Proper liver retraction was a key to the success of the laparoscopic gastrectomy. Our preference is the “V-shape retraction technique” as follows: a straight needle with 2-0 nylon was used to puncture first the upper abdomen and then at the right crus and through the abdominal wall again. It was simple and inexpensive without leaving a scar at the punctured site.

Suprapancreatic lymphadenectomy is one of the most important and technically difficult aspects of laparoscopic gastrectomy. Various approaches, such as right-to-left, left-to-right (left-sided approach), and medial-to-lateral (medial approach), have been reported in conventional laparoscopic gastric surgery, which can be applied to the single port approach. In these approaches, dissection is initially performed at the cranial edge of the pancreas and then proceeds in a dorsal-to-cranial direction. The medial approach is quite effective for complete dissection of the lymph nodes, with dissection of the layer between the adipose tissue (including lymphatic tissue and the autonomic nerve sheath of major arteries) and medial transection of the left gastric artery [12]. We commonly use the cranial-to-caudal approach (cranial approach), in which the mobilization of the stomach and pancreas and the dissection of the cranial side of the station no. 9 lymph nodes are performed prior to the medial approach. We believe that prior dissection of cranial connections between the lymph nodes and the plexus celiacus will make it easier to perform cephalad dissection of the suprapancreatic lymph nodes in the conventional approach.

The patient was placed in the reverse Trendelenburg position. The assistant introduced the intestinal grasping forceps with gauze from the top trocar to retract the stomach caudad. The main surgeon retracted the liver cephalad for retraction of the hepatogastric ligament. The assistant’s forceps were placed between the surgeon’s bilateral forceps. The procedure was performed smoothly without interference of each instrument in this formation, which is a basic positioning for this surgery (Fig. 17.2). The hapatogastric ligament was then dissected towards the esophagus with preservation of the hepatic branches of the vagus nerve (Fig. 17.2). The mesogastrium was retracted anteriorly using a grasper introduced through the right trocar. The peritoneum was incised at the level of the right crus of the diaphragm (Fig. 17.3). This incision continued downward along the right crus up to the celiac artery. The mesogastrium was retracted anteriorly to expose the posterior space. The plane between Gerota’s fascia and Toldt’s fusion fascia could then be identified. This plane is avascular and easily divided. The dissection continued posterior to the Toldt’s fusion fascia going laterally and caudad. By this dissection, both the pancreatic body and stomach were mobilized.

The left gastric artery was carefully grasped and retracted in a ventro-lateral direction. The adipose tissue including the station no. 9 lymph nodes was separated from the outer layer of plexus celiacus, and we identified the three branches of the celiac artery—the left gastric artery, the common hepatic artery, and the splenic artery. If possible, the left gastric artery should be skeletonized distally, clipped, and divided at its origin using a vessel-sealing device or laparoscopic coagulation shears (Fig. 17.4). This adequate separation of the lymph nodes from the nerve increased the movability of the lymph nodes and facilitated the following caudal-to-cranial dissection of the suprapancreatic lymphadenectomy (Fig. 17.5).

The assistant introduced the intestinal grasping forceps with gauze from the top trocar to retract the duodenum caudad and stretch the hepatoduodenal ligament. The main surgeon retracted the right gastric artery in a ventro-lateral direction. The ventral peritoneum was initially incised along the duodenum, and the opening window was spread. Under continuous traction, the peritoneum was incised cephalad along the right edge of the proper hepatic artery up to its bifurcation. Using a combination of gentle force and sharp dissection, the right gastric artery with lymph nodes was swept ventrally and the hepatic plexus swept dorsally. Then the right gastric artery was divided using a vessel-sealing device or laparoscopic coagulating shears (Fig. 17.6).