Anti-reflux effects of a novel esophagogastric asymmetric anastomosis technique after laparoscopic proximal gastrectomy

Figure 3 Surgical Procedure of laparoscopic-assisted esophagogastric asymmetric-anastomosis. A: Reverse Trendlenborg position with both legs separated. Using five-hole method, the points I-V show the location of Trocars and operators respectively; B: The transverse incision of residual stomach wall is about 3.2-3.5 cm away from the proximal end at approximately 3.5 cm; C: The lower end of the esophagus is cut oblique, the length of both sides is asymmetric, the difference is approximately 1.5 cm; D: First, a full-thickness intermittent suture was performed between the right side (point d) of the lower esophagus and the middle point (point d) of the posterior wall in gastric incision. Then, the right point of the gastric wall incision (point a) was sutured to the middle point (point a) of the anterior wall in the lower esophagus, and the left point (point b) of the gastric incision was sutured to the middle point (point b) of the posterior wall in the lower esophagus. After performing a three-needle whole-layer positioning suture of the posterior wall in oesophagogastric anastomosis, oesophageal torsion was completed at a 90° anticlockwise; E: The back wall of the anastomosis was continuously stitched; F: The front wall of the anastomosis was continuously stitched; G: The seromuscular layer of the anterior wall of the anastomosis was further stitched; H: The residual gastric cutting end (approximately 3 cm from the anastomosis) was stitched to the posterior wall of the esophagus, about 0.5-1 cm away from the anastomosis.