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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_841_Библиотеки_им_академика_М_И_Перельмана.pdf
F. Corcione and P. Angelini130
19. Bracale U, Marzano E, Nastro P, Barone M, Cuccurullo D,
Cutini G, Corcione F, Pignata G. Side-to-side esophagojejunostomy during totally laparoscopic total gastrectomy for malignant disease: a multicenter study.
Surg Endosc. 2010;24(10):2475–9.
20. Corcione F, Pirozzi F, Marzano E, Cuccurullo D, Settembre A, Miranda L. Laparoscopic approach to gastric
remnant-stump: our initial successful experience on 3
cases. Surg Laparosc Endosc Percutan Tech. 2008;
18(5):502–5.
21. Cho HJ, Kim W, Hur H, Jeon HM. Laparoscopy-assisted
completion total gastrectomy for gastric cancer in
remnant stomach: report of 2 cases. Surg Laparosc
Endosc Percutan Tech. 2009;19(2):57–60.
18
131
Surgical Technique
and Difficult Situations
from Arnulf H. Hoelscher
(Conventional)
ArnulfH.Hoelscher
19.1 Introduction – 132
19.1.1 Classification and Staging – 132
19.1.2 Therapeutic Strategies – 132
19.1.3 Extent of Resection – 133
19.2 Preparation – 135
19
19.3 Surgical Technique – 135
19.3.1 Reconstruction After Gastrectomy
and Transhiatal Extended Gastrectomy – 137
19.3.2 Pouch Formation in Case of Abdominal
Gastrectomy – 139
19.3.3 Subtotal Gastric Resection – 139
19.4 Difficult Situations – 141
19.4.1 Classification of the Intraoperative Difficulties – 141
© Springer-Verlag Berlin Heidelberg 2017
M. Korenkov et al. (eds.), Gastrointestinal Operations and Technical Variations,
DOI 10.1007/978-3-662-49878-1_19
132
A.H. Hoelscher
19
19.1 Introduction
19.1.1 Classification and Staging
For the planning and performance of surgical
treatment, the exact topographic assignment of
carcinomas of the stomach and the esophagogastric junction is of central importance. In distal
gastric adenocarcinoma of the antrum or the
pylorus especially of category cT1 or cT2 with
intestinal type of Lauren, a subtotal gastric resection can be performed. However in more proximally located carcinomas of the corpus or fundus
especially those of the diffuse type, a total gastrectomy is necessary.
In adenocarcinomas of the esophagogastric
junction, it is decisive if the carcinoma can be
completely resected via an abdominal and transhiatal approach or if an extended resection of the
thoracic esophagus is necessary. Further the main
lymphatic draining area is important for the planning of surgical resection.
For the description of adenocarcinomas of the
esophagogastric junction, the classification of
1987 with type I, type II, and type III is most
appropriate (Siewert etal. 1987). is therapeutically relevant classification is currently internationally applied under the name “adenocarcinoma
of the esophagogastric junction” (AEG):
5 AEG type I: Barrett carcinoma of the dis-
tal esophagus which cannot be completely
resected via an abdomino-transhiatal
approach and which has a lymphatic drain-
age area to the mediastinum as well as along
the lesser curvature in direction to the le
gastric artery and celiac trunk.
5 AEG type II: real cardia cancer in the nar-
rower sense
5 AEG type III: subcardial gastric cancer
e lymphatic drainage of type II and type III carcinoma is mainly directed into the abdomen like a
gastric cancer but also in the lower mediastinum.
ese lymph nodes can be completely resected via
abdomino-transhiatal approach.
For the pre-therapeutic classification of the
tumor according to the AEG classification, the
following diagnostics are necessary:
5 Esophagogastroscopy with biopsy, endosonog-
raphy, and spiral CT scan of the abdomen and
thorax. e sagittal reconstruction for the CT
data and in some cases also an esophagogram
by barium swallow show the extent of the
carcinoma in relation to the esophagogastric
junction. is is especially important in case
of a large hiatal hernia. e endoscopic and
radiologic examinations are also the basis of a
clinical TNM staging.
