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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_536_Библиотеки_им_академика_М_И_Перельмана.pdf
Spleen-Preserving Splenic Hilar Dissection for Proximal Gastric Cancer
Takahiro Kinoshita
38
38.1 Introduction
Lymph nodes around the splenic hilum is numbered as station No. 10 in the Japanese Gastric Cancer Classification [1].
Nodal metastasis to No. 10 is sometimes seen in proximal
advanced stomach cancer. For complete removal of No. 10,
splenectomy had been performed in Japan. However, a randomized clinical trial (JCOG0110) which compared between
splenectomy versus non-splenectomy clearly demonstrated
unnecessity of splenectomy or intensive dissection of the
No. 10 if the tumor does not invade the greater curvature
[2]. Meanwhile, if the tumor invades the greater curvature,
metastasis to No. 10 is recognized in around 15% of the
patients [3]. Necessity of splenectomy or efficacy of spleenpreserving dissection is still unclear, but the potential benefits gained by preserving the spleen seems unquestionable. In
this context, the indication of the spleen-preserving splenic
hilar dissection in our center is advanced gastric cancer
involving the proximal greater curvature site without direct
invasion to the splenogastric ligament nor obvious nodal
metastasis to No. 10. Remarkable anatomical variation of
the splenic vessels is well acknowledged. Preoperative anatomical reconstruction using three-dimensional CT images is
effective to understand individual anatomy in advance [4].
Description of the surgical rechnique (see Video 38.1).
The key steps to perform a Spleen-preserving splenic hilar
dissection for proximal gastric cancer are.
Electronic supplementary material The online version of this
chapter (https://doi.org/10.1007/978-3-030-55176-6_38) contains
supplementary material, which is available to authorized users.
T. Kinoshita (*)
National Cancer Center Hospital East, 6-5-1 Kashiwanoha,
Kashiwa 277-8577, Japan
e-mail: takkinos@east.ncc.go.jp
1. Port placement and patient’s position
The patient is positioned in supine legs apart with
head-up and left-up tilted rotation to obtain optimal
exposure around the splenic hilar region. Five ports are
used, and the operator stands at the right side of the
patient. The first assistant stands at the left side of the
patient and the camera assistant between the legs.
2. Technical steps
Timing of the splenic hilar dissection
Splenic hilar dissection is usually employed in combi-
nation with total gastrectomy. After exploration of the
abdominal cavity (and lavage cytology if required), the
lateral segment of the liver is retracted (Fig. 38.1). Then,
splenic hilar dissection should be immediately initiated.
Performing splenic hilar dissection at the late phase of
the surgery is challenging because of the excessive
fluid (lymphatic or bloody) at the left subphrenic fossa.
Splenic hilar dissection is certainly a complex procedure; therefore, it should be finished at the early phase of
surgery in the finest circumstances.
1. Dissection of the greater omentum. The greater omentum is
dissected at their attachment to the transverse colon toward
the lower pole of the spleen (Fig. 38.2); however, spleno-
pancreatic mobilization from the retroperitoneal bed is not
required. When the omental disection reaches the splenic
lower pole, adipose tissue including the gastroepiploic vessels arcade at the greater curvature of the stomach body is
ligated to be lifted up using a pre-tied loop which is pulled
out through the abdominal wall (Fig. 38.3). By performing
this retraction, the splenogastric ligament is stretched and a
favorable view around the splenic hilum can be provided.
2. Exposure of the left gastroepiploic vessels originated
from the inferior branch (Fig. 38.4). Then, the splenic
hilum is identified from the caudal view to be dissected exposing the inferior branch of the splenic vessel
(Fig. 38.5). The left gastroepiploic vessel can be identified which is usually originated from the inferior branch.
© 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_38
311
312 T. Kinoshita
Fig. 38.1 The liver is
retracted with a special
constructed retractor. Close
(a, b, c, d) and schematic
view (e, f)
Fig. 38.2 Omentectomy in
direction to the spleen. Close
(a) and schematic view (b)
After cutting the left gastroepiploic vessels, in most of
the cases, a short gastric vessel tends to be identified
close to its stump, which can be also divided at this timing (Fig. 38.6).
