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Right
gastric vessels
Right
gastroepiploic vessels
6
Gastrohepatic
ligament
7
Pyloric vein
Right
gastroepiploic
vessels
Diaphragm
Right
8
gastric vessels
9
Triangular ligament
Line of incision
Gastrohepatic
ligament
Branch of inferior
phrenic vessels
Right
gastroepiploic
vessels
10
Line of incision
Diaphragm
Spleen
83
PLATE
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33
DETAILS OF PROCEDURE e peritoneum over the esopha-
gus is divided and all bleeding points are carefully ligated. Several small
vessels may require ligation when the peritoneum between the gastric fundus and base of the diaphragm is separated. e lower esophagus is freed
by nger dissection similar to the technique of vagotomy (Plates and ).
e vagus nerves are divided to further mobilize the esophagus into the
peritoneal cavity. By blunt and sharp dissection, the le gastric vessels are
isolated from adjacent tissues (figure 11). ese vessels should be encircled
with the surgeon’s index nger and carefully palpated for evidence of metastatic lymph nodes. A pair of clamps, such as curved half-lengths, should
be applied as close as possible to the point of origin of the le gastric artery,
and a third clamp applied nearer the gastric wall. e contents of these
clamps are rst ligated and then trans xed distally. Likewise, the le gastric
vessels on the lesser curvature should be ligated to enhance the subsequent
exposure of the esophagogastric junction. Depending on the location of the
tumor and the ndings on palpation, the surgeon may decide upon further
celiac and preaortic lymph node dissection.
When the tumor is near the greater curvature in the midportion of the
stomach, it may be desirable to remove the spleen and tail of the pancreas
to assure a block dissection of the immediate regional lymphatic drainage zone. e location and extent of the tumor, as well as the presence or
absence of adhesions or tears in the capsule, determine whether the spleen
should be removed. If the spleen is to remain, the gastroplenic ligament
is divided, as described for splenectomy (Plates and ). e le gastroepiploic vessel is doubly tied. e greater curvature is freed up to the
esophagus. Several vessels are usually encountered entering the posterior
wall of the fundus near the greater curvature.
e anesthetist should aspirate the gastric contents from time to time to
prevent possible regurgitation from the stomach as it is retracted upward,
as well as peritoneal soiling when the esophagus is divided.
e duodenum is closed in two layers (see Plate ). e walls of the
duodenum are closed with a rst layer of interrupted silk sutures,
Connell type. ese are invaginated with a second layer of silk mattress
sutures. Some prefer to close with staples.
One of the numerous methods that have been devised for reconstructing
gastrointestinal continuity following total gastrectomy is selected.
e surgeon should keep in mind certain anatomic di erences of the
esophagus, which make its management more di cult than that of the rest
T G
of the gastrointestinal tract. First, since the esophagus is not covered by
serosa, the longitudinal and circular muscle layers tend to tear when sutured.
Second, the esophagus, while at rst appearing to extend well down into the
abdominal cavity, tends to retract up into the thorax when divided from the
stomach, leaving the surgeon hard pressed for adequate length. It should be
mentioned, however, that if the exposure is inadequate, the surgeon should
not hesitate to remove more of the xiphoid or to split the sternum with
potential extension into the le fourth intercostal space. Adequate and free
exposure must be obtained to secure a safe anastomosis.
e wall of the esophagus can be lightly anchored to the crus of the diaphragm on both sides, as well as anteriorly and posteriorly (figure 12),
to prevent rotation of the esophagus or upward retraction. ese sutures
must not enter the lumen of the esophagus. Two or three silk sutures are
placed posterior to the esophagus to approximate the crus of the diaphragm
(figure 12).