5 Malignant tumor is proved and classified via
an endoscopic biopsy. An experienced endoscopist can evaluate the T category with a high
accuracy. e accuracy of the T category by
endosonography however varies between 65
and 92 % (Hoelscher a. Fetzner 2012). Limited accuracy exists concerning the extent of
invasion of early cancer into the mucosa or
submucosa. e clinical N category by endosonography or CT scan is only based on the
measurement of the lymph node diameter less
or more than 1cm. erefore the N category
remains unsafe (Hoelscher a. Fetzner 2012).
5 e cytological approval of lymph node metas-
tasis by transmural puncture does not influence the surgical procedure as the lymph nodes
directly adjacent to the esophagus are anyhow
removed during the operation. e contrastenhanced spiral CT scan is mainly used to
exclude distant metastases and the infiltration
into neighboring organs (cT4 category). Magnetic resonance imaging (MRI) does not gain
significant further advantages compared to a
technically good CT scan with evaluation by an
experienced radiologist. A PET-CT should only
be used in cases of special questions.
If there is any clinical or radiological suspicion
of peritoneal carcinomatosis, e.g., in case of
ascites, a diagnostic laparoscopy should be performed. is is especially indicated in type II
and III carcinomas prior to neoadjuvant therapy. e preoperative diagnostics comprise also
the functional risk assessment of the patient
because the procedure is extended, and therefore the functional load-bearing capacity is very
important.
19.1.2 Therapeutic Strategies
In cT1 carcinomas, it has to be decided whether
an endoscopic or surgical resection is appropriate. Criteria for this decision are the diameter of
the tumor and the possibility of a complete endoscopic en bloc resection as well as the depth of
Surgical Technique and Difficult Situations from Arnulf H. Hoelscher (Conventional)
Clinical Staging
133
19
T1a N0 M0
(< 2 cm)
Endoscopic
Resection
R0
Follow-up Operation
. Fig. 19.1 Gastric carcinoma and adenocarcinoma of the esophagogastric junction: Multimodal therapeutic strat egies
according to the clinical staging
T1b, T2 Nx M0
R1
infiltration in the mucosa or submucosa
(Hoelscher 2012, Annals of Surgery, Hoelscher a.
Fetzner 2012). Mucosal carcinomas of less than
2cm in diameter can be resected aer submucosal injection either in the cap technique or more
safe with the so-called endoscopic submucosal
dissection (ESD). Carcinomas with these kinds of
characteristics never had lymph node metastases
in the own case material (Hoelscher 2012). is
supports the possibility of endoscopic resection
(Pech, Annals of surgery). In mucosal cancer of
less than 2cm in diameter especially those with
infiltration of the deepest third of the mucosa
(m3), lymph node metastases can already be
T3, T4 (resectable)
Nx M0
neoadjuvante therapy
T4 (not resectable)
Tx Nx M1
palliative therapy
recommended (. Fig. 19.2). In gastric carcinoma
and type II and III AEG carcinomas, neoadjuvant
therapy comprises especially chemotherapy like
FLOT followed by operation aer an interval of
about 4 weeks.
In AEG type I carcinoma and also in some
cases of type II which extend into the distal
esophagus, neoadjuvant radiochemotherapy is
favored, especially with the CROSS regimen.
Nonresectable T4 carcinomas and all gastric
carcinomas of category M1 should be treated by
definite chemotherapy or definite radiochemotherapy (type I) with an appropriate palliative
the r apy.
present in 10 % of the cases. erefore the indication for local resection should be established very
carefully in these cases.