3. Dissection along the main trunks of splenic vessels.
Next, dissection is resumed from the main trunk of
the splenic vessels which are likely to be visualized at
the upper rim of the distal pancreas. This dissection is
Fig. 38.3 Stomach is
retracted by means of an
endoloop. Close (a, b) and
schematic view (c)
31338 Spleen-Preserving Splenic Hilar Dissection …
Fig. 38.4 Proximal stomach
is further retracted by means
of a rolled gauze. Close (a)
and schematic view (b)
carried out toward the splenic hilum and ordinally the
bifurcation is identified at the level of the pancreas
tail (Fig. 38.7). During these procedures, preoperative
anatomical reconstruction using three-dimensional CT
images is indeed helpful. A separated small branch
running into the upper pole of the spleen is recognized in about 35% of the patients. This branch can be
preserved if possible, but its division is even considered to be basically non-problematic in clinical sense
(Fig. 38.8).
4. Dissection around the upper branch. Finally, the adi-
pose tissue along the superior branch is dissected. In this
region, the stomach wall tends to be located adjacently
near the spleen, and the short gastric vessels have very
short segment. Therefore, careful attention should be
paid when dividing these vessels not to cause hemorrhage. If the plane in front of the Gerota fascia is dissected in advance, the splenogastric ligament at the
upper pole can be extended, which facilitates the consequent division of the short gastric vessels (Fig. 38.9).
314 T. Kinoshita
Fig. 38.5 The splenic hilum
is identified from the caudal
view to be dissected exposing
the inferior branch of the
splenic vessel (a, b)
Fig. 38.6 After cutting the
left gastroepiploic vessels,
in most of the cases, a short
gastric vessel tends to be
identified close to its stump,
which can be also divided at
this time (a, b)
Fig. 38.7 Dissection is
carried out toward the splenic
hilum, and ordinally the
bifurcation is identified at
the level of the pancreas tail
(a, b)
Fig. 38.8 A separated small
branch running into the
upper pole of the spleen is
recognized in about 35% of
the patients. Close (a, b) and
schematic view (c)
31538 Spleen-Preserving Splenic Hilar Dissection …
Fig. 38.9 Final view of the
lymphadenectomy. Close (a)
and schematic view (b)
316 T. Kinoshita
References
1. Japanese Gastric Cancer Association. Japanese classification of gastric carcinoma: 3rd English edition. Gastric Cancer.
2011;14(2):101–12.
2. Sano T, Sasako M, Mizusawa J, et al. Randomized controlled trial
to evaluate splenectomy in total gastrectomy for proximal gastric
carcinoma. Ann Surg. 2017;265(2):277–83.
3. Watanabe M, Kinoshita T, Enomoto N, et al. Clinical significance of
splenic hilar dissection with splenectomy in advanced proximal gastric cancer: an analysis at a single institution in Japan. World J Surg.
2016;40(5):1165–71.
4. Kinoshita T, Shibasaki H, Enomoto N, et al. Laparoscopic splenic
hilar lymph node dissection for proximal gastric cancer using
integrated three-dimensional anatomic simulation software. Surg
Endosc. 2016;30(6):2613–9.
End-To-Side Esophagojejunal Anastomosis Using the Circular Orvil Device
Suzanne S. Gisbertz and Mark I. van Berge Henegouwen
39
39.1 End-To-Side Esophagojejunal Anastomosis Using the Orvil Device
There are four ways to perform the esophagojejunal anastomosis after a total gastrectomy: the conventional circular
stapler (described in Chap. 36), the circular Orvil® device
anastomosis, the linear stapler side-to-side, and the handsewn anastomosis (reported in Chap. 39).
In this chapter, first of all a description is made of
the end-to-side anastomosis by means of circular Orvil®
device, followed by a description of the linear side-to-side
anastomosis.
