Multimedia Journal of Metaverse in MEDICINE
METHODOLOGY | JANUARY 13, 2026
Laparoscopic radical total gastrectomy: a complete procedural workflow and quality control
Lei Meng¹, Gang Xu¹, Ruixiang Tang¹, 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 radical total gastrectomy (LTG) with D2 lymphadenectomy is the standard curative treatment for advanced proximal gastric cancer. The procedure involves complete gastric mobilization, D2 lymphadenectomy, and Roux‑en‑Y esophagojejunostomy. Due to the complexity of these steps and the proximity of critical structures, quality control at each phase is essential for optimal outcomes. Based on one surgical video of laparoscopic radical total gastrectomy, this study provides a multi‑perspective analysis of the complete procedural workflow, including intraoperative staging, greater curvature mobilization, suprapancreatic lymphadenectomy, esophageal transection, Roux‑en‑Y reconstruction, and specimen retrieval. Through first‑person view, assistant view, and microscopic close‑ups, we demonstrate the key technical points, common pitfalls, and quality control measures for each step. This video‑based analysis provides a comprehensive technical framework for surgeons performing laparoscopic radical total gastrectomy.
Keywords
Laparoscopic radical total gastrectomy; D2 lymphadenectomy; Roux‑en‑Y anastomosis; procedural workflow; quality control
Introduction
Laparoscopic radical total gastrectomy (LTG) with D2 lymphadenectomy has become the standard of care for advanced proximal gastric cancer. Compared to open total gastrectomy, LTG offers reduced blood loss, faster recovery, and shorter hospital stay without compromising oncological outcomes [1]. A recent network meta‑analysis including 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) [2].
However, LTG is a technically demanding procedure with a steep learning curve. The procedure involves multiple complex steps: laparoscopic exploration and staging, greater curvature mobilization, suprapancreatic D2 lymphadenectomy (stations No. 7, 8a, 9, 11p), esophageal transection, Roux‑en‑Y esophagojejunostomy, and specimen retrieval. Each step requires precise anatomical knowledge and meticulous surgical technique. Quality control at each phase is essential to minimize complications and ensure oncological radicality [3].
The learning curve for laparoscopic gastrectomy has been well studied. Brenkman et al., in a multicenter study of 540 patients, found that the overall complication rate reached a plateau after 20 cases, with the most challenging aspects related to dissection rather than reconstruction [4].
This study is based on one surgical video of laparoscopic radical total gastrectomy. Through multi‑perspective analysis, we systematically demonstrate the complete procedural workflow with an emphasis on quality control measures at each step, providing a comprehensive technical framework for surgeons.
Methods
1 Research Design
This study analyzed one surgical video of laparoscopic radical total gastrectomy performed at the Department of Surgical Oncology, the First Affiliated Hospital of Xi‘an JiaoTong University in June 2024. The patient was diagnosed with advanced proximal gastric cancer (cT3N1M0) and underwent curative‑intent LTG with D2 lymphadenectomy and Roux‑en‑Y reconstruction. Cases with distant metastasis or tumor invasion of adjacent organs (pancreas, 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), laparoscopic linear staplers (Medtronic), a circular stapler with transoral anvil (OrVil™, Medtronic), and an ICG near‑infrared fluorescence imaging system (Karl Storz).
3 Surgical steps
(1) Laparoscopic exploration and staging: The abdominal cavity was systematically inspected for peritoneal metastases, liver metastases, and ascites. The tumor location and local invasion were assessed.
(2) Greater curvature mobilization and omental bursa entry: The greater omentum was divided lateral to the gastroepiploic arcade. The avascular area of the gastrocolic ligament was opened to enter the omental bursa. The short gastric vessels were divided using ultrasonic shears.
(3) Suprapancreatic D2 lymphadenectomy (pancreas‑compressionless technique): The anterior surface of the pancreas was exposed. The common hepatic artery, splenic artery, left gastric artery, and portal vein were identified. The LGA was clipped and divided at its root. Lymph nodes along the CHA (No. 8a), celiac axis (No. 9), and proximal SA (No. 11p) were dissected en bloc. Direct pancreatic compression was avoided. ICG fluorescence was used to guide lymph node identification.
(4) Esophageal transection: The esophagus was circumferentially dissected at the planned transection line (approximately 2–3 cm above the esophagogastric junction). A laparoscopic linear stapler was applied, and the esophagus was divided.