19.1.3 Extent of Resection
In submucosal cancer of the stomach and
esophagogastric junction, the percentage of lymph
node metastasis is 15–20 % in case of infiltration of
the upper third (sm1), 20 % in case of infiltration
of the middle third (sm2), and 40–55 % in case of
infiltration of the lowest third (sm3) (Hoelscher
2012). erefore submucosal cancer is not appropriate for endoscopic resection (. Fig. 19.1). is
recommendation is in accordance with the current German S3-guideline for gastric cancer
(Möhler 2011). As indicated in . Fig. 19.1, gastric
cancer and adenocarcinoma of the esophagogastric junction in the categories cT1b and cT2 NX
M0 should directly be operated. In advanced
carcinomas, i.e., cT3 and resectable cT4 carcinoma,
a neoadjuvant therapy followed by surgery is
According to the German S3-guideline of gastric
cancer of 2011, the aim of curative surgery of gastric cancer is the complete resection of the primary tumor and the regional lymph nodes with
histological approval of tumor-free proximal, distal, and circumferential resection margins (R0
resection) (Möhler 2011).
In distal tumors of the stomach, i.e., antrum
and pylorus, the proximal stomach can be preserved without negative effect on the prognosis.
is is especially true for T1 and T2 carcinomas of
the antrum and pylorus. In case of intestinal type
of Lauren, a sufficient oral resection margin of
5 cm should be achieved and 8 cm in case of
diffuse type of Lauren (. Fig. 19.2).
134
A.H. Hoelscher
Classification
19
Type IIIType I Type II
evtl.
transthoracic en-bloc
esophagectomy and
gastric pull-up
high intrathoracic
esophagogastrostomy
. Fig. 19.2 Gastric carcinoma and adenocarcinoma of the esophagogastric junction (AEG): surgical procedures
according to the classification
transhiatal extended
D2-Gastrectomy
distal
esophageal resection
Ösophagojejunostomy
Roux-Y
In more proximally located carcinoma, usually a
total gastrectomy is necessary. In adenocarcinoma
of the esophagogastric junction of types II and III
additionally to the gastrectomy, a distal esophageal
resection is necessary. In some cases of AEG type II
carcinomas with a luminal extent into the distal
esophagus, an esophagectomy with proximal gastric
resection and reconstruction by a narrow gastric
conduit can also be necessary in order to achieve an
R0 resection at the esophageal resection margin.
In some cases of far advanced tumors which
infiltrate the stomach as well as the esophagus, an
R0 resection can only be achieved by total esophagogastrectomy with reconstruction by colon
interposition. If possible also in T4 carcinomas,
an R0 resection should be achieved by multivisceral resection of adherent structures to the tumor
like the diaphragm, le liver lobe, pancreas, or
transverse colon en bloc with the primary cancer.
Multivisceral R0 resections have a decisive
advantage in comparison to R1 resections. A routine splenectomy should be avoided. Laparoscopic
resections of gastric cancer are possible, but the
experiences especially in the western world are limited. Most reports about this minimal invasive technique come from Asia and are especially concerning
Billroth I resections of small distal carcinomas.
e standard of lymphadenectomy in case of
subtotal resection as well as gastrectomy or
transhiatal extended total gastrectomy is D2
lymphadenectomy, i.e., compartment one with
Gastric cancer
(Fundus, Korpus,
Antrum T3, T4)
D2-Gastrectomy
Ösophagojejunostomy
Roux-Yevtl. Pouch
the lymph node areas 1–6 and compartment two
with the lymph node areas 7–11. In AEG type II
and III carcinoma in addition, the lymph nodes of
the lower mediastinum are resected. In case of
suspicious lymph nodes of the splenic hilum or
direct infiltration of the tumor into the spleen, the
so- called pancreatic preserving zone splenectomy
should be performed. An extension of lymphadenectomy to the para-aortic lymph nodes is not
improving the prognosis (Sasako).
In AEG carcinomas type I, the transthoracic
en bloc esophagectomy with radical mediastinal
lymphadenectomy and abdominal D2 lymphadenectomy is performed with reconstruction by
gastric pull-up and high intrathoracic esophagogastrostomy. e abdominal part of the procedure can mostly be done by a minimal invasive
approach.
e operation of Merendino, i.e., limited distal
esophageal and proximal gastric resection with the
reconstruction by isoperistaltic jejunum interposition between the esophagus and stomach, is a very
rare indication. is procedure has especially an
indication in case of mucosal carcinoma which can
today mostly be resected by endoscopic means.
