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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_841_Библиотеки_им_академика_М_И_Перельмана.pdf
140
ab
A.H. Hoelscher
. Fig. 19.7 a Exposed completed posterior wall of the gastrojejunostomy after subtotal gastric resection. b Com-
pleted suture of the anterior wall of the gastrojejunostomy
mobilization of the abdominal esophagus, the integrity of the esophagogastric junction and the esophagus has to be guaranteed. As the vascularization of
the gastric remnant aer preparation of the whole
lesser curvature is only maintained by the upper
short gastric arteries and veins, the integrity of the
spleen and the mentioned vessels is very important.
5 e greater omentum of the greater curvature
is dissected and cut according to a 4/5 resection of the stomach.
5 On the minor side, the lymphadenectomy is
the same as in total gastrectomy. e lymph
nodes at the esophagogastric junction are
resected from the esophagus in direction to
not appropriate because of the small gastric remnant which would provoke a very
intense bile reflux. e Roux-en-Y loop is
performed in the typical manner like in
total gastrectomy and closed with a linear
stapler at the blind edge which is placed at
the lesser curvature of the gastric remnant.
e jejunal loop is also moved into the
upper abdomen retrocolic.
5 e stapler line at the gastric remnant is over-
sewn at the minor side until an area of 3cm
at the major side. is part of the stapler line
is resected and the jejunal loop is opened at
the antimesenteric side also at 3cm in length.
the stomach up to 3cm below the cardia. e
integrity of the esophageal and gastric wall in
this area is very important.
5 is procedure is followed by closing and cut-
ting of the stomach with a linear stapler from
about 2cm below the cardia transverse to the
side of the greater curvature, e.g.,. with a TA
90. e consistency of the distal esophagus
must be assured.
5 The lymphadenectomy along the vessels
As the jejunum is more easy to stretch than the
stomach, it is suggested to open the jejunum a bit
less than the opposite side of the stomach.
5 e anastomosis is performed with 3-0
mattress sutures at the posterior wall and
extramucosal single wall stitches at the ante-
rior wall (. Fig. 19.7). In the same manner,
the anastomosis can be performed in con-
tinuous suturing technique.
of the upper abdomen is performed as has
been described for total gastrectomy. The
lymph nodes are removed en bloc with the
19
gastric specimen. In comparison to the
gastrectomy only the lymph node area 2
subcardial at the major side of the gastric
fundus is preserved.
5 e reconstruction is done by a Roux-en-Y
jejunal loop. A Billroth II reconstruction is
e so-called “Jammerecke” is closed with a
3-stitch technique which comprises the anterior
wall of the stomach, the posterior gastric wall at
the lesser curvature and the jejunum. is ensures
a good coverage of this sensitive area of the anastomosis.
5 e Roux-en-Y anastomosis is performed in
a typical manner as has been described above.
Surgical Technique and Difficult Situations from Arnulf H. Hoelscher (Conventional)
19.4 Difficult Situations
A Case Example
141
19
Situation
The case comprises a AEG type II
tumor with a large part of this tumor
in the distal esophagus. Because of
the preoperative diagnostic
(endoscopy, CT scan), it seems to be
possible to remove the tumor via an
abdomino-transhiatal approach.
After transhiatal exposure and
palpation as well as intraoperative
esophagogastroscopy, it is clear that
the tumor cannot be removed
completely at the esophagus via a
transhiatal approach.
Problem
There is the danger that the stomach
is completely dissected and removed
at the duodenum. If it is not possible
to remove the tumor at the
esophagus with a tumor-free margin
via the transhiatal approach, the
stomach can no more be used for a
reconstruction. The only alternative
then would be reconstruction via
colon interposition. The patient
however has not been prepared for
this procedure. A colonoscopy and
an anterograde lavage of the bowel
have not been performed. According
to the experience of the surgeon,
perhaps he is not able to perform a
reconstruction via a colon
interposition.
Solution
Because of this potential situation,
it is suggested in cases which are
difficult to judge preoperatively
first to dissect the distal esophagus
by transhiatal approach in the
lower mediastinum. The
esophagus can be cut and the
frozen section can be performed. If
the cutting section is infiltrated,
another segment of the esophagus
can be resected in order to achieve
a tumor-free resection margin.
