Gastrectomy

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  • Universität Witten/Herdecke

    Prof. Dr. med. Gebhard Reiss

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  • Surgical anatomy of the stomach

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    In terms of function, the stomach mixes and stores food and is an expansion of the alimentary tract between the esophagus and the duodenum. This muscular hollow viscus produces acidic gastric juice (mucus and HCl) and enzymes, which predigest some elements of the ingested food, and portions the chyme into the duodenum.

    Usually, the stomach is located immediately inferior to the diaphragm in the left upper quadrant and epigastrium. Location, size and shape of the stomach vary from person to person and may differ substantially, depending on age, filling condition and body position. The moderately filled stomach has a mean length of 25-30 cm and can hold 1.5 liters, in extreme cases up to 2,5 liters.

    Within the abdominal cavity the stomach is held in position and stabilized by ligaments inserting at the liver and spleen Its convex aspect forms the major curvature (curvatura major gastrica) and its concave aspect the lesser curvature (curvatura minor gastrica). Its anterior wall is termed paries anterior gastrica and its posterior aspect paries posterior gastrica.

    Since the stomach is an intraperitoneal viscus, it is covered by the gastric serosa (tunica serosa gastrica), and only the posterior aspect of the cardia is free of serosa. Stomach rotation shifts the embryonic mesogastrics from their former sagittal position to a frontal location. The lesser omentum originates at the lesser curvature and extends to the hepatic portal, while the greater omentum originates at the greater curvature and courses to the transverse colon, spleen and diaphragm.

    The stomach displays the following portions:

    • Entrance of stomach / Cardia / ostium cardiacum:
      The superior opening of the stomach, where the esophagus enters the stomach, is 1 cm–2 cm long. It is characterized by a marked transition from the mucosa of the esophagus to that of the stomach.
    • Gastric fundus / fundus gastricus:
      Superior to the level of entrance of the esophagus the fundus arches cephalad, which then is called gastric fornix (fornix gastricus). Usually, the fundus is full of air which is swallowed automatically when ingesting food. In the erect position the fundus is the highest point of the stomach, and on abdominal films its trapped air is evident as the “gastric bubble”. A notch (incisura cardialis) clearly delimits the fundus from the entrance of the stomach.
    • Body of the stomach / Corpus gastricum:
      The main portion of the stomach is taken up by the gastric body. The deep mucosal folds (plicae gastricae) found here extend from the cardia to the pylorus and are also known as “magenstrasse”.
    • Pylorus / Pars pylorica:
      This portion begins with the extended pyloric antrum, followed by the pyloric canal, and terminates at the actual pylorus. It is formed by the pyloric sphincter (m. sphincter pyloricus), a strong circular layer of muscle which closes off the inferior gastric orifice (ostium pyloricum). The pylorus closes off the gastric outlet and periodically lets some of the chyme pass into the adjacent duodenum.
  • Layers and structure of the gastric wall

    Gastric wall
    Under the microscope the gastric wall displays a characteristic layered structure with the following sequence from the inside out:

    • The internal aspect of the gastric wall is lined by mucosa (tunica mucosa). The gastric mucosa is made up of three sublayers: The lamina epithelialis mucosae produces viscous neutral mucus which protects the gastric mucosa against mechanical, thermal and enzymatic injury. This is followed by the loose connective tissue coat of the lamina propria mucosae into which the gastric glands (glandulae gastricae) descend. The outermost layer of the mucosa is the small lamina muscularis mucosae which can change the relief of the mucosa.
    • The gastric mucosa is followed by a loose layer of connective tissue (tela submucosa gastrica), which houses not only a dense network of blood and lymph vessels but also a nerve plexus (plexus submucosus or Meissner plexus) which controls gastric secretion. Although this plexus is independent of the central nervous system (CNS), the latter may affect the former via the autonomic nervous system.
    • Next is the marked tunica muscularis with its three sublayers, each comprising muscle fibers coursing in different directions: The inner layer of small oblique muscle fibers (fibrae obliquae), then a circular layer (stratum circulare) and finally the outermost longitudinal layer of muscle fibers (stratum longitudinale). These muscles effect the peristalsis of the stomach and ensure thorough mixing of the chyme with the gastric juice. Muscular function is controlled by a nerve plexus, the plexus myentericus or Auerbach plexus, in between the circular and longitudinal layers. Just like the plexus submucosus, this plexus is mostly autonomous but is also affected by the autonomic nervous system.
    • Next is another layer of loose connective tissue (tela subserosa gastrica).
    • The peritoneum (tunica serosa) covering the external aspect of the stomach is its final layer.

