完全腹腔鏡下幽門側胃切除術における口側胃切離線決定のための色素注入法

Dye injection method to determine proximal gastric cut line in laparoscopic distal gastrectomy for gastric cancer

◆要旨：【目的】完全腹腔鏡下幽門側胃切除術における課題として，腹腔鏡下での病変の正確な位置の把握と口側胃切離線の決定がある．当科では術前内視鏡を用いた胃粘膜下色素注入法により胃切除範囲を決定している．【方法】術前日までに内視鏡下に病変口側にマーキングクリップをかける．術当日，全身麻酔下に再度内視鏡を行い，マーキングクリップの口側前壁に切離線を想定して色素を注入する．腹腔内操作を開始し，胃前壁漿膜側に透見される色素を確認して結紮糸をかけ，切離ラインを決定する．【成績】2011年10月から2013年1月まで52例に本法を施行した．切除標本の口側断端距離は平均33.1mmであり，全症例において術後の病理結果で断端陰性であった．

［Background］‘Dye injection method' for totally laparoscopic distal gastrectomy is used at our institute to ensure histologically cancer-free proximal margin of the resected stomach. ［Objective］ Totally laparoscopic surgery is less invasive and has benefits for cosmetic reason and postoperative wound pain. However, in case of laparoscopic distal gastrectomy, to ensure histologically cancer-free proximal margin may be a problem. We developed ‘Dye injection method that enabled us to see the stained marks on the gastric serosa and to confirm the dissecting line. ［Methods］ Prior to the day before the operation, marking clips were placed 2cm proximal to the cancer lesion under gastroscopy. Immediately before the operation, under general anesthesia, ‘Dye injection method' was performed again through gastroscope. First, the marking clips were confirmed under gastroscopy. Then dye solution of indigo-carmine and hyaluronic acid was injected into the sub-mucosal layer of the stomach, as well as several spots along the assumed gastric dissection line. Under the laparoscopic view, we could easily recognize the stained spots on the ventral gastric serosa. We were then able to place some monofilament stitches along the markings to confirm the proximal cut line. ［Results］ Fifty-two patients underwent laparoscopic distal gastrectomy using this ‘Dye injection method' from October, 2011 to January, 2013. None of the resected stomach had positive proximal margin histologically and the average length of the margin was 33.1mm.