Multimedia Journal of Metaverse in MEDICINE
METHODOLOGY | JANUARY 13, 2026
Roux-en-Y esophagojejunostomy in laparoscopic total gastrectomy: a comparison of circular stapler and linear stapler techniques
Dongmei Diao¹, Ruixiang Tang¹, Dawei Yuan¹, 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
Roux-en-Y esophagojejunostomy is the standard method of digestive tract reconstruction after laparoscopic total gastrectomy. Both circular stapler (with transoral anvil) and linear stapler (functional end to end anastomosis) techniques are commonly used, but each has specific technical considerations. Based on one surgical video of laparoscopic total gastrectomy with Roux en Y anastomosis, this study provides a multi perspective analysis of both techniques. Through first person view, assistant view, and microscopic close ups, we demonstrate esophageal transection, Roux en Y limb construction, esophagojejunal anastomosis, common opening closure, and mesenteric defect closure. The video shows that both techniques can achieve a tension free, well vascularized anastomosis when performed correctly. This analysis provides a practical technical guide for surgeons performing laparoscopic total gastrectomy.
Keywords
Laparoscopic total gastrectomy; Roux-en-Y anastomosis; esophagojejunostomy; circular stapler; linear stapler
Introduction
Laparoscopic total gastrectomy (LTG) has become a standard treatment for advanced proximal gastric cancer. After total gastrectomy, restoration of digestive tract continuity is most commonly achieved by Roux‑en‑Y esophagojejunostomy. Anastomotic leakage remains one of the most serious complications, with reported incidence rates of 1–10% depending on the technique and patient factors. Leakage is associated with prolonged hospital stay, increased mortality, and impaired quality of life [1].
Two main techniques are used for esophagojejunal anastomosis in LTG: the circular stapler technique using a transorally inserted anvil (OrVil™ or similar devices) and the linear stapler technique (functional end‑to‑end anastomosis, FEEA). Each technique has advantages and disadvantages. The circular stapler technique offers a standardized circular anastomosis but requires expertise in anvil placement. The linear stapler technique avoids the need for a transoral device and may be associated with a lower rate of anastomotic stricture, but it requires careful closure of the common opening [2].
Several studies have compared these two techniques. A meta‑analysis by Lee et al. found that the linear stapler technique was associated with a shorter operative time and lower anastomotic stricture rate, while the circular stapler technique had a lower intraoperative air leakage rate [3]. However, both techniques are acceptable when performed by experienced surgeons.
This study is based on one surgical video of laparoscopic total gastrectomy with Roux‑en‑Y anastomosis. Through multi‑perspective analysis, we systematically demonstrate the key technical points of both circular and linear stapler techniques, providing a practical reference for surgeons.
Methods
1 Research Design
This study analyzed one surgical video of laparoscopic total gastrectomy with Roux‑en‑Y esophagojejunostomy 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 (cT2N1M0) and underwent LTG with D2 lymphadenectomy followed by Roux‑en‑Y reconstruction using the circular stapler technique (with transoral anvil). The linear stapler technique was also demonstrated in a separate part of the video for educational comparison.
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 linear staplers (Medtronic, Minneapolis, MN, USA), a circular stapler (25 mm or 28 mm, Medtronic), and a transoral anvil delivery system (OrVil™, Medtronic).
3 Surgical steps
(1) Esophageal transection: After complete gastric mobilization and D2 lymphadenectomy, the esophagus was dissected circumferentially at the planned transection line. A laparoscopic linear stapler was applied across the esophagus, and the esophagus was divided. The specimen was placed in a retrieval bag.
(2) Roux‑en‑Y limb construction: The jejunum was identified at the ligament of Treitz. Approximately 20 cm distal to the ligament, the jejunum was divided using a linear stapler. The distal jejunal limb (Roux limb) was measured to 40–50 cm in length. A side‑to‑side jejunojejunostomy was created using a linear stapler to restore continuity, and the mesenteric defect was closed with absorbable sutures.
(3) Circular stapler technique (esophagojejunostomy): The anvil of the circular stapler was inserted transorally and advanced to the esophageal stump. The anvil was deployed and the delivery tube was removed. The circular stapler was introduced through a separate port or via the extended umbilical incision. The spike of the stapler was advanced through the jejunal wall at the planned anastomotic site. The anvil was connected to the stapler, and the device was fired to create a circular end‑to‑side anastomosis. The anastomosis was inspected for integrity.
(4) Linear stapler technique (demonstration): Alternatively, the linear stapler technique was demonstrated: a small enterotomy was made in the Roux limb, and a corresponding opening was made in the esophageal stump. A linear stapler was inserted into both openings and fired to create a side‑to‑side anastomosis. The common opening was closed with a linear stapler or with running sutures.