In submucosal carcinomas, the limited lymphadenectomy with preservation of both vagus
trunks has disadvantages of radicality if the
Merendino operation is applied. Further the
functional long-term results with substantial
percentage of dysphagia, gastroesophageal reflux,
Gastric cancer
(Antrum, Pylorus)
T1, T2
not diffuse type
subtotal
gastric resection
Gastrojejunostomy
Roux-Y
Surgical Technique and Difficult Situations from Arnulf H. Hoelscher (Conventional)
135
19
or gastric emptying disturbances are dismal
(Zapletal).
19.2 Preparation
e patient is placed in supine position. In order
to expose the upper abdomen, it is appropriate to
li the thorax up by a so towel in the back.
19.3 Surgical Technique
Gastrectomy comprises a resection of the whole
stomach, pylorus, and cardia.
5 e standard approach is median laparotomy
of the upper abdomen le of the umbilicus.
5 A very good overview can be achieved by an
approach via a combination of median upper
abdominal laparotomy and transverse incision (turned around T shape).
5 e upper abdominal cavity can be
approached very easily by a self-holding
retrac tor.
5 e first step aer opening of the abdominal
cavity is the evaluation of the oncologic situation, especially the exclusion of peritoneal
carcinomatosis or liver metastasis and the
localization and extension of the primary
tumor. In adenocarcinoma type II or III, it
is most appropriate first to dissect the distal
esophagus in order to decide if the procedure
can be done from an abdominal approach.
e le lobe of the liver has to be dissected
from the diaphragm and should be retracted
to the right side. e peritoneum on the distal
esophagus should be incised and the right
and the le diaphragmatic crus have to be
dissected.
5 e esophageal hiatus is opened, and the
esophagus which is secured by a large gastric
tube is bluntly dissected between the index
finger and the thumb and taped. If necessary,
the esophagus can further be dissected in the
lower mediastinum by an anterior incision of
diaphragm in front of the pericardium.
5 e next step is a dissection of the greater
omentum from the transverse colon and the
opening of the bursa omentalis. e gastrosplenic ligament is severed close to the spleen
by conventional technique or a dissection
device. e le gastroepiploic artery and vein
are dissected between ligations and suture
ligations.
5 e gastric fundus is freed from retroperito-
neal adhesions and completely mobilized by
reaching the primary area of dissection at the
le diaphragmatic crus.
5 e right colonic flexure is freed and the
postpyloric duodenum is dissected. e dissection of the gastroduodenal artery and
the identification of the origin of the right
gastroepiploic artery and vein are performed.
Both vessels are suture ligated at their origin
with complete removal of lymph node area 6,
the so-called infrapyloric lymph nodes. ese
remain at the gastric specimen.
5 At the lesser curvature, the right gastric artery
is suture ligated and the postpyloric duodenum is dissected on a length of about 3cm.
About 2cm distal to the pylorus, the duodenum is closed and cut with a stapler, e.g.,
GIA 60 blue. e stapler line at the duodenal
stump is oversewn with 3–0 seromuscular
single stitches.
5 Along the gastroduodenal artery, the lymph-
adenectomy of compartment two is started,
i.e., lymph node areas 6–12. Along the gastroduodenal artery, the common hepatic artery
and the proper hepatic artery are prepared
and the lymph nodes from these arteries are
removed.
5 e lymphadenectomy of the hepatoduo-
denal ligament with lymph node area 12 is
performed. During this lymphatic dissection
along the proper hepatic artery and the le
hepatic artery, the right gastric artery can be
dissected again at its origin und should be
suture ligated. e lymph nodes are removed
from the upper edge of the portal vein which
runs dorsal in the hepatoduodenal ligament.
