Minimally invasive Merendino procedure for a small gastroesophageal junction tumor with ArtiSential articulated instruments (with video)

Abstract

A proximal gastrectomy is sufficient for patients with small gastroesophageal junction (GEJ) tumors. Continuity can be restored with an esophagojejunostomy with jejunal interposition, offering significant functional advantages. However, the primary challenge is creating a mediastinal anastomosis. This multimedia article demonstrates our technique for laparoscopic proximal gastrectomy with jejunal interposition and hand-sewn esophagojejunostomy, performed using ArtiSential wristed instruments, in a 76-year-old woman with Siewert type II gastroesophageal junction cancer staged as cT2N0M0.

INTRODUCTION

Proximal gastrectomy can be considered oncologically adequate for early Siewert type II gastroesophageal junction cancer lacking high-risk features such as poorly cohesive histology or distal gastric lymph node metastasis. However, the extent of mediastinal lymph node dissection should be tailored to the length of esophageal invasion, with more extensive dissection required when invasion exceeds 2–4 cm [1,2]. For reconstruction, four options are possible: (1) direct gastroesophageal reconstruction; (2) double tract reconstruction; (3) gastroesophagectomy with anti-reflux valve procedure; and (4) jejunal interposition—the Merendino procedure. Jejunal interposition offers several advantages, most notably a lower rate of late stenosis [3–5]. The primary challenge is creating a high mediastinal anastomosis. Robotic platforms have made this procedure more straightforward, although they are not yet widely available, and the operation times are significantly longer than laparoscopy [4,5]. Wristed instruments provide a good balance between laparoscopy and robotic surgery [4,5]. This multimedia article presents our approach to laparoscopic proximal gastrectomy and sutured esophagojejunostomy with articulated ArtiSential instruments (Livsmed) for small GEJ cancer.

CASE

We present a case of a 76-year-old woman with Siewert type II (SII) GEJ carcinoma. The 25-mm tumor invaded up to 3 cm into the distal esophagus and was preoperatively staged as cT2N0M0. The first step was the fixation of the falciform ligament, the lateral mobilization, and the fixation of the left liver lobe. Once the esophagus was mobilized and the lymph node (LN) stations 19 and 20 were dissected, LN stations 10 and 11 and the common hepatic artery were dissected. A strong aberrant left hepatic artery was identified and preserved. Lastly, the lower mediastinal LNs 112 and 110 dissection was performed using the wristed ArtiSential grasper. A 20 cm long jejunal interposition was brought via the retrocolic route into the upper abdomen. A linear-stapled 45-mm esophagojejunostomy was created. Using the articulated instrument, two angular stay sutures were placed, and the anterior wall was sutured with barbed 3-0 running suture in two layers. Finally, a linear-stapled 60-mm gastrojejunostomy was created (Supplementary Video 1).

The patient started an oral liquid diet on the first postoperative day. The swallow-contrast computed tomography performed on day 5 excluded a leak. The patient suffered from mild postoperative pneumonia, which was treated conservatively with antibiotics. Otherwise, the postoperative course was uneventful. The pathological examination revealed a pT3N0M0 SII cardia carcinoma, the LN status was 0/40, and microscopic resection margins were negative. The patient was discharged on day 22 after surgery. At discharge, she did not complain about reflux problems or dysphagia. On the follow-up one year after surgery, there was no evidence of disease recurrence; the patient had gained weight and could tolerate solid food without reflux problems.

DISCUSSION

In the present paper, we have shown the feasibility of the ArtiSential wristed instruments for the laparoscopic transhiatal extended proximal gastrectomy with distal esophagectomy and the reconstruction with jejunal interposition. The ArtiSential instruments proved effective, allowing us to securely perform the transhiatal resection and, most importantly, safe transhiatal suturing of the anastomosis. To the best of our knowledge, this is the first report of the Merendino procedure utilizing the ArtiSential instruments.

Pring and Dexter [3] have described their approach to the laparoscopic Merendino procedure. In their paper, the patient had high-grade dysplasia. Therefore, extensive resection of the esophagus was not necessary. The level of the anastomosis was sufficiently low to perform an Orvil stapled reconstruction (Medtronic) [3]. In cases where the esophageal stump is short, the Orvil reconstruction is much more challenging. In such instances, the stapler must be inserted into the jejunal limb, shortening its length. Additionally, the visibility in the restricted space is poor because of the bulk of the stapler. In the present paper, we performed the resection of a tumor invading 3 cm into the esophagus, which meant that the resection of the distal 5 cm of the esophagus was necessary to obtain a sufficient free margin. Although linear-stapled anastomosis allows a longer jejunal limb and a tensionless anastomosis, we feel that constructing an anastomosis in the posterior mediastinum is very difficult with conventional straight laparoscopic instruments. Especially when suturing the edges, the angles of the stitch placements can be acute and challenging to perform with straight graspers. The ArtiSential instruments were invaluable in this case. We could efficiently perform the reconstruction from the position between the legs of the patient and did not require additional ports. Because the wristed needle grasper had a 360° range of motion, the suturing could be comfortably done through the periumbilical ports. The enhanced ergonomics led to confident and safe placement of suture bites and a secure anastomosis at a fraction of the cost compared to robotic surgery.

The ArtiSential instruments were also used for the transhiatal stage of the dissection. In this phase, the limited space of the posterior mediastinum limits the accessibility of straight laparoscopic instruments. The range of motion of the wristed instruments allows easier grasping of lymphatic tissue over the whole circumference of the esophagus. The touching of the esophagus is minimized, limiting the potential for inadvertent damage to the organ.

We agree with Lee et al. [6] and Kang et al. [7] that a skilled laparoscopic gastric cancer surgeon should use the ArtiSential instruments. In the present case, the surgery was performed by a surgeon who had already overcome the learning curve for laparoscopic gastrectomy and routinely uses the articulated stitch holder for the esophagojejunostomy. We agree that the surgeons using these instruments should have a proficient laparoscopic technique for gastric resections and dry-lab training before attempting complex surgery.

In this paper, we demonstrate that ArtiSential instruments offer significant advantages for a transhiatal resection and reconstruction, enabling the execution of a complex Merendino procedure. The ArtiSential instruments offer a substantial advantage in laparoscopy for transhiatal resection and reconstruction, potentially providing a more cost-effective option than robotic platforms for SII early GEJ cancer.

Supplementary materials

Supplementary materials can be found via https://doi.org/10.7602/jmis.2025.28.3.151.