Many methods have been devised for facilitating the esophagojejunal
anastomosis. Some prefer to leave the stomach attached as a retractor until
the posterior layers have been completed. e posterior wall of the esophagus may be divided and the posterior layers closed before the stomach
is removed by dividing the anterior esophageal wall. In another method
a non-crushing vascular clamp of the modi ed Pace-Potts type can be
applied to the esophagus. Because the esophageal wall tends to tear easily,
it is helpful to give substance to the wall of the esophagus and prevent fraying of the muscle layers by xing the mucosa to the muscle coats proximal
to the point of division. A series of encircling mattress sutures of silk
can be inserted and tied, using a surgeon’s knot (figure 13). ese sutures
include the full thickness of the esophagus (figure 14). e angle sutures,
A and B, are used to prevent rotation of the esophagus when it is anchored
to the jejunum (figure 14).
e esophagus is then divided between this suture line and the gastric
wall itself (figure 15). Soiling should be prevented by suction on the
Levin tube as it is withdrawn up into the lower esophagus and a clamp is
placed across the esophagus on the gastric side. In the presence of a very
high tumor that reaches the gastroesophageal junction, several centimeters of esophagus should be resected above the tumor. If . cm or more
of esophagus does not protrude beyond the crus of the diaphragm, the
lower mediastinum should be exposed in order to ensure a secure anastomosis without tension.
CONTINUES
84
11
Left
gastric
vessels
Tumor
12
Esophagus
Anchoring
sutures
Pancreas
Stump of left
gastric vessels
13
Pancreas
Anchoring sutures
Esophagus
A
B
Right crus of diaphragm
15
Muscles layers
A
Mucosa
14
B
A
Traction sutures
Levin tube
B
85
PLATE
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34
DETAILS OF PROCEDURE e next step consists of mobiliz-
ing a long loop of jejunum, redundant enough so that it extends easily to
the open esophagus. e jejunal loop is brought up through an opening
in the mesocolon just to the le of the middle colic vessels. e region about
the ligament of Treitz may need to be mobilized to ensure that the jejunum
will reach to the diaphragm for easy approximation with the esophagus.
e surgeon should be sure that the mesentery is truly adequate for the
completion of all the layers of the anastomosis.
Various methods have been used to assure better postoperative nutrition
and fewer symptoms following the complete removal of the stomach. A
large loop of jejunum with an enteroenterostomy has been commonly used.
Regurgitation esophagitis may be lessened by the Roux-en-Y procedure.
Interposition of jejunal segments between the esophagus and duodenum,
including reversed short segments, has been found to be very satisfactory.
e Roux-en-Y procedure can be used a er division of the jejunum
at approximately cm beyond the ligament of Treitz. With the jejunum
held outside the abdomen, the arcades of blood vessels can be more clearly
de ned by transillumination with a portable light (figure 16). Two or
more arcades of blood vessels are divided and a short segment of devascularized intestine resected (figure 17). e arm of the distal segment of
jejunum is passed through the opening made in the mesocolon to the le of
the middle colic vessels. Additional mesentery is divided if the end segment
of the jejunum does not easily extend up to and parallel with the crus of
T G
the diaphragm behind the esophagus. When the adequate length has been
assured, the decision must be made whether it is safer and easier to do an
end-to-end anastomosis or an end to-side anastomosis with the esophagus.
If the end-to-side anastomosis is selected, the end of the jejunum is closed
with two layers of silk (figures 18 and 19). e end of the jejunum
is then pulled through the opening made in the mesocolon to the le of
the middle colic vessels (figure 20). Care must be taken to avoid angulating or twisting the mesentery of the jejunum as it is pulled through. e
jejunal wall is anchored about the margins of the hole in the mesocolon.
