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Open Total Gastrectomy and Splenectomy

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Abstract

Open total gastrectomy remains the standard approach to complete surgica; resection of the stomach. Although laparoscopic techniques and minimally invasive surgery may have advantages in patients requiring distal or subtotal resection, a total gastrectomy requires an esophagojejunal anastomosis. There is debate over the best method to perform this anastomosis and no technique appears to be superior. In this chapter, we describe our approach to open total gastrectomy, highlighting the importance of lymph node dissection and a reliable esophagojejunal anastomotic technique.

Keywords

  • Gastric cancer
  • Total gastrectomy
  • Open resection

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Reference

  1. Japanese Gastric Cancer Association. Japanese classification of gastric carcinoma: 3rd English edition. Gastric Cancer. 2011;14(2):101–12. doi:10.1007/s10120-011-0041-5.

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Correspondence to Han-Kwang Yang M.D., Ph.D., F.A.C.S. .

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In this video, the surgeon demonstrates his approach to total gastrectomy and splenectomy with Roux-en-Y esophagojejunostomy. (MP4 374484 kb)

Key Operative Steps

  1. 1.

    Begin with omentectomy from the middle of the transverse colon and towards the left.

  2. 2.

    For proper dissection of lymph node station 4sb, the root of the left gastroepiploic artery must be ligated. Division of the splenocolic ligament is useful to expose this artery.

  3. 3.

    Continue omentectomy towards the hepatic flexure. Follow transverse mesocolic veins to find the avascular plane leading to the gastrocolic trunk and superior mesenteric vein. Expose and divide the root of the right gastroepiploic vessels. Dissect lymph node station 6.

  4. 4.

    Expose the proximal proper hepatic artery and root of the right gastric artery and dissect lymph node stations 12 and 5, respectively.

  5. 5.

    Divide the duodenum with a linear stapler. Reinforcement of the staple line is optional.

  6. 6.

    Consider splenectomy for advanced gastric cancer with serosal invasion located along the greater curvature or for bulky lymphadenopathy in the splenic hilum for dissection of lymph node station 10.

  7. 7.

    For total gastrectomy without splenectomy, meticulous dissection of the gastrosplenic ligament near the upper pole of spleen should be considered for lymph node station 4sa.

  8. 8.

    Expose the superior border of the pancreas to dissect from right to left, lymph node stations 8, 11p, and 11d.

  9. 9.

    Expose the celiac axis and left gastric artery and dissect lymph node stations 9 and 7, respectively. Ligate the left gastric artery before ligating the coronary vein.

  10. 10.

    Dissect lymph node stations 1 and 2 along the diaphragmatic crus and esophageal hiatus.

  11. 11.

    Identify and ligate the inferior phrenic artery.

  12. 12.

    Once the esophagus is fully mobilized, place a purse-string clamp on the esophagus.

  13. 13.

    Prepare Roux limb approximately 20 cm downstream from ligament of Treitz.

  14. 14.

    Perform end-to-side esophagojejunostomy with circular stapler.

  15. 15.

    Create jejunojejunostomy 40 cm downstream from the esophagojejunostomy.

  16. 16.

    Close intermesenteric space to prevent internal hernia.

  17. 17.

    Place two closed suction drains.

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Yang, HK., Oh, SY. (2015). Open Total Gastrectomy and Splenectomy. In: Kim, J., Garcia-Aguilar, J. (eds) Surgery for Cancers of the Gastrointestinal Tract. Springer, New York, NY. https://doi.org/10.1007/978-1-4939-1893-5_9

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  • DOI: https://doi.org/10.1007/978-1-4939-1893-5_9

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  • Publisher Name: Springer, New York, NY

  • Print ISBN: 978-1-4939-1892-8

  • Online ISBN: 978-1-4939-1893-5

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