5 e small omentum is dissected close to the
liver. A small le hepatic artery in the small
omentum can be closed and cut without any
severe sequelae. A larger artery which mostly
carries also the origin of the le gastric artery
and which is coming from the celiac trunk
should be dissected from the lymph nodes
and preserved. In this case, the le gastric
artery is cut aer suture ligation directly at its
origin from the le hepatic artery.
5 Lymphadenectomy now runs along the com-
mon hepatic artery in median direction with
resection of the lymph nodes at the upper
136
A.H. Hoelscher
19
edge of the pancreas and the anterior surface and behind this artery. In some cases, it
is appropriate to tape the artery in order to
complete the resected lymph nodes behind
this vessel.
In order to dissect the portal vein more clearly
and avoid injuries, this vessel should be pushed
with the index finger of the le hand through the
foramen of Winslow in medial and anterior direction. is allows a clear view of the upper edge of
the portal vein and a very radical lymphadenectomy. is maneuver also facilitates the preparation of the origin of the le gastric vein into the
portal vein.
5 At this area, the le gastric vein is suture
ligated and cut. Further dissection is along
the common hepatic artery in the direction
of the celiac trunk. e splenic artery is dissected and the le gastric artery is cut and
suture ligated at its origin.
In the case of a large le-sided hepatic artery originating together with the le gastric artery from
the celiac trunk, the le hepatic artery must be
preserved, and the le gastric artery has to be dissected and cut aer suture ligation at its origin.
5 Aer freeing the celiac trunk, the le and right
diaphragmatic crus is dissected. e lymph
node dissection is further extended to the
splenic artery with resection of lymph nodes
of station 11.
5 Aer dissection of further retrogastric con-
nective tissue, the stomach is completely free
together with the lymph node compartments
one and two, and it only remains connected
to the esophagus. If the lymph node 13in the
dorsal part of the hepatoduodenal ligament
is obviously infiltrated, this can be resected
behind the pancreatic head aer mobilization of the duodenum according to Kocher.
5 Now the anterior and the posterior vagus
trunk of the distal esophagus is dissected and
cut aer coagulation. is gives further length
of the abdominal esophagus. e esophagus
is cut above the cardia and the specimen is
delivered for histological examination. At the
esophageal stump, a purse-string suture with
monofilament thread size 0 is placed, and the
28 head of a circular stapler is inserted and
purse-string suture is tied. In some cases of
a very small diameter of the esophagus or
the upper jejunum, the 25 stapler can also be
used.
5 e spleen is preserved in the standard gas-
trectomy. Only if lymph nodes are suspicious
of metastasis in the hilum of the spleen, a
so- called pancreas-preserving splenectomy
(zone splenectomy) should be performed.
is affords a mobilization of the spleen
and the pancreatic tail aer dissecting the
retroperitoneal connective tissue. Aer care-
ful elevation of spleen and pancreatic tail in
anterior direction, the splenic artery and the
splenic vein can be dissected in the splenic
hilum and suture ligated and cut. e pancre-
atic tail has to be dissected from the splenic
hilum under preservation of the pancreatic
capsule. e spleen together with the lymph
nodes at the upper edge of the pancreas and
from the splenic hilum is removed. Splenec-
tomy can also be performed en bloc with the
gastrectomy.
In resectable T4 carcinomas of the stomach,
adherent structures to the tumor, like the diaphragm, spleen, le lobe of the liver, pancreatic
tail, or transverse colon, should be resected en
bloc with the primary carcinoma. In case of the
le regional extended gastrectomy with resection
of the celiac trunk because of large lymph node
metastasis (Appleby operation), the vascularization of the liver is preserved by the gastroduodenal artery as well as the proper hepatic artery. e
common hepatic artery is suture ligated and cut
proximal of the origin of the gastroduodenal
artery. is operation is completed by cutting the
pancreas above the portal vein and extirpation of
the pancreas and the stomach in the le direction. e celiac trunk is suture ligated or sutured
at the origin of the aorta. e stomach is resected
together with the le pancreas and the spleen en
bloc. In case of this operation, it has to be assured
that the vascularization of the liver via the gastroduodenal artery is sufficient. In the same
manner, a right regional gastrectomy with en
bloc resection of the pancreatic head and the
duodenum can be performed like in Whipple’s
operation.
