Multimedia Journal of Metaverse in MEDICINE
METHODOLOGY | JANUARY 13, 2026
Laparoscopic D2 total gastrectomy: suprapancreatic lymphadenectomy and pancreatic protection
Dawei Yuan¹, Gang Xu¹, Dongmei Diao¹, Yong Zhang¹*
1 Department of Surgical Oncology, The First Affiliated Hospital of Xi’an JiaoTong University, Xi’an 710061, China.
Corresponding Authors: Yong Zhang. E-mail: [email protected]
Address: Department of Surgical Oncology, The First Affiliated Hospital of Xi’an JiaoTong University, Xi’an 710061, China.
Summary
Laparoscopic D2 total gastrectomy is the standard surgical treatment for advanced proximal gastric cancer. Among all operative steps, suprapancreatic lymphadenectomy (stations No. 7, 8a, 9, and 11p) is the most technically demanding due to the proximity of critical structures including the pancreas, common hepatic artery, splenic artery, left gastric artery, and portal vein. Pancreatic compression and thermal injury during dissection are major contributors to postoperative pancreatic fistula. Based on one surgical video of laparoscopic D2 total gastrectomy, this study provides a multi‑perspective analysis of suprapancreatic lymphadenectomy with an emphasis on pancreatic protection. Through first‑person view, assistant view, and microscopic close‑ups, we demonstrate precise exposure of the left gastric artery root, identification of the pancreatic fusion fascia, and application of a “pancreas‑compressionless” dissection technique. This video‑based analysis offers a technical framework for safe and effective suprapancreatic D2 lymphadenectomy.
Keywords
Laparoscopic D2 total gastrectomy; suprapancreatic lymphadenectomy; pancreatic protection; left gastric artery; gastric cancer
Introduction
Laparoscopic total gastrectomy (LTG) with D2 lymphadenectomy has become a widely accepted treatment for advanced proximal gastric cancer. Compared to open total gastrectomy, LTG offers advantages including reduced intraoperative blood loss, faster postoperative recovery, and shorter hospital stay. A recent network meta‑analysis including 68 studies and 44,689 patients demonstrated that totally laparoscopic TG was associated with a reduced rate of overall postoperative complications compared to open TG (risk ratio 0.82, 95% CrI 0.73–0.92) [1].
The suprapancreatic region is the anatomical epicenter of D2 lymphadenectomy. It contains the celiac trunk, common hepatic artery (CHA), splenic artery (SA), left gastric artery (LGA), portal vein (PV), and lymph node stations No. 7 (root of LGA), No. 8a (anterior surface of CHA), No. 9 (celiac axis), and No. 11p (proximal SA) [2]. Complete clearance of these stations is essential for oncological radicality, but the procedure carries substantial risks. The pancreas lies immediately posterior to these vascular structures, and conventional retraction often involves direct compression of the pancreas, which combined with thermal spread from ultrasonic devices can lead to postoperative pancreatic fistula (POPF). The incidence of clinically relevant POPF after LTG is reported to be 1–5% [3].
Tsujiura et al. introduced the concept of “pancreas‑compressionless gastrectomy,” demonstrating that avoiding direct pancreatic compression significantly reduced severe POPF from 11.8% to 2.2% and intra‑abdominal infectious complications from 17.6% to 2.2% [4]. Similarly, Ebihara et al. reported that a preemptive retropancreatic approach helped prevent postoperative pancreatic complications by releasing the fusion fascia between the retroperitoneum and the pancreas [5].
This study is based on one surgical video of laparoscopic D2 total gastrectomy. Through multi‑perspective analysis, we systematically demonstrate the key techniques for suprapancreatic lymphadenectomy with effective pancreatic protection, providing a reproducible technical framework for gastrointestinal surgeons.
Methods
1 Research Design
This study analyzed one surgical video of laparoscopic D2 total gastrectomy performed at the Department of Surgical Oncology, the First Affiliated Hospital of Xi‘an JiaoTong University in May 2024. The patient was diagnosed with advanced proximal gastric cancer (cT3N1M0) and underwent curative‑intent LTG with D2 lymphadenectomy. Cases with tumor invasion of the pancreas or portal vein were excluded.
2 Surgical team and equipment
The surgery was performed by a senior gastrointestinal surgical team. Equipment included a high‑definition 4K laparoscopic system (Olympus, Tokyo, Japan), laparoscopic ultrasonic shears (Harmonic ACE, Ethicon, Cincinnati, OH, USA), laparoscopic linear staplers (Medtronic, Minneapolis, MN, USA), and an indocyanine green (ICG) near‑infrared fluorescence imaging system (Karl Storz, Tuttlingen, Germany).
3 Surgical steps
(1) Exposure of the suprapancreatic region: After entering the omental bursa and mobilizing the greater curvature, the stomach was lifted anteriorly. The anterior surface of the pancreas was exposed. The gastrocolic ligament was divided, and the fusion fascia between the posterior gastric wall and the pancreas was bluntly dissected.
(2) Identification of vascular landmarks: The following landmarks were systematically identified: (i) the common hepatic artery running along the superior border of the pancreas; (ii) the splenic artery originating from the celiac trunk; (iii) the left gastric artery arising from the celiac axis; (iv) the portal vein posterior to the CHA; and (v) the left gastric vein (coronary vein).
(3) “Pancreas‑compressionless” technique: Direct compression of the pancreatic parenchyma was strictly avoided. The operative field was established by pulling the connective tissues along the inferior border of the pancreas and the nerves along the CHA and SA, using gentle traction and counter‑traction. The fusion fascia between the retroperitoneum and the posterior pancreas was carefully dissected to mobilize the pancreas downward, creating a natural working space without external compression.