Analysis
If the frozen section shows a
tumor-free resection margin, a
transhiatal extended gastrectomy
with D2 lymphadenectomy is
completed and reconstruction
according to Roux-en-Y. If the
frozen section shows an infiltrated
resection margin, still the decision
can be taken to perform a
reconstruction with a gastric
pull-up after extended
esophagectomy. The
reconstruction is then performed
by gastric pull-up with a narrow
gastric conduit. However at the
aboral resection margin of the
stomach, a tumor-free resection
also has to be guaranteed. If the
stomach is infiltrated widely by the
subcardial part of the tumor and if
it is not appropriate for formation
of a gastric tube, a total
esophagogastrectomy and a colon
interposition with proximal
esophagocolostomy and distal
colojejunostomy have to be
performed.
19.4.1 Classification of the Intraoperative Difficulties
We classify the intraoperative difficulties in patients which have to be operated for gastric cancer as
mentioned in . Table 19.1.
. Table 19.1 Grade of intraoperative difficulties in gastrectomy for carcinoma
Grade I: ideal
patient
Technically simple to
operate, each surgical
method can be performed
without problems
Small gastric cancer in the antrum or corpus in patients
without abdominal surgery before and without
neoadjuvant treatment
Treatment by subtotal gastric resection, modified D2
lymphadenectomy, and reconstruction after Roux-en-Y
with gastric jejunostomy or treatment by gastrectomy
with D2 lymphadenectomy with reconstruction after
Roux-en-Y esophagojejunostomy
(continued)
142
A.H. Hoelscher
. Table 19.1 (continued)
Grade II: not a very
ideal patient
Grade III:
problematic patient
Grade IV: very
difficult patient
Moderate technical
difficulties, some surgical
methods can be more
difficult than others
Difficult to operate, some
surgical methods
significantly more difficult
than others
Each step of the operation
is difficult
AEG type II or type III tumor: treatment by transhiatal
extended gastrectomy with distal esophageal resection,
D2 lymphadenectomy in the lower mediastinum
Advanced carcinoma of the gastric antrum with
infiltration of the pylorus: treatment by gastrectomy, D2
lymphadenectomy, more extended duodenal resection
Patient after neoadjuvant therapy and reasonable scaring
of the lymph nodes along the suprapancreatic vessels and
at the upper edge of the pancreas: exact dissection of this
vessels during lymphadenectomy and preservation of the
pancreas
Patient with abdominal surgery before: abdominal
adhesiolysis
AEG type II tumor with significant infiltration of the
esophagus: Very high esophagojejunostomy with
transhiatal or by right transthoracic approach if necessary,
intraoperative decision to perform esophagectomy and
reconstruction by gastric pull-up, mediastinal
lymphadenectomy, abdominal modified D2
lymphadenectomy
Intense intraabdominal adhesions: very difficult
adhesiolysis
Patients with a gastric stump cancer or Billroth I or
Billroth II resection before, especially after retrocolic
reconstruction
Patients after neoadjuvant therapy and intense scaring
of the lymph nodes along the suprapancreatic vessels:
exact dissection of these vessels during
lymphadenectomy and preservation of the pancreas
Extended AEG type II tumor with very large infiltration of
the esophagus and stomach: esophagogastrectomy,
mediastinal and abdominal D2 lymphadenectomy,
reconstruction by colon interposition with
esophagocolostomy and colojejunostomy
Extended T4 gastric cancer: multivisceral resection with
extended gastrectomy and en bloc resection of the liver,
spleen, colon, duodenum, pancreas, and necessary
intestinal or biliary reconstruction, Appleby operation in
case of infiltration of the celiac trunk
19
143
Operative Technique
and Difficult Situations
by Joachim Jähne
(Conventional)
JoachimJähne
20.1 Introduction – 144
20.2 Pre- and Intraoperative Setting – 144
20.3 Operative Technique – 144
20.3.1 Resection – 144
20.3.2 Reconstruction – 149
20.3.3 Specifics of Gastrectomy for Proximal Cancers – 151
20.3.4 Subtotal Distal Gastrectomy – 151
20
20.4 Difficult Situations – 152
20.4.1 Classification of Intraoperative Challenges – 153
Literature – 153
© Springer-Verlag Berlin Heidelberg 2017
M. Korenkov et al. (eds.), Gastrointestinal Operations and Technical Variations,
DOI 10.1007/978-3-662-49878-1_20
144
J. Jähne
20.1 Introduction
With respect to the actual guidelines for the
diagnostic and therapeutic approach to gastric
carcinoma and due to the generally accepted
histology-, stage-, and localization-oriented
surgical therapy, the intra- and extraluminal
extent of gastric resection can be well defined
in order to achieve a R0 resection [3]. For
oncological reasons, approximately 80 % of all
gastric carcinomas require a total gastrectomy – eventually transhiatal or abdominothoracic– while in about 20 % of all patients, a
subtotal, distal gastrectomy is adequate.
