to the free wrist function. This technique combined with a sharp instrument using conventional bipolar electricity seems to be helpful for a safe and effective operation, which can use the benefit of the vessel sealer to its full potential, for instance with a high degree of freedom of the movement and secure sealing of lymphovascular structures.
Surgical intervention
3 years ago
1391 views
81 likes
0 comments
10:38
Robotic distal gastrectomy with the EndoWrist® One Vessel Sealer
The EndoWrist® One vessel sealer is a wristed, single-use instrument of the da Vinci surgical robotic system intended for bipolar coagulation and mechanical transection of vessels up to 7mm in diameter and tissue bundles. It could be a potential instrument to overcome the limitation of straight energy-based devices. Although it has the advantage of having an endowrist function which allows easy access to the surgical planes in ideal directions, it requires special caution and know-how to use the device safely and effectively, because of a relatively blunt tip and the absence of an active blade at the tip.
This video of the robotic distal gastrectomy for early gastric cancer shows how to harmonize the use of a sharp instrument with conventional bipolar electricity and of the vessel sealer device to maximize the advantages of such devices and to ensure safety. A conventional bipolar forceps is used to make entrance holes on the tissue for a safe application of the vessel sealer, and to perform fine dissections of small tissues, which are difficult to manage using a vessel sealer. Once the access hole has been made, the vessel sealer is applied in an ideal axis to the avascular tissue plane, thanks to the free wrist function. This technique combined with a sharp instrument using conventional bipolar electricity seems to be helpful for a safe and effective operation, which can use the benefit of the vessel sealer to its full potential, for instance with a high degree of freedom of the movement and secure sealing of lymphovascular structures.
Laparoscopic wedge resection of gastric gastrointestinal stromal tumor (GIST) with linear staplers in a transverse direction
This video presents a case of laparoscopic wedge resection for a gastric gastrointestinal stromal tumor (GIST). Exogastric resection using a stapler is effective for most GIST cases. However, there is a risk of gastric lumen narrowing after stapling in case of endophytically growing tumor unless the direction of the stapler is aligned transversely, which means in a perpendicular direction to the long axis of the stomach. This video shows how to access the tumor located at the posterior wall of the stomach, usefulness of the intraoperative endoscopy to identify the location of the tumor, and the presence of intraluminal bleeding from the staple line, and how to apply the linear stapler in a transverse direction in a laparoscopic wedge resection for gastric GIST.
Surgical intervention
3 years ago
2136 views
117 likes
0 comments
03:36
Laparoscopic wedge resection of gastric gastrointestinal stromal tumor (GIST) with linear staplers in a transverse direction
This video presents a case of laparoscopic wedge resection for a gastric gastrointestinal stromal tumor (GIST). Exogastric resection using a stapler is effective for most GIST cases. However, there is a risk of gastric lumen narrowing after stapling in case of endophytically growing tumor unless the direction of the stapler is aligned transversely, which means in a perpendicular direction to the long axis of the stomach. This video shows how to access the tumor located at the posterior wall of the stomach, usefulness of the intraoperative endoscopy to identify the location of the tumor, and the presence of intraluminal bleeding from the staple line, and how to apply the linear stapler in a transverse direction in a laparoscopic wedge resection for gastric GIST.
Laparoscopic total gastrectomy and D2 dissection guided by fluorescence imaging system, followed by esophagojejunostomy using an intracorporeal purse-string suture method
This video demonstrates a case of gastric cancer, which is located at the cardia, and a total gastrectomy was planned. For D2 dissection in a total gastrectomy, lymph node dissection around the splenic artery and splenic hilum is one of the most challenging area. Here, we present an example of complete dissection by following the plane around the splenic vessels.
Fluorescence imaging using indocyanine green (ICG) is a promising technology not only for sentinel node navigation surgery but it is also a guide for extensive lymph node dissection. The laparoscopic fluorescence imaging system was used here as a guidance and assessment tool for complete lymph node dissection. Also, an original method for intracorporeal esophagojejunal anastomosis is introduced, which enables purse-string suture and insertion of the anvil of the circular stapler in a quite stable manner, and reproduces conventional esophagojejunostomy without specialized devices.
Surgical intervention
4 years ago
2787 views
51 likes
0 comments
28:29
Laparoscopic total gastrectomy and D2 dissection guided by fluorescence imaging system, followed by esophagojejunostomy using an intracorporeal purse-string suture method
This video demonstrates a case of gastric cancer, which is located at the cardia, and a total gastrectomy was planned. For D2 dissection in a total gastrectomy, lymph node dissection around the splenic artery and splenic hilum is one of the most challenging area. Here, we present an example of complete dissection by following the plane around the splenic vessels.
