The supra-pancreatic lymph nodes are a critical component of D2 lymphadenectomy. However, due to the complex anatomy of this region and its proximity to vital blood vessels and organs, it remains a challenging area in radical gastrectomy for gastric cancer. A thorough understanding of the anatomical boundaries of the various lymph node groups in the supra-pancreatic area, along with standardized lymph node dissection and clear exposure of relevant anatomical landmark boundaries, forms the foundation for quality control in supra-pancreatic lymph node dissection. Integrating the concept of meticulous dissection throughout the process of supra-pancreatic lymphadenectomy is crucial for safely and completely clearing lymph nodes in this region. This ensures the high-quality completion of D2 radical gastrectomy for gastric cancer.

The D2 plus complete mesogastrectomy, based on the membrane anatomy theory, significantly enhances the thoroughness and safety of lymph node dissection by utilizing the natural embryonic developmental planes. In the No.11p lymph node area, dissection along the avascular plane between the Treitz fascia and the splenic arterial vascular sheath enables en bloc resection of lymph node adipose tissue, preventing residual micrometastases. For No.12 lymph node dissection, precise separation of the extra-Glissonian plane ensures complete skeletonization of the proper hepatic artery, reducing the risk of tumor cell shedding. The concept of membrane anatomy emphasizes operating anterior to the splenic arterial sheath to avoid the area posterior to the pancreas where the splenic vein courses. During No.12 lymph node dissection, protection of the portal vein and common bile duct relies on identifying the layers within the hepatoduodenal ligament to prevent excessive deep dissection. During No.11p lymph node dissection, adhering closely to the splenic arterial sheath prevents incision into the pancreatic parenchyma, thereby reducing the risk of pancreatic fistula. Thorough dissection of No.11p and No.12 lymph nodes is crucial for preventing local recurrence. The “complete mesogastric excision” principle of membrane anatomy minimizes intraperitoneal tumor cell dissemination, creating favorable conditions for subsequent adjuvant therapy.

With the advancement of minimally invasive techniques, the concept of membrane anatomy has propelled gastric cancer surgery toward the goal of complete mesenteric excision. Due to its unique anatomical location (adjacent to the cardia, esophagus, and diaphragm), upper gastric cancer presents significant surgical challenges, high complication rates, and ongoing controversies in treatment strategies. Ensuring the integrity of key mesenteric structures, such as the left gastric vascular mesentery, splenic vascular mesentery, and left inferior phrenic artery mesentery, constitutes the core prerequisite for improving therapeutic efficacy. By implementing the surgical strategy of “complete mesenteric excision”, combined with precise dissection along interfascial planes and vascular-guided operative principles, this approach effectively reduces intraoperative cancer cell spillage, decreases postoperative complication rates, and enhances the thoroughness of lymph node dissection alongside surgical safety. 

The number of obese patients with gastric cancer is increasing day by day. Due to their unique physiological and anatomical characteristics, concurrent medical diseases, and the impact of neoadjuvant chemotherapy and immunotherapy, they face problems such as difficulties in perioperative management and high surgical complexity. When performing surgery on obese patients with gastric cancer, surgeons should conduct adequate preoperative imaging evaluation and surgical planning, deeply understand the inherent anatomical layers and the concept of membrane anatomy obscured by fat, and skillfully use various instruments and energy devices for delicate operations. Meanwhile, certain techniques should be adopted to reduce the operational difficulty for assistants, so as to achieve continuous, stable and effective exposure of the surgical field. During the operation, surgeons should be patient and meticulous, avoid rough traction and blind separation, and always pay attention to protecting important tissue structures and adjacent organs. Furthermore, more emphasis should be placed on perioperative management and comprehensive treatment, so as to achieve proper perioperative management and reduce the incidence of postoperative complications.