This anastomosis is ideal for a situation where the
distal part of the esophagus has been resected with the
stomach (e.g., Siewert 2), and there is no space for a sideto-side anastomosis by means of linear stapler (Fig. 39.1).
39.2 Description of the Surgical Technique
(See Videos 39.1 and 39.2)
The key steps to perform an end-to-side esophagojejunal
anastomosis using the Orvil® device are:
1. The stapled esophagus is brought in view, and the anaes-
thesiologist introduced the 25 mm Orvil device (R)
through the mouth (tube first)
2. The tube is felt in the distal esophagus, and the middle of
the stapled line is open by diathermy in order to retrieve
the tube (Fig. 39.2)
3. The tube is pulled until the anvil is correctly placed in
the distal esophagus
4. The thread is cut, and the tube and the anvil are disconnected (Fig. 39.2)
5. The previously prepared jejunal loop (with the circular
stapler inside) is advanced and assembled with the anvil)
6. An end-to-side esophagojejunostomy anastomosis is performed (Fig. 39.3)
7. Lateral jejunal loop is stapled (Fig. 39.4).
39.3 Linear Side-To-Side Esophagojejunal
Anastomosis
This side-to-side anastomosis has been developed by the
bariatric surgeons, and it seems to be the ideal anastomosis
after total gastrectomy with enough length of distal esophagus [1, 2].
39.4 Description of the Surgical Technique
(See Video 39.2)
The key steps to perform a laparoscopic linear side-to-side
esophagojejunal anastomosis are.
1. Both parts, the distal esophagus and the jejunal loop are
Electronic supplementary material The online version of this
chapter (https://doi.org/10.1007/978-3-030-55176-6_39) contains
supplementary material, which is available to authorized users.
S. S. Gisbertz (*) · M. I. van Berge Henegouwen
Department of Surgery, Amsterdam UMC, Amsterdam,
The Netherlands
e-mail: s.s.gisbertz@amsterdamumc.nl
M. I. van Berge Henegouwen
e-mail: m.i.vanbergehenegouwen@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_39
prepared for the anastomosis
2. An opening is made with diathermia at the level of the
stapled distal esophagus and the jejunal loop (Fig. 39.5)
3. Linear stapler is introduced in the jejunal loop (5–6 cm
from the staple line), and in the esophagus (Fig. 39.6)
4. Linear endostapler (medium thick reload) is
closed and fired being the side-to-side anastomosis
performed (Fig. 39.7)
317
318 S. S. Gisbertz and M. I. van Berge Henegouwen
Fig. 39.1 The stapled
esophagus is brought in view
(a, b)
Fig. 39.2 The 25 mm
®
Orvil
device is introduced
through the mouth by
anaesthesiologist. The tube is
exteriorized through a small
opening in the stapled line.
The tube is pulled out and the
anvil is placed in the distal
esophagus. The thread is cut,
and the tube and the stapler
are disconnected. Close (a)
and schematic view (b)
Fig. 39.3 The prepared
jejunal loop (with the stapler
inside) is advanced and
connected with the anvil,
and a circular end-to-side
esophagojejunostomy is
performed. Close (a, b, c)
and schematic view (d)
Fig. 39.4 Jejunal loop
is shortened and stapled.
Anastomosis is placed in the
mediastinum. Close (a, b)
and schematic view (c)
31939 End-To-Side Esophagojejunal Anastomosis Using …
Fig. 39.5 Stump of the
esophagus and of the jejunual
loop are open. Close (a) and
schematic view (b, c)
320 S. S. Gisbertz and M. I. van Berge Henegouwen
Fig. 39.6 Linear stapler is
introduced in the jejunum and
esophagus. Close (a, b, c)
and schematic view (d)
Fig. 39.7 Linear side-to-side anastomosis is performed
5. After the Side-to-side anastomosis is performed, the
opening is closed by suture (Fig. 39.8)
6. Nasogastric tube is passed through the anastomosis to
distal before the closure
7. After closure, anastomosis is tested for watertight.