Effectiveness and safety of a laparoscopic training system combined with modified reconstruction techniques for total laparoscopic distal gastrectomy

BACKGROUND: Total laparoscopic distal gastrectomy (TLDG) is increasing due to some advantages over open surgery, which has generated interest in gastrointestinal surgeons. However, TLDG is technically demanding especially for lymphadenectomy and gastrointestinal reconstruction. During the course of training, trainee surgeons have less chances to perform open gastrectomy compared with that of senior surgeons. AIM: To evaluate an appropriate, efficient and safe laparoscopic training procedures suitable for trainee surgeons. METHODS: Ninety-two consecutive patients with gastric cancer who underwent TLDG plus Billroth I reconstruction using an augmented rectangle technique and involving trainees were reviewed. The trainees were taught a laparoscopic view of surgical anatomy, standard operative procedures and practiced essential laparoscopic skills. The TLDG procedure was divided into regional lymph node dissections and gastrointestinal reconstruction for analyzing trainee skills. Early surgical outcomes were compared between trainees and trainers to clarify the feasibility and safety of TLDG performed by trainees. Learning curves were used to assess the utility of our training system. RESULTS: Five trainees performed a total of 52 TLDGs (56.5%), while 40 TLDGs were conducted by two trainers (43.5%). Except for depth of invasion and pathologic stage, there were no differences in clinicopathological characteristics. Trainers performed more D2 gastrectomies than trainees. The total operation time was significantly longer in the trainee group. The time spent during the lesser curvature lymph node dissection and the Billroth I reconstruction were similar between the two groups. No difference was found in postoperative complications between the two groups. The learning curve of the trainees plateaued after five TLDG cases. CONCLUSION: Preparing trainees with a laparoscopic view of surgical anatomy, standard operative procedures and practice in essential laparoscopic skills enabled trainees to perform TLDG safely and feasibly.