1. Novel Use of Surgical Glove Port to Perform Laparoscopic Total Gastrectomy 
Elio Jovine, MD, PhD, Simone Nicosia, MD, Michele Masetti, MD, Raffaele Lombardi, MD, Claudia Benini, MD, Salomone Di Saverio, MD, FACS, FRCS 
Journal of the American College of Surgeons 
Volume 223, Issue 4, Pages e35-e41 (October 2016)
DOI: /j.jamcollsurg
Copyright © 2016 American College of Surgeons Terms and Conditions

2. Figure 1
Initial setup and trocar positions: the patient is in a lithotomy position with both legs abducted and slightly flexed; the first umbilical port (Bluntport, Covidien) is inserted with an open Hasson technique. Pneumoperitoneum is established at 12 mmHg pressure. Three additional 12-mm trocars are then placed under direct vision: one in the left upper quadrant and 2 in the right upper quadrant.
Journal of the American College of Surgeons  , e35-e41DOI: ( /j.jamcollsurg )
Copyright © 2016 American College of Surgeons Terms and Conditions

3. Figure 2
(A) Operative scheme. Our technique is entirely laparoscopic, and each step is performed completely intracorporeally, including the enterotomy on the jejunal loop and the insertion of the circular stapler into the jejunal loop, as well as fashioning intracorporeally both the circular esophago-jejunal anastomosis and the linear side-to-side Roux-en-Y anastomosis. (Reprinted courtesy of the artist, Dr Serena Galli.) (B) Step 1: Surgical resection of the stomach is carried out in the usual way, as in laparoscopic total gastrectomy. Resection of the distal esophagus is performed with a linear endostapler. (C) Step 2: The OrVil device is delivered trans-orally and the anvil is extracted from the esophageal distal end, through a mini-incision made on the staple line. (D) Step 3: A 3- to 4-cm large incision is made, enlarging the port site located in the patient's left flank, and a small size wound protector is inserted for protected extraction of the specimen. (E) Step 4: After specimen extraction, a surgical glove port is fashioned and positioned over the wound protector. Pneumoperitoneum is then reinduced by reinsufflation through the remaining trocars. After proper inflation of the surgical glove port, the 12-mm trocar previously located in the left flank, is recycled and reintroduced into one of the fingers of the latex glove; it can be used for inserting grasping forceps. An additional 5-mm trocar can be added within any one of the other fingers of the glove port, if needed. (F) Step 5: A mesenteric window is made laparoscopically in the transverse mesocolon and an undivided jejunal loop, long enough for reaching the future anastomotic site without tension, is brought up in the supra-mesocolic region, through this same mesocolic window. (G) Step 6: An enterotomy is made with hook or harmonic scalpel in the biliary limb of the jejunal loop. (H) Step 7: Left, at this point, the circular stapler is introduced within the surgical glove port through an appropriately shaped incision of the glove finger. A proper air-tight seal is achieved with the aid of surgical tape fixing the edges of the orifice on the glove finger to the metallic stem of the circular stapler. Right, 1 or 2 additional trocars can be used within the surgical glove port for helping in both grasping the anvil and easing the intracorporeal maneuvre of introducing the circular stapler into the lumen of jejunum and subsequent pushing the jejunal loop upward, close enough to the esophageal distal end for connecting the anvil and the rod, and firing the esophago-jejunal anastomosis. (I) Step 8: The circular stapler is connected to the anvil and closed. We recommend waiting for at least 15 to 20 seconds before firing the anastomotic staple line, in order to achieve proper compression of the tissues between the anvil rod and the staple cartridge (decreasing the excess fluid in the tissues) and thereafter, the circular stapler is extracted. (J) Step 9: The circular stapler is extracted from the surgical glove and the finger where it was secured, is then cut with scissors and sealed with tape. The surgical glove port is kept in place and the other operative trocars are left in the remaining fingers of the glove port. (K) Step 10: The jejunal loop is stapled out on the proximal side, just on the left of the esophago-jejunal anastomosis. The alimentary limb is therefore disconnected from the proximal jejunum and the biliary limb is freed. (L) Step 11: The distal end of the biliary limb is closed with linear stapler and trimmed as necessary. The biliary limb is brought down, below the transverse mesocolon. (M) Step 12: Roux-en-Y side-to-side J-J anastomosis is fashioned intracorporeally in the sub-mesocolic region, having achieved a convenient triangulation of the operative trocars thanks to the use of the surgical glove port as an access. In our experience, the mesenteric defect of the Roux-en-Y should be routinely closed.18
