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62 Atlas of Gastrointestinal Surgery: The Stomach
Esophagus
Tear
closed with
locking suture
The tear should be oversewn with a con-
tinuous locking suture of 3-0 silk (3).
3
Once the bleeding has been controlled, the gastrotomy is
closed in two layers, using a continuous Connell suture of
3-0 synthetic absorbable material for the inner layer
and an interrupted layer of 3-0 silk Lembert
sutures for the outer layer (4). If the patient
has had a clear history of forceful vomiting,
followed by upper gastrointestinal bleeding,
the Mallory–Weiss tear can be treated
merely with oversewing. However, in many
instances there is no clear history of forceful
vomiting preceding the bleeding. In that
instance, with the etiology of the bleeding less
certain, many surgeons prefer to add a truncal
vagotomy and pyloroplasty to the procedure (5).
Gastrotomy
closed
Alternative
Vagotomy
and
pyloroplasty
4
5
Partial Gastrectomy for Cancer
Operative Indications
Although decreasing substantially in prevalence over the past several decades, carcinoma of the stomach remains one of the
more common alimentary tract cancers that the general surgeon encounters. The mainstay of therapy, both curative and pal-
liative is surgical. The goal in managing carcinoma of the stomach is to diagnose it early enough so that surgical extirpation
can be complete, resulting in long-term survival. However, even when the diagnosis is made when curative resection is not
possible, most patients should be managed surgically. Because of bleeding, obstruction, and inanition from the main tumor
mass, most patients with a reasonable life expectancy should be treated by gastric resection. In the past, gastrojejunosto-
my was used for distal incurable gastric cancers to avoid obstruction and allow oral alimentation. It is generally accepted
today that this procedure provides little or no benefit and, in most instances, does not improve the symptoms in patients
with incurable carcinoma of the stomach.
The role of radical lymphadenectomy in this disease is controversial. Surgical experience from Japan was suggestive that
more radical operative procedures, including extended lymphadenectomies, improved long-term survival. The evidence from
the United States was less convincing. More recently, prospective randomized studies have indicated no survival benefit
from radical operations with extended lymphadenectomy. Today, most alimentary tract surgeons perform gastrectomies that
are large enough to ensure gross and microscopically negative margins. In addition, lymph nodes surrounding the celiac axis
and the hepatic artery are removed, the omentum is removed, and if the tumor is proximal, the spleen is removed. A por-
tion of the pancreas is removed only if directly invaded by the tumor. The number of lymph nodes removed appears to be
more important than the actual site of removal.
64 Atlas of Gastrointestinal Surgery: The Stomach
Operative Technique
The patient is explored through an upper midline incision. This patient’s tumor
is in the antrum of the stomach. The omentum is removed from the transverse
colon (1).
Gallbladder
Liver
Stomach
Omentum
Tumor
Mesocolon
Transverse
colon
1
Lesser
omentum
Stomach
Partial Gastrectomy for Cancer 65
The thin lesser omentum is divided (2). The
left gastric artery is taken at its origin from
the celiac axis. This can be approached
either anteriorly through the lesser omentum
along the lesser curvature, or frequently
more easily by retracting the greater curva-
ture in a cephalad direction and dissecting
the celiac axis through the lesser sac (3).
2
Posterior wall
Lymph
nodes
of stomach
Pancreas
Left gastric a.
3
66 Atlas of Gastrointestinal Surgery: The Stomach
Gastrohepatic
Liver
ligament
Stomach
Tumor
Omentum
4
An effort should be made to remove all lymph nodes surrounding the celiac axis. Some surgeons feel the lymph
nodes extending along the hepatic artery should also be removed. The site of proximal resection is determined
by picking a spot where there is a grossly normal margin of between 5 and 10 cm (4). Most studies have
suggested that if a grossly and microscopically negative margin is obtained, performing a total
gastrectomy affords no further advantage over partial gastrectomy in long-term
survival. For a distal tumor, an adequate margin is usually easily
obtained along the greater curvature. Along the
lesser curvature, the resection line often
approaches the gastroesophagael junc-
tion. The omentum is cleared from
the stomach at the point chosen
along the greater curvature for
division (4). The stomach is
divided with two or three firings
of a GIA stapler (5).
5
GIA
stapler
The duodenum is then dissected free
from its pancreatic attachments. Tumor
may cross the pylorus and invade prox-
imal duodenum, but this is unusual.
