Plate 23

Subtotal gastrectomy is indicated in the presence of malignancy; in the presence of gastric ulcer that persists despite 3 weeks of intensive medical therapy; and in the presence of anacidity, pernicious anemia, suspicious cells by gastric cytology, or equivocal evidence for and against malignancy by repeated barium studies or fiberoptic gastroscopic observation with direct biopsy. It is most commonly utilized to control the acid factor in cases of intractable duodenal ulcer. A more conservative procedure should be considered in underweight patients with duodenal ulcer, especially females. Likewise, block excision of a gastric ulcer with multicentric frozen section studies should be made for proof of malignancy before performing a radical resection on the assumption the lesion may be malignant. This special effort for proof is especially important in all females as well as in underweight males.

The preoperative preparation will be determined largely by the type of lesion presented and by the complication it produces. After surgery has been definitely planned, the patient without pyloric obstruction is encouraged to substitute a high-protein, high-carbohydrate, and high-vitamin diet for the rigid regimen so as to prepare for the postoperative period of limited caloric intake. Sufficient time should be taken to improve the nutrition if possible, especially if there has been considerable weight loss in a patient with obstruction. The fluid and electrolyte balance must be established by the intravenous injection of Ringer's lactate solution. Potassium deficiencies are corrected. Anemia and hypoproteinemia should be corrected as nearly as possible by transfusion of whole blood and plasma or by TPN. The increased incidence of pulmonary complications associated with upper abdominal surgery makes it imperative that elective gastric surgery be carried out only in the absence of respiratory infection, and active pulmonary physiotherapy with possible bronchodilators, expectorants, and positive pressure breathing exercises should be started in patients with chronic lung disease.

If there is any degree of pyloric obstruction, the electrolyte balance, which includes potassium and sodium chloride; blood urea nitrogen levels; blood pH; and PCO2 or carbon dioxide combining power, must be returned to normal by the appropriate replacement therapy. Repeated gastric lavage, including several days of constant gastric suction, may be indicated until a satisfactory balance is attained. Constant gastric suction by means of a Levin tube is instituted before operation and maintained during and after operation unless a gastrostomy is performed following the resection. Whole blood in the amount of 1,000 to 2,000 mL should be available for transfusion during the operation. Preoperative antibiotics should be considered, and gastrin levels determined if a gastrinoma is suspected.

General anesthesia with endotracheal intubation should be used. Excellent muscular relaxation without deep general anesthesia can be attained by utilizing muscle relaxants. Spinal anesthesia, either continuous or single-injection technique, provides excellent relaxation; however, supplementation with intravenous sedative may be indicated to prevent nausea during visceral manipulation.

As a rule, the patient is laid supine on a flat table, the feet being slightly lower than the head. If the stomach is high, a more erect position is preferable.

The skin is prepared in the routine manner.

A midline incision extending from the xiphoid to the umbilicus may be used. Additional exposure can be obtained by excising the xiphoid. Bone wax is applied to the sternal end to control bleeding. Active arterial bleeding on either side of the xiphoid is ligated with a transfixing suture of 00 silk. Further exposure can be obtained by splitting the sternum with a sternal knife. If preferred, a paramedian incision can be made to the left of the midline. The left paramedian incision if preferable to the right, since the most difficult part of the procedure may be the gastrojejunal anastomosis following a high resection. Either of these incisions will give adequate exposure without great traction, but either a self-retaining retractor or a broad-bladed, fairly deep retractor placed against the liver down to the gastrohepatic ligament will aid in visualization.

The surgeon should focus his on her attention on the arterial blood supply (Figure 1). Although the stomach will retain viability despite extensive interference with its blood supply, the duodenum lacks such a liberal anastomotic blood supply, and great care must be exercised in the latter instance to prevent postoperative necrosis in the duodenal stump. The blood supply to the lesser curvature of the stomach can be totally interrupted, and the retained fundus will be nourished by the small vessels in the gastrosplenic ligament in the region of the fundus. Importantly, if it is desirable to mobilize the stomach into the chest, its viability can be retained if only the right gastric artery is left intact. In such instances, however, the gastrocolic ligament should be divided some distance from the greater curvature to prevent interference with the right and the left gastroepiploic vessels.

