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INDICATIONS

Gastrectomy is most often performed for gastric cancer or peptic ulcer disease. The complexity of the operation needs to be matched with the expertise of the surgeon. Wedge resection of a small gastric tumor (e.g., leiomyoma) falls on the simpler end of the complexity spectrum and can be performed by most well-trained minimally invasive general surgeons. Total gastrectomy with J-pouch reconstruction and D2 lymph node dissection for proximal gastric cancer falls on the more difficult end of the complexity spectrum and should be performed by experts in minimally invasive surgery for upper GI malignancy. This chapter addresses the more complex procedures, subtotal and total gastrectomy, with extensive (D2) lymph node dissection, the international “standard” for gastric cancer surgery. D2 dissection requires removal of lymph node stations along the celiac trunk, left gastric, splenic, and hepatic arteries. Familiarity with regional lymph node anatomy and the international naming conventions is critical to adequate lymph node harvest and subsequent staging (Figure 1). The final anatomy of the subtotal gastrectomy with Roux en Y gastrojejunostomy is shown (Figure 2).

PATIENT SELECTION, STAGING, AND PREOPERATIVE PREPARATION

A complete preoperative upper GI endoscopic examination is necessary in all patients to characterize gastric pathology and identify synchronous pathology. Cancer staging also requires pre-treatment computed tomography (CT) scanning, endoscopic ultrasonography, and diagnostic laparoscopy with peritoneal washings. Positron emission tomography (PET) scanning may be useful, but is less frequently performed with gastric cancer than with thoracic malignancies. Prior to treatment, multidisciplinary discussion (tumor board) should occur. In many cases of advanced malignancy, preoperative (neoadjuvant) chemotherapy with or without radiation therapy may be indicated. Restaging with CT scanning, at a minimum, should precede operation.

A full cardiopulmonary evaluation should be considered. Stair climbing or a 6-minute walk test may be as valuable as noninvasive cardiac imaging. Patients should continue all preoperative medications until the morning of surgery, with the exception of aspirin, nonsteroidal anti-inflammatory agents, warfarin, or heparin. Mechanical bowel preparation is generally not necessary. Intraoperative esophagogastroduodenoscopy may aid in localizing pathology and determining the limits of resection, as well as completion examination of the anastomosis for patency and integrity (i.e., negative leak test). Intraoperative laparoscopic hepatic ultrasound may be necessary, depending on the indication for operation and the results of preoperative imaging studies.

ANESTHESIA

General anesthesia with complete neuromuscular blockade is required for laparoscopic gastrectomy. Intravenous antibiotics directed against intestinal flora are administered preoperatively. A nasogastric tube is placed into the stomach to low wall suction.

OPERATIVE PREPARATION

A urinary catheter should be placed. The upper abdomen is shaved with clippers from the nipple lines to the umbilicus after induction of ...

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