The patient was placed in a lithotomy position with reverse Trendelenburg. The operator and a scopist were positioned between the patient's legs. A longitudinal transumbilical 2.5-cm long incision was made. A commercial 4-hole single port (Glove port, Nelis, Bucheon, Korea) was placed in the single incision, and the abdominal cavity was insufflated with carbon dioxide at a pressure of 13 mmHg. No additional assistant trocar was used. A 10-mm flexible high-definition scope (Endoeye flexible HD camera system, Olympus Medical Systems Co., Tokyo, Japan), a Harmonic Scalpel (Ethicon Endo-Surgery Inc., Cincinnati, OH, USA), and a LigaSure 5-mm Blunt Tip (Covidien, Mansfield, MA, USA) were used to visualize nearly the same field as that observed in conventional laparoscopic gastrectomy and to facilitate dissection and bleeding control. The detailed procedures, including a modified combined suture retraction of the liver, partial omentectomy, and LND for LNs 6, 5, 12a, 8a, and 7, have been described in our previous reports [7].

Herein, we will focus on the detailed procedures regarding 11p LND through MPM.

After completion of 8a/12a, 7, and 9 LND in the suprapancreatic portion, which is located on the right side of the suprapancreatic area, 11p LND was started from the midpancreas. First, we dissected around the inferior border of pancreas from the left side of inferior mesenteric vein and kept the mobilization plane upward along the white line of Toldt, identifying the left renal vein on the dorsal side and the splenic vein on the ventral side. This plane was maintained to dissect up to the suprapancreatic border, which resulted in mobilization of the entire mid-pancreas from the white line of Toldt (Fig. 1). Then, two gauzes were inserted behind the pancreas, and the splenic vein could be easily exposed because of dorsal tilting of the suprapancreas and detachment of soft tissue, including 11p LNs, from the white line of Toldt (Fig. 2). The dissection plane along the splenic artery and vein for 11p LND could be visualized and exposed just through control of the operator's grasper without the need of an assistant (Fig. 3).

After 11p LND (Fig. 4), LN 1, including the vagus nerve, was dissected and the lesser curvature was cleared for transection of the stomach. We usually perform uncut Roux-en Y gastrojejunostomy for reconstruction after pure SIDG. One Jackson-Pratt (J-P) drainage tube was placed through the umbilical wound around the suprapancreatic area, and the incision was closed.

Between January 2013 and November 2013, 14 consecutive patients underwent pure SIDG with D2 LND at Seoul National University Bundang Hospital. In this study, patient eligibility criteria were a preoperative diagnosis of stage I gastric cancer, according to the American Joint Committee on Cancer staging manual 7th edition, with no LN enlargement, 20 to 80 years of age, no history of other malignancies, chemotherapy, or radiotherapy, and no severe comorbidity. Patients underwent the procedure after providing written informed consent. This study was approved by the Institutional Review Board of Seoul National University Bundang Hospital. The clinical features, demographics (e.g., sex, age, tumor size, and number of retrieved metastatic, suprapancreatic 11p LNs), and early postoperative complications such as postoperative pancreatic fistula (POPF) (0-30 days) were analyzed based on the information obtained from our prospectively collected gastric cancer database. During the postoperative hospital stay, the patients were managed according to our institutional critical pathway protocols. Sips of water, a semifluid diet (SFD), and a soft blended diet (SBD) were given to the patients on postoperative days 2, 3, and 4, respectively. After SBD intake, the J-P drainage tube was removed. Finally, the patients were routinely discharged from the hospital on the fifth postoperative day, if they exhibited no discomfort, abdominal pain, or abnormal results on laboratory tests. Early and late complication was defined as complications that occur within thirty days and after postoperative day 30, respectively. The surgery and after postoperative day 30, respectively. POPF is diagnosed when the drainage amylase is three times higher than the upper normal limit of serum amylase on the third postoperative day. Thus far, pure SIDG with D2 LND using MPM has been performed for 14 patients with gastric cancer at clinical stage I. The demographics and operative data of patients are described in Table 1. No intraoperative events occurred (conversion to conventional laparoscopy or open gastrectomy, uncontrolled bleeding, unexpected injury to the adjacent organ, or surgery-related complications). The mean operation time was 156.8 ± 34.6 minutes (range, 120-235 minutes). The mean estimated blood loss was 65.6 ± 36.8 mL (range, 3-150 mL). The total number of retrieved LNs was 61.3 ± 9.0 (range, 49-70), including 15.3 suprapancreatic LNs (range, 5-23). The mean number of 11p LNs was 4.00 ± 3.38 (range, 1-10) (Table 2).

All the patients recovered rapidly after the operation. They tolerated consumption of SFD on the third postoperative day and SBD on the fourth postoperative day. No POPF was observed. The mean levels of serum amylase and drain amylase were 55.16 ± 25.82 U/L (range, 30-86 U/L) and 101.75 ± 73.98 U/L (range, 47-211 U/L), respectively. Postoperative delirium was the only early postoperative complication and was observed in a 77-year-old man who had chronic obstructive pulmonary disease and was receiving a medication for delirium. The mean duration of postoperative hospital stay was 6.25 ± 3.15 days (range, 5-14 days) (Table 3).