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.