Plate 31
###### Figure 5

Total gastrectomy may be indicated in treating extensive stomach malignancies. This radical procedure is not performed when carcinoma with distant metastasis to the liver or pouch of Douglas or seeding throughout the peritoneal cavity is present. It may be performed in association with the extirpation of adjacent organs, such as the spleen, body and tail of the pancreas, a portion of the transverse colon, and so forth. It is also the procedure of choice in controlling the intractable ulcer diathesis associated with non-beta islet cell tumors of the pancreas when pancreatic tumor or metastases remain that cannot be controlled medically.

The blood volume should be restored and antibiotics given in the presence of achlorhydria. If colonic involvement is anticipated, the colon should be emptied with appropriate bowel cleansing, and perioperative antibacterial agents should be administered. Four to six units of blood should be readily available for transfusion. Pulmonary function studies may be indicated.

General anesthesia with endotracheal intubation is used.

The patient is placed in a comfortable supine position on the table with the feet slightly lower than the head.

The area of the chest from above the nipple downward to the symphysis is shaved. The skin over the sternum, lower chest wall, and entire abdomen is cleansed with the appropriate antiseptic solution. Preparation should extend sufficiently high and to the left on the chest for a midsternal or left thoracoabdominal incision if necessary.

A minimally invasive laparoscopic peritoneoscopy is often performed first to rule out inoperable spread of a malignancy. If this view is clear, then a limited incision is made in the midline (Figure 1, A–A1) between the xiphoid and umbilicus. The initial opening is only to permit inspection of the stomach and liver and to introduce the hand for general exploration of the abdomen. Because of the high incidence of metastases, a more liberal incision extending up to the region of the xiphoid and down to the umbilicus, or beyond it on the left side, is not made until it has been determined that there is no contraindication to total or subtotal gastrectomy (Figure 1). Additional exposure is allowed by removal of the xiphoid. Active bleeding points in the xiphocostal angle are transfixed with 00 silk sutures, and bone wax is applied to the end of the sternum. Some prefer to split the ...

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