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198 I. Diez del Val and C. Loureiro González
Fig. 24.6 Suture of the
anterior layer (a, b). Before
the anterior layer is sutured,
pass the nasogastric tube
through the anastomosis (c)
Fig. 24.7 Resection of the
lateral loop by linear stapler.
Close (a) and schematic view
(b)
Fig. 24.8 Final aspect of the esophago-gastric anastomosis
19924 Intrathoracic Robot-Assisted Minimally …
References (References 2 and 3 could be deleted)
1. Pennathur A. The, “best operation” for esophageal cancer? Ann
Thorac Surg. 2010;89:S2163–7.
2. Díez del Val I, Loureiro González C, Larburu Etxaniz S.
Contribution of robotics to minimally invasive esophagectomy. J
Rob Surg. 2013;7:325–32.
3. Bhat MA, Dar MA, Lone GN, Dar AM. Use of pedicled omentum
in esophagogastric anastomosis for prevention of anastomotic leak.
Ann Thorac Surg. 2006;82:1857–62.
4. Dai JG, Zhang ZY, Min JX, et al. Wrapping of the omental pedicle
flap around esophagogastric anastomosis after esophageectomy for
esophageal cancer. Surgery. 2011;149:404–10.
Surgical Anatomy of the Stomach and the Omental Bursa
Ronald L. A. W. Bleys and Teus J. Weijs
25
25.1 Introduction
The role of the stomach in the digestive system is that of a
food blender and a reservoir. Inside the stomach mechanical and chemical breakdown into a liquid mass, the chyme,
takes place. Food particles have to be as small as 1–2 mm
in diameter before they pass to the duodenum. The reservoir
function is reflected by the fact that an empty stomach contains approximately 100 ml, while a full stomach may contain
more than 2 l and may even extend as low as the pelvic brim.
The reflux of gastric content is prevented by, among others,
the lower esophageal sphincter and emptying into the duodenum is regulated by the pyloric sphincter. The functional
aspects make the stomach a highly mobile and distensible sac.
25.2 Anatomical Features
Several anatomical features accommodate for the mobility
and distensibility. First, the true fixation points of the stomach are proximal and distal to the stomach. Proximally, it is
the passage of the esophagus through the diaphragm, where
it is surrounded by the right crus of the diaphragm. Distally,
it is where the superior part of the duodenum becomes retroperitoneal in position, after its first 2.5 cm. The attachments of the stomach by the lesser omentum and peritoneal
ligaments permit mobility and do not really fixate the stomach. Second, the stomach is covered by peritoneum which
produces fluid, and thereby contributes to the sliding planes
inside the peritoneal cavity. Third, the omental bursa (lesser
sac) behind the stomach provides freedom of movement
against the posterior abdominal wall.
R. L. A. W. Bleys (*) · T. J. Weijs
Department of Anatomy, University Medical Center Utrecht,
Utrecht, The Netherlands
e-mail: R.L.A.W.Bleys@umcutrecht.nl
The stomach is subdivided into four parts: cardia, fundus,
corpus (body), and the pyloric part. The latter consists of the
pyloric antrum, the pyloric canal, and the pylorus (Fig. 25.1).
The term pylorus is reserved for the transition to the duodenum. The stomach has the shape of the letter J, and therefore,
lesser and greater curvatures can be readily identified.
25.3 Structure
The wall of the stomach is formed by four layers, from
inward to outwards: mucosa, submucosa, muscularis, and
serosa. The mucosa is composed of columnar cell epithelium. The transition of the squamous cell epithelium of the
esophagus into the columnar epithelium of the stomach at
the gastro-esophageal junction can be visualized as a zigzag line; the z-line. Along the lesser curvature the mucosa
forms longitudinal folds called gastric canal or magenstrasse under the influence of muscle contractions [1]. In
the empty stomach this creates a highway for liquids from
esophagus to pylorus. The muscularis consists of three layers of muscle fibers: an inner layer which is obliquely oriented, a middle layer which is circularly oriented, and an
outer layer which is longitudinally oriented. The obliquely
oriented muscle fibers are unique since they do not exist in
the rest of the gastro-intestinal tract. Due to their orientation
these contribute to the cardiac notch and flap-valve of Hill
[2], which are components of the gastro-esophageal closure
mechanism, and the formation of the gastric canal along
the lesser curvature. The circular muscle layer is thickened
at the exit of the stomach (pylorus) to form the pyloric
sphincter (Fig. 25.2a,b). The pylorus controls the passing
of chyme into the duodenum. The muscularis is best developed in the antrum because here the propulsion of chyme
to the duodenum takes place. Finally, the serosa or visceral
peritoneum is a thin layer of connective tissue covered by
mesothelium.
