Total Gastrectomy, Stapled

The indications and preoperative preparation are specific and are reviewed in Total Gastrectomy, Plate 31, where the commonly used methods of reconstruction are shown with hand-sewn anastomoses. Many surgeons, however, prefer to use staples, because they simplify the anastomoses and lessen the total time of this operation, which is now more frequently performed.

General anesthesia is given by endotracheal intubation.

Exposure is enhanced if the patient is placed in a reversed Trendelenburg position.

The skin over the lower thorax as well as the abdomen is shaved and cleansed with the appropriate antiseptic solution.

A minimally invasive laparoscopic peritoneoscopy is often performed first to rule out inoperable spread of a malignancy. If this is clear, then a midline incision starting over the xiphoid and extending down to the umbilicus is made initially. This permits abdominal exploration and enables the surgeon to make a decision for or against proceeding with total gastrectomy. The incision is usually extended to the left and below the umbilicus if the decision is made to proceed with total gastrectomy. In the absence of metastases to the liver, peritoneum, omentum, and pelvis, the greater omentum is completely freed from the transverse colon. This permits evaluation of the posterior wall of the stomach as well as an evaluation for metastases about the left gastric vessels and attachments to the pancreas. Excision of the xiphoid provides a better exposure of the esophagogastric junction, along with medial mobilization of the left lobe of the liver following the division of the suspensory ligament to this lobe. An outline of a final reconstruction is shown in Figure 1.

As in Plates 31 and 33, the region of the duodenum is first mobilized by the Kocher maneuver, and the blood supply about the pylorus ligated to prepare only the duodenal wall for the application of the stapler. The right gastroepigastric vessels are doubly ligated as far away from the duodenal wall as possible to ensure the inclusion of any possible lymph node metastases. The right gastric blood supply to the superior surface of the duodenum should also be divided and ligated to ensure the removal of 2.5 to 3 cm of duodenum distal to the pyloric vein if the procedure is being performed for gastric carcinoma. The duodenum is closed with a non cutting linear stapler (TA 30 or 60). The duodenum is divided between the stapler and the Kocher clamp on the pyloric end of the duodenum. Alternatively the duodenum may be divided with a linear stapler. The entire stomach, along with the omentum and the gastric hepatic ligament, is then mobilized as shown in Plates 32 and 33. The gastric vessels are divided and ligated in the presence of cancer of the fundus of the stomach. The spleen may also be resected, but this is indicated only if the spleen is involved with local spread of the tumor.

A good clear exposure of the lower esophagus is essential, along with the margins of the esophageal hiatus. Since the esophagus tends to retract upward when divided, it is helpful if the esophagus is pulled gently downward after vagotomy and anchored to the margins of the hiatus with four or five interrupted sutures that include only a modest bite of the esophageal wall (Figure 2). This ensures 5 or 8 cm of nonretractable esophagus below the hiatal opening. The crus of the diaphragm should be approximated posterior to the esophagus, allowing a reasonable-sized opening.

The nasogastric tube is retracted, and the modified Furniss clamp is applied to the esophagus above the gastric junction (Figure 2). The esophagus is divided against the clamp after a monofilament polypropylene suture on a straight needle has been inserted. This resection line must be close to the clamp to ensure a safe and secure closure by the stapler. It is also acceptable to divide the esophagus and place a purse string freehand. The jejunum about 30 cm below the ligament of Treitz is exposed, and the blood supply in the mesentery studied to ensure a good blood supply to the mobilized arm of jejunum, which should be 50 to 60 cm long. The division of the jejunum and mesenteric blood vessels is demonstrated in Plate 34, Figures 16 and 17.

The divided jejunum is brought up through an opening in the avascular area to the left of the middle colic vessel. Special attention is required to avoid twisting the section of jejunum or in any way interfering with its blood supply. The jejunum is anchored to the margin of the opening, which must be closed to avoid internal herniation. The limb must extend easily up to the end of the esophagus as well as 5 to 8 cm beyond to provide entrance for the stapler to effect the esophagojejunal anastomosis (Figure 3).

The blood supply to the end of the jejunal limb is reconfirmed to be strong and adequate. The esophageal size is measured (Figure 4) with a calibrated sizing instrument. Some prefer to dilate the end of the esophagus by inserting a Foley catheter (size 16 French) into the lower esophagus and injecting 7 to 10 cm of saline, which gently dilates the end of the esophagus for the easier introduction of the anvil of the stapler. This may permit the introduction of a larger stapler. The appropriately sized circular stapler (EEA) instrument is passed through the open end of the jejunum and directed toward the antimesenteric surface. The sharp plastic trocar on the end of the circular stapler (EEA) instrument is passed through the antimesenteric surface of the small intestine. The tilting anvil is inserted through the opening made by the trocar and attached to the main portion of the circular stapler (EEA) instrument. The tilted circular stapler (EEA) cap is then carefully introduced into the esophagus (Figure 5).

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The security of the esophageal purse string should be evaluated before the handle and cartridge are approximated (Figure 6). After verifying that the combined thickness of the esophagus and jejunum is within the safe range of the staples, the circular stapler (EEA) instrument is fired. Superficial interrupted sutures about the anastomosis are added after the instrument has been opened, gently rotated, and withdrawn. The nasogastric tube is passed beyond the anastomosis.

The open end of the jejunal limb is prepared for a stapled closure (Figure 7). Once again, the noncutting linear stapler (TA 60) should be applied to serosa and at an angle to ensure an adequate blood supply to the antimesenteric border. Some prefer to place several sutures to anchor the arm of the jejunum posteriorly. This removes tension from the suture line and ensures against possible rotation.

The reestablishment of the gastrointestinal tract continuity beyond the ligament of Treitz can be accomplished in many ways. The afferent limb is connected to the Roux-en-Y jejunal loop approximately 25 cm from the ligament of Treitz and about 40 cm from the esophagojejunal anastomosis. A side-to-side anastomosis is performed, using a cutting linear stapler (GIA 60) introduced into the antimesenteric sides of the jejunum (Figure 8). This anastomosis can be accomplished like the enteroenterostomy of a Roux-en-Y. The mucosal stab wounds are then closed with a noncutting linear stapler (TA 60) (Figure 9).

The construction of a pouch below the esophagojejunal anastomosis does not seem to have a significantly beneficial effect on long-term nutrition.

The two jejunal limb mesenteries are approximated to eliminate potential internal hernia. The adequacy of the blood supply of each limb is verified, especially at the critical point near the anastomosis.

The blood volume is sustained, along with fluid and electrolyte balance. Early ambulation is encouraged. Clear liquids are given in limited amounts after 24 hours. Oral feedings are begun once the integrity of the anastomosis is established with a fluoroscopic water-soluble contrast study. The patient is instructed in the value of six small feedings per day initially and is gradually advanced to three regular meals. The patient and family require reassurance that problems concerning eating should be minimal. The weight should slowly increase, unless a diagnosis of extensive malignancy has been verified. Vitamin B12 injections must be given monthly along with a monthly dietary survey and nutritional evaluation. These monthly visits with reassurance can be helpful to the patient in returning the caloric intake toward normal during the first year after operation (see also discussion at Plate 36, Total Gastrectomy).