Gastrectomy
Procedure
Examine peritoneal cavity for metastatic disease.
Confirm resectability.
1. Form avascular plane between transverse mesocolon and greater
omentum (sharp)
2. Dissect greater omentum off colon.
3. Separate anterior sheath of transverse mesocolon back to pancreas
(no evidence for taking pancreatic capsule).
4. Take short gastrics and lateral omental attachments, e.g. with
ligasure, as far as dictated by need:
5. For distal cancers = subtotal gastrectomy (RCTs show no diff in
survival vs total gastrectomy); for proximal cancers: total
gastrectomy; cardiac = oesophagogastrectomy.
- reconstruction
by oesophageal anastomosis to a Roux-en-Y segment of jejunum.
- intestinal pouch has no clear nutritional value, and increases
risks of
immediate complications.
6. Isolate duodenum and transect using a GIA stapler, 2-3cm distal
to pylorus; avoid leaving antrum.
7. Dissect along porta hepatis toward coeliacs, taking all nodal
tissue anterior to portal vein.
- nodes between common hepatic and superior portion of pancreas
reflected towards coeliac.
8. L gastric identified, divided at base, and nodal tissue wept off
right crus.
9. L Splenic artery dissected along superior pancreas, lymph nodes
taken toward splenic hilum.
10. Divide proximal specimen.
11. Reconstruct: Billroth II or Roux-en-Y for subtotal (latter
favoured for lack of bile reflux). Roux-en-Y for total.
Cameron