© Springer Nature Switzerland AG 2021
M. Asunción Acosta et al. (eds.), Atlas of Minimally Invasive Techniques in Upper Gastrointestinal Surgery,
https://doi.org/10.1007/978-3-030-55176-6_25
201
202 R. L. A. W. Bleys and T. J. Weijs
25.4 Topographical Relationships
The stomach is located high in the left upper quadrant of
the abdomen which makes it difficult to access. It is entirely
covered by peritoneum, double layers of which attach the
stomach to surrounding structures. Along the greater curvature, the attachments of the stomach are: cranially to
the diaphragm by the gastrophrenic ligament, left lateral
to the spleen by the gastrosplenic ligament, and caudally
to the colon by the gastrocolic ligament. These ligaments
are continuous to each other. Along the lesser curvature,
the hepatogastric ligament connects the stomach to the
liver. This ligament is part of the lesser omentum which,
furthermore, consists of the hepatoduodenal ligament containing the common bile duct, hepatic artery, and portal
vein (Fig. 25.3). Anterosuperiorly, the stomach is related to
the left lobe of the liver. The omental bursa is behind the
stomach. In its posterior wall are the inferior vena cava, the
abdominal aorta, the left adrenal gland, the upper pole of
the left kidney, and the pancreas. The term stomach bed is
used for all structures directly behind the stomach. These
comprise the diaphragm, the spleen, the left adrenal gland
and kidney, the splenic artery, the pancreas, and transverse
mesocolon (Fig. 25.4).
Fig. 25.1 Parts of the stomach
Fig. 25.2 Muscular structure of the stomach (a, b)
Fig. 25.3 Schematic view of the relation of the stomach with other
structures and attachments of the stomach (1: hepatogastric ligament,
2: omental foramen (Winslow), 3: gastrosplenic ligament, 4: greater
omentum, 5: hepatoduodenal ligament) [3]
Fig. 25.4 Bed of the stomach. Posterior wall of the omental bursa (1:
omental foramen (Winslow), 2: inferior vena cava , 3: gastropancreatic fold, 4: celiac trunk, 5: right gastroomental fold, 6: short vessels
fold, 7: left gastroomental fold, 8: superior recess, 9: splenic recess,
10: inferior recess, 11: transverse mesocolon, 12: hepatoduodenal ligament, 13: aorta, 14: vestibule) [3]
25.5 Vascular Supply
The stomach has an abundant arterial supply. Arterial
arcades are formed along the lesser and greater curvatures
and many anastomoses exist in the submucosa, also with
esophageal arteries. Therefore, ligating one of the supplying
arteries of the stomach should not be a problem.
All gastric arteries are derived from the celiac trunk
which arises from the abdominal aorta just cranial to the
pancreas. The three branches of the celiac trunk have a
20325 Surgical Anatomy of the Stomach and the Omental Bursa
retroperitoneal course and finally reach the stomach through
its peritoneal attachments (Fig. 25.5a,b). The left gastric
artery and the common hepatic artery raise folds in the posterior wall of the omental bursa: the gastropancreatic fold
and hepatopancreatic fold, respectively. The left gastric
artery reaches the lesser omentum to supply the stomach
and also gives off small ascending branches to the esophagus. Occasionally, there may be an anastomosis with the
left inferior phrenic artery, and this anastomosis is named
Belsey’s artery. Another important variation is an accessory
left hepatic artery branching off from the left gastric artery
(10–27%). Sometimes this branch replaces the original left
hepatic artery. In its course in the lesser omentum the left
gastric artery divides into anterior and posterior branches,
of which the posterior branch generally forms an anastomosis with the right gastric artery.
