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INDICATIONS

The indications and preoperative preparations are specific and are reviewed in Chapter 34, where the commonly used methods of reconstruction are shown with hand-sewn anastomoses. Many surgeons, however, prefer to use staples because they simplify the anastomoses and lessen the total time of this operation.

ANESTHESIA

General anesthesia is administered by endotracheal intubation.

POSITION

Exposure is enhanced if the patient is placed in a reversed Trendelenburg position.

OPERATIVE PREPARATION

The skin over the lower thorax and the abdomen is shaved and cleansed with the appropriate antiseptic solution. Then a time-out is performed.

INCISION AND EXPOSURE

A diagnostic laparoscopy may be considered first to rule out inoperable spread of a malignancy commonly to the liver, peritoneum, omentum, and pelvis. If this is clear, then a midline incision starting over the xiphoid and extending down to the umbilicus is made initially. This permits abdominal exploration and enables the surgeon to make a decision for or against proceeding with total gastrectomy. The incision is usually extended to the left and below the umbilicus if the decision is made to proceed with total gastrectomy. The greater omentum is completely freed from the transverse colon, facilitating dissection into the lesser sac and permitting evaluation of the posterior wall of the stomach as well as an evaluation for metastases about the left gastric vessels and attachments to the pancreas. Improved exposure of the esophagogastric junction may be facilitated by excision of the xiphoid along with medial mobilization of the left lobe of the liver following division of the suspensory ligaments (left triangular and left coronary) to this lobe. An outline of a final reconstruction is shown in FIGURE 1.

DETAILS OF THE PROCEDURE

As in Chapter 34, the region of the duodenum is first mobilized by the Kocher maneuver, and the blood supply about the pylorus is ligated to prepare only the duodenal wall for application of the stapler. The right gastroepiploic vessels are doubly ligated at their origin to ensure inclusion of any possible lymph node metastases. The right gastric blood supply to the superior surface of the duodenum also should be divided and ligated to ensure removal of 2.5–3 cm of duodenum distal to the pyloric vein if the procedure is being performed for gastric carcinoma. The duodenum is closed with a noncutting linear stapler. The duodenum is divided between the stapler and the Kocher clamp on the pyloric end of the duodenum. Alternatively, the duodenum may be divided with a cutting linear stapler. The entire stomach, along with the greater omentum and the gastrohepatic ligament, is then mobilized as shown in Chapter 34. The gastric vessels are divided and ligated in the presence of cancer of the fundus of the ...

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