We have also created this anastomosis with a circular stapling device as an end jejunum to side Roux limb. Here the entero-enterotomy is created before the esophageal anastomosis. The purse string and anvil are placed in the jejunal stump in a similar fashion to that previously mentioned for the esophagus. The stapling device is passed well down the cut end of the Roux limb (> 40cm) before the receiving pin is deployed through the wall of the jejunum. The circular stapling device is then deployed in the routine fashion.

Postoperative Management
Pain control in the post-operative period governed by symptoms, but may include narcotic and NSAIDS per preference. We treat these patients the same as with conventional gastric surgery. The nasogastric tube remains until the patient passes flatus. Diet is then advanced over the next 48 hrs. We prefer to perform a Gastrografin swallow prior to oral intake for the total gastrectomy patients.

Summary
Our operative times for purely laparoscopic total gastrectomy averaged 6.5 hours, and 4 hours for subtotal gastrectomy . We are fairly confident that hand-assistance will allow us to reduce our operative times substantially (perhaps by as much as 50% or greater). The hand assist method should also allow for greater control that should result in fewer conversions. The other potential benefits of the hand-assisted approach remain to be determined.