Journal of the American College of Surgeons  , e35-e41DOI: ( /j.jamcollsurg )
Copyright © 2016 American College of Surgeons Terms and Conditions

4. Figure 2
(A) Operative scheme. Our technique is entirely laparoscopic, and each step is performed completely intracorporeally, including the enterotomy on the jejunal loop and the insertion of the circular stapler into the jejunal loop, as well as fashioning intracorporeally both the circular esophago-jejunal anastomosis and the linear side-to-side Roux-en-Y anastomosis. (Reprinted courtesy of the artist, Dr Serena Galli.) (B) Step 1: Surgical resection of the stomach is carried out in the usual way, as in laparoscopic total gastrectomy. Resection of the distal esophagus is performed with a linear endostapler. (C) Step 2: The OrVil device is delivered trans-orally and the anvil is extracted from the esophageal distal end, through a mini-incision made on the staple line. (D) Step 3: A 3- to 4-cm large incision is made, enlarging the port site located in the patient's left flank, and a small size wound protector is inserted for protected extraction of the specimen. (E) Step 4: After specimen extraction, a surgical glove port is fashioned and positioned over the wound protector. Pneumoperitoneum is then reinduced by reinsufflation through the remaining trocars. After proper inflation of the surgical glove port, the 12-mm trocar previously located in the left flank, is recycled and reintroduced into one of the fingers of the latex glove; it can be used for inserting grasping forceps. An additional 5-mm trocar can be added within any one of the other fingers of the glove port, if needed. (F) Step 5: A mesenteric window is made laparoscopically in the transverse mesocolon and an undivided jejunal loop, long enough for reaching the future anastomotic site without tension, is brought up in the supra-mesocolic region, through this same mesocolic window. (G) Step 6: An enterotomy is made with hook or harmonic scalpel in the biliary limb of the jejunal loop. (H) Step 7: Left, at this point, the circular stapler is introduced within the surgical glove port through an appropriately shaped incision of the glove finger. A proper air-tight seal is achieved with the aid of surgical tape fixing the edges of the orifice on the glove finger to the metallic stem of the circular stapler. Right, 1 or 2 additional trocars can be used within the surgical glove port for helping in both grasping the anvil and easing the intracorporeal maneuvre of introducing the circular stapler into the lumen of jejunum and subsequent pushing the jejunal loop upward, close enough to the esophageal distal end for connecting the anvil and the rod, and firing the esophago-jejunal anastomosis. (I) Step 8: The circular stapler is connected to the anvil and closed. We recommend waiting for at least 15 to 20 seconds before firing the anastomotic staple line, in order to achieve proper compression of the tissues between the anvil rod and the staple cartridge (decreasing the excess fluid in the tissues) and thereafter, the circular stapler is extracted. (J) Step 9: The circular stapler is extracted from the surgical glove and the finger where it was secured, is then cut with scissors and sealed with tape. The surgical glove port is kept in place and the other operative trocars are left in the remaining fingers of the glove port. (K) Step 10: The jejunal loop is stapled out on the proximal side, just on the left of the esophago-jejunal anastomosis. The alimentary limb is therefore disconnected from the proximal jejunum and the biliary limb is freed. (L) Step 11: The distal end of the biliary limb is closed with linear stapler and trimmed as necessary. The biliary limb is brought down, below the transverse mesocolon. (M) Step 12: Roux-en-Y side-to-side J-J anastomosis is fashioned intracorporeally in the sub-mesocolic region, having achieved a convenient triangulation of the operative trocars thanks to the use of the surgical glove port as an access. In our experience, the mesenteric defect of the Roux-en-Y should be routinely closed.18