The right gastric and right gastro-omental arteries are
derived from the common hepatic artery. The right gastric
artery is normally given off by the hepatic artery proper
and courses to the lesser omentum. The right gastro-omental artery is a branch from the gastroduodenal artery and
reaches the gastrocolic ligament to run along the greater
gastric curvature. A true external anastomosis between right
and left gastro-omental arteries exists in 55–65% of the
cases. The location of the true anastomosis, or otherwise
the watershed area, is called Demel’s point (Fig. 25.5b) [5].
The supply area of the left gastric artery is larger than that
of the right gastric artery while the opposite is found along
the greater curvature: the supply area of the right gastroomental artery is larger than that of the left gastro-omental
artery (Fig. 25.5a,b).
The left gastro-omental artery comes from the splenic
artery which follows a tortuous course along the superior
border of the pancreas to the splenorenal ligament. From
the middle third of the splenic artery a branch courses to
the posterior wall of the superior portion of the body of the
stomach in 62% of cases. This is the posterior gastric artery
[6]. From the terminal portion of the splenic artery and
its splenic branches, 3–10 short gastric arteries arise and
course to the fundus and body of the stomach through the
gastrosplenic and gastrophrenic ligaments (Fig. 25.5a,b).
The gastric veins follow the arteries and drain into the
portal vein. The left gastric vein is connected to esophageal
veins and this forms the anatomical basis for a portocaval
shunt. Because of the low intrathoracic pressure there is
flow from the left gastric vein into the thorax under normal
conditions.
204 R. L. A. W. Bleys and T. J. Weijs
Fig. 25.5 Gastric arteries (a). Demel’s point where left and right gastro-omental arteries meet (b) [4]
25.6 Lymphatic Drainage
Gastric lymph is collected in the mucosa and a dense submucosal network of lymph vessels. It drains via a subperitoneal plexus into the perigastric lymphatic system.
The lymphatics follow all gastric arteries and therefore
the lymph nodes are located along the curvatures, near the
spleen, near the pancreas, near the esophagus, and in the
hepatoduodenal ligament (Fig. 25.6a,b). The coeliac nodes
are the collecting nodes, and most lymph drains via these
nodes into the intestinal trunk. However, due to the low
pressure in the thorax, the lymph flow around the esophagogastric junction is directed cranially. The lymph node stations surrounding the stomach are classified following the
system of the Japanese society for gastric cancer (Fig. 25.6
c) [7]. The number of lymph nodes in these stations, and
thus the number, that can be resected is subject to large
interindividual variation. For example, the number of lymph
nodes in stations 1–11 (corresponding with an R2 lymph
node resection) varies from 17 to 44 [8].
25.7 Innervation
Motor and secretory activities of the stomach are influenced
by the autonomic nervous system. Sympathetic fibers travel
in the greater and lesser splanchnic nerves, the coeliac
plexus, and periarterial plexuses. These fibers are partially
vasomotor. Anterior and posterior vagal trunks supply parasympathetic fibers. There is considerable variation regarding the level at which the vagal trunks form and branch, so
there may be 3 or 4 separate vagal nerve branches at the
esophageal hiatus [9].
After entering the abdomen the anterior vagal trunk
gives off a hepatic branch which courses toward the liver
and gallbladder between the layers of the lesser omentum.
It also provides a branch to the pylorus. The anterior vagal
trunk continues as the anterior nerve of Latarjet and follows
the anterior side of the lesser curvature up to the pylorus
[10]. Along its route small branches supply the stomach.
The nerve ends in several small branches for the antrum and
the pyloric region is the so-called crow’s foot (Fig. 25.7).
After entering the abdomen the posterior vagal trunk
gives off a coeliac branch which runs along the left gastric
artery to the coeliac plexus and supplies more distal parts
of the digestive tract up to the transverse colon. A second
branch is the cardiac branch, which curves posteriorly
around the esophagus to the cardia, and is also known as
the criminal nerve of Grassi [11]. The posterior vagal trunk
continues as the posterior nerve of Latarjet which sends
many branches to the stomach and like its anterior fellow
terminates as a crow’s foot for the antrum (Fig. 25.7).
