Plate 31

Total gastrectomy may be indicated in treating extensive stomach malignancies. This radical procedure is not performed when carcinoma with distant metastasis to the liver or pouch of Douglas or seeding throughout the peritoneal cavity is present. It may be performed in association with the extirpation of adjacent organs, such as the spleen, body and tail of the pancreas, a portion of the transverse colon, and so forth. It is also the procedure of choice in controlling the intractable ulcer diathesis associated with non-beta islet cell tumors of the pancreas when pancreatic tumor or metastases remain that cannot be controlled medically.

The blood volume should be restored and antibiotics given in the presence of achlorhydria. If colonic involvement is anticipated, the colon should be emptied with appropriate bowel cleansing, and perioperative antibacterial agents should be administered. Four to six units of blood should be readily available for transfusion. Pulmonary function studies may be indicated.

General anesthesia with endotracheal intubation is used.

The patient is placed in a comfortable supine position on the table with the feet slightly lower than the head.

The area of the chest from above the nipple downward to the symphysis is shaved. The skin over the sternum, lower chest wall, and entire abdomen is cleansed with the appropriate antiseptic solution. Preparation should extend sufficiently high and to the left on the chest for a midsternal or left thoracoabdominal incision if necessary.

A minimally invasive laparoscopic peritoneoscopy is often performed first to rule out inoperable spread of a malignancy. If this view is clear, then a limited incision is made in the midline (Figure 1, A–A1) between the xiphoid and umbilicus. The initial opening is only to permit inspection of the stomach and liver and to introduce the hand for general exploration of the abdomen. Because of the high incidence of metastases, a more liberal incision extending up to the region of the xiphoid and down to the umbilicus, or beyond it on the left side, is not made until it has been determined that there is no contraindication to total or subtotal gastrectomy (Figure 1). Additional exposure is allowed by removal of the xiphoid. Active bleeding points in the xiphocostal angle are transfixed with 00 silk sutures, and bone wax is applied to the end of the sternum. Some prefer to split the lower sternum in the midline and extend the incision to the left into the fourth intercostal space. Adequate exposure is mandatory for a safe anastomosis between the esophagus and jejunum.

Total gastrectomy should be considered for malignancy high on the lesser curvature if there is no metastasis to the liver or seeding over the general peritoneal cavity, particularly in the pouch of Douglas (Figure 2). Before the surgeon is committed to a total gastrectomy, he or she must have a clear view of the posterior relationship of the stomach to determine whether the growth has extended into the adjacent structures—i.e., pancreas, mesocolon, or the major vessels (Figure 3). This can be determined by reflecting the greater omentum upward, withdrawing the transverse colon from the peritoneal cavity, and searching the transverse mesocolon for evidence of invasion. By palpation the surgeon should determine that there is free mobility of the growth without involvement of fixation to the underlying pancreas or major vessels, especially in the region of the left gastric vessels (Figure 4).

The entire transverse colon, including the hepatic and splenic flexures, should be freed from the omentum and retracted downward. As the omentum is retracted upward and the transverse colon downward, the venous branch between the right gastroepiploic and middle colic veins is visualized and ligated to avoid troublesome bleeding. The greater omentum in the region of the head of the pancreas and the hepatic flexure of the colon should be freed by sharp and blunt dissection so that it can be entirely mobilized from the underlying head of the pancreas and duodenum.

When the lesser sac has been explored, the surgeon proceeds with further mobilization of the stomach. If the growth appears to be localized, even though it is large and involves the tail of the pancreas, colon, and kidney, a very radical extirpation may be carried out. Resection of the left lobe of the liver occasionally may be necessary.

To ensure complete removal of the neoplasm, at least 2.5 to 3 cm of duodenum distal to the pyloric veins should be resected (Figure 2). Since it is not uncommon to have metastasis to the infrapyloric lymph nodes, they should be included in the resection. The right gastroepiploic vessels are doubly ligated as far away from the interior surface of the duodenum as possible, to ensure removal of the infrapyloric lymph nodes and adjacent fat (Figure 5).

Next >