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150
J. Jähne
. Fig. 20.22 Sutures at the rear wall of the
esophagojejunostomy
. Fig. 20.23 Approximation of jejunum and esophagus
. Fig. 20.25 Insertion of an endoluminal tube
. Fig. 20.26 Completion of the anastomosis by
suturing the front wall
20
. Fig. 20.24 Knotted sutures at the rear wall of the
esophagojejunostomy
. Fig. 20.27 End-to-side esophagojejunostomy, view
from the left side
Operative Technique and Difficult Situations by Joachim Jähne (Conventional)
aged conservatively and/or interventionally.
In general, morbidity may be between 20 and
30 % and mortality should be below 5 % [1].
20.3.3 Specifics of Gastrectomy
for Proximal Cancers
For carcinomas at the esophagogastric junction,
the preoperative classification according to
Siewert may be difficult. Additionally, many
pathologists do not apply the Lauren classification
when describing the preoperative biopsies. For
. Fig. 20.28 Hand-sewn end-to-side jejuno-jejunostomy
5 A stapler anastomosis is basically performed
in the same fashion. For technical reasons, the
esophagus is transected by a purse-string
clamp and the purse-string suture is placed. At
the esophagus the head of the stapler is placed,
usually with a diameter of 21–25mm. To
establish the anastomosis, a jejunostomy is
performed 20cm distal to the blind end of the
loop and the stapler is inserted. In contrast to
a hand-sewn anastomosis, the stapled anastomosis is exposed to methylene blue to check
for sufficiency. In case of leaks, single 4-0 Vicryl sutures are placed.
5 e end-to-side jejuno-jejunostomy is placed
50–60cm distal to the esophagojejunostomy
to avoid bile reflux. It is sutured in a running
seromuscular fashion with 4-0 Monocryl
. Fig. 20.28). In Longmire reconstruction,
(
the jejuno-duodenostomy is also sutured in
that fashion. At the jejuno-jejunostomy as
well as at the mesocolon, the mesenterial
defects are closed by single sutures.
5 A drainage catheter is placed behind the hep-
atoduodenal ligament to drain the esophagojejunostomy as well as the duodenal stump.
Following team time-out and instrument and
sponge count, the abdomen is closed in a
running fashion.
5 Patients do not get a suprapubic catheter.
Extubation is performed in the operating
room and the patients are transferred for one
night to the ICU.
5 During the postoperative course, a couple of
complications may occur despite a perfect
technique. In most cases, they can be man-
these reasons, difficulties arise when determining
the extent of intraluminal resection.
While carcinomas of Siewert type I are best
treated by subtotal esophagectomy with
reconstruction by a gastric tube, eventually colonic
interposition, Siewert type II or III carcinomas
require either a transhiatal or abdomino-thoracic
total gastrectomy. In these cases it may be helpful
to evaluate the mesenteric vessel arcades initially
to assure that the Roux-en-Y loop will be long
enough for reconstruction. A good arterial and
venous blood supply is essential in these cases.
erefore, the Roux-en-Y loop is created prior to
resection. If a jejunal reconstruction is not feasible, type II and III cancer are resected by subtotal
esophagectomy and gastric tube reconstruction.
If an abdomino-thoracic resection is necessary,
it needs to be considered that an intrathoracic
resection of the esophagus is usually only possible
with a 3–5cm distance. To assure an intrathoracic
anastomosis without tension, the Roux-en-Y loop
is first transposed into the chest before the esophagus is finally transected. Additionally, it is necessary that the blind end of the jejunal loop is
rectified toward the surgeon. Intrathoracic anastomosis is performed in the same fashion as an intraabdominal esophagojejunostomy.
