Laparoscopic spleen-preserving splenic hilar lymphadenectomy using a plane-first “Sandwich” sequence during total gastrectomy for gastric cancer: a technical video report

Spleen-preserving station No. 10 lymphadenectomy is technically demanding because the splenic hilar branches and pancreatic tail occupy a deep, confined field. We present a plane-first “Sandwich” sequence that organizes established anatomical planes and vessel-oriented maneuvers into a structured teaching workflow. A 50-year-old man (170 cm, 55 kg) with poorly differentiated gastric adenocarcinoma, staged cT3N+M0, received three cycles of neoadjuvant SOX plus camrelizumab. Endoscopy placed the esophagogastric junction at approximately 40 cm and the infiltrative lesion at 45–53 cm from the incisors. After multidisciplinary review and endoscopic carbon-nanoparticle marking, total gastrectomy was selected to secure an oncologically appropriate proximal margin. Station No. 10 dissection was an individualized decision based on the pretreatment tumor extent, posterior gastric-body involvement toward the greater-curvature side, radiographic nodal risk, planned total gastrectomy, and team experience. The upper and lower exposure planes were established before vessel-oriented removal of the intervening splenic hilar lymphoadipose layer. Operative time was 257 min, estimated blood loss was 100 mL, and no conversion, transfusion, pancreatic injury, splenic injury, or major vascular injury occurred. Permanent paraffin pathology showed residual moderately-to-poorly differentiated adenocarcinoma with negative margins, modified Ryan tumor regression score 2, and 2/41 metastatic lymph nodes (station No. 3, 1/2; station No. 5, 1/6; station No. 10, 0/3), yielding ypT3N1M0, post-neoadjuvant stage II. A postoperative pulmonary infectious episode requiring continued antibiotics and respiratory therapy was classified as Clavien–Dindo grade II. At approximately 51 months, the patient was alive with no reported recurrence. In this patient, the plane-first Sandwich sequence enabled completion of spleen-preserving No. 10 dissection with defined anatomical landmarks and completion criteria. Its principal contribution is a structured operative sequence and visual teaching framework for selected patients undergoing hilar lymphadenectomy. Not applicable.