A Case of Laparoscopic Distal Gastrectomy for Early Gastric Cancer Associated With an Upside-Down Stomach: Sac-First Dissection Before Lymphadenectomy.

Gastric cancer associated with an upside-down stomach, an advanced form of paraesophageal hiatal hernia, is rare, and laparoscopic surgery is technically demanding because of marked anatomical distortion. We report an 88-year-old woman with marked kyphosis who presented with vomiting and was diagnosed with early gastric cancer on the lesser curvature of the gastric angle. Computed tomography revealed a giant hiatal hernia with an upside-down stomach. Laparoscopic distal gastrectomy with D1 plus lymphadenectomy and concomitant hiatal hernia repair were performed. The herniated stomach was first reduced into the abdominal cavity, followed by circumferential dissection of the hernia sac at the hiatus and mobilization of the lower esophagus. Lymphadenectomy was then performed with improved orientation. After gastric transection, the redundant hernia sac was excised before Roux-en-Y reconstruction and hiatal closure. The postoperative course was uneventful. This case suggests sac-first dissection may be feasible for laparoscopic gastrectomy in patients with an upside-down stomach.