A 55-year-old male patient was admitted to our hospital due to upper abdominal discomfort accompanied with belching for three years. Gastroscopic biopsy confirmed the presence of adenocarcinoma of the gastric antrum (well differentiated). Abdominal computed tomography (CT) scan revealed the location of the gastric tumor (Fig. 1). No evidence of distant metastasis was observed during the preoperative abdominal CT scan. The preoperative tumor-node-metastasis (TNM) stage was cT2N0M0.

Following the administration of general anesthesia, the patient was placed in the supine position with the head elevated and legs apart. During the surgery, five trocars were inserted. CO₂ pneumoperitoneum of 12 to 14 mmHg was established. Standing on the left side of the patient, the surgeon divided the stomach and duodenum using an ultrasonic scalpel (Ultracision Harmonic scalpel; Johnson & Johnson, Cincinnati, OH, USA), and dissected the associated lymph nodes according to the 2002 edition of the Gastric Cancer Treatment Guidelines in Japan (8). In brief, firstly, the left side of the gastrocolic ligament was dissected near the transverse colon through to the lower splenic pole and the pancreatic tail. Next, the origins of the left gastroepiploic vessels were ligated. The aim was to dissect station number 4 sb and 4 d lymph nodes. Then, the right side of the gastrocolic ligament was cut near the transverse ligament through to the hepatic flexure, and the hepatic flexure of the colon was separated from the duodenal bulb and the surface of the pancreatic head. In this way, the gastrocolic trunk formed by the right gastroepiploic vein, right colic vein and their confluence was completely revealed. Next, the right gastroepiploic vessels were transected. The aim was to dissect station number 6 lymph nodes. Next, the gastroduodenal artery was exposed and the right gastric artery was transected. The aim was to dissect station number 12a and 5 lymph nodes. Then, the three branches of the celiac trunk were divided and the left gastric artery was transected. The aim was to dissect station number 7, 8a, 9 and 11p lymph nodes. Finally, the hepatogastric ligament and the anterior lobe of the hepatoduodenal ligament were transected close to the lower edge of the liver, and the right side of the cardia and the lesser curvature were fully separated. The aim was to dissect station number 1 and 3 lymph nodes.

Following mobilization of the gastroduodenum, a 45-mm gastroscopic linear stapler was inserted through the left upper trocar, positioned across the duodenum in the ventrodorsal direction and fired (Fig. 2A and B). Consequently, the transection line was rotated ~90 degrees from the usual position. The stomach was then transected by successively transecting from the greater curvature to the lesser curvature with two 60-mm linear staplers (Fig. 2C and D). The resected specimen including the stomach and the surrounding tissue were placed into a large plastic bag and placed beneath the umbilicus.

A small incision was created on the greater curvature side of the remnant stomach and in the jejunum, 15 cm away from the ligament of Treitz, respectively (Fig. 3A), by the ultrasonic scalpel. The upper and lower anvils of a 60-mm linear stapler were inserted into one end to close the posterior walls of the stomach and the jejunum, respectively (Fig. 3B). The posterior wall of the stomach and that of the jejunum were placed together, and the 60-mm linear stapler was closed and fired (Fig. 3C). Upon confirmation of no leakage and bleeding of the anastomosis, the gastric tube was inserted into the distal anastomotic end of the jejunum. Finally, the common stab incision was closed using one 60-mm endoscopic linear staple (Fig. 3D). The surgical wound and anastomosis were explored to identify any active bleeding. Thus, the reconstruction of the gastrointestinal tract was completed.

The resected specimen in the large plastic bag was removed through the umbilical incision, extended by cutting the fascia longitudinally with a U-shaped skin incision.

The surgery time was 180 min, and the time required for totally laparoscopic Billroth II anastomosis was 15 min. The percentage of the anastomotic time to the total time of surgery was 8.3%. The number of staples used was five, the estimated blood loss was 30 ml, and no blood was transfused during the surgery. The postoperative pathological stage was T2N0M0. The first flatus was observed at 3 days and a liquid diet was started at 6 days. Postoperative analgesic was used twice, and the patient's postoperative hospital stay was 8 days. The patient developed no complications such as anastomotic leakage, postoperative hemorrhage, anastomotic stenosis or delayed gastric emptying, and followed a satisfactory postoperative course.