Journal of the American College of Surgeons  , e35-e41DOI: ( /j.jamcollsurg )
Copyright © 2016 American College of Surgeons Terms and Conditions

5. Figure 2
(A) Operative scheme. Our technique is entirely laparoscopic, and each step is performed completely intracorporeally, including the enterotomy on the jejunal loop and the insertion of the circular stapler into the jejunal loop, as well as fashioning intracorporeally both the circular esophago-jejunal anastomosis and the linear side-to-side Roux-en-Y anastomosis. (Reprinted courtesy of the artist, Dr Serena Galli.) (B) Step 1: Surgical resection of the stomach is carried out in the usual way, as in laparoscopic total gastrectomy. Resection of the distal esophagus is performed with a linear endostapler. (C) Step 2: The OrVil device is delivered trans-orally and the anvil is extracted from the esophageal distal end, through a mini-incision made on the staple line. (D) Step 3: A 3- to 4-cm large incision is made, enlarging the port site located in the patient's left flank, and a small size wound protector is inserted for protected extraction of the specimen. (E) Step 4: After specimen extraction, a surgical glove port is fashioned and positioned over the wound protector. Pneumoperitoneum is then reinduced by reinsufflation through the remaining trocars. After proper inflation of the surgical glove port, the 12-mm trocar previously located in the left flank, is recycled and reintroduced into one of the fingers of the latex glove; it can be used for inserting grasping forceps. An additional 5-mm trocar can be added within any one of the other fingers of the glove port, if needed. (F) Step 5: A mesenteric window is made laparoscopically in the transverse mesocolon and an undivided jejunal loop, long enough for reaching the future anastomotic site without tension, is brought up in the supra-mesocolic region, through this same mesocolic window. (G) Step 6: An enterotomy is made with hook or harmonic scalpel in the biliary limb of the jejunal loop. (H) Step 7: Left, at this point, the circular stapler is introduced within the surgical glove port through an appropriately shaped incision of the glove finger. A proper air-tight seal is achieved with the aid of surgical tape fixing the edges of the orifice on the glove finger to the metallic stem of the circular stapler. Right, 1 or 2 additional trocars can be used within the surgical glove port for helping in both grasping the anvil and easing the intracorporeal maneuvre of introducing the circular stapler into the lumen of jejunum and subsequent pushing the jejunal loop upward, close enough to the esophageal distal end for connecting the anvil and the rod, and firing the esophago-jejunal anastomosis. (I) Step 8: The circular stapler is connected to the anvil and closed. We recommend waiting for at least 15 to 20 seconds before firing the anastomotic staple line, in order to achieve proper compression of the tissues between the anvil rod and the staple cartridge (decreasing the excess fluid in the tissues) and thereafter, the circular stapler is extracted. (J) Step 9: The circular stapler is extracted from the surgical glove and the finger where it was secured, is then cut with scissors and sealed with tape. The surgical glove port is kept in place and the other operative trocars are left in the remaining fingers of the glove port. (K) Step 10: The jejunal loop is stapled out on the proximal side, just on the left of the esophago-jejunal anastomosis. The alimentary limb is therefore disconnected from the proximal jejunum and the biliary limb is freed. (L) Step 11: The distal end of the biliary limb is closed with linear stapler and trimmed as necessary. The biliary limb is brought down, below the transverse mesocolon. (M) Step 12: Roux-en-Y side-to-side J-J anastomosis is fashioned intracorporeally in the sub-mesocolic region, having achieved a convenient triangulation of the operative trocars thanks to the use of the surgical glove port as an access. In our experience, the mesenteric defect of the Roux-en-Y should be routinely closed.18
Journal of the American College of Surgeons  , e35-e41DOI: ( /j.jamcollsurg )
Copyright © 2016 American College of Surgeons Terms and Conditions