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 4

Overlap anastomosis involves linear-stapled reconstruction using an isoperistaltic side-to-side approach. Functional and surgical anastomoses are distinct for overlap anastomosis, and postoperative passage depends on patency at the functional anastomosis (blue area), not on the length of the staple line at the surgical anastomosis (red area). The endostapler entry site was carefully closed with layer-to-layer sutures using running sutures in the mucosa and interrupted sutures in the seromuscular layer using absorbable monofilament suture. Longer staple lines may result in a postoperative pouch-like dilatation in the lifted jejunal limb; therefore, we set the length of the staple line at 35–40 mm. A defect behind the staples at the tip of endostapler was closed. Inverted staple lines were covered. Even subtle tension on the mesojejunum was avoided as much as possible by sacrificing the jejunum (blue solid arrow), and a well-defined mesojejunum in the lifted jejunal limb (red dotted arrow) effectively preserved the mesenteric autonomic nerves. Mesenteric gaps were closed routinely.