(4) Lymph node dissection: D2 lymphadenectomy was performed according to the Japanese Gastric Cancer Treatment Guidelines [2]. The LGA was identified at its root, clipped, and divided. The lymph nodes along the CHA (No. 8a), celiac axis (No. 9), and proximal SA (No. 11p) were dissected en bloc using ultrasonic shears with meticulous hemostasis. Pancreatic branches of the SA were preserved whenever possible. ICG fluorescence imaging was used to guide lymph node identification.
(5)Pancreatic protection measures: During dissection, the active blade of the ultrasonic shears was directed away from the pancreas; intermittent rather than prolonged activation was used near pancreatic tissue; thermal spread was minimized by using low‑power settings; and a clear plane was maintained between the dissected lymph nodes and the pancreatic capsule.
4 Data collection and analysis
The surgery was recorded from three perspectives: first‑person perspective (head‑mounted camera), surgical assistant perspective (laparoscopic camera feed), and microscopic close‑up (magnified view of suprapancreatic dissection). The video was reviewed and annotated by two independent surgical oncologists.
5 Ethical Statement
This study was approved by the Ethics Committee of the First Affiliated Hospital of Xi‘an JiaoTong University (Approval No. 20250922). The patient provided written informed consent.
Methods Video
RESULTS
The video successfully demonstrated suprapancreatic D2 lymphadenectomy with complete clearance of stations No. 7, 8a, 9, and 11p. The “pancreas‑compressionless” technique was successfully applied. The LGA root, CHA, SA, and celiac trunk were clearly exposed and protected. The portal vein was identified and preserved. No intraoperative complications such as pancreatic injury, portal vein injury, or uncontrolled bleeding occurred. The mean operative time for the suprapancreatic dissection phase was 65 minutes. Intraoperative blood loss was 60 mL. ICG fluorescence imaging provided enhanced visualization of lymphatic drainage, facilitating thorough lymph node retrieval.
The multi‑perspective recording clearly presented the delicate dissection planes. Microscopic close‑ups and first‑person perspective provided intuitive guidance for identifying the pancreatic fusion fascia, distinguishing the LGA from surrounding lymphatic tissue, and applying ultrasonic shears safely near the pancreas.
Discussion
This study focuses on suprapancreatic lymphadenectomy and pancreatic protection—one of the most technically challenging components of laparoscopic D2 total gastrectomy. Through multi‑perspective video analysis, we have systematically demonstrated the key anatomical landmarks, dissection techniques, and protective maneuvers required for safe and effective completion of this procedure.
1 Clinical significance of suprapancreatic lymphadenectomy
D2 lymphadenectomy with clearance of suprapancreatic stations is essential for curative treatment of advanced proximal gastric cancer. The suprapancreatic region is particularly important because lymph node metastases at these stations are common and directly affect prognosis. Lv et al. reported that ICG fluorescence imaging significantly improved the mean number of lymph nodes dissected in suprapancreatic stations compared to conventional LTG (P < 0.05) [6].
2 Pancreatic protection: rationale and techniques
The pancreas is vulnerable during suprapancreatic dissection for two reasons: its anatomical position posterior to the suprapancreatic vessels, and the conventional practice of direct pancreatic compression for exposure. Tsujiura et al. demonstrated that the “pancreas‑compressionless” technique significantly reduced severe POPF and intra‑abdominal infectious complications [4]. Our video analysis confirms the feasibility of this approach. Key elements include pulling connective tissues rather than compressing the pancreas, dissecting the fusion fascia to mobilize the pancreas downward, and using ultrasonic shears with the active blade directed away from the pancreas.
Ebihara et al. described a preemptive retropancreatic approach that involves initial dissection of the left side of the retropancreatic space, followed by release of the fusion fascia [5]. In their series, none developed postoperative pancreatic complications. These findings suggest that fusion fascia dissection is a critical step that should be incorporated into standard LTG technique.
3 Role of intraoperative navigation
ICG fluorescence imaging represents an important advancement. Lv et al. reported that the ICG‑guided group had a significantly higher mean number of dissected lymph nodes (52.34 vs. 37.38, P < 0.001) and a higher proportion of patients with more than 30 lymph nodes (96.55% vs. 76.81%, P = 0.018) [6]. The sensitivity of ICG for detecting metastatic lymph nodes was 85.9%, with a negative predictive value of 96%.
4 Limitations
This study has limitations, including a single case and single‑center design. Future studies should include larger prospective cohorts and long‑term survival analysis.
Conclusion
This study confirms that suprapancreatic lymphadenectomy with effective pancreatic protection is safe and feasible in laparoscopic D2 total gastrectomy when performed using meticulous anatomical dissection and a “pancreas‑compressionless” technique. Key technical points include systematic identification of suprapancreatic vascular landmarks, dissection of the pancreatic fusion fascia, avoidance of direct pancreatic compression, careful use of ultrasonic energy, and application of ICG fluorescence imaging in selected cases.
Author Contributions
Dawei Yuan wrote the first draft. Gang Xu and Dongmei Diao contributed to the critical revision of the manuscript. Yong Zhang reviewed and revised the manuscript. All authors have read and agreed to the published version of the manuscript.
Funding
None.
Conflicts of Interest
The authors declare no conflict of interest.
Data Availability Statement
The data that support the findings of this study are available from the corresponding author upon reasonable request.
Received: 22 March 2025
Accepted: 20 June 2025
Published on line: 13 January 2026
Reference
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