100: Robotic Subtotal Gastrectomy with D2 Lymph Node Dissection using Indocyanine Green Sentinel Lymphatic Mapping

Saturday, March 25, 2023

9:48 AM – 10:01 AM

Location: Veterans Memorial Auditorium

Video Presenter(s)

Pamela W. Lu, MD, MPH (she/her/hers)

Clinical fellow
MD Anderson Cancer Center, Texas, United States

Disclosure(s): No financial relationships to disclose

First Author(s)

Pamela W. Lu, MD, MPH (she/her/hers)

Clinical fellow
MD Anderson Cancer Center, Texas, United States

Disclosure(s): No financial relationships to disclose

Author(s)

YH

Yuki Hirata, MD

Postdoctoral fellow
MD Anderson Cancer Center, United States

Disclosure information not submitted.
PM

Paul Mansfield, MD

Professor
The University of Texas MD Anderson Cancer Center, United States

Disclosure information not submitted.
Brian Badgwell, MD, MS

Professor
The University of Texas MD Anderson Cancer Center
Houston, Texas, United States

Disclosure(s): No financial relationships to disclose
Naruhiko Ikoma, MD, MS

Assistant Professor
The University of Texas MD Anderson Cancer Center
Houston, Texas, United States

Disclosure information not submitted.

Disclosure(s):

Pamela W. Lu, MD, MPH: No financial relationships to disclose

Brian Badgwell, MD, MS: No financial relationships to disclose

Introduction: Adequate lymphadenectomy for gastric adenocarcinoma has implications for survival after gastrectomy. The robotic approach and use of indocyanine green (ICG) have been shown to be useful tools in performing D2 lymphadenectomy during gastrectomy. Here we show our approach to the robotic subtotal gastrectomy with D2 lymphadenectomy utilizing intraoperative ICG sentinel lymphatic mapping.

Methods: A 59 year-old male patient was diagnosed with adenocarcinoma of the distal stomach, with clinical stage T3N0M0. He underwent neoadjuvant chemoradiation and chemotherapy, followed by robotic subtotal gastrectomy.

Results: After induction of anesthesia, ICG solution is injected in the peritumoral submucosal layer via endoscopy. This assists with tumor localization, determination of appropriate transection lines for adequate margin, and identification of lymph nodes that directly receive lymphatic drainage. During inferior pyloric lymph node dissection (station #6), fluorescent imaging identified an ICG positive lymph node deeper in the mesentery, which was then targeted for removal. The central (D2) lymph node dissection was then performed to include left gastric (#7), common hepatic (#8a), celiac (#9), and splenic artery (#11p) lymph nodes. An important oncological concept is to complete clearance of the lesser curvature of the stomach (#1 and 3) even for distal gastric cancer. Lesser curvature dissection is achieved first on the posterior stomach, then the anterior stomach, extending up to the GEJ proximally. The stomach is then divided at the previously marked transection line with the stapler. The Roux limb is created and a stapled retrocolic gastrojejunostomy at the posterior stomach along the greater curvature is performed. Postoperatively patient did well and was discharged on postoperative day 3.

Conclusions: In this video we demonstrate robotic technique for subtotal gastrectomy with D2 lymphadenectomy utilizing intraoperative ICG sentinel lymphatic mapping. This approach has the potential to improve oncological outcomes by ensuring removal of lymph nodes that directly receive lymphatic drainage from the tumor.

Learning Objectives:

Describe the oncological concept of the D2 lymph node dissection for gastric cancer resection
Describe the use of peritumoral ICG injection to help define proximal transection line and sentinel lymphatic mapping in gastrectomy for cancer
Describe steps of a robotic retrocolic Roux -en - Y reconstruction after subtotal gastrectomy