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Unaided Stapling Technique for Pure Single-Incision Distal Gastrectomy in Early Gastric Cancer: Unaided Delta-Shaped Anastomosis and Uncut Roux-en-Y Anastomosis

Purpose Intracorporeal anastomosis is the most difficult procedure during pure single-incision distal gastrectomy (SIDG) that affects its generalization. We introduced unaided delta-shaped anastomosis (uDelta), a novel anastomosis technique, for gastroduodenostomy after pure SIDG, and compared the results with those of previously reported Roux-en-Y anastomosis (RY). Materials and Methods Between March 2014 and March 2015, SIDG with D1+ lymph node dissection was performed for early gastric cancer through a 2.5-cm transumbilical incision without any additional port. uDelta was performed by the operator alone, without any intracorporeal assistance. Results uDelta was performed on 11 patents, and uncut RY was performed on 5-patients without open or multiport conversion. R0 resection was performed in all cases. No significant differences were observed in mean age and body mass index between patients who underwent uDelta or RY. Mean operation times were 214.5±36.2 minutes for uDelta and 240.8±65.9 minutes for RY, which was not significantly different. Reconstruction time for uDelta was shorter than that for RY, with marginal statistical significance (26.1±8.3 minutes vs. 38.0±9.1 minutes, P=0.05). There were no intraoperative transfusions, 30-day mortality, or anastomosis-related complications in either group. Average length of hospital stay was 8.2±1.9 days in the uDelta group and 7.2±0.8 days in the RY group (P=0.320). Conclusions After carefully considering indications, uDelta can be a feasible and can be a reproducible reconstruction method after SIDG in early gastric cancer.

it is simpler to perform, leads to less anatomical change after anastomosis, allows for more physiological food passage, and confers a lower incidence of internal hernia or adhesion. Consequently, Billroth I is the most common anastomosis technique used after distal gastrectomy in Korea and Japan, even among expert groups. 10,11 To achieve intracorporeal Billroth I anastomosis in laparoscopic surgery, delta-shaped anastomosis for gastroduodenostomy using linear staplers was introduced. Since then, this has become the most popular technique for intracorporeal gastroduodenostomy, and has shown acceptable postoperative results. 12,13 However, to perform this type of anastomosis, advanced laparoscopic cooperation between the operator and the assistant is essential. When performing pure SIDG, such advanced cooperation is nearly impossible because of the absence of additional ports, the collision of instruments, and narrow working space. To date, only two authors have reported their initial experience with or modification of Billroth I anastomosis after SIDG, and the reproducibility or generalization of gastroduodenostomy in pure SIDG has been controversial until recently. 7,14,15 On the basis of our experience with SIDG, we introduced unaided delta-shaped anastomosis (uDelta), a novel technique for gastroduodenostomy, without any additional port or intracorporeal assistance for pure SIDG, and compared the results with those of previously reported RY technique.

Patients
We retrospectively reviewed the clinicopathological data of pa- Using a single incision site without any additional port or assistance, laparoscopic distal gastrectomy with D1+ lymph node dissection is performed according to the Japanese gastric cancer treatment guidelines. 16

Uncut Roux-en-Y anastomosis surgical technique
The proximal jejunum, 20 cm below the ligament of Treitz, is harvested extracorporeally through a single incision site. This Peterson's space is closed using a barbed suture.

Results
The uDelta procedure was performed in 11 patients, and RY was performed in 5 patients ( Table 1) 17 There was no significant difference in age, sex, and body mass index between the uDelta and RY groups. Fig. 2 shows the number of examined lymph nodes at each lymph node station after total 16 cases of SIDG with D1+ lymph node dissection. Fig. 3 shows a series of average operation times for  each SIDG case, along with each patient's body mass index. Table 2 shows that the operation time for the uDelta procedure was shorter

Discussion
In order to generalize a new procedure such as SIDG, the simplicity, safety, and reproducibility of the whole procedure including reconstruction should be evaluated and compared with a conventional one. Therefore, to consider procedure generalization, gastroduodenostomy or gastrojejunostomy should be evaluated equivocally, not only after conventional open surgery or TLDG but also after SIDG. Compared with gastroduodenostomy, gastrojejunostomy can be relatively easily performed, and most studies describing the initial experience with SIDG had used gastojejunostomy. 8,18,19 A recent retrospective comparative study reported that SIDG with RY resulted in better short-term outcomes than TLDG in terms of postoperative pain, estimated blood loss, inflammatory reaction, and cosmetic results. 9   We introduced the uDelta anastomosis under the direct visualization of a flexible scope and without any additional port or intracorporeal assistance grasper. In short, our novel method is a modification of the way how delta-shaped anastomosis is performed which is optimized for SIDG, and the anatomical results after anastomosis are similar to those following the original delta-shaped anastomosis procedure. Therefore, postoperative outcomes would be easily expected based on several previous reports. 13,21 Our method is characterized by 1) appropriate 'aiding' stitches as assistance through the single port, and 2) simultaneous manipulation of the linear stapler and those stitches. In single-port surgery, intracorporeal suturing and knot-tying is usually considered a more complicated technique than in converntional laparoscopic surgery.
However, our technique requires only simple suturing at appropriate points without intracorporeal tying. Here, the simultaneous manipulation of the linear stapler using aiding stitches substitute the role of advanced assistance in TLDG. Finally, the operator can control the whole anastomosis procedure himself without further collision among instruments or obstacles to the laparoscopic view.
This 'unaided procedure' leads to a simple and easily reproducible technique. In addition, this procedure can be effectively applied to multiport TLDG, especially when advanced assistance is not available. Whether the surgical team is expert or not, the application of our procedure to SIDG as well as TLDG can be expected to result in consistent anastomosis outcomes as well as a more standardized laparoscopic procedure.
In our early experience, one patient was readmitted to the hospital because of splenic artery pseudoaneurysm and required reoperation with intensive care. This type of unique complication might result from thermal damage by an ultrasonic energy device, and was previously reported at the same vessel (splenic artery) in a large-scale study of laparoscopic distal gastrectomy with lymph node dissection. 22 In particular, the use of an energy-based device should be considered much more cautiously in SIDG because no effective assistance is available to avoid possible thermal injury to adjacent tissues, including major vessels. According to Japanese treatment guidelines for performing distal gastrectomy, dissection Values are presented as mean±standard deviation or number only . *One patient was managed by simple observation, and the other patient by ultrasonography-guided percutaneous aspiration (single aspiration). † Pseudoaneurysmal bleeding at splenic artery.
around the splenic artery is not mandatory. 16