    Gastric glands
    The gastric glands (glandulae gastricae) located in the fundus and body of the stomach are part of the lamina propria mucosae. 1 mm2 of mucosal surface comprises up to 100 such glands. The ductal wall of the gland is lined with different types of cells:

    • Mucous cells: They produce the same neutral mucus as the epithelial cells.
    • Surface mucous cells: Foveolar cells are close to the surface of the gland and contain alkaline mucus, i.e., the pH of its hydrogen carbonate ions (HCO3–) is rather high. This property is rather important in controlling the gastric pH. The mucus lines the gastric mucosa and protects it against autodigestion by the aggressive hydrochloric acid (HCl) and enzymes as autodigesting proteins. This type of cells is mostly found in the cardia and fundus of the stomach.
    • Chief cells: These cells produce the inactive proenzyme pepsinogen which, once released, is activated by hydrochloric acid (HCl) to the active enzyme pepsin, the latter starting the digestion of the alimentary proteins. Since the initial contact of the enzyme with hydrochloric acid is at the surface of the gland, this ensures that the glands will not be autodigested by the enzyme. This type of cells is mostly found in the body of the stomach.
    • Parietal cells: Mostly found in the body of the stomach, these cells produce plenty of hydrogen ions (H+) needed in the production of hydrochloric acid (HCl). The latter has a rather low pH of 0.9–1.5. In addition, the parietal cells also produce the so-called intrinsic factor. Together with vitamin B12 from the ingested food this substance generates a complex in the small intestine which can pass through the intestinal wall. This vitamin plays a pivotal role in erythropoiesis (gastric resection may result in anemia).
    • G cells: Primarily found in the gastric antrum, these cells produce gastrin which increases HCl production in the parietal cells.
  • Function

    The stomach acts as a reservoir for ingested food. Since it may store food for hours, it ensures that we can meet our daily nutritional requirements with a few major meals. Peristalsis thoroughly mixes the chyme with the gastric juice, the food is broken up chemically, predigested and then portioned into the duodenum.

  • Arterial and venous blood supply, innervation

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    The arteries supplying the stomach all arise from the unpaired celiac trunk, comprise numerous anastomoses with each other and course as arterial arcades along the gastric curvatures:

    • Right gastric artery arising from the hepatic artery proper and supplying the inferior portion of the lesser curvature
    • Left gastric artery supplying the superior portion of the lesser curvature
    • Short gastric arteries arising from the splenic artery and supplying the fundus
    • Right gastro-omental artery arising from the gastroduodenal artery and supplying the inferior (right) portion of the greater curvature
    • Left gastro-omental artery arising from the splenic artery and supplying the left portion of the greater curvature
    • Posterior gastric artery arising from the splenic artery and supplying the posterior gastric wall.

    This way, the stomach is supplied along the lesser curvature by an arterial arcade between the left and right gastric artery and along the greater curvature by another arcade between the left and right gastro-omental artery.

    The 4 major veins parallel the arterial blood supply along both curvatures of the stomach. They unite to collecting veins (left and right gastric vein draining directly into the hepatic portal vein; left gastro-omental vein and the short gastric veins drain into the splenic vein; while the right gastro-omental vein drains into the superior mesenteric vein) which all drain into the portal vein.

    While gastric innervation is primarily controlled by the autonomic nervous system, there are also sensory fibers: The sympathetic nervous system innervates the pyloric muscles, while the parasympathetic nervous system (vagus nerve, CN X) supplies the other gastric muscles and the gastric glands. The vagus parallels the esophagus on the left and right and passes through the esophageal hiatus in the diaphragm; on the left side it then reaches the anterior gastric wall (t. vagalis anterior), while on the right side it innervates the posterior wall of the stomach (t. vagalis posterior). The afferent signals from sensory fibers of the stomach, on the other hand, pass via the greater splanchnic nerve to the thoracic spinal ganglia.

  • Lymphatic drainage

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    Lymphatic drainage of the stomach parallels its arterial and venous blood supply :

    • The lymphatics of the lesser curvature parallel the left / right gastric artery and drain into the left / right gastric lymph nodes
    • The lymphatics from the gastric fundus parallel the splenic artery and drain into the splenic lymph nodes
    • The lymphatics from the greater curvature parallel the suspension of the greater omentum and drain into the left / right gastro-omental lymph nodes
    • The lymphatics from the pyloric region drain into the pyloric lymph nodes.

    From these lymph nodes mentioned above the lymph then drains into the celiac nodes, the superior mesenteric nodes and the thoracic duct.

    Since the pancreatic lymph nodes are another pathway for lymph drainage, tumors of the stomach may very well metastasize into the pancreas. One special sign of gastric cancer is the frequent prominent supraclavicular lymph node of the left lateral region of the neck (Virchow / signal node) which signals advanced metastasis.

