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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_536_Библиотеки_им_академика_М_И_Перельмана.pdf
300 A. T. T. de Oliveira et al.
Fig. 37.1 Operative field with lymph node stations
Fig. 37.3 Placement of trocars and help incision
Fig. 37.2 Position of patient and surgeons during laparoscopic
gastrectomy
3. Lymphadenectomy of station 6 (right gastroepiploic vessels). Division of the right gastroepiploic vessels with
clips at the level of the head of the pancreas (Fig. 37.6).
4. Opening hepatoduodenal ligament in the length with
division of pars flaccida along the liver edge, up to the
right crus (Fig. 37.7). Division of the right gastric artery
and lymphadenectomy of stations 8 and 12, along the
common and hepatic artery proper. (Fig. 37.8).
5. Dissection of the superior part of the duodenum
(supraduodenal window) and posterior division of the
proximal duodenum by stapler (Fig. 37.9).
6. Retraction of stomach to the left. Dissection and lymphadenectomy of the celiac trunk (stations 9, 7, and
11p). Division of the left gastric vessels between clips
(Fig. 37.10). General view of lymphadenectomy of the stations 12, 8, 9, 7 and 11p, along the hepatic artery, and celiac
trunk. Left gastric vessels have been divided (Fig. 37.11).
7. Continue the dissection from here to the hiatus. Dissect
the distal esophagus free and divide the distal esophagus by staplers, and prepare it depending on the type of
esophagojejunostomy anastomosis that you will perform
(Fig. 37.12).
8. Complete the lymphadenectomy of distal splenic
artery and hilum of the spleen (stations 11d and 10)
(Fig. 37.13). General view of the D2 lymphadenectomy
in total gastrectomy (Fig. 37.14).
37.4 Reconstruction After Total Gastrectomy
There are four ways to perform the esophagojejunostomy
anastomosis:
1. Conventional circular stapler.
2. Circular Orvil® stapler device (21 or 25 mm) (Chap. 39).
3. Linear stapler side to side anastomosis (Chap. 39).
4. Hand-sewn (Chap. 40).
1. Conventional circular stapler
• Introduction of the anvil and preparation for circular
anastomosis.
• Loop around the esophagogastric junction for traction
of the esophagus (Fig. 37.15a) and open the anterior
wall of the esophagus.
Fig. 37.4 Omentectomy
to the left crus (ligation of
the left gastroepiploic and
short vessels). Close (a, b)
and schematic view (c, d)
30137 Laparoscopic Total Gastrectomy for Gastric Cancer
Fig. 37.5 Omentectomy to
the hepatic flexure. Close (a)
and schematic view (b)
302 A. T. T. de Oliveira et al.
Fig. 37.6 Dissection and lymphadenectomy (station 6) of the right gastroepiploic vessels. Close (a, b) and schematic view (c)
Fig. 37.7 Open the
hepatoduodenal ligament and
division of the hepatogastric
ligament. Close (a, b, c) and
schematic view (d)
30337 Laparoscopic Total Gastrectomy for Gastric Cancer
Fig. 37.8 Dissection and ligation of right gastric artery. Close (a, b, c) and schematic view (d). Lymphadenectomy of the hepatoduodenal liga-
ment (8a, 12) Lymphadenectomy station 12 along portal vein (e, f, g)
Fig. 37.9 Dissection of the supraduodenal space (a). Duodenum division by staplers. Close (b) and schematic view (c)
304 A. T. T. de Oliveira et al.
Fig. 37.10 Lymphadenectomy (stations 9, 7, and 11p). Dissection and ligation of the left gastric vessels by clips. Close (a, b, c) and schematic
view (d)
Fig. 37.11 General view of
the lymphadenectomy (8a,
12, 7, 9, and 11p) (a, b)
Fig. 37.12 Dissection (a)
and division (b) of the distal
esophagus
30537 Laparoscopic Total Gastrectomy for Gastric Cancer
Fig. 37.13 Lymphadenectomy distal splenic artery (station 11p and 10). Close (a, b, c) and schematic view (d)
Fig. 37.14 General view of
the lymphadenectomy
306 A. T. T. de Oliveira et al.
• Introduce the anvil (25 mm) through the widened
opening of the trocar of the left flank (Fig. 37.15b).
• To the end of the anvil is a thread with circular needle
attached.
• Introduce the anvil through the opening in the anterior wall of the distal esophagus; push the anvil
proximally in the esophagus (Fig. 37.15c, d, e) and
use the needle to put the thread (and the needle) out
the wall of the esophagus (Fig. 37.15f).
• Division of the esophagus by linear stapler, distal of the
thread. The opening of the distal esophagus is included
in the specimen with the whole stomach (Fig. 37.15g, h).
Fig. 37.15 A sling is placed around the esophagus (a). An anvil (25 mm) attached to a thread and a needle is introduced through the widened
opening of the trocar of the left flank: close (b, c) and schematic view (d). The anvil is push in the esophagus and the thread (and the needle)
is put through the anterior wall of the esophagus (e, f). Division of the esophagus by linear stapler, distal of the thread: close (g) and schematic
view (h). Preparation of the anvil by traction of the thread attached to the anvil: close (i, j) and schematic view (k)
Fig. 37.16 A opening
is made in the transverse
mesocolon. Close (a) and
schematic view (b)
• Preparation of the anvil by traction of the thread
attached to the anvil, the prick perforates the anterior wall of the distal esophagus near the stapled line
(Fig. 37.15e).
• The specimen is placed in a bag.
• Preparation of the jejunal loop:
– Opening the transverse mesocolon (Fig. 37.16)
– Divide the proximal jejunum by means of the
stapler
– The distal loop is introduced through the open
transverse mesocolon in direction to the distal
esophagus (Fig. 37.16b and 37.17).
• Esophagojejunal anastomosis:
®
– Introduce the EEA device
through the widened
trocar opening in the abdominal wall.
– Perform an end-to-side esophagojejunal anastomo-
sis with 25 mm circular stapler (Fig. 37.18).
30737 Laparoscopic Total Gastrectomy for Gastric Cancer
Fig. 37.17 Jejunal loop is divided by staplers. The distal jejunal loop
is introduced through the open transverse mesocolon in direction to
the distal esophagus
308 A. T. T. de Oliveira et al.
Fig. 37.18 Perform an
end-to-side esophagojejunal
anastomosis with 25-mm
circular stapler. Close (a, b,
c) and schematic view (d)
Fig. 37.19 A side-to-side jejunojejunal anastomosis by means of lin-
ear stapler is performed follow by closure of the opening
– A side-to-side jejunojejunal anastomosis by means
of linear stapler is performed. The anastomosis is
located inframesocolic (Fig. 37.19).
– Closure the mesenteric spaces. The mesenteric
defects and the Petersen space are closed by means
of a running suture.
– Retrieval of the specimen is performed through a
small assistance incision at the level of the trocar
of the left flank (Fig. 37.20). Protect the extrac-
tion site with Alexis type device®. Protected
Pfannenstiel incision is other option.
– Drain the anastomosis using a Jackson Pratt drain.
– General view of the reconstruction (Fig. 37.21).
Fig. 37.20 Retrieval of
the specimen in a bag is
performed through a small
assistance incision. Close (a)
and schematic view (b)
Fig. 37.21 General view of the reconstruction
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