Gastrectomy Tutorial

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Total Gastrectomy

The operation begins in the same fashion as for subtotal gastrectomy. The first goal is to pedicalize the stomach. After the right gastric artery is divided, the remainder of the lesser curvature is divided up to the level of the right crus. The left gastric artery is identified while the hand is retracting the pedicalized stomach toward the anterior abdominal wall. The left lobe of the liver will need retraction by the assistant with a blunt probe through the epigastric 5 mm port. Once the left gastric artery is divided, the hiatus is approached. Here the hand is most useful for encircling the esophagus, creating inferior retraction, and bluntly dissecting posteriorly and/or guiding careful electrocautery. The phreno-esophageal ligament is divided, as are both vagus nerves.

Paraesophageal dissection is aided by use of the hand

Division of the short gastric vessels

Before the esophagus is transected, the remaining attachments on the greater curvature are divided (short gastric vessels, left gastroepiploic). The stomach may be retracted medially with aid of the hand or laparoscopic grasping device through the right abdominal ports. The short gastric vessels are divided with ultrasonic scalpel. The left gastroepiploic is divided between endoclips. The stomach can now be elevated with the hand and any posterior attachments are taken to the level of the hiatus.

The distal esophagus is then transected with the linear stapler passed through the 12 mm port. The esophagus may be held proximally with a non-crushing 5 mm laparoscopic clamp (DeBakey type) prior to transection in order to prevent esophageal retraction into the chest (this may placed through the 5 mm epigastric port). Additional left lobe retraction may be provided by several extended fingers of the hand. The specimen is removed through the HandPort.

Esophageal transsection