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Background: Laparoscopic techniques have been applied to gastric cancer patients for some time with relative success. Most series describe primary resections in patients with low body mass index (BMI) and few comorbidities. The purpose of this study is to describe the lessons learned from our unique population of patients with high BMI and multiple comorbidities that required total gastrectomy for oncologic purposes. Methods: A retrospective review of all consecutive patients undergoing laparoscopic total gastrectomy for gastric cancer at a tertiary referral center was performed. Demographic information, pathologic evaluation, perioperative morbidity and mortality, and short-term outcomes were analyzed Results: Six patients (n=6) underwent laparoscopic total gastrectomy for gastric cancer from 2008-2009. All patients underwent laparoscopic total gastrectomy with Roux-en-Y esophagojejunostomy reconstruction using a per-oral circular stapling technique. The mean BMI was 33 kg/m2. Three patients required conversion; one due to adhesions, and the other two due to technical difficulties with creation of the esophagojejunostomy. One patient required re-operation for anastomotic leak. All margins were negative for cancer. The mean estimated blood loss was 400 cc (range 100-850cc). Length of stay was 11 days average (range 4-30 days). There were no other complications or deaths. All patients at follow up (3-15 months) are tolerating a regular diet and without evidence of recurrence. Conclusions: Despite the technical challenges and steep learning curve of laparoscopic gastrectomy, minimally invasive techniques can be applied to high-risk patients requiring gastrectomy for cancer. Creation of the esophagojejunostomy can be completed safely with high conversion rate but low overall leak rate.