Chapter 34: Total Gastrectomy

INDICATIONS

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 extirpation of adjacent organs, including the spleen, body and tail of the pancreas, or a portion of the transverse colon. It is also the procedure of choice for patients with hereditary gastric cancer syndrome and 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.

PREOPERATIVE PREPARATION

Electrolyte replacement and fluid resuscitation should be complete. If colonic involvement is anticipated, the colon should be emptied with appropriate mechanical preparation. Blood should be readily available for transfusion.

ANESTHESIA

General anesthesia with endotracheal intubation is used.

POSITION

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

OPERATIVE PREPARATION

The area of the chest from above the nipples downward to the pubic 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. Then a time-out is performed.

INCISION AND EXPOSURE

A diagnostic laparoscopy is often performed first to rule out inoperable spread of a malignancy (see Chapter 15). 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 may be applied to the end of the sternum. Some operators prefer to split the lower sternum in the midline and extend the incision to the left into the fourth intercostal space. Adequate exposure is mandatory for a safe anastomosis between the esophagus and jejunum.

DETAILS OF THE PROCEDURE

Total gastrectomy should be considered for malignancy high on the lesser curvature if there is no metastasis to the ...