20.3.4 Subtotal Distal Gastrectomy
e operative principles are almost identical to
total gastrectomy. e embracement of the esophagus is not performed. Lymphadenectomy
includes the paracardiac lymph node station 1.
e stomach is transected above the arcades of
the right and le gastroepiploic vessels by means
of a Payr clamp. e lesser curvature is transected
with a TA 55/90 or the Contour stapler. e
151
20
152
J. Jähne
resection margin at the lesser curvature is about
2cm below the esophagogastric junction. In order
to avoid an intraoperative injury to that region, a
gastric tube is inserted. e stapler line at the
lesser curvature is oversewn by 4–0 Vicryl.
20.4 Difficult Situations
Case 1
Situation
A 68-year-old patient with a
distal carcinoma in the
pretherapeutic uT3 uN0 stage
denies the proposed
neoadjuvant chemotherapy.
During the operation the
carcinoma shows extension well
below the pylorus. Intraoperative
Case 2
Situation
A 78-year-old female patient with
bleeding distal gastric carcinoma,
ASA-3 classification. Following
subtotal distal gastrectomy
without intraoperative
complication, postoperative
recovery was prolonged. Initially,
laboratory values returned to
normal. On postoperative day 7,
fever and a CRP increase were
frozen section of the duodenal
resection margin shows a R1
situation.
Problem
Acceptance of a R1 resection or
extension of the resection, e.g.,
Whipple’s procedure?
noted. Drainage tubes were
already removed, and on clinical
examination, the abdomen was
distended with slight pain. Due to
meteorism, ultrasonography was
difficult. On postoperative day 9,
computed tomography showed a
right subhepatic fluid collection
with signs of air bubbles.
Problem
Reoperation yes or no?
Reconstruction is performed by a retrocolic
and isoperistaltic 50cm Roux-en-Y loop. e gastrojejunostomy is hand-sewn with 4-0 Monocryl
in a running seromuscular technique. Jejunojejunostomy completes the reconstruction.
Solution
Whipple’s operation to achieve a
R0 resection
Analysis
Careful evaluation of the
prognostic benefits versus the
possible increase of perioperative
morbidity and mortality
Solution
Reoperation with signs of a small
insufficiency of the duodenal
stump, oversewing, alternative:
Roux-en-Y loop for closure of the
defect
Result
The patient recovered slowly and
discharged on postoperative
day 21.
20
Case 3
Situation
A 58-year-old patient with locally
advanced carcinoma of the
esophagogastric junction, type
Siewert II, intestinal type according
to Lauren, status post neoadjuvant
chemotherapy with clinically partial
remission, and significant morbid
obesity (BMI 31) showed during the
operation tumor growth into the
esophagus of 4 cm length.
Furthermore, the jejunal
mesenterium was obese, so that a
precise evaluation of the vessel
arcades was limited.
Problem
Transhiatal gastrectomy versus
abdomino-thoracic gastrectomy
versus (as alternative) subtotal
esophagectomy with gastric tube
reconstruction?
Solution
Subtotal esophagectomy
with gastric tube reconstruction
to achieve a R0 resection. The
extraluminal resection included
a D2 lymphadenectomy, but
the infrapyloric lymph nodes
in the region of the right
gastroepiploic vessels were
not dissected.
Result
Pathology confirmed the R0
resection with only limited nodal
involvement.
Analysis
Particular intraoperative situations
may require alternative resection
strategies without impairment of
the aim of R0 resection.
Operative Technique and Difficult Situations by Joachim Jähne (Conventional)
. Table 20.1 Level of intraoperative challenges in patients with gastric carcinoma
153
20
Level I: ideal patient Technically easy to operate on,
every resection is possible
without problems
Level II: patient with slight
challenges
Grad III: problematic patient Difficult to operate on, some
Level IV: very problematic
patient
Moderate technical challenges,
some resection strategies may
be more difficult than others
methods are significantly more
challenging than others
Each operative step is difficult Like level III, additionally BMI >30 and, for
20.4.1 Classification
of Intraoperative Challenges
We classify intraoperative challenges in patients
with gastric carcinoma as shown in . Table 20.1.
