Partial Gastrectomy Technique
- Author: Vikram Kate, MBBS, PhD, MS, FRCS, FRCS(Edin), FRCS(Glasg), FACS, FACG, FIMSA, MAMS, MASCRS; Chief Editor: Vinay Kumar Kapoor, MBBS, MS, FRCS, FAMS more...
Patients with a malignancy in whom partial gastrectomy is planned can undergo a staging laparoscopy to assess the extent of the tumor and metastasis. Laparoscopy may detect peritoneal dissemination or liver metastasis which may not have been detected by conventional methods of imaging and other modalities. It is a safe and effective method of staging which can help in avoiding nontherapeutic explorations and provide guideline for appropriate treatment planning.
An upper midline incision from the xiphoid process to the umbilicus with an optional extension inferior to the umbilicus provides quick and bloodless access to the abdomen. Another option is a Chevron or a rooftop incision. This, combined with self-retaining subcostal retractors, provides excellent access to the upper abdomen.
A thorough exploration of the abdominal cavity to look for metastasis in the liver, peritoneum, omentum, and pelvis is performed first.
Further elements of the procedure depend on the choice of reconstruction.
After resection of the stomach, continuity can be achieved with a gastroduodenal anastomosis (Billroth I). A tension-free gastroduodenal anastomosis requires good duodenal mobilization.
The second option is to close the duodenal end and to perform a gastrojejunal anastomosis (Billroth II or its modifications). Several techniques have been described for the gastrojejunal anastomosis, and a description of each technique is beyond the scope of this topic. Two main variations to the gastrojejunal anastomosis include an end-to-side gastrojejunostomy using an uninterrupted loop of jejunum and an end-to-side gastrojejunostomy to a Roux loop.
Gastroduodenal anastomosis, when possible, is preferred because it maintains the physiologic route of gastric emptying. However, it is technically unfeasible if a more extensive gastric resection is necessary or if duodenal mobilization is difficult owing to inflammation or adhesions, in which cases a gastrojejunal anastomosis is recommended.
If the intention is to perform a gastroduodenal anastomosis, the first step is duodenal mobilization. The duodenum is mobilized by incising the peritoneum along its lateral border and then reflecting the duodenum to the left side until the inferior vena cava is exposed. This process is also referred to as kocherization. Care should be taken to avoid injury to the structures in the lesser omentum and middle colic vessels while mobilizing the duodenum.
The greater omentum is freed from the transverse colon by dividing along the avascular plane between the transverse colon and the anterior leaf of the omentum. It is easier to identify an avascular window along the left half of the transverse colon. Further division of the omental reflection is extended toward the right side.
This step carries the potential of inadvertent injury to the middle colic artery. Such an injury can be avoided by spreading the gastrocolic omentum along the greater curvature to clearly visualize and demonstrate the vascular pattern of the gastroepiploic vessels and lifting the transverse colon intermittently to clearly visualize the vascular pattern of the transverse colon. As the lesser sac is entered, the posterior wall of the stomach is visible.
The posterior wall of the stomach is freed by dividing gastropancreatic folds of peritoneum. The lesser omentum is separated from the undersurface of the liver for malignancy and along the lesser curvature for ulcer disease.
The right gastric artery is identified at the inferior end of the lesser curvature as originating from the proximal hepatic artery or the gastroduodenal artery. This is doubly ligated and divided. Similarly, the gastroepiploic artery is identified close to the inferior end of the greater curvature, doubly ligated, and divided.
At this point, about 1-2 cm of duodenum adjacent to the pylorus is cleared of all fat and vascular adhesions. Care is taken to avoid injury to the pancreatic tissue while clearing the duodenum. The duodenum is divided by a linear cutter or linear stapler at this level (see the image below).
Further mobilization of the stomach is easier after duodenal division.
The greater curvature of the stomach is mobilized further by dividing the gastrosplenic ligament. Depending on the extent of the planned gastrectomy, the greater curvature is mobilized to the point where the gastroepiploic artery is closest to the gastric wall (hemigastrectomy) or farther proximally to the second short gastric artery (subtotal gastrectomy). The first short gastric artery is left behind to supply the remnant stomach.
Similarly, the point of division of the stomach along the lesser curvature is marked at the level of the third prominent vein (hemigastrectomy) or about 1 cm inferior to the esophagogastric junction (subtotal gastrectomy) (see the image below).
The left gastric artery is divided as a part of subtotal gastrectomy. This artery divides into two branches close to the lesser curvature. The left gastric artery is secured via double ligation or ligation followed by a transfixing suture on the arterial side and a tie on the gastric side before being divided.
The lesser and greater curvatures should be prepared at the elected site and omental fat cleared at the line of section for a couple of centimeters.
The stomach is divided with a linear cutter at the site identified for proximal resection. At this stage, the specimen is delivered out.
Lymph node dissection
According to Japanese Gastric Cancer Association, lymph node dissection can be categorized as D1, D2, D3, or D4 on the basis of the lymph node stations, as follows :
D1 lymphadenectomy - Removal of perigastric nodes (3 cm around tumor)
D2 lymphadenectomy - Removal of nodes along the left gastric artery, common hepatic artery, celiac trunk, splenic hilus, and splenic artery
D3 lymphadenectomy - Include dissection of lymph nodes along the hepatoduodenal ligament, posterior surface of the head of the pancreas, and the root of the mesentery (superior mesenteric vessels)
D4 lymphadenectomy - Dissection along the para-aortic and paracolic region
Resection of adjacent organs
Resection of adjacent organs (eg, distal pancreas, spleen, colon) is performed for lesions with direct involvement into these structures. Distal pancreatectomy and splenectomy are not performed as part of a conventional D2 lymphadenectomy, owing to increased postoperative morbidity and mortality.