Irrespective of the intraluminal extent of resection, a D2 lymph node dissection should be an
integral part of surgery.
e following description for both procedures
reflects the author’s experience. Multivisceral
resections as “le upper quadrant evisceration”
with en bloc le pancreatic resection, splenectomy and resection of the le colonic flexure, as
well as gastrectomy with simultaneous resection
of the head of the pancreas are not described
herein.
20.3 Operative Technique
20.3.1 Resection
5 e abdomen is opened by a transverse laparot-
omy with upper extension to the xiphoid in the
midline (. Fig. 20.1). Skin incision is done with
a scalpel and further tissue separation by mono-
polar coagulation. e wound edges are covered
by laparotomy sponges. For retraction an Ulrich
retractor is placed.
5 e intraoperative findings are documented
and technical as well as prognostic resect-
ability is clarified. In case of resectability, the
le lobe of the liver is mobilized in order to
get good access to the esophagogastric junc-
tion (. Fig. 20.2). Prior to that, the spleen is
covered in a laparotomy sponge to avoid iat-
rogenic lesions.
20
20.2 Pre- and Intraoperative
Setting
5 All patients are discussed in the daily indica-
tion’s conference. At the day before surgery,
all patients’ charts are intensively reviewed.
During rounds in the morning before surgery, the incision is marked.
5 In the OR patients’ charts are again reviewed
by the anesthesiologists. Following intubation
and in general anesthesia, the intraoperative
checklist is reviewed and team time-out is
performed.
5 During the operation, the surgeon uses a
headlight to avoid recurrent manipulation at
the OR light and to get a good view in particular in deeper areas of the situs.
5 Resection is performed by the use of bipolar
scissors and bipolar coagulation. Opening of
the abdomen and transection of the bowl is
performed by monopolar coagulation.
5 For ligations 3-0 Vicryl is used. Hemostasis
by sewing is done by 5-0 or 4-0 Prolene.
. Fig. 20.1 Preoperative mark of skin incision and
transverse laparotomy
. Fig. 20.2 Mobilization of the left lobe of the liver
Operative Technique and Difficult Situations by Joachim Jähne (Conventional)
145
20
. Fig. 20.3 Incision of the small omentum close to the
liver toward the esophagogastric junction; accessory left liver
artery originating from the left gastric artery
. Fig. 20.4 Incision of the peritoneum at the
esophagogastric junction and exposure of the esophagus
> Routine en bloc splenectomy is no longer
performed. Only in case of locally advanced
proximal gastric cancer that splenectomy is
carried out by a ventral approach.
5 e small omentum is incised close to the
liver and in direction toward the esophageal
hiatus. An eventually occurring accessory le
liver artery originating from the le gastric
artery needs to be preserved (. Fig. 20.3). If
this is not feasible, it usually does not cause
harm to liver perfusion (
. Fig. 20.3).
5 e peritoneum at the esophagogastric junc-
tion is incised (. Fig. 20.4). Both branches of
the diaphragm are exposed and the esophagus including the vagal branches is embraced
(. Fig. 20.5). In particular in carcinomas of
. Fig. 20.5 Embracement of the esophagus including
the vagal nerves
. Fig. 20.6 Mobilization of the duodenum, lymph node
dissection at stations 13 and 16
the esophagogastric junction, this is important to clarify resectability. Additionally, it
enables significantly the retroperitoneal
lymph node dissection during further resection.
