Under general anesthesia, the patient was placed in the reverse Trendelenberg position. After pneumoperitoneum was established using the open technique, 5 ports (two 12 mm and three 10 mm in diameter) were placed. Once the abdominal cavity was explored via laparoscope, the stomach, duodenum and proximal jejunum were usually distended with swallowed or introduced gases during induction of anesthesia. The gases in the duodenum and proximal jejunum were forced into the stomach by external serial squeezing aborally using laparoscopic bowel clamps. The location for the percutaneous introduction of the needle was identified by manually pressing on the abdominal wall. A 9 cm long 19-gauge disposable needle was then introduced through the abdominal wall (Fig. 1). The anterior gastric wall was pulled up using a laparoscopic Babcock clamp and the percutaneously punctured needle was introduced to the stomach through the anterior wall. The gases and fluids collected in the stomach were aspirated by connecting the needle to suction (Fig. 1). During the aspiration, compression of the dependent portion of the stomach such as the fundus and upper body of the stomach facilitates effective aspiration of gastric air and fluid. After aspiration, the upper gastrointestinal tract collapsed, and we were able to perform the surgery for early gastric cancer under optimal conditions. Laparoscopic surgery for early gastric cancer was performed using the following standardized operative procedures: 1) A total or distal subtotal gastrectomy was performed depending on the location of the tumor; 2) D1 + beta or D2 lymphadenectomy was performed according to the rules of "The Japanese Research Society for Gastric Cancer".6 The greater omentum was first divided and dissected using ultrasonic shears (Laparoscopic Coagulating Shears: LCS; Ethicon, Cincinnati, OH, USA) toward the lower pole of the spleen. Division was then continued all the way to the short gastric vessels to dissect the left gastroepiploic vessels at their roots. The division of the gastrocolic ligament was continued distally toward the pylorus, then the right gastroepiploic vessels were divided at their roots. The soft tissues attached to the duodenum were dissected. The lesser omentum was then opened and the duodenum was transected 1 cm distal to the pylorus using an endoscopic stapling device. The right gastric artery was exposed and divided at its origin. The lymph nodes bearing soft tissues around the common hepatic artery were dissected, revealing the left gastric vein, which was divided at the upper margin of the common hepatic artery or pancreas. This was achieved by lifting the stomach superiorly. The left gastric artery was also exposed and severed at the root during the dissection of the lymph nodes. Perigastric lymph nodes were dissected along the lesser curvature up to the esophagocardial junction. By connecting two epigastric trocar incisions, a 5 cm mini-laparotomy incision was located in the epigastrium. The stomach was taken out for resection and anastomosis. After gastrectomy, the gastrointestinal continuity was restored by either a gastroduodenostomy or gastrojejunostomy depending on the location of tumors in a distal subtotal gastrectomy and by Roux-en-Y esophagojejunostostomy in a total gastrectomy. Gastroduodenostomy was constructed using a circular stapler (Ethicon, Cincinnati, OH, USA). The gastrojejunostomy was performed using interrupted 3-0 silk Lembert sutures for the outer layer and a running 3-0 polyglycolic suture for the transmural inner layer. Esophagojejunostomy was done using a circular stapler. Minilaparotomy was closed with continuous 1-0 polydioxanone sutures and the trocar sites were closed with 2-0 polydioxanone sutures. The subcutis and cutis were restored with interrupted 3-0 silk sutures and skin staples.