25.8 Omental Bursa
The omental bursa or lesser sac is part of the peritoneal cavity that extends behind the stomach and the lesser omentum. Originally, it is part of the right half of the peritoneal
cavity and is formed when through growth processes the
stomach changes position (it ‘rotates’) and the dorsal mesentery extends to the left. The main and larger rest of the
20525 Surgical Anatomy of the Stomach and the Omental Bursa
Fig. 25.6 Schematic view of gastric lymph node stations (a, b). Lymph node stations according to the system of the Japanese Gastric Cancer
Society (c). Abbreviations: APIS: artery phrenica inferior sinistra, AGB: arteries gastricae breves, AGES: artery gastroepiploica dextra, VCDA:
vein cilica dextra accessoria, VCM, vein colica media, VCD: vein: colica dextra, VJ: vein jejunalis, AGP: artery gastrica posterior, AHC: artery
hepatica communis, VP: vein portae, VL: vein lienalis, VMS: vein mesenterica superior, VPDIA: vein pancreatoduodenalis inferior anterior,
TGC: truncus gastrocolicus, ACM: artery colica media, AJ: artery jejunalis
206 R. L. A. W. Bleys and T. J. Weijs
omental bursa into two parts (Fig. 25.4). On the right is the
smaller part which is mainly formed by the superior recess.
This recess extends superiorly between the inferior vena
cava and the esophagus and lies behind the caudate lobe of
the liver. The narrow passage at the left of the omental foramen, between the caudate process of the liver and first part
of the duodenum, is called the vestibule and this is also in
the right part of the omental bursa.
The greater part of the omental bursa is left and inferior
of the arterial folds and contains two recesses: the splenic
recess and the inferior recess. The splenic recess extends to
the left border of the omental bursa which is formed by the
attachments of the spleen, the gastrosplenic, and splenorenal ligaments. In the upper part of the left border the short
gastric vessels protrude into the splenic recess as the short
vessels folds (Fig. 25.4) [3]. The inferior recess extends
inferiorly anterior to the pancreas and transverse mesocolon
and ends at the line of fusion of the layers of the greater
omentum. The line of fusion runs from the gastrosplenic
ligament on the left to the first part of the duodenum to the
right. At these locations the gastro-omental vessels enter the
gastrocolic ligament and raise peritoneal folds which protrude into the omental bursa and are called left and right
Fig. 25.7 Gastric innervation
gastro-omental folds (Fig. 25.4) [3].
peritoneal cavity is called the greater sac. The natural orifice which connects the greater sac and the omental bursa
is the omental foramen (epiploic foramen, foramen of
Winslow), a slit-like structure behind the hepatoduodenal ligament, of approximately 3 cm height (Fig. 25.3).
The other borders of the foramen are the caudate lobe of
the liver (superior), inferior vena cava (posterior), and the
first part of the duodenum (inferior); all with peritoneal
covering.
The omental bursa itself is narrow and has anterior and
posterior walls. Their peritoneal lining permits much freedom of movement for the stomach against the posterior
abdominal wall. The anterior wall is formed by the lesser
omentum, the posterior wall of the stomach, and the gastrocolic ligament (Fig. 25.3). The peritoneum of the upper part
of the posterior wall covers from right to left inferior vena
cava, abdominal aorta, left adrenal gland, and upper pole
of the left kidney. More inferiorly, it covers the pancreas
and forms the anterior layer of the transverse mesocolon
(Fig. 25.4). Many of the structures in the posterior wall of
the omental bursa are part of the stomach bed; see the paragraph ‘Topographical relationships’.
The part of the abdominal aorta in the posterior wall
gives off the coeliac trunk. The course of two of its
branches, the left gastric artery and the common hepatic
artery, raise prominent peritoneal folds in the posterior wall
of the omental bursa, namely, the gastropancreatic fold and
hepatopancreatic fold, respectively. These folds divide the
References
1. Waldeyer W. Die Magenstrasse. Sitzungsberichte Der Königlich
Preussischen Akademie Der Wissenschaften. 1908;391:595–606.
2. Thor KB, Hill LD, Mercer DD, Kozarek RD. Reappraisal of the
flap valve mechanism in the gastroesophageal junction. A study
of a new valvuloplasty procedure in cadavers. Acta Chir Scand.
1987;153:25–8.