The blood supply may also be used as landmarks in designating the extent of the gastric resection. Approximately 50 percent of the stomach is resected where the line of division extends from the region of the third large vein on the lesser curvature down from the esophagus to a point on the greater curvature where the left gastroepiploic vessels most nearly approach the gastric wall. Approximately 75 percent resection can be assumed when the line of resection includes most of the lesser curvature with extra gastric ligation of both the left gastric and left gastroepiploic vessel.

The surgeon likewise should be familiar with the major lymphatic drainage of the stomach in determining the presence or absence of metastasis if malignancy is suspected. Under such circumstances it is advisable to keep the dissection as far away as possible from both curvatures in order to retain all involved lymph nodes with the specimen. There is a tendency for metastases to involve distant lymph nodes of the lesser curvature (A) and the lymph nodes beneath the pylorus (B) as well as those of the greater omentum (C). Chances for prolonged survival in the presence of malignant disease are greatly enhanced if consideration is given to lymphatic drainage in planning the extent of removal necessary (Figure 1).

In general, it is desirable to move the greater omentum, most of the lesser curve to the esophagus, and about 21/2 cm of the duodenum (including subpyloric lymph nodes), and the greater curvature up to and at times including the spleen. Extended radical dissection of the preaortic (D) and portal area (E) lymph nodes has been shown to be beneficial in the Japanese experiences; however these dissections are still under study.

Prior to operation, external (CT, MRI, PET) imaging and internal endoscopic transluminal ultrasound evaluations may show an inoperable extension of the malignancy. Additionally, many potential candidates for a cancer resection are first evaluated with laparoscopy (see Hasson open technique, Plate 91) with laparoscopic peritoneoscopy and biopsy, as up to 40 percent of patients may have occult distant spread. Such findings preclude curative resection but not necessarily a gastric procedure for relief of obstruction and bleeding.

If the exploratory peritoneoscopy does not reveal contraindications to resection, the abdomen is opened and a careful regional inspection with palpation is performed. It must also be determined whether there have been direct extension and fixation to adjacent structures, such as the pancreas, liver, or spleen. Additional information may be obtained as to the extent and fixation of the tumor mass by exploring the lesser omental cavity through an opening made in the relatively avascular gastrohepatic ligament (Figure 2). Evidence of fixation of the posterior gastric wall with the pancreas or involvement of the tissues about the middle colic vessels should be sought. However, in the absence of visible or palpable distance metastases, it may be feasible to excise the stomach, en masse, along with the spleen and portions of the left lobe of the liver, or tail and body of the pancreas, if the involvement is by direct extension of the tumor. If there is widespread metastatic involvement with impending pyloric obstruction, it may be wiser to avoid radical surgery and to carry out the simple procedure of anterior or posterior gastrojejunostomy.

After evaluation indicates that a subtotal gastrectomy is practicable, it has been found that preliminary mobilization of the duodenum by the Kocher maneuver may facilitate some of the subsequent steps necessary in the procedure (Figures 3, 4, and 5). The duodenum is grasped with Babcock forceps in the region of the pylorus, and traction is sustained downward (Figure 3). Any avascular adhesive bands that appear to be fixing the duodenum in the region of the hepatoduodenal ligament should be severed. The common duct is exposed so that is can be identified easily from time to time as the duodenum is divided and the stump is inverted (Figure 6).

After the duodenum and region of the pylorus have been mobilized by freeing all the avascular attachments, the index finger of the right hand is passed through an avascular portion of the gastrohepatic ligament above the pylorus to facilitate the introduction of a Penrose drain or gauze tape, which is brought up through an avascular space along the greater curvature and is used for traction (Figure 7).

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