Intraoperative tumor stage T1–T3, tumor
localization in the middle third of the
stomach, limited nodal involvement
Normal BMI
No comorbidities
No neoadjuvant treatment
Like level I, but obesity with a BMI of 25–30
Neoadjuvant treatment
Like level II, but comorbidities (e.g.,
diabetes, coronary artery disease), prior
surgery
Additionally tumor in the distal third of the
stomach with extension to the duodenum
Tumor at the esophagogastric junction
example, COLD
Tumor at the esophagogastric junction
2. Kobayashi T, Hisanga M, Kanehiro H, et al. Analysis of
risk factors for the development of gallstones after
gastrectomy. Br J Surg. 2005;92:1399–403.
3. Moehler M, Al-Batran SE, Andus T, et al. S3-Leitlinie
“Magenkarzinom”– Diagnostik und Therapie der
Adenokarzinome des Magens und ösophagogastralen
Übergangs. Z Gastroenterol. 2011;49:461–531.
Literature
1. Jähne J. Chirurgische Komplikationen. In: Meyer HJ,
Buhr HJ, Wilke H, editors. Management des
Magen- und Ösophaguskarzinoms. Heidelberg:
Springer; 2004. p. 326–31.
155
Surgical Technique
andDicult Situations
fromGiovanni de Manzoni
(Conventional)
Giovannide Manzoni, SimoneGiacopuzzi, MariaBencivenga,
andEnhaoZhao
21.1 Introduction – 156
21.2 How WeDo Total Gastrectomy – 156
21.3 Subtotal Gastrectomy – 158
21
21.4 Deviations fromStandard Procedure – 159
21.5 Classication ofPatients According
toIntraoperative Diculty – 161
21.6 Dicult Situations: Personal Experience – 161
References – 162
© Springer-Verlag Berlin Heidelberg 2017
M. Korenkov et al. (eds.), Gastrointestinal Operations and Technical Variations,
DOI10.1007/978-3-662-49878-1_21
21
156
G. de Manzoni et al.
21.1 Introduction
We consider a total or subtotal gastrectomy with a
clear proximal resection margin of 5cm and a D2
lymphadenectomy as surgical standard for gastric
cancer treatment.
In this chapter, we report a detailed description of our surgical technique and some deviations from usual procedure depending on tumor
characteristics.
21.2 How WeDo Total Gastrectomy
Median laparotomy from the xiphoid process to
below the umbilicus; opened the peritoneal cavity,
we resect round and falciform ligaments.
5 At this point, a complete exploration of the
abdominal cavity is needed as the retrieval
of peritoneal or liver metastases could modify surgical indication; washings for peritoneal cytology are always performed.
5 We proceed with resection of the le triangular
ligament to mobilize liver segments II and III
medially and expose cardiac region [1].
5 e next step is the complete detachment of
greater omentum from the transverse mesocolon: it is performed along an avascular plane
that is easier to nd starting close to transverse
colon wall [1, 2]. Dissection includes removal
of the serous layer from the superior surface
of the mesocolon up to the front face of the
pancreas. For tumors of the posterior gastric
wall penetrating the serosa, a bursectomy with
complete removal of the inner peritoneal surface of the bursa omentalis is performed [3].
Detachment is continued to the right and le,
and it is completed with mobilization of the
hepatic and splenic exure of the colon. At this
point, aer opening the lesser omentum, a tape
is placed around the gastric body; in this way,
the second assistant can pull up the stomach,
while the rst assistant can traction the transverse colon to allow a good exposure of the
origin of the right gastroepiploic vessels [1, 2].
5 Hence, we rst proceed to isolation and sec-
tion of the right gastroepiploic vein proximal
to its conuence with the middle colic vein,
and then we perform the resection of the right
gastroepiploic artery [2]; at this time, lymphadenectomy of nodes at station n. 6 is performed, removing the adipose tissue located
. Fig. 21.1 Transverse upper abdominal laparotomy
with the use of two Stuhler’s retractors
between the trunk of Henle and the anterosuperior pancreaticoduodenal vein together
with dissection of corresponding portion of
the front face pancreatic serosa (
. Fig.21.1).
