Gastric cancer very often presents with locally advanced or metastatic disease. Accurate staging of gastric cancer aids in the appropriate treatment selection for both cure and palliation. Palliative resection may be indicated for gastric cancer causing obstruction, hemorrhage, or perforation; however, surgical resection alone for patients with advanced disease has not been shown to improve survival. Studies regarding neoadjuvant protocols for locally advanced gastric cancers are ongoing which makes accurate staging imperative. Moreover, even after many preoperative radiologic tests (CT scan, endoscopic and transabdominal ultrasound, and PET scan) for staging of gastric tumors, a proportion of patients are found to have unsuspected, unresectable disease at exploration. Thus, staging laparoscopy may aid in the more accurate staging of gastric cancers and guide appropriate treatment without the morbidity associated with exploratory laparotomy.

Severe upper abdominal adhesions from prior surgery that may preclude the procedure

The patient is placed in the supine position, and pneumoperitoneum is established. If present, ascitic fluid is aspirated and sent for cytology. In the absence of ascites, 200 cc of normal saline can be instilled into the peritoneal cavity and aspirated from the pelvis and bilateral subdiaphragmatic spaces for cytologic examination. Full inspection of the peritoneal cavity helps evaluate for peritoneal or liver metastases. Laparoscopic ultrasound may aid in the detection of deep hepatic lesions. If no metastatic disease is discovered, then the left lateral lobe of the liver is elevated to expose the entire stomach. The perigastric nodes along the greater and lesser curvature are inspected and biopsied if needed. In addition, the portahepatic and gastrohepatic ligaments are inspected carefully. Next, the gastric tumor itself is inspected for extra-serosal invasion and infiltration into surrounding structures. If the tumor is posterior, then the lesser sac must be accessed to gain appropriate visualization.