5 In case of a transhiatal extended gastrectomy
. Fig. 19.3), a preparation of the abdominal
(
esophagus is performed, and the diaphragm
is cut in anterior direction aer suture
ligation of both sides of the diaphragmatic
Surgical Technique and Difficult Situations from Arnulf H. Hoelscher (Conventional)
137
19
a
c
b
d
. Fig. 19.3 a–d Surgical technique of transhiatal
extended gastrectomy. a Taped esophagus with exposition of the lower mediastinum after suture ligation of
the phrenic vein, median incision of the diaphragm, and
dissection of the right and left diaphragmatic crus. b Situs
after lymphadenectomy in the lower mediastinum with
vein. is allows wide exposure of the esophagus and the lower mediastinum.
5 e lymph nodes between the pericardium
and aorta are excised with pleural stripes at
both sides. e right and the le pleural cavity are drained with thoracic drainages. Aer
insertion of two long Brunner hooks, the
esophagus can be dissected very high in the
lower mediastinum with resection well above
the tumor. To assure the complete resection
of the carcinoma at the esophageal resection
line, an intraoperative frozen section of the
resection margin of the esophagus should be
performed.
In this case, cutting of the vagus nerve is also
important as this gets more mobility to the esophagus.
dissected aorta and both lungs. c Situs after suprapancreatic en bloc lymphadenectomy before suture ligation and
cutting of the left gastric artery. d Inserted removable
device of the stapler via a purse-string suture in the lower
esophagus and in the lower mediastinum after gastrectomy and distal esophageal resection
5 In the same manner as in case of abdominal
gastrectomy, a purse-string suture is placed at
the esophageal stump.
19.3.1 Reconstruction
After Gastrectomy
and Transhiatal Extended
Gastrectomy
e standard reconstruction aer gastrectomy is a
Roux-en-Y esophagojejunostomy.
5 For preparation of this construction, the vas-
cularization of the upper jejunum is exposed
by diaphany with a light on the opposite side
of the small bowel mesentery. is allows a
very clear recognition of the mesenteric vascular arcade of the upper jejunum.
19
138
A.H. Hoelscher
. Fig. 19.4 Insertion of the stapler and antimesenteric
jejunal perforation of the central rod
5 e length of the chosen jejunal loop must
be enough for easily reaching the esophagus.
e fatty tissue between the mesenteric arteries and veins is cut and the vessels are suture
ligated. e aim is a formation of a long, wellvascularized aboral jejunal loop.
5 Aer cutting the continuity of the jejunum,
the aboral jejunal loop is moved via a retrocolic route into the upper abdomen. During
this maneuver however, the integrity of the
mesenteric vessels is of utmost importance.
At the edge of the jejunal loop, the stapler
is inserted and the central rod is perforated
in aboral direction antimesenteric and connected with the removable part of the stapler
in the esophagus (
. Fig. 19.4).
Aer closure of the stapler, it is very important
to prove that only the antimesenteric wall is
around the central rod of the stapler and not the
mesenteric wall. If the mesenteric wall of the
jejunum is completely or partially pulled into the
stapler anastomosis, a closure or a stenosis of the
lumen is the consequence. Aer closure of the
stapler and firing of the anastomosis, the rings of
both sides, esophageal and jejunal, should be
. Fig. 19.5 Completed Roux-en-Y anastomosis as an
end-to-side jejunojejunostomy
controlled for completeness. Further, the consistency of the lumen of the end-to-side
esophagojejunostomy should be approved by a
thick gastric tube.
