The stomach has a rich anastomotic blood supply. The largest blood supply comes from the celiac axis (1) by way of the left gastric artery (2) (bold numbers refer to parts of this chapter’s figure). The blood supply to the uppermost portion, including the lower esophagus, is from a branch of the left inferior phrenic artery (3). The left gastric artery divides as it reaches the lesser curvature just below the esophagogastric junction. One branch descends anteriorly (2a) and the other branch posteriorly along the lesser curvature. There is a bare area of stomach wall, approximately 1 to 2 cm wide, between these two vessels that is not covered by peritoneum. In the performance of total gastrectomy, it is necessary to ligate the left gastric artery near its point of origin above the superior surface of the pancreas. This also applies when 70% or more of the stomach is to be removed. Ligation of the artery in this area is commonly done in the performance of gastric resection for malignancy so that complete removal of all lymph nodes high on the lesser curvature may be accomplished.
A lesser blood supply to the uppermost portion of the stomach arises from the short gastric vessels (4) in the gastrosplenic ligament. Several small arteries arising from the branches of the splenic artery course upward toward the posterior wall of the fundus. These vessels are adequate to ensure viability of the gastric pouch following ligation of the left gastric artery as well as of the left inferior phrenic artery. If one of these vessels predominates, it is called the posterior gastric artery; its presence becomes significant in radical gastric resection. Mobilization of the spleen following division of the splenorenal and gastrophrenic ligaments retains the blood supply to the fundus and permits extensive mobilization at the same time. The blood supply of the remaining gastric pouch may be compromised if splenectomy becomes necessary. The body of the stomach can be mobilized toward the right and its blood supply maintained by dividing the thickened portion of the splenocolic ligament up to the region of the left gastroepiploic artery (5). Further mobilization results if the splenic flexure of the colon, as well as the transverse colon, is freed from the greater omentum. The greater curvature is ordinarily divided at a point between branches coming from the gastroepiploic vessels (5, 6) directly into the gastric wall.
The blood supply to the region of the pylorus and lesser curvature arises from the right gastric artery (7), which is a branch of the hepatic artery (8). The right gastric artery is so small that it can hardly be identified when it is ligated with the surrounding tissues in this area.
One of the larger vessels requiring ligation during gastric resection is the right gastroepiploic artery (6) as it courses to the left from beneath the pylorus. It parallels ...