Either a Billroth I or a Billroth II reconstruction is performed.
A part of the staple line on the gastric side in the inferior aspect toward the greater curvature is opened up corresponding to the duodenal end diameter. Interrupted delayed absorbable sutures are taken from the middle of the posterior walls of the stomach and the duodenum. After all sutures are placed along the posterior layer, they are tied starting from the lesser curvature side. Once secured, the anterior layer is then similarly sutured.
The duodenal stump remains closed. A loop of jejunum is identified close to the duodenojejunal flexure. Care should be taken to keep the afferent loop reasonably short. The loop is anchored along its axis and isoperistaltic to the posterior wall of the stomach with delayed absorbable seromuscular sutures. An opening is made in the jejunum equal to about twice the diameter of the jejunal lumen. The staple line on the stomach is opened to correspond to this length.
The anastomosis is performed with a continuous absorbable suture that starts from the middle of the posterior layer on either side and is continued to meet in the middle of the anterior layer. A fourth layer of seromuscular sutures is placed to bury the anterior continuous suture line (see the image below).
The principles of gastrojejunal anastomosis remain similar for a Roux-en-Y anastomosis. Instead of a conventional Polya complete anastomosis, a Hofmeister-Finsterer modification can be performed, in which the part of the opening in the stomach on the lesser curvature side is closed and fixed to the jejunum with seromuscular sutures so as to narrow the anastomosis and thus exert a valvular effect. This is more useful in patients who are undergoing stomach resection for benign conditions when the conventional Polya anastomosis may be very wide (see the image below).
The abdominal wound is lavaged thoroughly. A right subhepatic drain is useful in early detection of a possible duodenal stump blowout. The abdominal wound is then closed in layers.
Partial Gastrectomy With Stapled Anastomosis
A 30-mm linear cutter is applied at the desired level of section over the duodenum. Adequate care is taken to prevent inclusion of any other structures, including mesentery, before firing the stapler. Linear staplers can be similarly used to section the stomach. Because the stomach is fairly wide, it may be necessary to fire the stapler sequentially.
Once divided, a loop of jejunum is anchored to the posterior wall of the stomach with seromuscular stay sutures. The jejunal loop can also be anchored using Babcock forceps. A small enterotomy on the jejunal side and a small gastrotomy on the gastric side are made to allow insertion of the two limbs of the linear cutter.
Once the device has been inserted, its direction is adjusted so as to maintain it parallel to the axis of the jejunum before engaging and firing it. The device is then removed, and the suture line is visualized through the enterotomy to ensure adequate hemostasis. The gastrotomy and enterotomy can be closed with a suture closure (in one or two layers) or with a linear stapler.
The other method involves partial transection of the stomach with a linear cutter followed by a handsewn anastomosis between the remaining open part of the stomach and the jejunum. In comparison with the aforementioned techniques, the gastrojejunal anastomosis is limited in length (see the images below).
Port placement for laparoscopic gastrectomy involves a 12-mm optical port at the umbilicus, a 5-mm epigastric port for liver retraction, two operating ports, and a right lateral port for gastric retraction. The approach for gastrectomy is similar to the open approach.
Initially, the lesser sac is entered by opening the gastrocolic omentum and the lesser omentum. The greater and lesser curvatures are cleared to the initial 2 cm of the duodenum before a stapler is fired to divide the duodenum. The greater curvature is freed to the point of proximal division, and the left gastric artery is identified and divided after retraction of the stomach superiorly and to the left. The specimen is extracted by extending one or both of the operating port incisions. Gastrojejunostomy is usually performed extracorporeally via the same incision.
Laparoscopic partial gastrectomy has been demonstrated to have oncologic outcomes similar to those of open surgery. In addition, the laparoscopic approach has resulted in less severe postoperative complications, shorter hospital stays, and reduced opioid use.
Laparoscopic partial gastrectomy has become a common procedure for gastric submucosal tumors because of its accepted feasibility, safety, and oncologic outcomes. However, there remains a need for long-term postoperative outcome data, especially with respect to the location of submucosal tumors.
Hirota et al reviewed 52 patients with gastric submucosal tumors who underwent laparoscopic partial gastrectomy, dividing them into a lesser-curvature group (n = 23) and a greater-curvature group (n = 26) and comparing the two groups with respect to the following postoperative data :
Body weight change during the first postoperative year
Gastrointestinal (GI) symptoms
Amount of food residue at endoscopy
Need for medications
The investigators found that these patients did not have severe body weight loss but that those in the lesser-curvature group were at higher risk for postoperative GI symptoms, suggesting that this group should receive special attention.
A study by Takata et al reported the use of single-incision laparoscopic partial gastrectomy in 12 consecutive patients with gastric submucosal tumors. In this procedure, three trocars were placed in the umbilical incision, and the lesion was mobilized and resected with endoscopic staplers. The authors found this approach to be a safe and practical alternative to conventional multiport laparoscopy in these patients, except for lesions originating in the lesser curvature and close to the cardia/pylorus.
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