Plate 24
###### Figure 13

The gastrocolic ligament is divided near the epiploic vessels along the greater curvature, if there is no evidence of malignancy. The stomach is retracted upward, and the surgeon's left hand is introduced behind the stomach to avoid the possibility of damaging the middle colic vessels when the gastrocolic ligament is divided, since these vessels may be very near (Figure 9). Furthermore, by spreading the fingers apart beneath the gastrocolic ligament along the greater curvature, it is easier to identify the individual vessels so that they can be more accurately clamped and divided between pairs of small curved clamps (Figure 8). The dissection is carried around to the region of the gastrosplenic ligament, and a portion of this structure may also be removed, depending upon the amount of stomach to be resected. It is necessary to free the greater curvature to this extent to accomplish a 75 to 80 percent resection of the stomach. This usually demands the sacrifice of the left gastroepiploic artery and one or two of the short gastric arteries in the gastrosplenic ligament. The nutrition of the remaining fundus of the stomach depends upon the remaining short gastric arteries (Figure 10) when the left gastric artery has been ligated at its base. When hemigastrectomy is planned, the greater curvature is divided in the area where the left gastroepiploic artery most nearly approximates the gastric wall. On the lesser curvature the third large vein on the anterior gastric wall is used as the approximate point of division to ensure a hemigastrectomy.

In the obese patient the gastrosplenic ligament may be quite thickened and the identification of the vessels for ligation more difficult than elsewhere. However, fewer vessels require ligation if the omentum is removed, as in Plate 27, rather than repeatedly clamping and tying the blood vessels in the gastrocolic ligament near the greater curvature. The division of the usual attachments of the omentum to the lateral abdominal wall about the splenic flexure of the colon will further mobilize the greater curvature of the stomach. Undue traction on the stomach or omentum may result in troublesome bleeding from the spleen, especially if the small strands of tissue extending up to the anterior margin are torn along with some of the splenic capsule. Under such circumstances splenectomy may ...

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