clavien_atlas_of_upper_gastrointestinal_and_hepato-pancreato-biliary_surgery2007-10-01_3540200045_springer

The lesser omentum is incised along the hepatoduodenal ligament up to the left side of the common bile duct and caudally to the duodenum. After ligation and division of the supraduodenal vessels, the gastric artery clearly displays in the ligament.

The tissue defined by this incision is dissected from the proper hepatic artery and swept across to the patient’s left. The gastroduodenal artery is followed to its junction with the proper hepatic artery, and the latter is cleaned until the origin of the right gastric artery is found and ligated. The dissection to the left of the hepatoduodenal ligament should go deeper than the proper hepatic artery and clear the nodes from the left side of the portal vein.

Along the superior border of the pancreas the adipose tissue contains many lymph nodes. It is divided from the pancreas and the surface of the common hepatic, splenic, and celiac arteries. These arteries are surrounded by thick nerve tissue. It should be preserved in case of no adherence of suspect lymph nodes. The left gastric vein is visible and therefore ligated and divided. Caudally it crosses the origin of either the common hepatic or splenic artery before entering the splenic vein in about 30–40% of patients. In the majority the left gastric vein passes obliquely behind the hepatic artery to join the junction of the splenic and portal veins.

View from the patient’s feet. To carry out the dissection of the splenic artery and hilar lymph nodes, the pancreas body/tail and spleen should be mobilized from the retroperitoneum, beginning at the pancreas body from the inferior towards the superior border and then towards the tail and spleen. After total mobilization of the spleen, the retroperitoneum is incised lateral of the spleen and divided. The pancreas body/tail and spleen are now completely mobilized for a meticulous dissection of lymph nodes around the pancreas tail.

The splenic artery is divided near its origin but more distal in contrast to Maruyama’s procedure after branching-off of the great pancreatic artery in Sasako’s modification. Sometimes preservation of the tail artery is possible.

188 SECTION 2 Esophagus, Stomach and Duodenum

See chapter “Total Gastrectomy with Conventional Lymphadenectomy” for postoperative investigations and complications.

Tricks of the Senior Surgeon

■Avoid transecting the postpyloric duodenum to close to the pancreatic capsule, disabling oversew of the duodenal stump.

■Meticulous dissection of the proper hepatic artery and the splenic artery is mandatory to prevent postoperative pancreatitis.

Transhiatal Esophagogastrectomy

Enrique Moreno Gonzalez, Juan C. Meneu Diaz, Asad Kutup,

Jakob R. Izbicki, Almudena Moreno Elola-Olaso

Introduction

From the pathogenic and therapeutic point of view, adenocarcinomas of the esophagogastric junction (AEG) should be classified into adenocarcinoma of the distal esophagus (Type I), true carcinoma of the cardia (Type II), and subcardial carcinoma (Type III). In patients with potentially resectable, true carcinoma of the cardia (AEG Type II), this can be achieved by a total gastrectomy with transhiatal resection of the distal esophagus and en bloc removal of the lymphatic drainage in the lower posterior mediastinum and upper abdomen.

Indications and Contraindications

Preoperative Investigations/Preparation for Procedure

■Esophagogastroduodenoscopy with histologic diagnosis

■Total colonoscopy to exclude second neoplasm or diverticula in the transposed colon segment

■CT scanning of the thorax and abdomen

■Abdominal sonography

■Esophageal endosonography

■Pulmonary function tests and blood gas analysis

■Echocardiography

■Ergometry and other cardiac investigations if necessary

■Entire orthograde bowel preparation

Mobilization of the sigmoid colon is facilitated by performing mediocranial traction to expose the embryonic adhesions between the colon and retroperitoneum. Further dissection is done between the mesosigmoid and retroperitoneal fat, taking care of the left ureter and gonadal vessels.