5 Subsequently the duodenum is mobilized
according to Kocher. During the mobilization
of the duodenum, lymph node dissection at
the right edge of the hepatoduodenal ligament starts and the identification of lymph
node station 13 is possible. Additionally,
lymph node station 16 (right of the vena cava
and aorta) is dissected (
. Fig. 20.6).
5 Due to the increased incidence of cholecysto-
lithiasis following gastrectomy, we routinely
perform cholecystectomy [2], although hard
evidence for this approach is lacking.
146
J. Jähne
20
. Fig. 20.7 Lymphadenectomy at the hepatoduodenal
ligament with ligation of the right gastric artery
5 Subsequently, lymphadenectomy at the
hepatoduodenal ligament is performed. To
identify anatomical variations of the right
hepatic artery, e.g., origin from the mesenteric artery, lymph node dissection should
start at the right edge of the choledochal duct.
During lymph node dissection, the hepatic
artery and the right gastric artery are identified, the latter one being dissected
(. Fig. 20.7). In obese patients the initial
preparation at the hepatoduodenal ligament
is avoided, and instead the common hepatic
artery at the upper border of the pancreas
and the branch of the gastroduodenal artery
are identified. e common hepatic artery is
then used as a live rail for lymph node dissection at the hepatoduodenal ligament.
5 e lymph nodes behind the hepatoduodenal
ligament and along the portal vein are dissected. is is achieved while the tip finger of
the surgeon pushes the tissue behind the ligament from right to le (. Fig. 20.8). e result
is a compression of the portal vein, which is
completely dissected of all lymphatic tissue.
5 Lymph node dissection, always en bloc, is
then continued along the common hepatic
artery down to the celiac trunk. Small bleeding during the dissection is stopped by bipolar coagulation.
> Particular attention is paid to the upper
border of the pancreas. Injuries and necrosis due to coagulation must be avoided to
prevent postoperative pancreatitis.
. Fig. 20.8 Lymphadenectomy at the hepatoduodenal
ligament and at the portal vein
. Fig. 20.9 Omentectomy including excision of the
anterior layer of the mesocolon
5 Extensive coagulation is not necessary. Most
of the bleeding will stop automatically.
5 Complete omentectomy is performed by simul-
taneous excision of the anterior sheet of the
mesocolon (. Fig. 20.9). If the preparation is
done in the correct layer, this can be performed
without any bleeding. Blunt dissection by the
first assistant supports this step. Omentectomy
is performed down to the le colonic flexure.
5 e bursa omentalis is divided, omentectomy
is completed, lymph node dissection is per-
formed below the pylorus, and the right gas-
troepiploic vessels are taken off. is
procedure can be easily performed by palpa-
tion of the vessels between the thumb and tip
finger. It also helps to avoid damage to the
head of the pancreas (
. Fig. 20.10).
Operative Technique and Difficult Situations by Joachim Jähne (Conventional)
147
20
. Fig. 20.10 Lymphadenectomy below the pylorus
and take-off of the right gastroepiploic vessels
. Fig. 20.11 Transection of the duodenum with a linear
stapling device
5 Transection of the duodenum is done by use
of a linear stapling device (. Fig. 20.11). Until
a couple of years ago, the stapler line was
oversewn with single stitches. is was abandoned (. Fig. 20.12).
> In order to avoid thermic damage, hemostasis
at the stapler line is never done by coagulation. Significant bleeding is managed by single
stitches with 4–0 Vicryl.
5 In case of distal gastric cancer, the closure
of the duodenal stump may be difficult. In
these instances, a closure with a second
Roux-en-Y loop should be considered.
Additionally, intraoperative frozen section
of the distal resection margin appears to be
necessary to establish a tumor-free margin.
In all other cases, frozen section of the distal
. Fig. 20.12 Closure of the duodenal stump
. Fig. 20.13 Lymphadenectomy at the celiac trunk.