Fluorescence imaging using indocyanine green (ICG) is a promising technology not only for sentinel node navigation surgery but it is also a guide for extensive lymph node dissection. The laparoscopic fluorescence imaging system was used here as a guidance and assessment tool for complete lymph node dissection. Also, an original method for intracorporeal esophagojejunal anastomosis is introduced, which enables purse-string suture and insertion of the anvil of the circular stapler in a quite stable manner, and reproduces conventional esophagojejunostomy without specialized devices.
Laparoscopic distal gastrectomy with Billroth II reconstruction for peptic ulcer obstruction
This live surgery video demonstrates a laparoscopic distal gastrectomy with Billroth II reconstruction in a patient with pyloric stenosis which was caused by peptic ulcer. Treatment using balloon dilatation failed. The fibrotic area of the duodenal ulcer was approached by fine dissection and ligation of right gastro-epiploic and right gastric vessels. The dissection was performed around the duodenum until an adequate margin could be obtained in the healthy portion of the distal duodenum. The duodenum was then transected by means of a stapler. A relatively large dilated stomach including the antrum and part of the gastric body was transected, and a Billroth II gastrojejunostomy was performed.
Surgical intervention
4 years ago
3447 views
157 likes
0 comments
21:58
Laparoscopic distal gastrectomy with Billroth II reconstruction for peptic ulcer obstruction
This live surgery video demonstrates a laparoscopic distal gastrectomy with Billroth II reconstruction in a patient with pyloric stenosis which was caused by peptic ulcer. Treatment using balloon dilatation failed. The fibrotic area of the duodenal ulcer was approached by fine dissection and ligation of right gastro-epiploic and right gastric vessels. The dissection was performed around the duodenum until an adequate margin could be obtained in the healthy portion of the distal duodenum. The duodenum was then transected by means of a stapler. A relatively large dilated stomach including the antrum and part of the gastric body was transected, and a Billroth II gastrojejunostomy was performed.
Robot-assisted distal gastrectomy and D2 lymphadenectomy for early gastric cancer
We present the case of an early gastric cancer, which was located in the lower third of the stomach. The patient underwent a robot-assisted distal gastrectomy with D2 lymph node dissection. The da Vinci™ robotic system may provide some benefit to the operator in D2 dissection thanks to the articulating function of the arms, but the advantage for the patient has not been validated. The procedure was similar to a laparoscopic distal gastrectomy, starting from the omentectomy in the left side first and then the right side, followed by a lymphadenectomy around the infrapyloric and suprapyloric area. The lymphadenectomy is continued towards the suprapyloric area along the common hepatic artery and splenic artery, and the left gastric vein and artery are ligated. With a dissection of the lesser curvature aspect of the upper stomach, D2 dissection is completed “en bloc”.
Surgical intervention
4 years ago
1913 views
78 likes
1 comment
29:24
Robot-assisted distal gastrectomy and D2 lymphadenectomy for early gastric cancer
We present the case of an early gastric cancer, which was located in the lower third of the stomach. The patient underwent a robot-assisted distal gastrectomy with D2 lymph node dissection. The da Vinci™ robotic system may provide some benefit to the operator in D2 dissection thanks to the articulating function of the arms, but the advantage for the patient has not been validated. The procedure was similar to a laparoscopic distal gastrectomy, starting from the omentectomy in the left side first and then the right side, followed by a lymphadenectomy around the infrapyloric and suprapyloric area. The lymphadenectomy is continued towards the suprapyloric area along the common hepatic artery and splenic artery, and the left gastric vein and artery are ligated. With a dissection of the lesser curvature aspect of the upper stomach, D2 dissection is completed “en bloc”.
Laparoscopy-assisted pylorus-preserving gastrectomy using near-infrared imaging combined with indocyanine green (ICG) submucosal injection - (LAPPG - Near-infrared ICG camera)
Using a near infrared camera, lymph nodes can be visualized. For early gastric cancer located in the middle third of the stomach, laparoscopy-assisted pylorus-preserving gastrectomy (LAPPG) can be performed. Approximately, a 3cm cuff of distal antrum is preserved. Technically speaking, the preservation of infrapyloric vessels and of the hepatic branch of the vagus nerve represents the technical difference as compared to conventional radical distal gastrectomy. In this video, the audience can see how a near-infrared camera can be used to assist lymph node dissection.
Surgical intervention
4 years ago
1829 views
38 likes
0 comments
22:18
Laparoscopy-assisted pylorus-preserving gastrectomy using near-infrared imaging combined with indocyanine green (ICG) submucosal injection - (LAPPG - Near-infrared ICG camera)
Using a near infrared camera, lymph nodes can be visualized. For early gastric cancer located in the middle third of the stomach, laparoscopy-assisted pylorus-preserving gastrectomy (LAPPG) can be performed. Approximately, a 3cm cuff of distal antrum is preserved. Technically speaking, the preservation of infrapyloric vessels and of the hepatic branch of the vagus nerve represents the technical difference as compared to conventional radical distal gastrectomy. In this video, the audience can see how a near-infrared camera can be used to assist lymph node dissection.