The patient was a 63-years-old female with early gastric cancer in her upper stomach. Widely spreading on the mucous membrane, the cancer was too big to remove by endoscopical mucosal resection, although she wanted minimal invasive treatment. Therefore, we adopted total gastrectomy with hand-assisted laparoscopic surgery (HALS) after obtaining “informed consent” from her. Five small skin-incisions were necessary to perform it-one 7cm' for hand-port and four 1.2cm' for trocars.
The dissection was started from greater omentum and proceeded counterclockwise to remove primary lymphnodes. The abdominal esophagus and the duodenum were devided with a single or double application of Endo GIA stapler (linear stapler). All these steps were accomplished safely and securely with the effective support of the left hand of the operator. After extraction of the whole stomach through the 7cm-incision, Roux-en Y reconstruction was performed laparoscopically (esophago-jejunostomy) followed by hand sewing through the 7cm-incision (jejuno-jejunostomy). The anvil of 21mm circular stapler (EEA) was inserted orally in order to anastomose the esophagus to the jejunum. The patient had acceptable results intra-operatively as well as postoperatively by HALS total gastrectomy, which had been considered to be very hard to perform up to present time.

1)The Keio ACLS Popularizing and Promoting Association (KAPPA) is an official student organization that promotes advanced life support techniques.
2)KAPPA has provided 29 advanced cardiac life support courses, including 20 official ICLS (immediate cardiac life support) courses of the Japanese Association for Acute Medicine, which have trained 314 ICLS providers and 61 ICLS instructors during the past 8 years.
3)Peer–led training among students to maintain the quality of the courses has contributed to the activities of KAPPA.