3. Brenkman HJF, van der Wielen NI, Ruurda JP, et al. Surgical anatomy of the omental bursa and the stomach based on a minimally
invasive approach: different approaches and technical steps to
resection and lymphadenectomy. J Thorac Dis. 2017;9:S809–16.
4. Lanz T von,Wachsmuth W. Praktische Anatomie. Zweiter Band,
Teil 6, Bauch. Berlin, Springer Verlag; 1993. p.188
5. Buunen M, Rooijens PP, Smaal HJ, et al. Vascular anatomy of
the stomach related to gastric tube construction. Dis Esophagus.
2008;21:272–4.
6. Suzuki K, Prates JC, Didio LJA. Incidence and Surgical
Importance of the Posterior Gastric Artery. Ann Surg.
1978;187:134–6.
7. Kajitani T. The general rules for the gastric cancer study in surgery and pathology. Part I Clinical classification. Jpn J Surg.
1981;11:127–39.
8. Wagner PK1, Ramaswamy A, Rüschoff J, et al. Lymph node
counts in the upper abdomen: anatomical basis for lymphadenectomy in gastric cancer. Br J Surg. 1991;78:825–7.
9. Skandalakis LJ, Gray SW, Skandalakis JE. The history and
surgical anatomy of the vagus nerve. Surg Gynecol Obstet.
1986;162:75–85.
10. Latarjet A. Preliminarre sur I’innervation et I’enervation de
I’estomac. Lyon Med. 1921;130:166.
11. Skandalakis JE, Gray SW, Soria RE, et al. Distribution of the
vagus nerve to the stomach. Am Surg. 1980;46:130–9.
Minimally Invasive Treatment of Gastric GIST
Carlos Moreno-Sanz and Miguel A. Cuesta
26
26.1 Introduction
Gastrointestinal stromal tumours (GIST) form 5% of all
gastrointestinal tumours and 40–60% of these are located
in the stomach. GIST derive from the interstitial cells of
Cajal and constitute a separate entity from leiomyoma and
leiomyosarcoma [1]. The criteria for differentiating benign
from malignant gastric GIST have been debated for several
years. Gastric GIST that are smaller than 5 cm and have
fewer than 5 mitoses per high-power field (hpf) are considered to have low malignant potential. Tumours measuring 5–10 cm or having 5–10 mitoses per hpf are considered
intermediate risk, and those greater than 10 cm or having
more than 10 mitoses per hpf are considered high risk. After
taking biopsies, location and staging have been performed
by a combination of endoscopy, with detailed information
about the exact location and size of the tumour, endoscopic
ultrasonography, and CT scan.
The treatment of choice for gastric non-metastatic is complete bloc resection of the tumour and the surrounding tissue
by obtaining R0 margins. Laparoscopic approach has become
the choice of technique for resection of tumours up to 10 cm
without compromising oncological principle. Various minimally invasive techniques can be used to approach GIST
according to the size and location of the tumour [2], such
as endoscopic resection, atypical gastric resection (wedge),
standard gastric resections, and combination of techniques
involving endoscopic-guided laparoscopic resection or laparoscopic-guided endoscopic resection [3, 4].
Regarding the gastric location of the GIST we need to
take into account the anterior and posterior walls of the
stomach and the two curvatures, thereby allowing us to differentiate and classify these into three zones [5].
In zone A (lesser curvature and cardiac area) we prefer
applying the transgastric laparoscopic approach with endoscopic guidance. If there is no compromise of the gastric
inlet, a wedge resection may be performed. In special cases
in which the size and extension of the tumour is required, a
proximal gastrectomy or a transhiatal esophagogastrectomy
will be performed.
In tumours localized in zone B (greater curvature),
after endoscopic localization and adequate mobilization
of the greater curvature, doing a stapled transection under
simultaneous endoscopic guidance is a safe and effective
technique.
For tumours localized in zone C (antrum and pylorus),
a stapled wedge resection is often difficult to realize due
to risk of gastric outlet narrowing. When treating small
tumours some authors propose using the transgastric
approach with submucosal resection or even a wedge resection if tumour is located along the greater curvature. For
larger tumours we prefer a distal gastrectomy which precludes the possibility of outlet obstruction.
