Role of 3DCT in laparoscopic total gastrectomy with spleen-preserving splenic lymph node dissection

Abstract

AIM: To investigate whether computed tomography with 3D imaging (3DCT) can reduce the risks associated with laparoscopic surgery.

METHODS: We performed a retrospective case-control study evaluating the efficacy of preoperative 3DCT of the splenic vascular anatomy on surgical outcomes in patients undergoing laparoscopic spleen-preserving splenic hilar lymph node (LN) dissection for upper- or middle-third gastric cancer. The clinical records of 312 patients with upper- or middle-third gastric cancer who underwent laparoscopic total gastrectomy with spleen-preserving splenic lymph node dissection in our hospital from January 2010 to June 2013 were collected, and the patients were divided into two groups (group 3DCT vs group NO-3DCT) depending on whether they underwent 3DCT or not. Clinicopathologic characteristics, operative and postoperative measures, the number of retrieved LNs, and complications were compared between these two groups. Patients were further compared regarding operative and postoperative measures, the number of retrieved LNs, and complications when subdivided by body mass index ( ≥ 23 and < 23 kg/m²) and the number of operations performed by their surgeon (≤ 40 vs > 40).

RESULTS: The mean numbers of retrieved splenic hilar LNs were similar in patients in group 3DCT and group NO-3DCT (2.85 ± 2.33 vs 2.48 ± 2.18, P > 0.05). The operation time and blood loss at the splenic hilum were lower in the patients in group 3DCT (P < 0.05 each). The postoperative recovery time and complication rates were similar between the two groups (P > 0.05 each). Subgroup analysis showed that the operation time at the splenic hilum in patients with a BMI ≥ 23 kg/m² was significantly shorter in patients in group 3DCT than in group NO-3DCT (20.27 ± 5.84 min vs 26.17 ± 11.01 min, P = 0.003). In patients with a BMI < 23 kg/m², the overall operation time (171.8 ± 26.32 min vs 188.09 ± 52.63 min, P = 0.028), operation time at the splenic hilum (19.39 ± 5.46 min vs 23.74 ± 9.56 min, P = 0.001), and blood loss at the splenic hilum (13.27 ± 4.96 mL vs 17.98 ± 8.12 mL, P = 0.000) were significantly lower in patients in group 3DCT than in group NO-3DCT. After 40 operations, the operation time (18.63 ± 4.40 min vs 23.85 ± 7.92 min, P = 0.000) and blood loss (13.10 ± 4.17 mL vs 15.10 ± 4.42 mL, P = 0.005) at the splenic hilum were significantly lower in patients who underwent 3DCT, but there were no significant between-group differences prior to 40 operations.

CONCLUSION: 3DCT is critical for surgical guidance to reduce the risks of splenic LN dissection. This method may be important in safely facilitating laparoscopic spleen-preserving splenic LN dissection.

Keywords: Stomach neoplasms, Spleen preservation, Laparoscopy, Lymph node dissection, Computed tomography angiography with three-dimensional imaging

Core tip: The JGCA guidelines recommend splenic hilar lymph node (LN) dissection in patients with upper- and middle-third advanced gastric cancer. However, the surgery is made more difficult by anatomic complications of the vessels around the stomach, particularly the splenic vessels, which are located in a narrow, deep space. The inability to intuitively judge the shape of the splenic vessels increases the likelihood of vascular injury. Preoperative assessment of the splenic vascular anatomy at the splenic hilum is important for the safe and rapid performance of laparoscopic spleen-preserving splenic hilar LN dissection. Computed tomography with 3D imaging can be used for surgical guidance to reduce the risks of splenic LN dissection.