The peritoneum over the esophagus is divided and all bleeding points are carefully ligated. Several small vessels may require ligation when the peritoneum between the gastric fundus and base of the diaphragm is separated. The lower esophagus is freed by finger dissection similar to the technique of vagotomy (Plates 17 and 18). The vagus nerves are divided to further mobilize the esophagus into the peritoneal cavity. By blunt and sharp dissection, the left gastric vessels are isolated from adjacent tissues (Figure 11). These vessels should be encircled with the surgeon's index finger and carefully palpated for evidence of metastatic lymph nodes. A pair of clamps, such as curved half-lengths, should be applied as close as possible to the point of origin of the left gastric artery, and a third clamp applied nearer the gastric wall. The contents of these clamps are first ligated and then transfixed distally. Likewise, the left gastric vessels on the lesser curvature should be ligated to enhance the subsequent exposure of the esophagogastric junction. Depending on the location of the tumor and the findings on palpation, the surgeon may decide upon further celiac and preaortic lymph node dissection.
When the tumor is near the greater curvature in the midportion of the stomach, it may be desirable to remove the spleen and tail of the pancreas to assure a block dissection of the immediate regional lymphatic drainage zone. The location and extent of the tumor, as well as the presence or absence of adhesions or tears in the capsule, determine whether the spleen should be removed. If the spleen is to remain, the gastroplenic ligament is divided, as described for splenectomy (Plates 141 and 142). The left gastroepiploic vessel is doubly tied. The greater curvature is freed up to the esophagus. Several vessels are usually encountered entering the posterior wall of the fundus near the greater curvature.
The anesthetist should aspirate the gastric contents from time to time to prevent possible regurgitation from the stomach as it is retracted upward, as well as peritoneal soiling when the esophagus is divided.
The duodenum is closed in two layers (see Plate 25). The walls of the duodenum are closed with a first layer of interrupted 0000 silk sutures, Connell type. These are invaginated with a second layer of 00 silk mattress sutures. Some prefer to close with staples.
One of the numerous methods that have been devised for reconstructing gastrointestinal continuity following total gastrectomy is selected.
The surgeon should keep in mind certain anatomic differences of the esophagus, which make its management more difficult than that of the rest of the gastrointestinal tract. First, since the esophagus is not covered by serosa, the longitudinal and circular muscle layers tend to tear when sutured. Second, the esophagus, while at first appearing to extend well down into the abdominal cavity, tends to retract up into the thorax when divided from the stomach, leaving the surgeon hard pressed for adequate length. It should be mentioned, however, that if the exposure is inadequate, the surgeon should not hesitate to remove more of the xiphoid or to split the sternum with potential extension into the left fourth intercostal space. Adequate and free exposure must be obtained to secure a safe anastomosis.
The wall of the esophagus can be lightly anchored to the crus of the diaphragm on both sides, as well as anteriorly and posteriorly (Figure 12), to prevent rotation of the esophagus or upward retraction. These sutures must not enter the lumen of the esophagus. Two or three 0 silk sutures are placed posterior to the esophagus to approximate the crus of the diaphragm (Figure 12).
Many methods have been devised for facilitating the esophagojejunal anastomosis. Some prefer to leave the stomach attached as a retractor until the posterior layers have been completed. The posterior wall of the esophagus may be divided and the posterior layers closed before the stomach is removed by dividing the anterior esophageal wall. In another method a non-crushing vascular clamp of the modified Pace-Potts type can be applied to the esophagus. Because the esophageal wall tends to tear easily, it is helpful to give substance to the wall of the esophagus and prevent fraying of the muscle layers by fixing the mucosa to the muscle coats proximal to the point of division. A series of encircling mattress sutures of 0000 silk can be inserted and tied, using a surgeon's knot (Figure 13). These sutures include the full thickness of the esophagus (Figure 14). The angle sutures, A and B, are used to prevent rotation of the esophagus when it is anchored to the jejunum (Figure 14).
The esophagus is then divided between this suture line and the gastric wall itself (Figure 15). Soiling should be prevented by suction on the Levin tube as it is withdrawn up into the lower esophagus and a clamp is placed across the esophagus on the gastric side. In the presence of a very high tumor that reaches the gastroesophageal junction, several centimeters of esophagus should be resected above the tumor. If 2.5 cm or more of esophagus does not protrude beyond the crus of the diaphragm, the lower mediastinum should be exposed in order to ensure a secure anastomosis without tension.