Combined Endoscopic-laparoscopic Sentinel Lymph Node Navigation Surgery in Early Gastric Cancer

"1. Determination of tumor location and sentinel lymph node: endoscopic staining (2mg indocyanine green, four-quadrant submucosal injection) was used to determine the location of the lesion during laparoscopic surgery combined with endoscopic localization to ensure effective and safe resection margins. The staining technique was used to identify the sentinel lymph nodes basin, and en bloc resection of the lymph node basin biopsy was performed.~2. Standard of lymph node basin dissection: All sentinel nodes are located within the lymphatic basin, which is considered the primary lymphatic drainage area for each patient. Follow the SENORITA trail criteria\[9\], lymphatic basin is delineated by the distribution of dye within the lymphatic channels, as seen in dye mapping. The proximal extent of the lymphatic basin is demarcated by the fatty tissue adjacent to the stomach wall, while the distal boundary is marked by the most distant stained node from the stomach."

Preparation: The patient is positioned supine with general anesthesia. An orogastric tube and Foley catheter are inserted. Antibiotics are administered, and sequential stockings are applied. Port Placement: Pneumoperitoneum is created via a Veress needle at the umbilicus. Working ports are placed in the upper quadrants, with a fifth port for liver retraction. Abdominal Exploration: The abdomen is inspected for metastases, and peritoneal cytology is performed. Dissection and Lymph Node Removal: The lesser omentum is divided near the liver, reaching the cardia and diaphragm. The gastrocolic ligament is divided along the transverse colon. Lymph node dissection begins along the splenic artery, then proceeds to the left gastric artery and celiac nodes. The left gastric vessels are controlled with endoclips.After lymph node dissection, distal subtotal gastrectomy is performed. Digestive tract reconstruction is typically done through a mini-laparotomy.