5 Finally the redundant part of the jejunal loop
should be removed 2–3cm le of the esophagojejunostomy with a linear stapler. is
stapler line should be oversewn by 3–0 single
stitches. Oversewing of the esophagojejunostomy can be performed with 4–0 monofilament PDS sutures.
5 50cm distal to the esophagojejunostomy,
a Roux-en-Y anastomosis is performed
(
. Fig. 19.5) with extramucosal single-row
stitches or continuous suturing. e mesenteric gap is closed and the retrocolic gap of
the jejunum is also adapted to the jejunum
with single-row stitches. In case of a transhiatal extended gastrectomy, the jejunal
loop should be mobile enough to ensure a
tension-free anastomosis. e mobility of
the jejunal limb can be improved by loosening the root of the whole small bowl mesentery and the cecum from the retroperitoneal
connective tissue. If the diaphragm has
been incised in anterior direction for exposure of the lower mediastinum, an anterior
hiatoplasty with non- resorbable 1–0 stitches
should be performed. However, a narrowing
of the jejunal loop which leads to the lower
mediastinum should be avoided.
If in transhiatal extended gastrectomy with distal esophageal resection the anastomosis high in
the lower mediastinum is technically too
difficult, the anastomosis can also be performed
Surgical Technique and Difficult Situations from Arnulf H. Hoelscher (Conventional)
via a right lateral thoracotomy in the sixth intercostal space.
5 A drainage of the operative area is usually not
necessary. Only if there is suspicion of a pancreatic lesion or a certain tendency to bleed
especially in patients with a necessity to have
medication against thrombocyte aggregation, a drainage in the le subphrenic space
or below the le lobe of the liver should be
performed.
19.3.2 Pouch Formation in Case
of Abdominal Gastrectomy
Especially when the patient has a very favorable
tumor stage and good prognosis, a gastric substitute with a pouch can be created. Most appropriate is a turned J-pouch of a Roux-en-Y loop.
5 is affords a formation of a long Roux-en-Y
loop. Both jejunal loops are placed parallel to
each other at a length of 15cm. At the upper
edge of the pouch, a ring of about 5cm in
length remains open.
5 e side-to-side anastomosis of the jejunum
is planned for 8–10cm and prepared by stay
sutures.
5 At the lower edge of the pouch, an antimesen-
teric incision is performed on both limbs of
1.5cm and the 8cm long linear stapler (e.g.,
GIA 80) is inserted. Aer insertion of the two
branches of the stapler, it is very important
that they are placed in the antimesenteric part
of both limbs; otherwise, parts of the mesentery can be cut. e anastomosis is fired and
it is necessary to avoid intraluminal bleeding
of the long linear anastomosis inside. If necessary, a compress can be introduced into the
pouch for a short time in order to perform a
compression.
5 Via the open end of the jejunal limb, the
circular stapler is inserted. During this procedure, a too intense stretching of the jejunal
wall should be avoided. If the introduction
of the stapler, e.g., a 28 head, via this side is
not possible, it can also be introduced over an
enlargement of the introduction side of the
linear stapler.
5 e circular stapler is now proceeded in the
direction of the upper edge of the pouch, and
the central rod is perforated at the antimes-
. Fig. 19.6 Preparation of the J-pouch
enteric side. Aer connection of the stapler
device with the removable part in the esophagus, the anastomosis is fired as has been
described above for the end-to-side esophagojejunostomy.
5 Finally the insertion area of the linear sta-
pler at the lower edge of the anterior wall of
the pouch is closed with 3-O extramucosal
single-row stitches. e open blind loop of
the jejunal limb is closed with a TA 55 linear
stapler, and the staple line is oversewn. e
so-called esophagojejunoplication which
comprises the coverage of the anastomotic
anterior wall by a ring of the upper part
of the pouch is rarely performed today
(
. Fig. 19.6).
19.3.3 Subtotal Gastric Resection
In case of the subtotal gastric resection, about 4/5 of
the stomach is resected and 1/5 of the proximal
stomach is preserved. A preparation is formed quite
similar to total gastrectomy. However, during the
139
19