Gastric Cancer (1999) 2: 230–234  1999 by International and Japanese Gastric Cancer Associations Technical note Laparoscopic total gastrectomy with distal pancreatosplenectomy and D2 lymphadenectomy for advanced gastric cancer Ichiro Uyama, Atsushi Sugioka, Junko Fujita, Yoshiyuki Komori, Hideo Matsui, and Akitake Hasumi Department of Surgery, Fujita Health University, School of Medicine, 1-98 Dengakugakubo, Kutsukake-cho, Toyoake, Aichi 470-1192, Japan Patients We performed this surgery in two men, aged 71 years and 50 years, respectively. In both of these patients, the gastroendoscopic findings were advanced gastric cancer (c type 2) located in the upper portion. According to the Japanese classification of gastric carcinoma (JCGC) by the Japanese Research Society for Gastric Cancer [9] and the Japanese Gastric Cancer Association [10], both patients’ clinical findings were cT2, cN0, cH0, cP0, and cM0, cStage IB. We explained the operative procedure and the ad- vantages and risks, and our experience with laparo- scopic surgery, to the patients preoperatively. Both patients were notified of their cancer diagnoses preoperatively. Surgical technique The numbers and groups of regional lymph nodes were defined according to the JCGC. General anesthesia was induced and the patient was placed in the reverse Trendelenburg position with the legs apart so that the transverse colon and small bowel fell toward the lower quadrant. The surgeon stood on the patient’s right, with the first assistant on the patient’s left, and the camera operator stood between the patient’s legs. After pneumoperitoneum was established using the open technique, six ports were placed, consisting of bi- lateral subcostal, bilateral low abdominal, subxiphoidal, and supraumbilical ports (12-mm each). A flexible electrolaparoscope (Fujinon, Tokyo, Japan) was intro- duced through the supraumbilical port. The gastrectomy began with the mobilization of the greater curvature along the transverse colon, carried out with ultrasonic shears (laparoscopic coagulating shears [LCS]; Ethicon Endo-Surgery, Cincinnati, OH, Abstract: The standard lymph node dissection for advanced gastric cancer is a D2 dissection. Although D2 laparoscopy-assisted total gastrectomy with distal pancreatosplenectomy has been reported, no studies have reported a completely intra- abdominal laparoscopic approach, because of the technical difficulty of the procedure. We successfully performed this novel procedure in two patients with advanced gastric cancer located in the upper portion of the stomach. In fact, this surgery is technically feasible, and has a potential curability comparable with that of open surgery. Key words: laparoscopic surgery, total gastrectomy, pancreatosplenectomy, lymph node dissection, gastric cancer Introduction In recent years, laparoscopic surgery has been used in the treatment of early gastric malignancies [1–6], al- though there are a few reports of laparoscopic radical gastrectomy for advanced gastric cancer [7,8]. Although the D2 laparoscopy-assisted total gastrectomy with distal pancreatosplenectomy was reported, by Azagra et al. [7], no studies have reported a completely laparoscopic approach. Recently, we successfully performed completely intra-abdominal laparoscopic total gastrectomy with distal pancreatosplenectomy and D2 lymphadenectomy in two patients with advanced gastric cancer. We de- scribe here our surgical procedure and the initial clinical results. Offprint requests to: I. Uyama Received on Aug. 31, 1999; accepted on Jan. 27, 2000