Dissection of the left gastric artery
resection margin does not appear to be necess ar y.
5 If there remains uncertainty regarding an
intact papilla of Vater following transection of
the duodenum, cannulation of the choledochal duct is advised. In case of an injury to
the papilla of Vater, partial duodenopancreatectomy is unavoidable for a safe solution of that intraoperative challenge.
5 By liing-up of the stomach, lymphadenec-
tomy at the common hepatic artery to the
celiac trunk is completed. e le gastric vein
is taken off (
. Fig. 20.13). Lymph node dis-
section at the celiac trunk includes radicular
dissection of the le gastric artery. In case of
an accessory le hepatic artery, the le gastric
artery is preserved, and only the ascending
branches to the stomach of this artery are
148
J. Jähne
20
. Fig. 20.14 Dissection of the ascending branches of
the left gastric artery in order to preserve an accessory left
liver artery
. Fig. 20.15 Transection of the gastrosplenic ligament
dissected (. Fig. 20.14). In obese patients this
may be very difficult.
5 Aer completing the lymph node dissection
at the celiac axis, it is further performed at
the splenic artery. During this part of the
resection, the short gastric vessels are divided.
Later on, the gastrosplenic ligament is transected and the spleen is preserved
(. Fig. 20.15).
5 Subsequently, lymph node dissection is per-
formed in the retroperitoneum up to the
esophagogastric junction. Both branches of
the diaphragm are exposed, and in case of
carcinomas at the esophagogastric junction,
both branches of the diaphragm are partially
. Fig. 20.16 Truncal vagotomy
. Fig. 20.17 Transected esophagus which is hold with
two Ellis clamps
transected for better exposure of the esopha-
gus. Following truncal vagotomy
. Fig. 20.16) and paraesophageal lymphade-
(
nectomy, in case of a transhiatal approach
combined with lymphadenectomy in the pos-
terior mediastinum, the esophagus is distally
closed with a Satinsky clamp and proximal
transected. Frozen section of the proximal
resection margin is routinely performed
(. Fig. 20.17).
5 Following the resection, the abdominal cavity
is rinsed with distilled water, which enables
the detection of even the smallest bleeding. If
the proximal resection margin is free of
tumor, reconstruction starts.
Operative Technique and Difficult Situations by Joachim Jähne (Conventional)
149
20
20.3.2 Reconstruction
Among all available reconstruction methods,
Roux-en-Y reconstruction is the preferred type.
Reconstruction according to Longmire is only
applied in early tumor stages and in carcinomas
located in the proximal and middle third of the
stomach.
5 To establish the Roux-en-Y reconstruction,
the second jejunal loop is identified using
diaphanoscopy, and the vessels within
themesenterium are evaluated (. Fig. 20.18).
5 Following an asymmetric transection of the
mesenterium, the jejunum is divided by a
linear stapler (. Fig. 20.19). Oversewing
ofthe stapler line is abandoned
(. Fig. 20.20).
5 e isoperistaltic Roux-en-Y loop is
relocated in the upper abdomen through an
incision in the mesocolon. e blind end of
the loop always is on the right side to avoid
a twisting of the mesenterium. Only in
Longmire reconstruction the blind end is
on the le side.
5 Following an antimesenteric incision
2–3cm proximal of the stapler line, a handsewn end- to- side esophagojejunostomy is
performed. e anastomosis is performed
with single stitches, at the seromuscular
jejunum and at the transmural esophagus.
e rear wall of the anastomosis is knotted
inside (
20.26,
. Fig. 20.21, 20.22, 20.23, 20.24, 20.25,
and 20.27).
5 e endoluminal tube is removed within
12–24h aer surgery. Patients are allowed to
drink water on the first day postoperatively.
A fluid diet is given on the second postoperativ e day.
. Fig. 20.18 Evaluation of the vessel architecture of the
mesenterium of the small bowl
. Fig. 20.19 Transection of the mesenteric vessels to
establish the Roux-en-Y loop
. Fig. 20.20 Transection of the jejunum
. Fig. 20.21 Hand-sewn esophagojejunostomy,
stitches at the edges