Gastrectomy

The following are “Knows” from the syllabus

• Total gastrectomy
• Subtotal gastrectomy
• Oesopha-gastrectomy
• Radical distal gastrectomy

Total

Key principles

• Resection of the stomach (either subtotal or total) with appropriate oncological margins
  • Diffuse type - OGD intra-op, mark, 5cm margin +/- frozen
  • Proximal tumour or Linitus Plastica → Total
  • Distal 1/3 tumour → Subtotal
• Lymph node dissection in D1+ fashion (Perigastric + Coeliac axis nodes)
  • See Lymphadenectomy in gastric cancer
• Appropriate reconstruction of GI continuity

A Gastrectomy is a resection of the stomach, or part of, with appropriate reconstruction of continuity usually via anastomosis with the small bowel and is most commonly done in the setting of gastric malignancy.

Operation Details

• This can be done via an open or laparoscopic approach
• Description of open approach to Total Gastrectomy
• Supine position with arms out on arm boards, GA, pre-op IV prophylactic abx, TEDs and SCDs
• Vertical upper midline laparotomy to just below the umbilicus or you can use a central and L) subcostal incision
• Inspect for ascites or peritoneal disease
• Apply fixed table retractor eg) Omnitract
• Key steps
  • Nathension retractor if lap
  • Greater omentum
    • Dived through the gastrocolic ligament to enter the lesser sac
    • Up to the Crus - take the short gastrics and the left gastroepiploic
    • 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
    • Swab under pylorus from greater curve
    • 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 - 2cm distal to pylorus
  • Lymphadenectomy
    • Flip the stomach
    • Posterior dissection
      • Free any adhesions
      • Expose coeliac axis and ligate Left Gastric divided close to origin (ensuring left hepatic doesn’t come from it)
    • Skeletonize coeliac, splenic, hepatic arteries
  • Lesser omentum
    • Divide up to the hiatus
    • Looking out for aberrant or accessory left hepatic (10-20%)
  • Oesophagus mobilization
    • 360 mobilisation around the oesophagus
      • Open peritoneal reflection over hiatus to expose crura
      • Blunt dissection to encircle oesophagus, use Penrose drain for traction
      • Vagi may be sacrificed
    • Right angle clamp placed over distal oesophagus
    • Two stay sutures proximal to clamp
    • Divide specimen
• Reconstruction - tension free single layer, end to side anastamosis, leaving a blind of less than 5cm
  • Roux en Y configuration with 60cm roux limb
  • Transection SB approx. 40cm distal to DJF
  • Antecolic
  • Hand sewn single layer 3/0 PDS enteroesophageal anastomosis
  • Side to side jejunojejunostomy anastomosis 60cm from 1st join
    • Hand sewn doubled layered 3/0 PDS
  • Secure SB at mesocolic defect and close defect 3/0 vicryl
• Consider need for feeding jejunostomy
• Drain left in situ
• Abdomen closed in standard fashion

Intraoperative complications & challenges

• Length of SB for roux limb
  • Score peritoneum
  • Change piece of bowel
  • If antecolic, try retrocolic to shorten distance
• Major vascular bleeding
  • Pack and pressure control and proceed with repair/adjuncts
• Pancreatic injury
  • Ensure duct secure, drain area well, test all post op ascitic output
• Splenic injury
  • Can attempt preservation procedures, but most commonly needs splenectomy

Post-operative complications

• Immediate
  • Intra-op
    • As above
    • Anaesthetic complications
    • Visceral injury
    • Portal triad injury
• Early
  • Bleeding/Haematoma
  • Infection
  • Anastomotic leak
    • More common from proximal join or Duodenal stump (5%)
      • Need to look for and exclude distal obstruction
  • Gastroparesis (or retained stomach) + ileus
    • Normal factors + vagotomy
  • DVT/PE/MI/CVA
  • Pancreatic fistula
• Late
  • Post gastrectomy syndromes
  • Dumping
    • Early and late
  • Afferent or blind loop syndromes

Specific Post-operative Care

• Nurse in HDU setting
• Daily CRP may correlate with likelihood of complication, esp leak, if persistently raised >48hrs
• Upper GI ERAS

Distal gastrectomy

• Terminology is confusion - some use the following
  • Distal gastrectomy or antrectomy
    • Non-oncological operation
  • Subtotal/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 (2cm)
  • 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