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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.
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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.
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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.
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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.
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