Suture Guided Transabdominal Anvil Placement for Intracorporeal Circular Stapled Esophagojejunostomy After Laparoscopic Total Gastrectomy: Procedural Efficiency and Early Institutional Experience

Why clinicians should know about it

• Picked for Surgery (paper of the day, 22 September 2026): Transabdominal anvil improves gastrectomy efficiency

Abstract

BACKGROUND: Intracorporeal circular stapled esophagojejunostomy remains technically demanding, largely because secure anvil insertion and fixation are difficult in the restricted upper abdominal field [1-4,18]. Conventional intracorporeal purse string fixation requires circumferential laparoscopic suturing, whereas transoral anvil systems require dedicated equipment and transpharyngeal passage [5-8,18]. Transabdominal guided anvil techniques have therefore been developed to preserve direct laparoscopic control while simplifying the anvil placement step [6,8,24,25]. The present technique was designed to avoid circumferential purse string suturing, avoid transoral anvil delivery, maintain direct visual control of the anvil, and retain a familiar circular stapled reconstruction. METHODS: This retrospective comparative cohort study included 80 consecutive adults who underwent laparoscopic total gastrectomy with intracorporeal circular stapled esophagojejunostomy between January 2023 and January 2026. Forty patients underwent suture guided transabdominal anvil insertion and 40 underwent intracorporeal purse string reconstruction. All anastomoses used a 25mm Covidien circular stapler, which standardized device diameter across groups. Primary outcomes were technical feasibility and postoperative anastomotic leak and stricture. Secondary outcomes included reconstruction and total operative time, postoperative morbidity, length of stay, lymph node yield, mortality, and a descriptive comparison of early and later institutional experience. The study was interpreted as an exploratory IDEAL stage 2b evaluation rather than a superiority trial [9-11]. RESULTS: All planned reconstructions were completed laparoscopically without conversion or anvil related technical failure. Reconstruction time was significantly shorter with the suture guided technique than with intracorporeal purse string placement, 32 ± 8 versus 46 ± 10minutes, P < 0.001, a mean reduction of 14minutes. Total operative time did not differ significantly. Anastomotic leak occurred in 3 of 40 patients, 7.5%, versus 6 of 40, 15.0%, P = 0.481, and stricture in 2 of 40, 5.0%, versus 5 of 40, 12.5%, P = 0.432. Reintervention for leak occurred in 0 versus 2 patients, any 30 day complication in 25.0% versus 42.5%, and mean length of stay was 7 ± 2 versus 9 ± 3 days, P < 0.001. The clinical event estimates consistently favoured the suture guided group numerically, but confidence intervals were wide and the study was not powered for these outcomes. CONCLUSION: Suture guided transabdominal anvil placement provided a measurable procedural advantage within circular stapled reconstruction by eliminating circumferential intracorporeal purse string suturing and achieving a significantly shorter reconstruction time while retaining direct laparoscopic control of the anvil. The study does not establish superior leak or stricture outcomes, but the absence of anvil related technical failure and the directionally favourable clinical estimates support further prospective multicentre evaluation. For teams already using circular stapled esophagojejunostomy, the technique represents a practical alternative to purse string or transoral anvil placement rather than a replacement for all reconstructive strategies.

Abstract as published, via PubMed.