Overlap Anastomosis for Digestive Reconstruction during Laparoscopic Distal Gastrectomy with Intensive Regional Lymph Node Dissection: Physiological Impact of Preserving the Mesenteric Autonomic Nerves in the Lifted Jejunal Limb

Figure 1

(a) Camera port positioned via the umbilicus; a total of five ports (blue lines) were placed. A 45 mm long incision extending from the umbilicus (red line) was made. (b) Approximately 20 cm of jejunum was sacrificed (shaded area), with the sacrificed length decided based on the segment’s jejunal vessels (red solid lines). The jejunum was sacrificed (blue dotted line), and then, the mesojejunum was transected to lift the jejunal limb (red dotted line). (c) To preserve the distal mesojejunal autonomic nerves, the jejunum was sacrificed as close to the jejunal wall as possible (blue dotted line). Branches from the marginal vessels were carefully sealed in three groups using an advanced energy device to prevent both unexpected shortening of the mesojejunum and thermal nerve damage (blue dotted lines). (d) The sacrificed jejunum contributed well to ideal mesojejunal margins in the lifted jejunal limb (blue arrow). The jejunal limb could be lifted with no tension on the retracted mesojejunum (red arrows).

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