Plate 24

The gastrocolic ligament is divided near the epiploic vessels along the greater curvature, if there is no evidence of malignancy. The stomach is retracted upward, and the surgeon's left hand is introduced behind the stomach to avoid the possibility of damaging the middle colic vessels when the gastrocolic ligament is divided, since these vessels may be very near (Figure 9). Furthermore, by spreading the fingers apart beneath the gastrocolic ligament along the greater curvature, it is easier to identify the individual vessels so that they can be more accurately clamped and divided between pairs of small curved clamps (Figure 8). The dissection is carried around to the region of the gastrosplenic ligament, and a portion of this structure may also be removed, depending upon the amount of stomach to be resected. It is necessary to free the greater curvature to this extent to accomplish a 75 to 80 percent resection of the stomach. This usually demands the sacrifice of the left gastroepiploic artery and one or two of the short gastric arteries in the gastrosplenic ligament. The nutrition of the remaining fundus of the stomach depends upon the remaining short gastric arteries (Figure 10) when the left gastric artery has been ligated at its base. When hemigastrectomy is planned, the greater curvature is divided in the area where the left gastroepiploic artery most nearly approximates the gastric wall. On the lesser curvature the third large vein on the anterior gastric wall is used as the approximate point of division to ensure a hemigastrectomy.

In the obese patient the gastrosplenic ligament may be quite thickened and the identification of the vessels for ligation more difficult than elsewhere. However, fewer vessels require ligation if the omentum is removed, as in Plate 27, rather than repeatedly clamping and tying the blood vessels in the gastrocolic ligament near the greater curvature. The division of the usual attachments of the omentum to the lateral abdominal wall about the splenic flexure of the colon will further mobilize the greater curvature of the stomach. Undue traction on the stomach or omentum may result in troublesome bleeding from the spleen, especially if the small strands of tissue extending up to the anterior margin are torn along with some of the splenic capsule. Under such circumstances splenectomy may be safer than depending on a hemostatic sponge or splenorrhaphy to control the troublesome and persistent bleeding. However, every effort should be made to repair the torn capsule, either by the use of coagulant or by the use of sutures, which may include the omentum when tied, in order to conserve the spleen, especially in younger patients. The greater curvature can be further mobilized into the field of operation if the relatively avascular splenocolic ligament is divided (Figures 10 and 11). Indeed, the spleen may be quite extensively mobilized by dividing the splenorenal ligament laterally, permitting it, along with the fundus of the stomach, to be presented into the field of operation. This procedure ensures an easier exposure for the gastrojejunal anastomosis following a very high gastric resection. Any bleeding points in the splenic bed should be carefully ligated.

At this time it is desirable to prepare the greater curvature for subsequent anastomosis. The serosa should be dissected free of fat for approximately the width of the index finger. A transfixing silk suture is placed in the greater curvature in this area to serve as a guide suture at the time the clamps are finally applied for division of the stomach (Plate 26, Figure 30). In addition, such a transfixing suture tends to prevent damage to the adjacent blood supply from subsequent manipulation of the stomach while preparing it for anastomosis (Figure 11).

Upward retraction of the stomach is maintained as the gastrocolic ligament is divided up to the region of the pylorus. If there is a possibility of malignancy within the area, care should be taken to stay about 3 to 5 cm from the pylorus in order to include the subpyloric nodes with the specimen. At the same time large, blind bites with hemostats in the neighborhood of the inferior portion of the duodenum should be avoided because of possible damage to the pancreaticoduodenal artery. It should be remembered that since the duodenum does not have a rich anastomotic blood supply but is supplied from end arteries, it is necessary to guard its blood supply carefully. The right gastroepiploic vessels should be carefully isolated from the surrounding fat and securely ligated (Figure 12).

After the blood supply of the greater curvature of the stomach has been divided and tied, the vascular supply and ligamentous attachments to the superior portion of the first part of the duodenum can be divided. Freeing the pylorus and the upper portion of the duodenum may be one of the most difficult steps in the operation, especially in the presence of a large, penetrating ulcer. One cannot state beforehand whether the attack should begin at the upper or lower border of the duodenum. In the presence of gastric malignancy extending to the pylorus, it is essential to remove at least 3 cm of the duodenum because of the possibility of infiltration of carcinoma for some distance within the wall of the duodenum itself. Additionally, a more extensive lymph node dissection is accomplished (regions B and E) along with an omentectomy (see Plate 27). The most medial portion of the hepatoduodenal ligament, which includes the right gastric artery, is divided. It is better to take small bites in this area with a small curved hemostat and reapply the clamps repeatedly than to attempt mass ligation (Figure 13). The location of the common duct and adjacent vessels within the hepatoduodenal ligament should be accurately identified before these clamps are applied. The mobilization of the duodenum is facilitated by the division and ligation of the contents of these clamps. The vascular pedicles from the duodenal side of the anastomosis are clearly defined.

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