During gastrectomy for gastric cancer, the short gastric vessels are a challenge in radical resection due to their complex anatomy and proximity to the splenic hilum and pancreatic tail, which can easily lead to intraoperative bleeding and postoperative complications. In distal gastrectomy, only 2 short gastric vessels at the inferior pole of the spleen need to be managed. These vessels are relatively long with a large operative space, and safe and effective lymph node dissection and vascular ligation can be achieved with minimal surgical skills. However, in proximal gastrectomy or total gastrectomy, the short gastric vessels at the superior pole of the spleen are short with a narrow operative space. The traditional bottom-up approach is prone to bleeding, and hemostasis is difficult in such cases. Adopting a “short gastric vessels first” strategy can address splenic hilum bleeding caused by visual field obstruction and excessive traction on the short gastric vessels under the traditional approach. This strategy improves surgical safety while ensuring the quality of lymph node dissection.

The precise dissection of the vagus nerve has become a critical element in the technical chain of function-preserving gastrectomy (FPG). At the technical level, innovations such as intraoperative nerve monitoring combined with navigation by indocyanine green fluorescence, optimization of surgical approaches, robotic surgical systems, and artificial intelligence (AI) -assisted surgical planning and navigation systems have significantly enhanced the precision and feasibility of vagus nerve preservation. However, controversies persist: while preservation of the hepatic branch has become a consensus, preservation of the celiac branch still requires more high-quality evidences due to its technical difficulty and potential impact on the thoroughness of lymph node dissection. Future research directions include: determining the safety of implementing nerve-preserving, reduced surgery or even exempt from surgery in patients achieving significant downstaging after neoadjuvant therapy, as well as evaluating the oncological safety of nerve preservation in advanced gastric cancer. In conclusion, precise vagus nerve preservation is crucial for improving the postoperative quality of life of gastric cancer patients. Advancing personalized and precision surgery requires the continued integration of technological progress combined with evidence-based medicine.

Although neoadjuvant therapy significantly improves tumor control rates and pathological complete response (pCR) rates, the tissue edema and fibrosis it induces obscure the anatomical planes of the gastric mesentery, thereby increasing surgical complexity and complication risks (e.g., increased intraoperative blood loss and prolonged operation time). The tissue alterations primarily manifest as: (1) Edema causing difficulties in identifying anatomical planes, obvious exudation in the surgical area, and tissues being prone to tearing. (2) Fibrosis leading to the disappearance of anatomical spaces, making dissection difficult and increasing the risk of collateral damage. To address these challenges, the following surgical quality control strategies are recommended: (1) Precise clinical staging to avoid overtreatment. (2) Prudent implementation of function-preserving surgery. Standard gastrectomy with D2 lymphadenectomy should still be adhered to currently. Exploration of reduced or omitted surgery should only be considered for specific patient groups. (3) Prioritize dissection of normal tissue areas, avoid entering incorrect anatomical planes, employ suction devices for assistance, and enhance team collaboration. Future efforts should focus on establishing an intraoperative tissue alteration evaluation system, advancing multimodal precision staging, exploring pathways for function-preserving surgery in clinical research, and optimizing perioperative treatment through multidisciplinary collaboration. 

The core advancements in refined anatomical research within gastric surgery involve: encompassing refined classification of the vascular and lymphatic systems, nerve preservation mechanisms, the application of membrane anatomy theory, individualized dissection strategies for splenic hilar lymph nodes, adaptability of minimally invasive techniques, and progress in function-preserving surgeries. Meanwhile, it details research progress in complication prevention and control, such as early warning for anastomotic leaks and postoperative gastric emptying disorders. The precision of gastric surgery fundamentally relies on an in-depth understanding of vascular, neural, lymphatic, and membrane anatomy. Therefore, future research necessitates integrating traditional anatomy with membrane anatomy theory, establishing multi-dimensional anatomical databases, and further combining artificial intelligence with real-time navigation technologies to advance the development of individualized and minimally invasive surgical techniques, ultimately improving patient quality of life.