Distal gastrectomy

The following are “Does” from the syllabu

• Local gastric resection (lap/open)
• Distal gastrectomy (lap/open)

Procedure

• Subtotal/distal gastrectomy or antrectomy
  • Non-oncological operation
• Radical distal gastrectomy
  • Oncological operation
  • Includes lymphadenectomy
  • Includes high ligation of left gastric
• Key steps
  • Greater omentum
    • Dived through the gastrocolic ligament to enter the lesser sac
    • Divide from planned resection margin
    • Then head medial to the pancreas
    • Encounter right gastroepiploic vessels adjacent to head of the pancreas
      • R) gastroepiploic artery iolated along with subpyloric nodes and ligated
      • Vein taken with
  • Retroduodenal
    • Open the lesser sac
    • Create a plane behind the duodenum distal to the pylorus
    • Identify and divide the right gastric artery off the Common hepatic artery
    • Staple across the duodenum distal to the pylorus
  • Lesser omentum
    • Divide up to planned resection margin
  • Posterior dissection
    • Free any adhesions
    • Radical
      • Expose coeliac axis and ligate Left Gastric divided close to origin (ensuring left hepatic doesn’t come from it)
    • Antrectomy/subtotal
      • Divide adhesion/vascular close to the stomach as required depending on planned resection margin
  • Lymphadenectomy - if radical
    • Skeletonize coeliac, splenic, hepatic arteries
• Reconstruction
  • Loop or R&Y Gastrojejunostomy