Background

Patient is a 37-year-old female with a history of morbid obesity (body mass index of 40) who underwent an uneventful laparoscopic sleeve gastrectomy for weight loss. The patient was incidentally found to have a poorly differentiated adenocarcinoma with signet ring features, with tumor invading the lamina propria (pT1a) and negative resection margins on pathology. Surgical oncology and medical oncology were consulted and decision was made to proceed with surveillance. On surveillance esophagogastroduodenoscopy the patient was found to have persistent diffuse type poorly differentiated adenocarcinoma on random biopsy (there was no evidence of gastric masses). PET/CT and diagnostic laparoscopy with peritoneal washings did not reveal any evidence of metastases. Patient underwent neoadjuvant chemotherapy and was subsequently taken for a robotic assisted laparoscopic total gastrectomy with D2 lymphadenectomy and stapled end to side esophagojejunostomy. This video demonstrates the surgical steps of the operation including the reconstruction with the use of a circular EEA stapler for creation of the esophagojejunostomy. The patient had an uneventful recovery, was discharged on postoperative day 3, completed adjuvant chemotherapy and currently is with no evidence of disease. Pathology from the total gastrectomy revealed a T1N0 poorly differentiated adenocarcinoma, with negative margins and 0 positive out of 17 lymph nodes.