Laparoscopic gastrectomy is superior to conventional open gastrectomy because it is less invasive, which may lead to smaller wounds, faster recovery, fewer complications, and better cosmetic results. In addition, better clinical efficacy is achieved [1–4]. Currently, reconstruction of the digestive tract following laparoscopic gastrectomy is mostly divided into two categories: laparoscopy-assisted reconstruction and totally laparoscopic reconstruction. With laparoscopy-assisted gastrectomy (LAG), mobilization of the digestive tract, vascular ligation, and lymph node dissection are performed laparoscopically, while resection of the specimen and reconstruction of the digestive tract are performed under direct view through a minilaparotomy made on the epigastrium. The resected specimen mostly has to be removed via the minilaparotomy made on the epigastrium. Furthermore, the anastomosis can be performed with less difficulty, shorter operating time, and lower cost when surgery is performed through minilaparotomy, and this is a safe and feasible method. Thus, LAG has become a common approach in laparoscopic surgery.

Laparoscopic techniques were developed to achieve a radical cure with minimal invasion and to improve postoperative quality of life. Compared with LAG, totally laparoscopic gastrectomy (TLG) is considered to be more minimally invasive and has several superiorities in vision and tension, particularly for obese patients. Therefore, researches on the application of TLG have never stopped.

In 1996, Ballesta-Lopez et al. first reported Billroth-II anastomosis in totally laparoscopic distal gastrectomy (TLDG) for gastric cancer [5]. Uyama et al. first described totally laparoscopic side-to-side esophagojejunostomy after total gastrectomy in 1999 [6]. A method for intracorporeal Billroth-I anastomosis, called delta-shaped gastroduodenostomy (DSG) and using only endoscopic linear staplers, was first reported in 2002 by Kanaya et al. [7]. In 2005, Takaofi et al. proposed a secure technique of intracorporeal Roux-Y reconstruction after laparoscopic distal gastrectomy using linear staplers [8]. Intracorporeal circular stapling esophagojejunostomy using the transorally inserted anvil (OrVil™; Covidien) after laparoscopic total gastrectomy was reported in 2009 by Jeong et al. [9]. With improvements of surgical skills and dedicated intracorporeal devices, such as linear staplers and ultrasonic scalpels, Billroth-I, Billroth-II, and Roux-en-Y reconstruction, which are usually performed by open surgery, can all be performed laparoscopically.

Mobilization of the stomach and lymph node dissection should be carried out completely by laparoscopy to prepare for successful reconstruction of the digestive tract through minilaparotomy. One should try to avoid other redundant operations through the minilaparotomy.

After the distal stomach is freed and the lymph nodes (LNs) are dissected, the intra-abdominal gas is expelled from the trocar, and the laparoscopic instruments are removed. A 5–7-cm midline incision below the xiphoid is made in the epigastrium as an accessory incision. The abdominal cavity is entered layer-by-layer, and the wound protector is placed in position. After complete retrieval of the duodenum from the abdominal cavity, a purse-string clamp is applied to the duodenum 3 cm distal to the pylorus. A Kocher clamp is applied just proximal to the purse-string clamp, and the duodenum is transected between the two clamps. The anvil of a disposable 28- or 29-mm circle stapler is inserted into the disinfected duodenal stump (Fig. 8.1), and a purse-string suture is tied over the anvil. Gastrotomy is performed on the anterior wall 5 cm away from the tumor edge and the shaft of the circular stapler is introduced into the stomach through the gastrotomy. The center rod of the stapler is advanced to penetrate the posterior wall at the greater curvature side of the stomach (Fig. 8.2) and then connected to the anvil placed in the duodenal stump, completing the end-to-side gastroduodenostomy between the duodenal stump and the gastric posterior wall (Fig. 8.3). After checking and confirming the quality of the anastomosis through the gastrotomy under direct view, the stomach is closed 5 cm away from the tumor edge using the extracorporeal linear stapler (Fig. 8.4). The resected distal gastric specimen is sent for histopathological examination. Thus, Billroth-I reconstruction is accomplished (Fig. 8.5). Although the visual field and working space are narrow during laparoscopy-assisted reconstruction, every step of the procedure should be completed under direct view, which avoids iatrogenic injury or uncertain anastomosis caused by blind operation.

After completing lymph node dissection and mobilization of the stomach laparoscopically, the duodenal bulb is transected 3 cm distal to the pylorus using the intracorporeal linear stapler, and the duodenal stump is closed. The laparoscopic instruments are removed, and a 5–7-cm upper midline abdominal incision below the xiphoid is made as an accessory incision. The abdominal cavity is entered layer-by-layer, and the wound protector is placed in position. A purse-string clamp is applied to the distal esophagus 5 cm away from the cardia and the esophagus is transected. Thereafter, a purse-string suture is placed in the disinfected esophageal stump. Once the frozen section confirms negative margins, the anvil of a disposable 25-mm circular stapler is inserted into the esophageal stump (Fig. 8.6), and the purse-string suture is tied over the anvil. The entire gastric specimen is delivered out through the minilaparotomy. The jejunum and the mesentery are cut off 15–20 cm distal to the ligament of Treitz. The body of the circular stapler is inserted into the distal limb of the jejunum, and this section of jejunum is brought up in antecolic fashion to meet the lower end of the esophagus, creating the end-to-side esophagojejunostomy with the jejunum configured in a “J” fashion (Fig. 8.7). The stumps of distal and proximal jejunum are closed respectively using the linear stapler. A side-to-side jejunojejunostomy is performed 40 cm distal to the J-shaped anastomosis under direct view using a linear stapler or hand-sewn suture (Fig. 8.8). The proximal and distal end of the mesojejunum should not be reversed and the mesentery should be maintained without tension, to prevent improperly clamping the surrounding tissues and foreign object. The cutting edge of mesojejunum can then be closed to accomplish the entire procedure of reconstruction.

Reconstruction of the digestive tract should be performed within a certain distance of the normal tissues. The normal tissues at a certain distance from the proximal or distal border of the tumor must be resected according to tumor location and TNM staging. Preoperative laparoscopic exploration is performed first to confirm the tumor site. Patients with T4b tumor, peritoneal implantation, or liver metastasis should be excluded. If it is difficult to identify the tumor site in early tumors during total laparoscopy, intraoperative gastroscopy can be used for accurate positioning to ensure R0 resection of the tumor. Transection of the duodenum, stomach, or esophagus should ensure not only R0 tumor resection but also appropriate anastomotic tension. The resected margins should be confirmed as tumor free, and the margin of the removed specimen must be sent for frozen section analysis prior to proceeding with anastomosis.

Currently, there are a variety of reconstruction methods after TLG for gastric cancer, including Billroth-I anastomosis, Billroth-II anastomosis, and Roux-en-Y reconstruction after TLDG, and functional side-to-side esophagojejunostomy, OrVil™-assisted anastomosis, and overlap anastomosis after totally laparoscopic total gastrectomy (TLTG). Here, the more mature techniques of delta-shaped Billroth-I anastomosis and Billroth-II anastomosis after TLDG, functional side-to-side esophagojejunostomy, and OrVil™-assisted anastomosis after TLTG are described. The patient’s position, surgeons’ locations, and location of trocars are identical to those during the process of lymph node dissection (described in Chap. 3).