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INDICATIONS

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The indications and preoperative preparations are specific and are reviewed in Chapter 31, where the commonly used methods of reconstruction are shown with hand-sewn anastomoses. Many surgeons, however, prefer to use staples, because they simplify the anastomoses and lessen the total time of this operation.

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ANESTHESIA

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General anesthesia is administered by endotracheal intubation.

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POSITION

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Exposure is enhanced if the patient is placed in a reversed Trendelenburg position.

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OPERATIVE PREPARATION

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The skin over the lower thorax as well as the abdomen is shaved and cleansed with the appropriate antiseptic solution.

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INCISION AND EXPOSURE

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A diagnostic laparoscopy is often performed first to rule out inoperable spread of a malignancy. If this is clear, then a midline incision starting over the xiphoid and extending down to the umbilicus is made initially. This permits abdominal exploration and enables the surgeon to make a decision for or against proceeding with total gastrectomy. The incision is usually extended to the left and below the umbilicus if the decision is made to proceed with total gastrectomy. In the absence of metastases to the liver, peritoneum, omentum, and pelvis, the greater omentum is completely freed from the transverse colon. This permits evaluation of the posterior wall of the stomach as well as an evaluation for metastases about the left gastric vessels and attachments to the pancreas. Excision of the xiphoid provides a better exposure of the esophagogastric junction, along with medial mobilization of the left lobe of the liver following the division of the suspensory ligament to this lobe. An outline of a final reconstruction is shown in figure 1.

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DETAILS OF PROCEDURE

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As in Chapter 31, the region of the duodenum is first mobilized by the Kocher maneuver, and the blood supply about the pylorus ligated to prepare only the duodenal wall for the application of the stapler. The right gastroepigastric vessels are doubly ligated as far away from the duodenal wall as possible to ensure the inclusion of any possible lymph node metastases. The right gastric blood supply to the superior surface of the duodenum should also be divided and ligated to ensure the removal of 2.5 to 3 cm of duodenum distal to the pyloric vein, if the procedure is being performed for gastric carcinoma. The duodenum is closed with a non-cutting linear stapler. The duodenum is divided between the stapler and the Kocher clamp on the pyloric end of the duodenum. Alternatively the duodenum may be divided with a linear stapler. The entire stomach, along with the omentum and the gastric hepatic ligament, is then mobilized as shown in Chapter 31. The gastric vessels are divided and ligated in the presence of cancer of the fundus of the stomach. The spleen may also be resected, but this ...

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