At this point, the dissection of the right gastric
vessels together with removal of suprapyloric
nodes (n. 5 nodes) allows complete mobilization
of the pylorus and the duodenal bulb.
5 e transection of the duodenum is done with a
mechanical linear stapler placed 2–3cm below
the pylorus. An oversewing of stapler line of the
duodenal stump with seromuscular suture is
always performed [1, 2].
5 We proceed with a complete division of the
lesser omentum; retrieval of an accessory le
hepatic artery is not uncommon; it can be
sectioned without problems [2].
5 Gastric mobilization continues with resection
of the gastrosplenic ligament carefully ligating
the le gastroepiploic vessels and then short
gastric vessels next to the splenic hilum to
ensure correct lymphadenectomy at station 4sa.
5 Now the stomach is tractioned upward and
medially to permit isolation and section of the
le gastric vessels. First, we identify and ligate
the vein just above upper pancreatic margin, and
then we isolate and dissect the artery. Removal
of the adipose tissue surrounding the le gastric
vein from the level of the upper pancreatic border to the origin of the le gastric artery allows
correct dissection of n. 7 nodes (
. Fig.21.2).
5 Division of the phrenoesophageal membrane
(Laimer-Bertelli membrane) leads to the
release of cardia and anterior surface of the
abdominal esophagus together with nodes at
Surgical Technique andDicult Situations fromGiovanni de Manzoni (Conventional)
157
21
. Fig. 21.2 Transection of duodenum
. Fig. 21.3 Thinning the second loop of jejunum
station n. 1; aer a careful posterior detachment of the esophageal wall with ligation of
vascular cardiac branches, we execute the section of the two vagus nerves [1].
At this point, we are ready for esophageal section.
We consider a safe proximal resection margin of
5cm; if it is respected, the section can be done just
above the EGJ carefully removing the le and
right paracardiac nodes. In this way, we have
completed gastrectomy and D1 lymphadenectomy. If a higher anastomosis is needed, the diaphragmatic hiatus must be opened, and, with the
help of two retractors, the mediastinal esophagus
is detached from the pericardium (Pinotti maneuver). Esophageal section is performed using a
rake clamp with the insertion of a 25mm circular
stapler anvil in the distal esophagus [1, 2]
. Fig. 21.3).
(
5 If a standard D2 lymphadenectomy is indicated,
prior to reconstruction, node dissection along
the common hepatic artery, the celiac trunk, and
the splenic artery is performed; anterior lymph
nodes of the hepatoduodenal ligament are also
. Fig. 21.4 Safeguarding of the pin penetration with
u-suture
. Fig. 21.5 Over-suturing of the stapler line
removed [1]. e line of dissection follows the
perivascular autonomic nerve branches to avoid
devascularization of structures especially for biliary ducts in case of posterior hepatoduodenal
lymphadenectomy (
. Fig.21.4).
5 If a super-extended lymphadenectomy has to
be done, we gain the access to the aortic plane
with duodenopancreatic kocherization, and
then we proceed to complete removal of paraaortic lymphatic tissue between the le renal
vein and the origin of the inferior mesenteric
artery [1].
5 Reconstruction is usually achieved with a
Roux- en- Y anastomosis.
5 is phase starts with the preparation of the
jejunal loop: anatomy of the arterial arcades is
examined by transillumination (
. Fig.21.5);
we usually preserve the arcades at the base of
the mesentery to ensure a good blood supply.
