++++++++++++++++
++
One of the important steps in gastric resection is the preparation of the lesser curvature. Frequently, the gastrohepatic ligament is quite thin and avascular at some distance from the lesser curvature. It is divided between pairs of small curved forceps (Figure 23). In the presence of malignancy the division of the gastrohepatic ligament should be as near the liver as possible and carried up almost to the esophagus to make certain that all involved nodes along the lesser curvature are removed. The uppermost portion of the gastrohepatic ligament must be clamped before division, since it contains a sizable artery that requires ligation. The division of the gastrohepatic ligament does not involve a division of the left gastric artery, which comes up from the celiac axis directly to the stomach (Figures 24 and 25). Whether the left gastric artery is ligated depends upon how extensive a resection is indicated. A radical gastric resection is usually interpreted as one in which the left gastric artery has been ligated and the stomach divided at this level or higher. Attempts at mass ligation, especially in the obese, of the fat and blood vessels along the lesser curvature are dangerous and do not ensure a lesser curvature properly prepared for closure or anastomosis, as the case may be. The left gastric vessels divide as they reach the stomach, extending paired branches to either side of the curvature to enter the gastric wall (Figure 24). An effort should be made to pass a right-angle clamp beneath an individual vessel before its division and ligation (Figure 25). The main vessels on either side of the curvature should be ligated as well as the individual tributaries that run down over the gastric wall (Figures 26 and 27). In a thin patient, a mass ligation may be carried out without difficulty by passing a small curved clamp from front to back, being careful to avoid the blood vessels extending downward over both anterior and posterior surfaces of the stomach. Following this, a transfixing suture, A (Figure 27), is placed to approximate the serosa of the anterior gastric wall to the serosa of the posterior gastric wall, so that when it is tied, a firm ...