Perineural Invasion Underlines the Necessity of Upper Lesser Curvature Skeletonization in Radical Distal Gastrectomy for Locally Advanced Gastric Cancer
The surgical technique of upper lesser curvature skeletonization is to completely dissect both the fat-lymphoid and perineural tissues surrounding the upper lesser curvature of remnant stomach in the en bloc manner.6 We consider that a standard upper lesser curvature skeletonization needs to visually expose the subserosal muscularis propria of the lesser curvature and right lateral wall of the abdominal esophagus and the posterior wall of the lesser curvature up to the right side of the posterior gastric artery. As cancer cells infiltrate and spread along with the nerve tract, right-side vagectomy is required to be performed at the site of diaphragmatic hiatus. Application of an ultrasonic scalpel is therefore suggested for clearance of fat tissue and devascularization at the upper lesser curvature. In contrast, conventional technique of suture and ligation may lead to more residual fat-lymphoid and nerve tissues. In addition, our experiences demonstrate that the technique of the lesser curvature skeletonization is relatively safe by experienced surgeons and does not increase the risk of postoperative morbidity and mortality.6 In short, concerning the possibility of perineural invasion of lesser curvature gastric cancer, the standard procedure of upper lesser curvature skeletonization is theoretically recommendable in radical distal gastrectomy, whereas its survival benefit needs further investigation among locally advanced gastric cancer patients.