All openings in the mesocolon should be occluded to avoid the possibility
of an internal hernia. e opening created beneath the free margin of the
mesentery and the posterior parietes should be obliterated by interrupted
sutures placed super cially, avoiding injury to blood vessels.
e length of jejunum should again be tested to make certain that the
mesenteric border can be approximated easily for to cm or more to
the base of the diaphragm behind the esophagus (figure 21). Additional
mobilization of the jejunal limb for a distance of or cm may be secured
by making relaxing incisions in the posterior parietal peritoneum around
the base of the mesentery. Additional distance may be gained by very carefully incising the peritoneum both above and below the vascular arcade
along with a few short radial incisions toward the mesenteric border. e
closed end of the jejunum is shown directed to the right, but more commonly it is directed toward the le .
CONTINUES
86
16
17
X
Line of incision
Y
Jejunum
Y
X
Ligament of Treitz
20
18
Colon
Opening
of mesocolon
19
Jejunum
21
B
A
Crus of
diaphragm
Middle
colic vessels
Y
Pancreas
Middle
colic vessels
87
PLATE
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35
DETAILS OF PROCEDURE A row of interrupted silk sutures
is placed to approximate the jejunum to the diaphragm on either side of the
esophagus, as well as directly behind it (figure 22). It is necessary to emphasize that the arm of jejunum is anchored to the diaphragm to remove tension from the subsequent anastomosis of the esophagus. A er these anchor
sutures are tied, angle sutures are placed in either side of the esophagus and
jejunum (figure 23, C, D). e esophageal wall should be anchored to the
upper side of the jejunum. An e ort should be made to keep the interrupted
sutures close to the mesenteric side of the jejunum, since there is a tendency
to use all the presenting surface of the jejunum in the subsequent layers of
closure. ree or four additional interrupted silk mattress sutures, which
include a bite of the esophageal wall with the serosa of the bowel, are required
to complete the closure between the angle sutures, C and D (figure 24). A
small opening is then made into the adjacent bowel wall with the jejunum
under traction so that during the procedure there is no redundancy of the
T G
mucosa from too large an incision. ere is a tendency to make too large an
opening in the jejunum with prolapse and irregularity of the mucosa, making
an accurate anastomosis with the mucosa of the esophagus rather di cult.
A layer of interrupted silk sutures is used to close the mucosal layer,
starting at either end of the jejunal incision with angle sutures (figure 25,
E, F). e posterior mucosal layer is closed with a row of interrupted
silk sutures (figure 26). e Levin tube may be directed downward into the
jejunum (figure 27). e presence of the tube within the lumen tends to
facilitate the placement of the interrupted Connell-type sutures closing the
anterior mucosal layer (figure 27). A larger lumen is ensured if the Levin
tube is replaced by an Ewald tube of a much larger diameter. is tube is
replaced by the Levin tube when the anastomosis is completed. An additional
layer will be added as carried out posteriorly. erefore, when the jejunum is
anchored to the diaphragm, the wall of the esophagus, and the mucosa of the
esophagus, a three-layered closure is provided (figure 28).
CONTINUES
88
23
A
B
25
22
Second row
A
B
Diaphragm
Posterior row
of sutures
of sutures
C
Incision
D
Jejunum
24
D
Incision
Third row of sutures
B
26
F
D
C
A
E
C
A
E
D
B
F
Lumen of
jejunum
27
Levin tube
jejunum
89
28
1
3
2
Diaphragm
PLATE
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36
DETAILS OF PROCEDURE e second layer of interrupted
silk sutures is completed anteriorly (figure 29). Next, the peritoneum,
which has been initially incised to divide the vagus nerve and mobilize the
esophagus, is brought down to cover the anastomosis and anchored with
interrupted silk sutures to the jejunum (figure 30). is ensures a third
layer of support that extends all the way anteriorly around the esophageal anastomosis and takes any tension o the delicate line of anastomosis
(figure 31). e catheter can be extended well down the jejunum through
the opening in the mesocolon to prevent angulation of the bowel. A number
of super cially placed ne sutures are taken to anchor the edge of the mesentery to the posterior parietes to prevent angulation and interference with
the blood supply (figure 31). ese sutures should not include pancreatic
tissues or vessels in the margin of the jejunal mesentery. e color of the arm
of the jejunum should be checked from time to time to make sure the blood
supply is adequate. e open end of the proximal jejunum (figure 32, Y)
is then anastomosed at an appropriate point in the jejunum (figure 32, X)
with two layers of silk, and the opening into the mesentery beneath
the anastomosis is closed with interrupted sutures to prevent any possibility
of subsequent herniation. figure 32a is a diagram of the completed Roux-
en-Y anastomosis. Some prefer to use a stapling instrument to fashion the
esophagojejunal anastomosis. Regardless of the technique used, consideration should be given to reinforcing the angles with interrupted sutures, as
well as anastomosing the jejunum to the adjacent diaphragm.