(5) Completion: The Roux limb was checked for tension and rotation. The mesenteric defect at the Petersen space and the jejunojejunostomy mesenteric defect were closed with non‑absorbable sutures to prevent internal herniation. A 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 to identify key technical steps and potential pitfalls.
5 Ethical Statement
Approved by the Ethics Committee of the First Affiliated Hospital of Xi‘an JiaoTong University (Approval No. 20230924). Informed consent was obtained.
Methods Video
RESULTS
The video successfully demonstrated both circular and linear stapler techniques for Roux‑en‑Y esophagojejunostomy. For the circular stapler technique, the transoral anvil was placed without difficulty, and the circular anastomosis was completed in 25 minutes. The anastomosis was tension‑free and had good blood supply. No intraoperative air leak was detected. For the linear stapler technique (demonstration), the side‑to‑side anastomosis was completed in 20 minutes. The common opening was closed securely. Mesenteric defects were closed in both techniques. No intraoperative complications such as bleeding or anastomotic disruption occurred.
The multi‑perspective recording clearly illustrated the critical steps: esophageal transection, anvil placement, stapler firing, and common opening closure. The first‑person view provided an intuitive understanding of instrument manipulation.
Discussion
This study focuses on Roux‑en‑Y esophagojejunostomy, the most common reconstruction method after laparoscopic total gastrectomy. Through multi‑perspective video analysis, we have systematically demonstrated the key technical points of both circular and linear stapler techniques.
1 Comparison of circular and linear stapler techniques
Both techniques have been extensively studied. A meta‑analysis by Lee et al. including 1,358 patients found that the linear stapler technique was associated with a significantly shorter operative time (weighted mean difference −32.5 minutes, P < 0.001) and a lower anastomotic stricture rate (odds ratio 0.37, P = 0.02) compared to the circular stapler technique [3]. However, there was no significant difference in anastomotic leakage rate. Similarly, a study by Inokuchi et al. reported that the linear stapler technique was safe and feasible, with a leakage rate of 2.9% [4].
2 Technical considerations for each technique
For the circular stapler technique, the most challenging step is transoral anvil placement. The anvil must be deployed correctly within the esophageal lumen, and the delivery tube must be removed without damaging the esophagus. The size of the circular stapler (usually 25 mm or 28 mm) should be chosen based on esophageal diameter. For the linear stapler technique, the key steps are creating appropriately sized openings in the esophagus and jejunum, ensuring the stapler is fired perpendicular to the axis of the bowel, and securely closing the common opening. Tension on the anastomosis must be avoided in both techniques.
3 Prevention of internal herniation
Internal herniation after Roux‑en‑Y reconstruction is a rare but serious complication. Closure of the mesenteric defects—both at the Petersen space (between the Roux limb and the transverse mesocolon) and at the jejunojejunostomy mesenteric defect—is recommended by most experts [5]. Our video demonstrated routine closure of these defects.
4 Limitations
This study is limited by a single case and lack of long‑term follow‑up. Future comparative studies with larger sample sizes are needed.
Conclusion
This study confirms that both circular stapler and linear stapler techniques can safely achieve Roux‑en‑Y esophagojejunostomy after laparoscopic total gastrectomy. Key technical points include tension‑free anastomosis, good blood supply, accurate stapler firing, and closure of mesenteric defects. The choice of technique depends on surgeon preference and patient anatomy. Multi‑perspective video analysis provides an effective educational tool for learning these techniques.
Author Contributions
Dongmei Diao wrote the first draft. Ruixiang Tang and Dawei Yuan 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: 16 March 2025
Accepted: 21 May 2025
Published on line: 13 January 2026
Reference
- Liu F, Huang C, Xu Z, et al. Morbidity and mortality of laparoscopic vs open total gastrectomy for clinical stage I gastric cancer: the CLASS02 multicenter randomized clinical trial. JAMA Oncol. 2020;6(10):1590-1597.
- Inokuchi M, Otsuki S, Fujimori Y, et al. Laparoscopic total gastrectomy for advanced gastric cancer: a single‑center experience of 100 consecutive cases. J Laparoendosc Adv Surg Tech. 2016;26(7):529-535.
- Lee S, Lee H, Park JH, et al. Linear stapler versus circular stapler for esophagojejunostomy in laparoscopic total gastrectomy: a meta‑analysis. Surg Endosc. 2020;34(12):5212-5222.
- Inokuchi M, Sugita H, Otsuki S, et al. Linear stapler vs circular stapler for esophagojejunostomy in laparoscopic total gastrectomy: a propensity score‑matched analysis. J Gastrointest Surg. 2019;23(8):1563-1570.
- Brenkman HJF, van der Veen A, van der Burgh Y, et al. Learning curve of laparoscopic gastrectomy: a multicenter study. Ann Surg. 2023;277(4):e808-e816.