The duodenum is generally easily dis-
sected because there is no inflamma-
tory disease present, as is the case
when performing surgery for duo-
Partial Gastrectomy for Cancer 67
Posterior wall
of stomach
Pancreas
denal ulcer disease. The first por-
Omentum
tion of the duodenum is divided
in its midportion with a GIA sta-
pler (6). The specimen is removed
from the operative field and sent to
the pathology department for confir-
mation of negative margins by frozen
section. For carcinoma of the stomach, a
Billroth II gastrojejunostomy should always be performed.
There is often a small gastric pouch, which will not readily reach
the duodenum. More importantly, however, local tumor recur-
rence is more apt to result in obstruction if a Billroth I is per-
formed rather than a Billroth II.
GIA
stapler
Duodenum
6
Esophagus
Invert
staple line
Stomach
7
Dudenum
68 Atlas of Gastrointestinal Surgery: The Stomach
Duodenum
8
The duodenal stump is inverted with a layer of 3-0
silk Lembert sutures (7,8).
An option is to then suture the duode-
nal closure into the capsule of the pan-
creas (9). In most instances with a safe
secure closure, this step is not necessary.
Alternative
Duodenal
closure
reinforced
Duodenum
9
Invert
staple
line
10
Stomach
The staple line along the lesser curvature of
the stomach is oversewn with a series of
interrupted 3-0 silk Lembert sutures (10).
Outer layer
of posterior row
Stomach
Staple
line
resected
Jejunum
Partial Gastrectomy for Cancer 69
An antecolic gastrojejunostomy is performed
between a proximal loop of jejunum, just distal to the
ligament of Treitz, and the greater curvature of the
stomach. Following gastric resection, a retrocolic
anastomosis provides no advantage over an
antecolic anastomosis. This procedure, unlike
gastrojejunostomy without gastric resection,
results in excellent emptying without a retro-
11
The gastrojejunostomy is performed in two
layers: an inner continuous layer of absorbable
3-0 synthetic suture material and an outer inter-
colic gastrojejunostomy. After gastric resection
an antecolic anastomosis is easier, quicker, and
empties just as well as a retrocolic anastomosis.
Furthermore, if a patient requires reoperation
subsequently, the antecolic position makes the
operative procedure easier.
Inner layer
of posterior row
Stomach
rupted layer of 3-0 silk. The outer posterior row
of sutures is placed using interrupted 3-0 silk
Lembert sutures. With the electrocautery the staple
line on the gastric side is excised, and an enteroto-
my is made in the jejunum (11). The inner layer of
the posterior row is run with a continuous locking stitch
of 3-0 synthetic absorbable material (12).
Jejunum
12
70 Atlas of Gastrointestinal Surgery: The Stomach
The inner layer is brought around anterior-
ly in a Connell fashion (13). The outer layer
13
Inner layer of
anterior row
of the anterior row is completed by placing a
series of 3-0 silk Lembert sutures (14). A
3-0 silk reinforcing suture is placed at the junc-
tion of the lesser curvature gastric suture line
and the gastrojejunostomy. This suture passes
into the stomach on one side of the gastric
suture line and out the other side, parallel to
the gastrojejunostomy. On the jejunum, the
suture passes in the opposite direction, also parallel
to the gastrojejunostomy, and is tied (15).
Outer layer of
anterior row
14 15
3-corner
suture
Partial Gastrectomy for Cancer 71
Esophagus
L. gastric a.
Duodenal
stump
Spleen
Stomach
Omentum
Pancreas
Transverse
colon
Whether a vagotomy is performed
depends on the age of the patient and the
size of the remaining gastric pouch (16).
However, because many patients with carcinoma of
the stomach are achlorhydric, a vagotomy is generally
not added.
Some surgeons prefer a retrocolic gastrojejunostomy
(17). If the patient is markedly obese and the
transverse mesocolon and transverse colon are
particularly large and fatty, a retrocolic anas-
tomosis may be appropriate. In that instance
the jejunum is brought up through a rent in
16
Alternative
Retrocolic
Billroth II
the transverse mesocolon and the anastomo-
sis is performed in a fashion identical to the
antecolic approach. The rent in the transverse
mesocolon is sutured to the afferent and effer-
ent limbs of the gastrojejunostomy with inter-
rupted 3-0 silk to prevent herniation (17).
Mesocolon
17
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