Technical tips of laparoscopic linear-stapled esophagojejunostomy (overlap method)

Laparoscopic esophagojejunostomy is one of the most technically challenging aspects when expanding institutional indication from distal to total gastrectomy. Expected advantages of linear-stapled overlap method are better intraperitoneal visibility, wide applicability to high anastomosis or small-sized intestine, and no concern for postoperative stenosis. In our standardized method, the esophagus is divided after twisted in 90 degree clockwise, so that the esophageal stump results in vertical direction. The jejunum is anastomosed to posterior wall of the esophagus, to make an opening hole face anterior, which enables stress-free suturing for closure. During the anastomotic steps, guidance by a nasogastric tube is very useful. Additionally, preparation of the tension-free jejunal limb is essential for secure anastomosis. In high anastomosis, the diaphragmatic crus should be cut to widen the esophageal hiatus. Articulating function of the linear stapler is useful to adjust the insertion axis to the esophagus. There are several well-known intraoperative pitfalls regarding this procedure, such as involvement of a nasogastric tube or miss-introduction of the stapler tip to the submucosal layer, therefore surgical team should pay maximum attention to prevent these events.