First, we do the jejuno-jejunal anastomosis at
about 20cm from the ligament of Treitz. It is a
mechanical end-to-side anastomosis, and it is
obtained by creating a purse-string suture on
the proximal end of the divided jejunum in
158
G. de Manzoni et al.
. Fig. 21.6 Lymphadenectomy of infrapyloric lymph
nodes
21
. Fig. 21.7 Lymph node dissection along of left gastric
artery
which we insert a 21mm anvil, and then a circular stapler is inserted for about 40cm
through the distal end of the divided jejunum;
at this level, the jejunal limb is perforated with
spike and the anastomosis is completed
(. Fig.21.6). A seromuscular oversewing is
always performed.
5 We proceed with the transposition of the eer-
ent jejunal loop to supramesocolic compartment
through an avascular area of the transverse mesocolon.
e last step is esophagojejunostomy: we introduce
the 25 mm circular stapler through the proximal
entrance of transposed loop, the spike is brought
out aer 5–6cm on the antimesenteric side, the
anvil on the distal esophageal stump is joined to the
stapler, and the end-to-side esophagojejunostomy
is performed (. Figs.21.7 and 21.8).
Finally, we use a linear stapler to close the jejunal stump and make a reinforcement of the esophagojejunal anastomosis with seromuscular 4–0
suture with absorbable thread [1, 2].
In case of necessity, we can perform an intrathoracic esophagojejunostomy with a right
. Fig. 21.8 Dissection of esophagus
anterolateral thoracotomy approach at the h or
sixth intercostal spaces. It is made possible by
Kasai’s technique: the resection of 5–6cm of the
jejunum keeping intact the mesentery allows the
realization of a tension-free intrathoracic anastomosis as tensions are discharged on the portion of
the mesentery without the jejunum [2].
21.3 Subtotal Gastrectomy
5 If a subtotal gastrectomy is indicated, the
ablative phase diers from that previously
described for total gastrectomy. In these cases,
the omentectomy starts proximally to insertion of the le gastroepiploic artery, and just
one or two short gastric vessels are sectioned.
Gastric section is performed along a line
extending from the greater curvature 2cm
below the lower splenic pole up to the right
margin of the heart in order to completely
remove the right paracardiac lymph nodes.
5 Reconstruction is usually obtained perform-
ing a Roux-en-Y end-to-side gastrojejunal
anastomosis.
Surgical Technique andDicult Situations fromGiovanni de Manzoni (Conventional)
21.4 Deviations fromStandard
Procedure
1. In case of upper third tumors or of macroscopic metastasis at the splenic hilum, it is possible to perform a spleen-preserving dissection
of lymph nodes at n. 10 and n. 11 stations by
Jinnai’s maneuver.
5 First step is section of posterior parietal
peritoneum from the right to left starting from the left margin of the upper
mesenteric vein along the lower margin
of the pancreas and posterior margin
of the spleen up to the superior splenic
pole.
5 en, aer a careful detachment from pos-
terior structures, the splenopancreatic block
is turned, and the dissection of lymph nodes
along the splenic artery and at splenic hilum
can be performed.
5 At the end, splenopancreatic block is
replaced in the le hypochondrium being
careful not to twist the vascular axis [2].
2. In case of demonstrated or suspected duodenal
invasion, the section of duodenum has to be
done more than 3cm from the pylorus.
Gastric adenocarcinoma with duodenal
invasion has been reported with an incidence
of 12–24 % for antral tumors. It is more frequent in cases of large >6cm AGC of the lower
third with inltrative grow pattern (Bormann
3 or 4) and inltration of the serosa layer. e
invasion is generally through the submucosa
or subserosa and its identication is not simple. Duodenal invasion is rare but reported
also in EGC (0.5–1.8 %).
In most of cases (>80 %), the extension of
duodenal invasion is <3cm [4].
In these cases, before duodenal resection,
we perform a complete kocherization with
medial rotation of the rst and second portion
of the duodenum and pancreatic head. In this
way, we can detach the duodenum from the
pancreatic head and execute the resection at
more of 3cm from the pylorus with the possibility of a safe oversewing. We usually perform
a frozen section of resection line.