POSTOPERATIVE CARE Constant suction is maintained through the
nasojejunal tube, which has been threaded through and beyond the anastomosis. During this period alimentation is maintained with intravenous
uids and supplemental vitamins. e patient is ambulated on the rst
postoperative day, and a gradual increase in activity is encouraged. Early
T G
return of peristaltic activity to the bowels may be stimulated by injecting
mL of mineral oil through the jejunal tube at regular intervals during
the rst few postoperative days. When intestinal peristalsis has been established, the suction may be discontinued. A slow administration of feedings
low in fat and carbohydrate content will avoid diarrhea. Usually, only water
followed by skim milk is given in - to -mL amounts as tolerated. Oral
feedings can be instituted as soon as there is complete assurance that no
stula has formed at the sites of anastomosis. is may be veri ed by uoroscopic x-ray studies using a water-soluble contrast dye. ese patients,
of course, will need frequent small feedings, and adequate caloric intake
will be a problem. e family will require instructions regarding diet. is
calls for careful collaboration between surgeon and dietitian. In addition,
supplemental vitamin B
and vitamins may be indicated for life.
Scheduled reevaluations at intervals of to months are advisable to assess
caloric intake. Stenosis of the suture line may require dilatations. e blood
volume may need to be restored and numerous dietary corrections made.
When total gastrectomy has been performed to control the hormonal
e ects of an islet cell tumor of the pancreas, serum gastrin levels are taken
to evaluate the presence and progress of residual tumor or metastasis.
Blood calcium levels are also advised to document the status of the parathyroids. e possibility of familial multiple endocrine adenomatosis should
be investigated in all members of the patient’s family. Long-term follow-up
studies should include determination of serial serum gastrin, calcium,
parathormone, prolactin, cortisol, and catecholamine levels. Evidence of
recurrent hyper-parathyroidism is not uncommon. Normal fasting serum
gastrin levels may become elevated if residual gastrin-producing tumor is
present. e presence of one endocrine tumor is an indication to search for
others over the years of follow-up observation. ■
will be necessary at monthly intervals. Oral iron
90
Peritoneum
29
Esophagus
Peritoneum
Transverse
mesocolon
Middle
colic vessels
30
32
Diaphragm
Jejunum
Roux-en-Y
anastomosis
Closed duodenum
31
Diaphragm
Ligament of Treitz
Closure of mesocolon
32a
Duodenum
Esophagus
Jejunum
91
PLATE
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37
INDICATIONS e indications and preoperative preparation are speci c
and are reviewed in Total Gastrectomy, Plate , where the commonly used
methods of reconstruction are shown with hand-sewn anastomoses. Many
surgeons, however, prefer to use staples, because they simplify the anastomoses and lessen the total time of this operation, which is now more frequently performed.
ANESTHESIA General anesthesia is given by endotracheal intubation.
POSITION Exposure is enhanced if the patient is placed in a reversed
Trendelenburg position.
OPERATIVE PREPARATION e skin over the lower thorax as well as the
abdomen is shaved and cleansed with the appropriate antiseptic solution.