    For reasons of surgical technique, the lymph node stations are grouped into 3 compartments:

    • Compartment I (LN stations 1–6): All lymph node directly at the stomach; paracardiac (station 1+2), along the lesser and greater curvature (station 3+4), suprapyloric and infrapyloric (station 5+6).
    • Compartment II (LN station 7–11): Lymph nodes along the major vessels: Left gastric artery (station 7), common hepatic artery (station 8), celiac trunk (station 9), splenic hilum (station 10), splenic artery (station 11).
    • Compartment III (LN station 12-16): Lymph nodes at the hepatoduodenal ligament (station 12), posterior to the pancreatic head (station 13), at the mesenteric root and the mesentery (station 14+15) and along the abdominal aorta (station 16).

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  • Indications

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  • Contraindications

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  • Preoperative diagnostic work-up

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  • Special preparation

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  • Informed consent

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  • Anesthesia

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  • Positioning

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  • Operating room setup

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  • Special instruments and fixation systems

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  • Postoperative management

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  • Bucket-handle incision

    45-6

    Open the abdomen via a transverse upper abdominal incision with upper midline extension, the so-called "inverted T".

    Transect the subcutaneous tissue with electrocautery, tunnel both rectus muscles with a nonmetal probe and divide them with electrocautery.

    Explore the abdominal cavity to assess the location and extent of the tumor and thus its resectability after ruling out distant metastases, specifically in the peritoneum and liver. In this case the tumor is in the middle third of the stomach at the large curvature.

  • Dividing the lesser omentum, dissecting the gastroesophageal junction

    45-7

    After dividing the pericholecystic adhesions, transect the lesser omentum close to the liver in a distal to proximal direction while sparing the hepatoduodenal ligament. Continue the dissection to the gastroesophageal junction. Expose the full circumference of the abdominal esophagus and loop it with a tape.

  • Kocher maneuver

    45-8

    Follow this with the Kocher maneuver. To this end, incise the paraduodenal peritoneum about 1 cm from its lateral edge and in a largely avascular plane lift the duodenum from posterior away from the retroperitoneum and expose the vena cava.

  • Exposing the hepatoduodenal ligament

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    Start the lymph node dissection at the hepatoduodenal ligament (LN station 12), divide the right gastric artery close to its origin and loop the common hepatic artery. 

  • Dividing the greater omentum and gastroepiploic vessels

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    Freeing the greater omentum from the transverse colon will completely open the lesser sac. Leave the greater omentum attached to the large curvature. In the next step, divide the gastroepiploic vessels centrad between Overholt forceps. 

    Note: Complete mobilization of the stomach requires that later on the short gastric vessels from the gastric fundus to the spleen, as well as smaller vessels at the posterior wall of the stomach, a possible posterior gastric artery, and also the dense part of the lesser omentum, be divided or ligated.

  • Transecting the duodenum

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    Now expose the full circumference of the duodenum about 3 cm distal to the pylorus and transect it with a linear stapler (not shown in the video). Secure the staple line of the duodenal stump with serosizing interrupted sutures.

    Note: Tension-free, secure closure of the duodenal stump is only possible if the duodenum has been mobilized enough by the previous Kocher maneuver.

  • Lymphadenectomy along the hepatic artery

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    Continue the lymphadenectomy to the left along the adventitia of the looped common hepatic artery. The first vessel encountered is the left gastric vein (formerly known as vena coronaria ventriculi), which is ligated and divided. The final step reaches the celiac trunk, where the left gastric artery is divided close its origin.

    Caution! Rule out beforehand any aberrant left hepatic artery or large branches thereof arising from the left gastric artery.

    Continue the para-aortic lymphadenectomy on the right to the right crus of the diaphragm.

  • Lymphadenectomy along the splenic artery

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    Complete the lymphadenectomy on the superior aspect of the pancreas along the splenic artery to the splenic hilum. Lift the entire lymph node package, which remains attached to the specimen, en bloc off the superior aspect of the pancreas and both arteries (common hepatic artery and splenic artery).

    Note: In the video the specimen is still in situ at the completion of the surgical step.

  • Transecting the specimen

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    After truncal vagotomy transect the esophagus openly and remove the specimen. In the video the specimen has been opened and enlarged. The video then demonstrates the surgical site after the specimen had been removed, with the common hepatic artery and splenic artery still looped.

    Note: Intraoperative frozen section of the esophageal resection margin is mandatory.

  • Constructing the Roux limb

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    In the next step construct a jejunal Roux limb. Under transillumination identify the mesenteric vessels about 20 cm–30 cm distal to the duodenojejunal flexure. Fashion an asymmetrical vascular pedicle proximad, since the blood supply should be primarily from distad. Transect the jejunum with a linear stapler (GIA) and serosize the distal stump. Now pass this efferent jejunal limb of adequate length into the upper abdomen through a window in the mesocolon.

  • End-to-side esophagojejunostomy

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  • Jejunojejunostomy

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  • Closing the abdomen

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  • Intraoperative complications

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  • Postoperative complications

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  • Literature summary

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  • Ongoing trials on this topic

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  • References on this topic

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  • literature search

    Literature search under: http://www.pubmed.com