(5) Roux‑en‑Y esophagojejunostomy (circular stapler technique): The jejunum was divided 20 cm distal to the ligament of Treitz. The Roux limb (40–50 cm) was brought up to the esophageal stump. The anvil was placed transorally, and a circular end‑to‑side anastomosis was created. The anastomosis was inspected for leakage. Mesenteric defects (Petersen space and jejunojejunostomy defect) were closed.
(6) Specimen retrieval and drainage: The resected specimen was placed in a retrieval bag and removed through a protected mini‑laparotomy (4–5 cm) in the upper midline. One drain was placed near the esophagojejunal anastomosis.
4 Data collection and analysis
The surgery was recorded from first‑person, assistant, and microscopic close‑up perspectives. Two independent surgical oncologists reviewed the video and annotated each step. Key quality indicators included: completeness of D2 lymphadenectomy, number of lymph nodes retrieved, pancreatic integrity, portal vein integrity, anastomotic integrity, and intraoperative blood loss.
5 Ethical Statement
Approved by the Ethics Committee of the First Affiliated Hospital of Xi‘an JiaoTong University (Approval No. 20250923). Informed consent was obtained.
Methods Video
RESULTS
The video successfully demonstrated the complete procedural workflow of laparoscopic radical total gastrectomy. All steps were completed without intraoperative complications. The D2 lymphadenectomy included complete clearance of stations No. 1, 2, 3, 4sa, 4sb, 4d, 5, 6, 7, 8a, 9, 11p, and 12a. A total of 42 lymph nodes were retrieved, including 15 from the suprapancreatic region. The “pancreas‑compressionless” technique was successfully applied; the pancreas was intact with no thermal injury. The portal vein and common hepatic artery were preserved. The Roux‑en‑Y esophagojejunostomy was tension‑free with good blood supply; no air leak was detected. Total operative time was 260 minutes, with an estimated blood loss of 90 mL.
The multi‑perspective recording provided clear visualization of each step. The first‑person view allowed trainees to see the surgeon’s instrument handling, while the microscopic close‑up revealed the delicate dissection planes in the suprapancreatic region. ICG fluorescence imaging enhanced visualization of lymphatic drainage.
Discussion
This study provides a complete procedural workflow for laparoscopic radical total gastrectomy with D2 lymphadenectomy and Roux‑en‑Y reconstruction. Through multi‑perspective video analysis, we have systematically demonstrated the key technical points and quality control measures for each step.
1 Quality control in LTG
Quality control in LTG encompasses several domains: oncological quality (complete D2 lymphadenectomy, adequate lymph node yield, negative resection margins), technical quality (no pancreatic injury, no portal vein injury, intact anastomosis), and perioperative outcomes (low blood loss, no conversions, no major complications) [5]. In our video case, all quality indicators were met. The lymph node yield of 42 exceeds the minimum requirement of 15 nodes recommended by the Japanese Gastric Cancer Treatment Guidelines [3].
2 The importance of a standardized workflow
A standardized procedural workflow reduces cognitive load, minimizes errors, and facilitates teaching. The workflow demonstrated in our video follows the sequence recommended by major gastric cancer guidelines: exploration → greater curvature mobilization → suprapancreatic dissection → lesser curvature dissection → esophageal transection → reconstruction → specimen retrieval [3]. Each step flows logically into the next, and critical structures are systematically identified and protected.
3 Comparison with existing literature
Our outcomes are consistent with published series. Liu et al., in the CLASS02 trial, reported that laparoscopic total gastrectomy for clinical stage I gastric cancer had a morbidity of 18.4% and no mortality, with a mean lymph node yield of 32.7 [5]. For advanced gastric cancer, Illuminati et al. reported that laparoscopic‑assisted total gastrectomy achieved a lymph node yield of 29, compared to 34 for open surgery (P < 0.01) [6]. Our lymph node yield of 42 is favorable, likely due to the use of ICG fluorescence guidance.
4 Learning curve implications
The complete workflow of LTG requires mastery of multiple individual skills. Brenkman et al. showed that the learning curve for laparoscopic gastrectomy plateaus after 20 cases, but this likely varies by the complexity of the case and the surgeon’s prior experience [4]. Our step‑by‑step video analysis, with multi‑perspective views, is designed to shorten the learning curve by providing a clear visual reference.
5 Limitations
This study is limited by a single case and lack of long‑term follow‑up. The findings may not be generalizable to all patients, particularly those with larger tumors or prior abdominal surgery. Future studies should include larger cohorts and long‑term survival data.
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
Lei Meng wrote the first draft. Gang Xu and Ruixiang Tang 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 April 2025
Accepted: 15 June 2025
Published on line: 13 January 2026
Reference
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