Surgical procedures

The patient was placed in supine reverse Trendelenburg position. The first port was inserted infra-umbilically with the open Hasson technique. The other four ports were inserted with laparoscopic visualization in the upper abdomen. Mobilization of the stomach and duodenum was performed along with en-bloc lymph node dissection including partial omentectomy. The mobilized duodenum and stomach were transected with a laparoscopic linear stapler (iDrive; Covidien, North Haven, CT, USA). After retrieving the specimen, reconstruction was performed. The ligament of Treitz was exposed by retracting the transverse colon, and the jejunum at 20 cm distal to the ligament of Treitz was dragged up towards the stomach. Enterotomy incisions were made in the jejunum and stomach for gastrojejunostomy (GJ) using a 60-mm linear endostapler (Fig. 1A), and the common entry hole was closed with self-retaining sutures (V-Loc; Covidien) (Fig. 1B). At 45 cm from the GJ in the efferent loop, and at 10–15 cm from the ligament of Treitz in the afferent loop, enterotomy incisions were made and Braun anastomosis was performed using a 45-mm linear endostapler (Fig. 2A), and V-loc for the common entry hole (Fig. 2B). At 2 to 3 cm from the GJ, a 45-mm no-knife stapler (ATS45NK: 45 mm ETS Articulating Linear Cutter (No Knife); Ethicon, Cincinnati, OH, USA) is used for the uncut procedure (Fig. 3). Closure of the jejunal mesenteric defect was routinely performed.

Construction of gastrojejunostomy. (A) Intracorporeal isoperistaltic side-to-side gastrojejunostomy is made using 60-mm linear stapler and (B) the common entry hole is closed with self-retaining sutures.

Construction of jejunojejunostomy. (A) Intracorporeal Braun anastomosis is done using 45-mm linear stapler and (B) the common entry hole is closed with self-retaining sutures.

Uncut procedure. A 45-mm no knife stapler is used on the afferent loop for the uncut procedure.