INCISION AND EXPOSURE A minimally invasive laparoscopic peritone-
oscopy is o en performed rst 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. is permits abdominal
exploration and enables the surgeon to make a decision for or against proceeding with total gastrectomy. e incision is usually extended to the le
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. is permits evaluation of the posterior wall of the stomach as well
as an evaluation for metastases about the le 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 le
lobe of the liver following the division of the suspensory ligament to this
lobe. An outline of a nal reconstruction is shown in figure 1.
DETAILS OF PROCEDURE As in Plates and , the region of the duode-
num is rst mobilized by the Kocher maneuver, and the blood supply about
the pylorus ligated to prepare only the duodenal wall for the application of
the stapler. e right gastroepigastric vessels are doubly ligated as far away
from the duodenal wall as possible to ensure the inclusion of any possible
lymph node metastases. e right gastric blood supply to the superior surface
of the duodenum should also be divided and ligated to ensure the removal of
. to cm of duodenum distal to the pyloric vein if the procedure is being
performed for gastric carcinoma. e duodenum is closed with a non cutting
linear stapler (TA or ). e duodenum is divided between the stapler and
the Kocher clamp on the pyloric end of the duodenum. Alternatively the duodenum may be divided with a linear stapler. e entire stomach, along with
the omentum and the gastric hepatic ligament, is then mobilized as shown in
T G, S
Plates and . e gastric vessels are divided and ligated in the presence of
cancer of the fundus of the stomach. e spleen may also be resected, but this
is indicated only if the spleen is involved with local spread of the tumor.
A good clear exposure of the lower esophagus is essential, along with
the margins of the esophageal hiatus. Since the esophagus tends to retract
upward when divided, it is helpful if the esophagus is pulled gently downward a er vagotomy and anchored to the margins of the hiatus with four
or ve interrupted sutures that include only a modest bite of the esophageal
wall (figure 2). is ensures or cm of nonretractable esophagus below
the hiatal opening. e crus of the diaphragm should be approximated posterior to the esophagus, allowing a reasonable-sized opening.
e nasogastric tube is retracted, and the modi ed Furniss clamp is
applied to the esophagus above the gastric junction (figure 2). e esophagus is divided against the clamp a er a mono lament polypropylene suture
on a straight needle has been inserted. is resection line must be close to
the clamp to ensure a safe and secure closure by the stapler. It is also acceptable to divide the esophagus and place a purse string freehand. e jejunum
about cm below the ligament of Treitz is exposed, and the blood supply in
the mesentery studied to ensure a good blood supply to the mobilized arm of
jejunum, which should be to cm long. e division of the jejunum and
mesenteric blood vessels is demonstrated in figures 16 and 17 in Plate .
e divided jejunum is brought up through an opening in the avascular area to the le of the middle colic vessel. Special attention is required
to avoid twisting the section of jejunum or in any way interfering with its
blood supply. e jejunum is anchored to the margin of the opening, which
must be closed to avoid internal herniation. e limb must extend easily up
to the end of the esophagus as well as to cm beyond to provide entrance
for the stapler to e ect the esophagojejunal anastomosis (figure 3).
e blood supply to the end of the jejunal limb is recon rmed to be
strong and adequate. e esophageal size is measured (figure 4) with a
calibrated sizing instrument. Some prefer to dilate the end of the esophagus
by inserting a Foley catheter (size French) into the lower esophagus and
injecting to cm of saline, which gently dilates the end of the esophagus for the easier introduction of the anvil of the stapler. is may permit
the introduction of a larger stapler. e appropriately sized circular stapler (EEA) instrument is passed through the open end of the jejunum and
directed toward the antimesenteric surface. e sharp plastic trocar on the
end of the circular stapler (EEA) instrument is passed through the antimesenteric surface of the small intestine. e tilting anvil is inserted through
the opening made by the trocar and attached to the main portion of the
circular stapler (EEA) instrument. e tilted circular stapler (EEA) cap is
then carefully introduced into the esophagus (figure 5).
CONTINUES
92
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