When Should Clearance of the Hepatoduodenal Ligament Be Performed

In Western countries gastric cancer continues to remain a biologically aggressive tumor, with poor long-term oncological outcomes. In Romania, the estimated gastric cancer was the fifth cause of oncological death in men and the eighth cause of oncological death in women in 2012.The objective of the study is to detail when should the hepatoduodenal ligament (station 12) be cleared surgically as a part of D2 dissection during radical gastrectomy.We have performed a review of the English language literature using PubMed/Medline library. As keywords we used a combination of the following terms: ‘gastrectomy’, ‘stomach’, ‘cancer’, and ‘lymphadenectomy’. According to the Japanese Gastric Cancer Association, the hepatoduodenal ligament includes the lymph nodes station 12, which are further divided in 12a – along left side of the proper hepatic artery, 12b – right side of the ligament and posterior to the common bile duct, and 12p – posterior to the portal vein. For middle and lower third gastric tumors, station 12a represents the N2 tier, while for upper third gastric tumors, it represents the N3 tier. Lymph nodes 12b and 12p represent N3, irrespective of the tumor location. For middle and lower third gastric tumors the clearance of the lymph nodes surrounding the proper hepatic artery is a part of the D2 dissection. Dissection of the lymph nodes surrounding the proper hepatic artery is a component of the D2 spleen and pancreas preserving lymphadenectomy, for lesions which extend further than submucosa.