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Objective: To analyze the application and clinical efficacy of the "three-step posterior approach" for preserving the vagus nerve in laparoscopic radical distal gastrectomy for gastric cancer. Methods: This was a retrospective cohort study. Clinical data of patients who underwent laparoscopic radical distal gastrectomy at the Department of Gastric Surgery, The First Affiliated Hospital of Nanjing Medical University from March 2020 to June 2023 were collected. Inclusion criteria included: age 18-75 years; pathological diagnosis of gastric adenocarcinoma; clinical stage cT1~2N0~1M0; and no history of gallstones. Patients with preoperative neoadjuvant chemotherapy, combined organ resection, or missing data were excluded. Patients were divided into a conventional laparoscopic radical distal gastrectomy (LDG) group and a laparoscopic vagus nerve-preserving distal gastrectomy (LVNPDG) group based on the surgical procedure. The preservation of the celiac branch of the vagus nerve was performed using the "three-step posterior approach". Step 1: First, lymph node dissection at No.11p was performed along the proximal splenic artery at the upper border of the pancreas. The left Toldt space was entered, Gerota fascia was exposed, and dissection was extended rightward along its surface to the left diaphragmatic crus. Step 2: Lymph nodes No.8 and No.12a were dissected, then retracted leftward to dissect No.9 lymph nodes. The adhesion between the right diaphragmatic crus and the left gastric mesentery was divided and connected to the left Toldt space, thereby completely mobilizing the left gastric mesentery from the posterior abdominal wall. Step 3: From the root of the left gastric artery, the left gastric mesentery was opened dorsally toward the diaphragm and incised distally to expose the left gastric artery. Using dissecting forceps, the left gastric mesentery was dissected toward the posterior trunk of the vagus nerve to identify, expose, and preserve the celiac branch running within it. Subsequently, dissection was extended along the celiac branch toward the cardia, and the posterior gastric branches of the vagus nerve to the posterior gastric wall were divided. Below the emergence of the hepatic branch from the anterior trunk of the vagus nerve, the hepatogastric ligament was incised to expose the right diaphragmatic crus, and a fixing suspension suture was placed while sparing the hepatic branch of the vagus nerve. A maximum ratio of 1∶3 propensity score matching (PSM) (caliper value 0.02) was performed using sex, age, body mass index (BMI), American Society of Anesthesiologists (ASA) score, tumor size, differentiation, depth of invasion, lymph node metastasis, TNM stage, and anastomosis method as covariates. Perioperative indicators (operation time, blood loss, lymph node count, time to first flatus and diet, hospital stay), early postoperative complications, quality of life at 1 year postoperatively (constipation, diarrhea, flatulence, appetite, dumping syndrome), and nutritional status. Results: After PSM, 76 patients were included in the LVNPDG group, and 204 patients in the LDG group. There were no statistically significant differences in baseline characteristics between the two groups (all P> 0.05). The operation time in the LVNPDG group was longer than that in the LDG group [(183.2±35.8) minutes vs. (168.4±34.9) minutes, t=-3.136, P=0.002], but the time to first flatus was shorter in the LVNPDG group [(2.6±0.8) days vs. (2.9±0.7) days, t=2.748, P=0.007]. No statistically significant differences were observed between the two groups regarding intraoperative blood loss, the number of retrieved lymph nodes (total and per station), time to first liquid diet, or postoperative hospital stay (all P> 0.05). The incidence of early postoperative complications was 5.9% (12/204) in the LDG group and 7.9% (6/76) in the LVNPDG group, with no significant difference (χ²=0.113, P=0.736). Regarding quality of life and long-term complications at 1 year postoperatively, the incidence of diarrhea in the LVNPDG group was lower than in the LDG group [3.9% (3/76) vs. 13.2% (27/204), χ²=4.993, P=0.025], and the incidence of increased flatulence was also significantly lower [17.1% (13/76) vs. 33.3% (68/204), χ²=7.092, P=0.008]. Additionally, the incidence of gallstones in the LVNPDG group was 1.3% (1/76), which was significantly lower than the 8.8% (18/204) observed in the LDG group (χ²=4.934, P=0.026). There were no statistically significant differences between the two groups in terms of constipation, appetite loss, dumping syndrome, or changes in postoperative albumin levels (all P >0.05). Conclusions: The "three-step posterior approach" for preserving the vagus nerve in laparoscopic radical distal gastrectomy is technically safe and feasible, without increasing the risk of postoperative complications. Compared with traditional laparoscopic distal gastrectomy, this procedure effectively improves patients' postoperative quality of life.