Electronic supplementary material The online version of this
chapter (https://doi.org/10.1007/978-3-030-55176-6_26) contains
supplementary material, which is available to authorized users.
C. Moreno-Sanz
Department of General and Digestive Surgery, Hospital General
La Mancha Centro, Alcazar de San Juan, Ciudad Real, Spain
e-mail: cmsurgery@hotmail.com
M. A. Cuesta (*)
Department of Surgery, Amsterdam UMC, Amsterdam, The
Netherlands
e-mail: ma.cuesta@amsterdamumc.nl
© Springer Nature Switzerland AG 2021
M. Asunción Acosta et al. (eds.), Atlas of Minimally Invasive Techniques in Upper Gastrointestinal Surgery,
https://doi.org/10.1007/978-3-030-55176-6_26
26.2 Description of the Surgical Technique
In this chapter two techniques will be described to remove
gastric GIST: transgastric and laparoscopic wedge resection
(Videos 26.1 and 26.2).
207
208 C. Moreno-Sanz and M. A. Cuesta
26.2.1 Transgastric Resection
1. Patient and trocar position
The patient is placed in lithotomy position, surgeon in
French position, and 5 trocars of 5/12 mm are placed as
shown in Fig. 26.1.
2. Localization and palpation of the tumour
First of all, localization and assessment of size and pre-
cise location of the GIST in the stomach is necessary.
According to this, make a plan in order to adopt the best
approach (Fig. 26.2).
3. Seromuscular stitch placement in gastric wall
One 2/0 superficial stitch is placed in the gastric wall for
traction and reference for next gastrostomy (opposite the
GIST) (Fig. 26.3).
4. Second stitch placement
A second stitch is placed, short distance from the for-
mer, leaving it long for traction and reference (Fig. 26.4).
5. Gastrotomy
After that, the stomach is opened between the two pre-
vious stitches using diathermia or preferably sealing
device to take down the gastric wall (Fig. 26.5).
6. Localize the tumour in the stomach, and put a strong
stitch at the top of tumour for traction
Through gastrotomy, it’s time to localize the tumour,
evert it, and place a stitch at the top of tumour for
Fig. 26.1 Position of patient and trocar’s placement
traction. The next step is to exteriorize completely the
GIST out of the stomach, inspecting the origin of the
tumour and the possible relation with the gastric inlet
(Fig. 26.6).
7. Resection of the GIST using stapler at the basis of the
tumour
A gastric resection is performed including the whole GIST
by stapling along the basis of the tumour (Fig. 26.7).
8. Retrieval of the specimen
After its resection, the specimen is placed into a bag in
order to retrieve the bag with specimen through a little
extended trocar incision, or if necessary (because of the
size of the tumour) through a new assisted incision (like
a Pfannenstiel) (Fig. 26.8).
9. Closure the gastrotomy
To finish the procedure it’s necessary to close the gastrotomy manually by a running suture (Fig. 26.9) or using a
stapler device (Fig. 26.10).
26.2.2 Transgastric Resection
1. Position of patient and placement of trocars
(Fig. 26.1).
2. Assessment and palpation of the GIST.
First of all, it is mandatory to explore the abdominal cav-
ity and assess by palpation and visualization the exact
location and extension of the GIST in order to plan the
most adequate approach to resect the tumour. In this par-
ticular case, due to tumour’s localization, resection of the
middle part of the stomach was performed (Fig. 26.11).
3. Open the omental bursa
The next step is to open the omental bursa along the
greater curvature and dissect the greater curvature along
the gastrocolic ligament (Fig. 26.12).
4. Dissect free the distal part of the greater curvature
It’s necessary to complete the dissection of the greater
curvature to distal (Fig. 26.13).
5. Open the pars flaccida
After that, the pars flaccida is open in order to mobilize
the distal stomach (Fig. 26.14).
6. Division of the stomach distal to the tumour
The stomach is divided distal to the tumour by means of
a linear stapler (Fig. 26.15).
7. Proximal division of the stomach proximal to the
tumour
Then the stomach is divided proximally to the tumour by
linear staplers (Fig. 26.16).
8. Retrieval of the specimen
The resected specimen is retrieved in a bag through one
of the trocar orifices, widened in order to get out of the