腹腔鏡補助下幽門側胃切除における三角吻合Billroth-I法再建

Triangular stapling Billroth-I reconstruction after laparoscopy-assisted distal gastrectomy

三角吻合はlinear staplerを3回用いて端々吻合を行う方法であり，狭窄や吻合部出血が少ない吻合法として各消化管吻合で従来から用いられてきた．当科では腹腔鏡補助下幽門側胃切除（laparoscopy-assisted distal gastrectomy：LADG）におけるBillroth-I法再建で三角吻合を採用しており，その工夫と利点を報告する．LADGでは通常小開腹創からアプローチし吻合するが，十二指腸に余裕が少ない場合や肥満例では難渋する．筆者らは，linear staplerを小開腹創だけではなくカメラポートからアプローチする工夫をした．それにより十二指腸の可動性や体型による影響が少なくなり，より容易に吻合が可能となった．また，当科では癌細胞を含有する可能性がある胃内容液が漏出しないような手順も工夫しているので紹介する．

　Triangular stapling technique has been used in various gastroenterological open and laparoscopic surgeries. In addition, we devised this method so that gastric juice leakage which may contain cancer cells can be prevented, and found a way to make stapling easier by changing the inserting port depending on the tension of anastomosis. We performed cytological examinations of gastric juice, and found that cancer cells in gastric juice were obtained in 25％of the cases of advanced gastric cancer and 5.3％in early gastric cancer. So we recommend preventing gastric juice leakage even in laparoscopic gastrectomy. Inserting the End Linear Stapler not only in the mini-laparotomic wound but also the camera port located near umbilicus makes easy to staple when the tension of anastomosis is tight. We performed 65 cases of triangular stapling Billroth-I reconstruction from Aug. 2004 to Oct. 2006. The mean time of anastomosis was 20.7±5.1 min. And complication of anastomosis was only 1 case of stenosis（1.5％）. We consider the triangular stapling Billroth-I reconstruction to be a safe, simple and easy method of anastomosis in laparoscopic gastrectomy.