3. In cases of early gastric cancer of the upper
third of the stomach or of EGJ (Siewert II with
<2cm of esophageal invasion), a proximal gastrectomy using a gastric conduit with personal
technique is feasible.
. Fig. 21.9 Intraoperative view after D2 lymph node
dissection
5 We start, as already described for total gas-
trectomy, with detachment of the greater
omentum from the transverse mesocolon
and mobilization of the right and le
colon exures, and then we kocherize the
duodenum to provide a good mobility of
gastric tube. e le gastroepiploic and
short gastric vessels are ligated. e lesser
omentum is divided and le gastric artery
and vein are divided and tied. Section of
the two vagus nerves allows a complete
exposition of the abdominal portion of the
esophagus; at this point, the esophagus is
divided using a GIA 60 linear stapler above
the level of EGJ or at least 2cm above the
tumor for EGC of EGJ (
5 We create a gastric conduit along the
greater curvature using multiple rings of
linear staplers: we start from the fundus
rst for 5–6cm parallel to the greater
curvature and then in the direction of
the lesser curvature (
second step, we excise the distal part of
the lesser curvature starting just above the
pylorus up to 5cm away from the upper
section to complete the gastric conduit and
create an access pouch for circular stapler
(. Fig.21.11). Aer sectioning the esophageal hiatus, we free the lower esophagus
and complete node dissection by removal
of lower mediastinal nodes. en a 25mm
anvil is placed in the esophageal stump,
and a purse-string suture is created at the
top of the gastric conduit (. Fig.21.12).
5 At this point, a circular stapler is inserted
through the gastric access pouch
(. Fig.21.13), and a stapled end-to-end
anastomosis is created; nally, gastric
159
. Fig.21.9).
. Fig.21.10). In the
21
21
160
G. de Manzoni et al.
. Fig. 21.10 Transillumination of the jejunal vessels
. Fig. 21.11 Creation of jejuno-jejunal
. Fig. 21.12 Creation of a 25-mm circular stapler
esophago-jejunal end-to-side anastomosis
pouch is closed with a linear stapler and
the anastomosis is oversewn [1]. is technique has been developed considering the
vascular anatomy of gastric tube as it is the
only possible way to perform anastomosis
without interruption of vascularity along
the entire circumference of the suture line.
. Fig. 21.13 completion of esophago-jejunal
end-to-side anastomosis
4. In case of advanced cardiac adenocarcinoma,
intrathoracic anastomosis has to be performed.
e creation of gastric tube follows the procedure described previously for proximal gastrectomy; in this case, gastric tube creation
starts at the angle of His. Diaphragmatic hiatus
is opened and a lower mediastinal node dissection is performed, and then the gastric tube is
attached to the esophageal stump before closing the abdominal cavity.
At this point, the patient is repositioned in
le lateral decubitus and a right anterolateral
thoracotomy at fourth or h intercostal space
is performed. e mediastinal pleura is incised
and the azygos vein is isolated and divided.
e esophagus is isolated and an extended
lymph node dissection is performed. en the
esophagus is divided 2–3cm above the azygos
vein. e gastric conduit is transposed in the
chest cavity, and aer the insertion of a circular
stapler through the gastric pouch, a circular
stapled end-to-end anastomosis is created [5]
(
. Fig.21.14).
5. In case of positive peritoneal washing, we can
complete radical surgery with a hyperthermic
intraperitoneal chemotherapy (HIPEC).
We usually perform HIPEC with the closed
technique. Aer completing anastomoses, two
inow and two outow drains are inserted in
the peritoneal cavity, and then the abdominal
wall is closed. Drains are connected to an external circuit including a pumping system and a
heat exchanger. When the abdominal temperature reaches 41.5–42.5° C, infusion of chemotherapeutic agents starts for the duration of an
hour. e drugs we usually use are mitomycin
C and cisplatin. At the end of perfusion, the