Prevention of Internal Hernia During Robotic Total Gastrectomy for Gastric Cancer.

Background: Postoperative internal hernia (IH) is a potentially life-threatening acute protrusion of viscus through an iatrogenic mesenteric defect. In our retrospective study of 1943 consecutive gastric cancer (GC) patients who had undergone surgery, the incidence of IH after laparoscopic total gastrectomy (LTG) was 4.9%.1 This high incidence seems to be caused by decreased adhesion formation after LTG. There is no consensus regarding orifice management during robotic total gastrectomy (RTG). We therefore developed a new procedure for IH prevention during RTG.

Methods: We performed RTG with antecolic Roux-en-Y reconstruction using the da Vinci S system (Intuitive, Sunnyvale, CA). We chose an intracorporeal side-to-side esophagojejunostomy (overlap method).2 First, mesenteric defect of jejunojejunostomy was closed under direct vision following retrieval of the stomach. Second, the esophagus hiatus and Petersen's defect were closed under laparoscopic vision using robotic suture.3 Finally, the duodenal stump and the Roux limb were fixed to prevent torsion of the Roux limb.

Results: We performed this procedure on five patients between May and October 2017. The median duration of surgery was 395 min (range, 319-442 min), median bleeding was 60 ml (range, 35-140 ml). There were no anastomosis-related complications higher than Clavien-Dindo grade II in any patients.4 Although the follow-up period is less than 1 year, no IH after RTG has been observed in any patients.

Conclusion: Regarding short-term surgical outcomes, this procedure is recommended for GC patients who undergo RTG. However, more long-term follow-up for patients who have undergone RTG with closure of all mesenteric defects is required.